**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the environment was free of accident hazards and supervision of staff for 1 of 7 residents (Resident #1) reviewed for accidents and hazards, in that: The facility failed to ensure Resident #1 had a low bed (bed positioned near the floor) as ordered on 04/16/2024 and instead had a regular bed in the lowest position. Resident #1 fell from the bed in the higher position and onto the mat beside her bed and she sustained a C2 vertebral fracture. An IJ was identified on 05/31/2024. The IJ template was provided to the facility on [DATE] at 4:00 PM. While the IJ was removed on 06/01/2024 the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm because all staff had not been trained on low bed orders and compliance. This deficient practice could affect residents and place them at risk for accidents resulting in fractures, disability, or death. The findings included: Record review of Resident #1's electronic face sheet, dated 05/30/2024, reflected she was admitted to the facility on [DATE] with diagnoses which included: dementia (condition characterized by a loss of cognitive functioning, the ability to think, remember, or reason), schizoaffective disorder (a mental disorder in which a person experiences a combination of symptoms of schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech and behavior), mood disorder (feeling sad or anxious affects emotions), muscle wasting (deterioration or thinning of muscle mass), difficulty in walking (unsteady or abnormal gait), not elsewhere classified, lack of coordination (disruption in communication between the areas of the brain that control balance, movement and coordination), atrophy (progressive and degenerative shrinkage of muscles and nerve tissues), and aphasia (comprehension and communication disorder). Record review of Resident #1's quarterly MDS assessment with an ARD of 05/07/2024 reflected she was understood and usually understands, and the resident had scored a 04/15 on her BIMS, which signified she was severely cognitively impaired. Further review revealed the resident had functional limitations in range of motion to her lower extremity (hip, knee, ankle, foot) and used a wheelchair for mobility, the resident required extensive assistance with her ADLs, and the resident had falls since her admission/entry or reentry or the prior assessment which noted 1 fall with no injury. Record review of Resident #1's Emergency Documentation record dated 05/29/2024 reflected Assessment/Plan, Type II fracture of dens (projection of the 2nd cervical neck bone), discharge. Resident #1 was sent to a level 3 trauma center and Transition of Care report dated 05/29/2024 reflected C2 dens (Cervical or neck bone odontoid process break at second vertebrae level) (can cause pain, tingling, numbness or weakness in arms or legs) fracture after unwitnessed fall. Record review of Resident #1's comprehensive person-centered care plan revised 01/16/2024 reflected Focus, at risk for falls r/t, impaired vision, cognitive deficit and muscle weakness, Interventions, floor mat while in bed, the bed in low position at night. Record review of Resident #1's Fall Risk Assessment dated 04/01/2024 reflected a score of 14.0 which signified high risk. Record review of Resident #1's Event Nurses Note-Fall dated 05/29/2024 reflected unwitnessed, hit head, discovered on floor, Interventions in place prior to this fall on 05/29/2024, floor mat and low bed, interventions in response to this fall, floor mat and low bed. Record review of Resident #1's physician orders Active as of: 05/30/2024 reflected May have low bed, Phone, Active, 04/16/2024. Record review of Resident #1's [NAME] dated 05/30/2024 (information given to CNAs for care of resident) did not reflect low bed with mat. Observation on 05/30/2024 at 10:45 AM of Resident #1 revealed she was lying in bed with a neck collar on. She had a low bed with a mat on the floor. Observation on 05/30/2024 at 11:30 AM of Resident #1 revealed she was sitting on the side of her low bed with no neck collar on. The neck collar was lying on the bed beside her. During an interview on 05/30/2024 at 3:05 PM CNA A, stated Resident #1 was not in a low bed at the time of the resident's unwitnessed fall on 05/29/2024 because she worked that day. CNA A stated she tried to give the resident breakfast the next day and the resident complained of her neck hurting. The resident was sent to the hospital. She stated she switched Resident #1's bed to a low bed on 05/29/2024 at the direction of the DON when Resident #1 returned from the hospital. She stated the low bed may have had influence. She stated Resident #1 may not have fallen out; she would have just crawled onto the mat. During an interview on 05/30/2024 at 03:26 PM with LVN C, stated Resident #1 had an unwitnessed fall on the night of 05/29/2024. LVN C stated she was doing neurological checks (evaluates brain and nervous system functioning), and Resident #1's neurological responses were within normal limits. LVN C stated when Resident #1 moved from lying to sitting, she had pain in her neck. LVN C notified the DON, ADON and the physician, and the resident was sent to the hospital. LVN C stated Resident #1 had a normal bed, not one that could be put in a low position. LVN C stated if Resident #1 was ordered a low bed, she should have had a low bed. During an interview on 05/30/2024 at 3:40 PM the DON, stated Resident #1's bed was a normal bed in the lowest position. The DON stated Resident #1 was never ordered a low bed and the order seen was not an active order. The DON stated she switched Resident #1's bed to a low bed when the resident returned from the hospital because the resident could no longer get out of bed by herself. During an interview on 05/31/2024 at 09:03 a.m. with MD B, he stated the order for the low bed on 04/16/2024 was an active order and he wanted Resident #1 to have a low bed, closest to the floor. MD B stated he was told by staff the resident was unsteady and had falls. MD B clarified that a normal bed in the lowest position was not what he ordered for the resident. He stated if Resident #1 had been on a low bed, she may not have fractured her neck. During an interview on 06/01/2024 at 2:05 p.m. with the RN C she stated fall preventive measures were important. RN C stated it was important to distinguish between a bed in a low position or a low bed because of the issue of falls and what the elderly required. During an interview on 06/01/2024 at 02:09 PM with the DON she stated fall preventive measures are implemented to keep residents safe, and they needed to be accurate and reflected in the [NAME]. During an interview on 06/01/2024 at 02:13 PM with the ADM he stated he was at the facility for one week, and he felt like in-services were required and getting back to the basics with communications, especially for the best interest of resident safety. Record review of the facility policy and procedure titled Preventive Strategies to Reduce Fall Risk revised date October 5, 2016, reflected The goal of fall prevention is to design interventions that minimize fall risk by eliminating or managing contributing factors while maintaining or improving the resident's mobility, 7. Environment: Keep bed in low position., Keep the bed wheels locked., Use mobility handles or ¼ rails in bed, low bed, scoop mattress, bolsters, or any combination of the previous per physician's order. This failure resulted in an identification of an Immediate Jeopardy on 05/30/2024 at 4:00 PM. The Administrator was informed and provided the IJ template at 4:00 PM, and a Plan of Removal (POR) was requested. The plan of removal was accepted on 05/31/24 at 09:40 PM and reflected: Facility: [Facility Name] Date: 5/31/24 Plan of Removal Problem:: F689 Accidents/Hazards Interventions for safe resident environment: - Low bed was initiated on 5/30/24 in response to fall on 5/29/24. - The affected resident's clinical record was reviewed to ensure all fall prevention interventions (previous and newly initiated) are care planned and are located on the [NAME] to communicate to nursing staff by DON, Regional Compliance nurse on 5/30/24. - Completed a low bed audit and all residents with orders for a low bed had a low bed in place. Audit was completed on 5/30/24 by Regional Compliance Nurse, Area Director of Operations, and facility Administrator. - The following in-services were initiated by the Regional Compliance nurse and DON on 5/30/2024. Inservices will be completed by 5/31/24. Any staff member not present or in-serviced on 5/30/2024 will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during their orientation period. - Licensed Nurses: FT, PRN, Agency 1. Ensure that any physician ordered or care planned fall prevention interventions are followed. 2. CHARGE NURSES-ENSURE PRE AND POST FALL INTERVENTIONS ARE APPROPRIATE TO FALL AND DOCUMENTED CORRECTLY IN EVENT NOTE. ONLY CHECK LOW BED IF RESI IS ON A LOW BED. DOCUMENT BED IN LOWEST POSITION UNDER OTHER. 3. Nurse - Reporting changes of condition to the physician and DON/ADON immediately - Nurse Aids: FT, PRN, Agency 1. How to use the [NAME] in PCC and to follow fall prevention interventions - all residents with multiple falls or had an injury from fall in the last 60 days were reviewed to ensure appropriate fall prevention interventions are care planned and are located on the [NAME] to communicate to nursing staff on 5/30/24 by Regional Compliance Nurse. - [NAME] audit to ensure all safety measures were included completed by ADON on 5/31/24. - The Medical Director [physician's name] was notified of the immediate jeopardy situation on 5/31/2024 at _1621_. - Ad Hoc QAPI meeting will be held on 5/31/24 to discuss the IJ and review plan of removal. Monitoring: - DON and Administrator will review all falls during the morning meeting starting 5/30/24 to ensure appropriate interventions have been implemented. Monitoring will occur 5 days per week for a minimum of 6 weeks. - DON/designee will Ask 10 nursing staff members per week how to locate fall prevention interventions for a resident x 4 weeks or until compliance is met. Document date/time, the staff member's name if they responded correctly, and any corrective action if needed. - The DON and/or ADON will review Event reports to ensure interventions are documented correctly. - The above will be reviewed during the facility monthly QA meeting for no less than 60 days, or until the Administrator determines substantial compliance has been achieved and maintained. SURVEYOR VALIDATIONS: OBSERVATIONS and RECORD REVIEWS: Reviewed all residents who required a low bed and mat or fall prevention measures: to include Resident #1. List of Residents: Orders, Care Plan review and [NAME] - Observed 17 residents ordered low beds, all complied safety measures observed to be in place such as low beds, scoop mattresses or floor mats at bedside, orders, care plans and [NAME] noted. Record reviewed residents with other safety measures for falls such as mats on floor at bedside or scoop mattresses. All complied, present in care plans and in [NAME]. MONITORING: - Record review of Ask 10 nursing staff per week how to locate fall prevention interventions. Document date/time, the staff members name, if they responded correctly and any corrective actions needed: reflected 5 staff were interviewed and satisfactorily checked off. - Record review of monitoring sheet, started on 5/30/2024, with NA D, CNA A, CNA E and LVN C, all staff were able to locate fall prevention interventions. - Record review of DON and ADON will review Event reports to ensure interventions are documented correctly, reflected review started on checklist dated 05/30/2024 and no events were noted. - Record review of the above will be reviewed during the facility QA meeting for no less than 60 days reflected a QAPI spreadsheet which addressed fall monitoring and preventions. 06/01/2024 at 11:40 a.m. LVN G, day shift worker. Able to show preventive measures in physician orders, care plan and [NAME] for Resident #1. 06/01/2024 at 11:45 a.m. CNA E, revealed she was able to demonstrate how to look up a resident [NAME] to find the safety information such as a low bed with mat for Resident #2. No issues noted. Knew to go to charge nurse if was unsure of information for resident safety. 06/01/2024 at 12:01 PM, Hospitality Aide H able to demonstrate how to look up a resident [NAME] to find the safety information such as low bed, scoop mattress and fall mat for Resident #3. Record review of monitoring check sheet reflected the monitoring that follows was initiated on 05/30/2024. The DON and Administrator will continue to review all falls during morning meeting starting 05/30/2024 (done per and ensure appropriate interventions have been implemented). Monitoring will occur for 5 days per week for a minimum of 6 weeks. Record review of calendar and checklist revealed compliance. Record review of notification of IJ revealed the Medical Director was notified by the DON on 5/29/2024 at 4:21 PM. Record review of ADHOC QAPI meeting dated in 05/29/2024 was held with 9 members. Record review of staff (nursing) in-services dated 05/30/2024 reflected a total of 30 nursing staff were in-serviced on fall prevention, orders, care plans and [NAME]'s for a total of 100% nursing staff. TRAINING RECEIVED BY STAFF: (VALIDATION) VERIFICATION 1. Ensure the physician ordered or care planned fall prevention interventions are followed. 2. Charge nurses-ensure pre and post fall interventions are appropriate to fall and documented correctly in event note. Only check low bed if resident is on a low bed, document bed in lowest position under other. 3. Nurse-Reporting changes of condition to the physician and DON/ADON immediately. Nurse Aides: FT, PRN, Agency (No agency nursing staff at present) 1. How to use the [NAME] in PCC and to follow fall prevention interventions. (Observations listed above, Interviews below). INTERVIEWS: STAFF (TOTAL of 30 Nursing Staff Members in facility). DAY SHIFT: 5 EACH plus two PRN 1. 06/01/2024 at 11:40 a.m. Interview with LVN G revealed that physician orders and care plan fall prevention are followed, pre and post fall interventions are appropriate and documented, report any change of condition immediately. To document if the bed is in the lowest position or a low bed. 2. 06/01/2024 at 11:52 AM, Interview with CNA E revealed that physician orders or care plans are followed for fall prevention. Check to make sure pre and post fall interventions are appropriate. Reporting any changes in condition immediately. How to find fall interventions in [NAME]. Ask nurse if unsure of fall interventions. 3. 06/01/2024 at 12:07 PM, Interview with Hospitality Aide H revealed she was trained on how to use the [NAME] to find information on fall prevention measures, check bed positions and fall mats, and to report to the nurse immediately any changes in condition. 4. 06/01/2024 at 12:15 PM, Interview with CNA F revealed she was trained on how to use the [NAME] in PCC to find information on fall prevention measures for residents, and how to make sure they are in place. If we have a resident with a change in condition to report it to the nurse immediately. 5. 06/01/2024 at 12:19 PM with LVN I revealed she was recently trained on how to follow physician orders for fall prevention, bed in the lowest position. Low bed versus a regular bed. To check to see if interventions are in place. Document if the resident has a low bed or bed in the lowest position. Report any changes in condition immediately. 6. PRN 06/01/2024 at 12:40 PM with Medication Aide J revealed she was recently trained on fall prevention, low beds, how to look up fall prevention interventions in the PCC [NAME], and how to check for having the fall preventions in place. If a resident has a change in condition, she stated she would report it to the nurse immediately. 7. PRN 06/01/2024 at 12:55 PM with LVN K revealed she was recently trained on fall prevention, checking orders, care plans and making sure fall prevention measures are in place. How to document correctly low bed or other and to report and changes in condition immediately. NIGHT SHIFT: 4 EACH and one PRN 1. 06/01/2024 at 1:07 PM with CNA L revealed she was recently trained on fall prevention, checking the [NAME], and if the resident has a change in condition report it to the nurse immediately. Check to make sure resident fall prevention measures are in place. 2. 06/01/2024 at 1:16 PM with LVN M revealed she was recently trained on fall prevention, checking the physician orders, care plan for interventions for residents who are at high risk for falls. To document about low bed or other if a resident has a bed to only be placed in a low position. She stated she needed to check to make sure fall interventions are in place as ordered, and to report any changes in condition immediately. 3. 06/01/2024 at 1:22 PM with PRN NA N revealed she was trained on how to find out what fall preventive measures are in place for residents using the [NAME]. To check to make sure the resident fall prevention measures are in place. If any questions go to the nurse. If resident has a change in condition notify the nurse immediately. 4. 06/01/2024 at 1:32 PM with NA O revealed that when a resident falls to notify immediately, and to check the [NAME] for what preventive measures are in place. If a resident has a change in condition to report to nurse immediately. 5. 06/01/2024 at 1:35 PM LVN P revealed she was trained on to check physician orders and to check to see what the resident has for fall prevention measures and to make sure they are in place. Document if low bed or other if bed is in the low position. Change in condition we report immediately to the doctor or DON. On 06/01/2024 at 3:00 PM., the Administrator was notified the IJ was removed. However, the facility remained out of compliance at a level of potential harm with a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm because the facility's need to monitor the implementation and effectiveness of their plan of removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure the environment was free of accident hazards and supervision of staff for one resident (#1) of 3 residents who required mechanical lift transfers. NA A transferred Resident #1 alone on 01/17/2024 at 08:15 AM with a mechanical lift which required 2 people for safety. One of the straps holding the sling came loose and Resident #1 slipped toward the floor and hit her head on the mechanical lift which caused a head laceration and fractures to C4 (provides sensation for parts of the neck, shoulders and upper arms) and C5 (controls the deltoid muscles of shoulders and biceps, provides sensation to the upper arm down to the elbow). The noncompliance was identified as PNC. The IJ began on 01/17/2024 and ended on 01/18/2024. The facility had corrected the noncompliance before the survey began. This deficient practice could affect residents who require transfers with the mechanical lift at risk for injury or death. The findings included: Record review of Resident #1's electronic face sheet dated 04/05/2024 reflected she was admitted to the facility on [DATE]. Her diagnoses included: Alzheimer's disease (progressive mental deterioration that can occur in middle or old age, due to generalized degeneration of the brain), dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), atherosclerotic heart disease (thickening or hardening of the arteries caused by a buildup of plaque in the inner lining of an artery (a blood vessel that carries blood from the heart to tissues and organs in the body) and neurocognitive disorder with Lewy bodies (a type of progressive dementia that leads to a decline in thinking, reasoning and independent function). Record review of Resident #1's annual MDS assessment with an ARD of 03/09/2024 reflected she was not a candidate for a BIMS assessment which signified she was severely cognitively impaired. She could rarely understand and rarely be understood. Resident #1 was dependent on staff for her ADL's. She required 2 people for her transfers. Record review of Resident #1's comprehensive person-centered care plan revised 01/05/2024 reflected Focus, resident has an ADL self-care performance deficit, Interventions, transfer the resident requires mechanical lift (devices used to assist with transfers and movement of individuals who require support for mobility beyond the manual type of transfer) for transfers x 2 staff. Date initiated: 11/05/2021. Further review reflected Focus, alteration in musculoskeletal status r/t fracture of the C2-4, C collar splint (a cervical collar, also known as a neck brace, is a medical device used to support and immobilize a person's neck) as recommended, when out of bed. Date initiated: 01/19/2024. Record review of Resident #1's progress note written by LVN B dated 01/17/2024 at 08:41 AM reflected Transfer Notification,] Resident #1] was transferred to a hospital on [DATE] 08:46 AM related to resident fell onto floor, causing a 2 cm laceration to top of head. Hematoma (a pool of mostly clotted blood that forms in tissue) to right forehead, 4x2 with abrasion. Record review of Resident #1's hospital CT (computed tomography scan is a medical imaging technique used to obtain detailed internal images of the body) dated 01/17/2024 at 09:54 AM reflected Reason for exam, laceration to head, trauma/injury, Findings, nondisplaced transversely oriented fracture ((still broken bones, but the pieces weren't moved far enough to be out of alignment during the break) involving the right C4 inferior articular facet (smooth, anterolaterally(the position of a structure as being away from the middle line, in front of the body) facing articular (referring to the joint or joints) processes of a lumbar vertebra) and right C5 superior articular facet (the superior articular processes project vertically upward from the articular pillars (the columnar arrangement of the articular portions of the cervical vertebrae) between the pedicles (connect the vertebral body to the transverse processes) and the [NAME] (connect the transverse and spinous processes) (a series of levers both muscles of posture and for muscles of active movement). Record review of NA A's written statement dated and signed 01/17/24 (untimed) reflected he was looking for someone to help, but no one was around and they were understaffed, so he attempted to place Resident #1 in the bed by himself. During the process, the sling on the mechanical lift on one side came undone and Resident #1 slipped out and he helped to guide her to the floor as safe as possible but she did hit the top of her head, and he immediately called for the nurse. Record review of the Administrator's follow-up note (undated) reflected he interviewed NA A on 01/17/2024 and was told NA A did not see anyone in his hall so he did not ask for assistance with the mechanical lift transfer for Resident #1. He stated his investigation of staffing revealed the census at the time was 58 and there were 2 nurses, one medication aide and 4 aides assigned to the units, and administrative staff was available. Record review of the Administrator's PIR dated 01/17/2024 at 10:39 AM reflected: Aide was suspended pending investigation. He was subsequently terminated. All staff were given abuse and neglect in-service and were trained on Hoyer policy requiring 2 people. Instructions given for intervening and reporting if witnessing improper Hoyer transfer. 100% of aides were required to perform return demonstration of proper Hoyer lift use. Family, physician, and Medical Director were informed of the incident. All Hoyer lift residents received a heat to toe assessment for any evidence of injury. Monitoring was implemented for incidents involving Hoyer residents. Five return demonstrations to be performed a week for 4 weeks and upon new hire. Training on recognizing sling condition was done with staff. Administrative staff examined all slings to ensure they were in good condition. Hoyer lifts were inspected. They were inspected in November 2023 by an outside company per policy. Aide verbalized to administrator that he knew a Hoyer transfer should be performed by 2 people. He verbalized that he had been trained to use the Hoyer. The NA chose not to wait for assistance as he did not see anyone in his hall. Hoyer was performed properly for getting Resident #1 out of bed. All equipment functioned properly and was in good condition during transfer. Poor decision making on part of the NA led to the incident .QA team had an Ad Hoc meeting to discuss and correct the situation. Record review of NA A's CNA Proficiency Audit dated 04/04/2023 reflected he was signed off as an S for Transfers Hoyer lift- 2 person assist. Observation on 04/04/2024 at 08:00 AM of Resident #1 revealed she was sitting in the dining room in a Geri-chair and had a C-collar around her neck. Interview on 04/05/2024 at 1:00 PM with the Administrator, he stated after Resident #1 was sent out to the hospital for evaluation he reported the incident to HHSC immediately. He stated that later in the day a nurse from the hospital informed a nurse at the facility of Resident #1's fracture. He immediately identified that 100% in-services for the nursing assistants needed to be done and a competency of their performance for mechanical lift transfers. He stated that was completed on 01/18/2024. He stated 100% of the staff, nursing and non-nursing staff were in-serviced on abuse and neglect and on having 2 people for a mechanical lift transfer and to report any variances of that immediately. He stated that was completed on 01/18/2024. He stated he checked the staffing for 1/17/2024 at 08:15 AM when the incident happened, and sufficient staff were available in the building and that NA A chose not to wait. Attempted interview on 04/09/2024 with NA A at 10:00 AM revealed the phone number listed for him at the facility was disconnected. Observation on 04/05/2024 at 09:10 AM of Resident #1 being transferred from her Geri chair to the bed by CNA D and NA E revealed no concerns. Observation on 04/08/2024 at 12:30 PM of Resident #2 being transferred from her Geri chair to the bed by CAN D and CNA F revealed no concerns. Interview on 04/09/2024 at 2:50 PM with LVN B revealed she assessed Resident #1 when the incident happened, made notifications to include the Administrator and had Resident #1 transferred to the hospital. Interview on 04/09/2024 at 09:00 a.m. with the DON at the time, RN C, she stated Resident #1 was transferred with a mechanical lift by NA A, who did not ask for help. She stated that he was trained on how to use the mechanical lift and everyone was retrained after the incident. Record reviews of the other two residents who required Hoyer lift transfers, Resident #2 and Resident #3 reflected both had 2-person transfers care planned and identified in their MDS assessments. Record review of the facility policy and procedure titled Hydraulic Lift (undated) reflected The hydraulic lift is a mechanical device used to transfer a resident from and to the bed and chair It is reserved for those who are paralyzed, obese or too weak to transfer without complete assistance. The number of staff to provide assistance with the transfer should be determined by manufacturer recommendations The resident will receive safe transfer to bed or chair via a mechanical lift device. Record review of the owners guide for the MEDLINE Hydraulic lift MODEL: MDS450EL (undated) reflected Transfer From Bed and From Chair To Bed .with the assistance of another caregiver. The facility course of action prior to surveyor entrance included: Record review of the Administrator's PIR dated 01/17/2024 revealed: All required notifications were made which included the Medical Director, Responsible Party, Physician, Nurse Practitioner, QA Ad Hoc Committee and HHSC. Record review of NA A's personnel folder reflected he was immediately suspended pending investigation on 01/17/2024 and subsequently terminated. Record review dated 01/17/2024- 54 staff, all staff, were in-serviced on using a staff roster were checked off and signed for in-services titled: Abuse/Neglect, Mechanical Lift. Record review of staff competencies dated from 01/17/2024 to 1/18/2024 reflected 100 return demonstrations were completed with the Hoyer transfers and 5 additional observations were done weekly and marked off by nurse managers for an additional 4 weeks. The staff who completed this training for the mechanical lift was all CNA's, MAs, and NAs, 12 CNAs, 6 MAs and 6 Student Nurse Aides to total 24 Record review of slings examined dated 01/17/2024 to 04/09/2024 reflected the slings were examined weekly for condition and wear. STAFF INTERVIEWS ON TRAINING: 04/05/2024 from 2:00 PM to 3:30 PM revealed staff were scheduled for 12-hour shifts, many worked both day, evening, and night shifts. On 04/05/2024 at total of 3 LVN's, 5 CNA's and 2 NAs were interviewed on the mechanical lift transfers, 2 people requirement, intervening, reporting, abuse, and neglect. They were trained on asking for assistance, reporting if they witnessed someone trying to transfer a resident with a mechanical lift with one person, and to let the charge nurse know if they could not find someone to help them with a transfer. They were trained to check the straps for wear and condition and placement on the lift to ensure they were secure. On 04/09/2024 between 02:00 PM and 5:00 PM, 2 RN's and 2 CNAs were interviewed on the mechanical lift, 2 people requirement, reporting, abuse, and neglect. They were trained on asking for assistance, reporting if they witnessed someone trying to transfer a resident with a mechanical lift with one person, and to let the charge nurse know if they could not find someone to help them with a transfer. They were trained to check the straps for wear and condition and placement on the lift to ensure they were secure. The noncompliance was identified as past noncompliance IJ. The noncompliance began on 01/17/2024 and ended on 01/18/2024 when all staff had been in-serviced on abuse/neglect, mechanical lift transfers (2 people required) and reporting it immediately if observed with only one person using the lift. The NA was suspended and then terminated before the surveyor entrance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's condition or need to alter treatment significantly for one (Resident #1) of thirteen residents reviewed for notification of changes. The facility failed to notify the physician for an acute change in a resident's condition related to type 2 diabetes, resulting in the resident was hospitalized on [DATE] and expired on [DATE]. An immediate jeopardy (IJ) was identified on [DATE] at 01:27 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of isolated due to the facility still monitoring the effectiveness of their Plan of Removal. This deficient practice could place residents at risks for a delay in medical treatment, which could lead to worsening of their condition, hospitalization, or death. Findings included: Record review of Resident #1's Administration Record, dated [DATE], revealed an [AGE] year-old male who originally admitted to the facility on [DATE] and last re-admitted on [DATE]. Resident #1 was noted to have discharged [DATE] to an acute care hospital. Resident #1 had diagnoses which included the following: diabetes mellitus (a condition that develops with the way the body regulates and uses sugar as fuel), chronic kidney disease (a condition where the kidneys lose their ability to filter blood and remove wastes), and heart failure. Record review of Resident #1's Quarterly MDS assessment, dated [DATE], revealed a BIMS score of 04, which indicated Resident #1's cognition was severely impaired. The MDS revealed Resident #1 was diabetic and received insulin injections. Further review revealed Resident #1 was dependent with mobility in rolling left to right, sit to lying, lying to sitting on side of bed, and sit to stand. Resident #1 required substantial to maximal assistance with chair to bed transfer, toilet transfer, and tub or shower transfer. Resident #1 was noted to have had an indwelling catheter (a tube that drains urine from the bladder into a bag outside the body) and always bowel incontinent. Record review of Resident #1's Care Plan, dated as last reviewed [DATE], reflected Resident #1 had diagnosed diabetes mellitus with other neurological complications (date initiated: [DATE] and date revised: [DATE]) and the interventions included: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. and Fasting Serum Blood Sugar as ordered by doctor, report any abnormal levels. The Care Plan reflected Resident #1 had an altered endocrine system (a network of glands and organs in the body that use hormones to control and regulate many of the body's functions) status related to chronic kidney disease (date initiated and revised: [DATE]) and the interventions included: Fasting Blood Glucose as ordered by MD, Monitor/document/report to MD PRN any s/sx (signs and symptoms) of behavioral changes: nervousness, increased irritability, emotional lability (change or inconsistency), insomnia, extreme fatigue, confusion, disorientation, delirium, psychosis, stupor, coma. and Monitor/document/report to MD PRN for s/sx of hyperglycemia (elevated or high blood sugar): increased thirst and appetite, weight loss, fatigue, dry skin, poor healing, muscle cramps, abdominal pain, deep labored breathing (Kussmaul), acetone (fruity) breath, stupor, coma. Record review of Resident #1's Order Summary Report, order date range: [DATE] - [DATE], revealed Resident #1 had active blood glucose check orders which included: Glucose Check BID x 7 days then report to PCP on 02/22 two times a day (repeated direction to check blood sugars twice a day) related to type 2 diabetes mellitus with hyperglycemia, ordered and start date: [DATE], Monitor for signs or symptoms of hypoglycemia or hyperglycemia Q shift. Every day and night shift related to type 2 diabetes mellitus with diabetic polyneuropathy (damage to the nerves that control arm and leg movement), ordered [DATE] and started [DATE], and Monitor resident for confusion, combativeness, and restlessness. If resident is experiencing any of these, check blood sugar, every day and night shift related to type 2 diabetes mellitus with diabetic polyneuropathy, ordered [DATE] and started [DATE]. Active blood glucose check orders found to not include blood sugar parameters, directing staff when they were to notify the physician of blood sugars below or above the expected range. Resident #1 had active diabetes medication orders which included: Glucagon Emergency Injection Kit 1 MG .Inject 1 mg subcutaneously (between the skin and muscle) as needed for signs or symptoms of hypoglycemia related to type 2 diabetes mellitus with other diabetic neurological complication, ordered and started [DATE] and Trulicity Subcutaneous Solution Pen-injector 0.75 mg/0.5 mL .Inject 0.75 mg subcutaneously one time a day every 7 days(s) related to Type 2 diabetes mellitus with hyperglycemia, ordered [DATE] and started [DATE]. Active diabetes medication orders found to not include an active order for insulin. Record review of Resident #1's TAR, dated [DATE] - [DATE], revealed Resident #1's blood sugar checks BID which included: - a blood sugar of 577 mg/dL (high) on [DATE] at 08:00 p.m. by the ADON, - a blood sugar of 432 mg/dL (high) on [DATE] at 07:00 a.m. by RN Z, - a blood sugar of 550 mg/dL (high) on [DATE] at 08:00 p.m. by the ADON, - a blood sugar of 487 mg/dL (high) on [DATE] at 07:00 a.m. by LVN R, - a blood sugar of 498 mg/dL (high) on [DATE] at 08:00 p.m. by LVN P, - a blood sugar of 502 mg/dL (high) on [DATE] at 07:00 a.m. by LVN R, - a blood sugar of 486 mg/dL (high) on [DATE] at 08:00 p.m. by LVN P, - a blood sugar of 424 mg/dL (high) on [DATE] at 07:00 a.m. by LVN R, - a blood sugar of 492 mg/dL (high) on [DATE] at 08:00 p.m. by LVN P, - a blood sugar of 498 mg/dL (high) on [DATE] at 07:00 a.m. by RN Z, and - the blood sugar check coded as not taken due to hospitalization by LVN M. Record review of Resident #1's progress notes, dated [DATE] at 07:00 p.m., revealed the following note by the ADON, [Resident #1's PCP] notified of resident with blood sugar 577. Asymptomatic (no symptoms). No new orders. Record review of Resident #1's progress notes, dated [DATE] at 10:00 a.m., revealed the following note by RN Z, [Resident #1's PCP] is aware of blood sugar this AM (morning) 432; no new orders at this time. Record review of Resident #1's progress notes, dated [DATE] at 12:55 p.m., revealed the following note by LVN 1, .[MD X] will no longer be PCP for [Resident #1]. She (Resident #1 RP) stated [MD W] will now be his primary care physician. I informed [MD X], and notified [MD W]'s nurse of change effective today. Record review of Resident #1's progress notes, dated from [DATE] at 10:01 a.m. to [DATE] at 03:53 p.m., revealed no progress notes mentioning blood sugar results or notification to physician. Record review of Resident #1's progress notes, dated [DATE] at 03:54 p.m., revealed the following note by RN Z, one week of blood sugar results sent to [Resident #1's PCP]. Pending response. Record review of Resident #1's progress notes, dated [DATE] at 04:00 p.m., revealed the following note by RN Z, called into room by CNAs. Res (resident) was lying in bed with eyes closed, respirations shallow, difficult to arouse. Unresponsive to tactile stimuli. Upon assessment .blood sugar too high to register on glucometer (machine used to test blood sugar). Immediately contacted [Resident #1's PCP]. New orders received to send to [local hospital] ER (emergency room) for further eval (evaluation) and tx (treatment) . Record review of Resident #1's progress notes, dated [DATE] at 04:09 p.m., revealed the following note by LVN N, [Resident #1] was transferred to a hospital on [DATE] 4:05 PM related to High blood sugar, unresponsive. Record review of Resident #1's progress notes, dated [DATE] at 11:40 a.m., revealed the following note by RN Z, Res (resident) is admitted to [hospital name and location]; ICU (intensive care unit) DX (diagnoses): Hyperglycemia, Altered Mental Status. Record review of Resident #1's hospital records, dated [DATE], reflected Resident #1 was admitted to the ER on [DATE] at 05:44 p.m. The records reflected Resident #1 was discharged from the ER on [DATE] to an alternate hospital. The ER notes dated [DATE] reflected Resident #1's chief complaint was hyperglycemia and an altered mental status. Resident #1 noted to had started seizing when on bed with no prior history of seizures. Resident #1 was intubated and placed on a mechanical ventilator, diagnosed with altered mental status, hyperglycemia (high blood glucose/sugar), hyperosmolar hyperglycemic state (HHS; a life-threatening complication of diabetes when the blood glucose or blood sugar levels are too high for a long period, leading to severe dehydration and confusion), seizure, respiratory failure, GI (gastrointestinal) bleed, sepsis (a condition in which the body's extreme response to an infection become life-threatening), urinary tract infection, and an electrolyte disorder. Glucose level measured at 798 mg/dL on [DATE] at 05:52 p.m. Record review of addendum to facility self-report to HHSC Complaint and Incident Intake, dated [DATE] at 03:53 p.m., revealed the following note by the ADMIN, He (Resident #1) passed away on [DATE] at 10:37 p.m. We (the facility) do not have a cause of death at this time. Interview with RN Z on [DATE] at 03:01 p.m. revealed she had reviewed Resident #1's weekend blood sugars when she came in to work on Monday, [DATE], seen that they were elevated, and sent the blood sugar results to Resident #1's physician. RN Z stated she had reported his high blood sugar that morning but Resident #1 was awake, alert, and up in the dining room for breakfast and lunch. RN Z stated Resident #1's change in condition started right before she had sent him out, after lunch. RN Z stated she did not hear back from Resident #1's physician when reporting the initial high blood sugar but called the physician again for the change of condition and transfer out to the hospital. RN Z did not state the time for the second call to Resident #1's physician. RN Z described Resident #1's change as condition as being slower to respond, not really answering staff, and just not himself. Interview with SNA AC on [DATE] at 03:17 p.m., revealed she had been taking care of Resident# 1 on Sunday, [DATE] and around 05:30 p.m. observed a concern about how Resident #1 was positioned in bed and that Resident #1 was not breathing as good as he normally did. SNA AC stated she had reported her observations to the nurse. SNA AC stated she had worked at the facility for less than a month and had not yet been trained on how to document in the facility's EMR. Interview with CNA A on [DATE] at 03:28 p.m., revealed she had been taking care of Resident #1 on Monday, [DATE] during the day. CNA A revealed she had observed Resident #1 to have been behaving normally, chatty and responsive that morning. CNA A stated after lunch, she had reported to Resident #1's nurse (RN Z) that when she and another CNA (CNA B) went into Resident #1's room to get him up from an after-lunch nap, he was not as responsive as normal. CNA A stated she had tried physical stimulus (rubbing Resident #1 wrist), which he did not respond to. CNA A stated she also observed an unknown purple substance around Resident #1's mouth, which she had cleaned off when the nurse came in to check Resident #1's vitals. CNA A did not state she documented her observations in the facility EMR or notify the nurse of the purple substance during the interview as part of her recollection of events. Interview with CNA B on [DATE] at 03:37 p.m., revealed she had observed Resident #1 during Monday, [DATE] and had noted that he was his normal responsiveness and able to have a conversation with her that morning. CNA B stated that after lunch Resident #1 started to be different, dazed. CNA B revealed she reported her observations to Resident #1's nurse (RN Z). Interview with the ADON on [DATE] at 04:08 p.m., revealed she had worked [DATE] for the 08:00 p.m. blood sugar check shift. The ADON stated that Resident #1 had looked fine, was acting his normal or not any different than he has been since his recent stroke. The ADON stated that for one of her shifts that week Resident #1 had a very high blood sugar and she had called Resident #1's physician who said he did not want to do anything if the resident was asymptomatic (without symptoms). The ADON stated she did not call Resident #1's physician again because when she had called on [DATE], the physician said that if Resident #1 was asymptomatic he was not going to do anything. Interview with MD W on [DATE] at 04:37 p.m., revealed he had been notified of changes in Resident #1's blood sugar medications, including the approval of diabetic medication Trulicity by Resident #1's insurance and that Resident #1's prior PCP had wanted to decrease Resident#1's insulin, but had not received any calls regarding Resident #1's high blood sugars until Monday morning, [DATE]. MD W revealed his expectation was for the facility to call him if a resident's blood sugar was below 60, over 400, or symptomatic (having symptoms). MD W stated he believed Resident #1's comorbidities (having more than one medical condition at the same time) were contributing to Resident #1's blood sugar problems. MD W revealed he was not sure that if the facility had contacted him sooner regarding Resident #1's elevated blood sugars, if it would have made a difference but it would have been ideal for the facility to have had contacted him sooner. Interview with LVN P on [DATE] at 05:37 p.m., revealed her observations for Resident #1 during her shifts on [DATE]- [DATE] were that he was fine when he had high blood sugars. His behaviors were fine and happy. He was back to his normal self. LVN P stated when Resident #1 had low blood sugars he would become confused and combative. LVN P stated she reported to Resident #1's physician when Resident #1 was experiencing lows but could not remember if she had called the physician for the high blood sugars. LVN P revealed Resident #1 did not have symptoms when his blood sugars were high. LVN P stated Resident #1's respirations were great, he was sleeping well, and he was his normal self. LVN P revealed she felt the physician would have known Resident #1 was having high blood sugars since the physician discontinued Resident #1's insulin. Interview with LVN R on [DATE] at 06:11 p.m., revealed her observations for Resident #1 during her shifts on [DATE] - [DATE] were that Resident #1 was good, just tired which was not abnormal for him recently. LVN R stated that she could recall that Resident #1 had an order during that time to monitor Resident #1's blood sugars and then to report it in 7 days, which she believed was either that following Monday ([DATE]) or Tuesday ([DATE]). LVN R stated she did not report Resident #1's high blood sugars during her shifts because of the monitoring order with instruction to report in 7 days and she had reviewed Resident #1's previous blood sugars and found them to be consistent with the blood sugars she had collected. LVN R stated Resident #1's blood sugars were all the same, all in the 400's and not fluctuating, such as from the 100's to the 400's. LVN R also revealed Resident #1 was not showing symptoms, which he did when experiencing a low blood sugar and that she did not have any concerns. Interview with MD X on [DATE] at 11:20 a.m., revealed Resident #1's blood sugars had been fluctuating quite a bit due to Resident #1's renal (kidney) failure, which was causing his blood sugars to become difficulty to control. MD X revealed that he did recall the facility's nursing staff contacting him regarding Resident #1's blood sugars but could not recall when without his notes. MD X stated the facility contacted him regarding Resident #1's change in physician on [DATE] and that was the last contact he received from the facility for Resident #1's care. MD X stated prior to the change in physician, he was trying to make chronic (long-term) changes and did not want to make acute (immediate) changes in regulating Resident #1's blood sugar. MD X revealed his expectation for the facility staff to notify him for blood sugars was for them to call if a resident's blood sugar was at 500. MD X revealed that if a resident was at 500 and symptomatic, he would order adjustments and send the resident out to the hospital, but if not symptomatic, he would just make adjustments to the insulin order. MD X revealed Resident #1's insulin orders had been discontinued due to Resident #1 having had bottomed out (experienced a low blood sugar episode) earlier that month (early February), Resident #1 was very brittle, and Resident #1's blood sugars had been going in the wrong direction (blood sugar dropped) with insulin. Interview with the RCN on [DATE] at 02:16 p.m., revealed the facility procedure for a blood sugar outside parameters (the expected range) was to follow the order, including to hold the medication, give an additional medication, re-check, and/or immediately contact the physician per the doctor's orders. She stated that staff are expected to contact the physician if there is a pattern in a resident's blood sugars being outside the blood sugar parameters or a pattern of refusals by the resident. She revealed that if a resident was experiencing a high blood sugar, the doctor was to tell them what they are to give to the resident and when to re-check the resident's blood sugar. The RCN stated that the nurse was responsible for entering the physician's order into the facility's EMR, documenting the order and interventions in a progress note, and reporting any changes to the resident's RP. She revealed that reporting high and low blood sugars is important for tracking the resident's blood sugar trends and that if a resident was running a high blood sugar all the time, their medications would need to be adjusted to limit the long-term effects it could have, which may be harmful if not treated. The RCN stated that facility staff should monitor blood sugars as ordered, notify the resident's physician immediately if outside parameters and follow the orders that the physician gives. Interview with the ADMIN on [DATE] at 02:34 p.m., revealed reporting any change of condition is important, to let the physician know and be aware of it. The ADMIN revealed his expectation was that staff call the resident's physician, report that they had contacted the physician, make the changes per the physician, and make notifications to the resident's family for any changes of condition. The ADMIN revealed that this was standard nursing practice and an order. Record review of facility policy, Notifying the Physician of Change in Status, dated revised [DATE], revealed The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgement deem it necessary for immediate medical attention .1. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record .11. Abnormal lab, x-ray and other diagnostic reports require physician notification. Record review of facility policy, Medication Administration Procedures, dated 2003, revealed 13. When ordered or indicated, include specific item(s) to monitor (e.g., blood pressure, pulse, blood sugar, weight), frequency (e.g., weekly, daily), timing (e.g., before or after administering the medication), and parameters for notifying the prescriber. This failure resulted in an identification of an immediate jeopardy on [DATE] at 01:27 p.m. The Administrator was informed and provided the IJ template on [DATE] at 06:00 p.m. and a plan of removal (POR) was requested. The plan of removal reflected: [DATE] Plan of Removal- F580 Notify of Changes Interventions: - 100% blood sugar audit completed on [DATE] by Regional Compliance Nurse - Blood sugar checks were assessed on [DATE] to ensure that blood sugar parameters were in place, if not, parameters were requested by attending physician and added. - 100% of residents with blood sugar checks were audited on [DATE] and Physician(s) were notified of all blood sugars outside of parameters or were excessively high or low. Date completed [DATE]. - The following in-services were initiated [DATE] by Regional Compliance Nurse. Inservice 100% of staff completion date: [DATE]. Inservice has been added to new-hire packets for all new hires and agency staff to ensure all staff is in-serviced prior to start of their first shift. - Perform blood sugar checks as ordered. - Ensure any resident who has blood sugar checks has a parameter to the physician or nurse practitioner (NP). This includes when to report new orders for current residents, new admissions, and readmissions. - To report to the MD or NP if a blood sugar check is outside the ordered parameters immediately and to initiate any new orders. - If resident(s) has an order for glucagon, follow the prescriber's orders. - Policy on Notifying the Physician of Change in Status - The following in-services were initiated on [DATE] for all NA/CNAs by nursing administration and/or Regional Compliance Nurse. Inservice 100% of NA/CNA completion date [DATE]. - Hyperglycemia - excessive thirst/dry mouth, excessive urine, increased fatigue/weakness, blurred vision - Hypoglycemia-sweating, dizzy, shaking, increased confusion, anxiety, drowsy, change in mental status, slurred speech, nausea, lightheaded, loss of coordination. - Notified Medical Director of IJ situation on [DATE] at 6:17 pm. Monitoring: - At least five (5) times per week, nursing administration will review the previous days orders using the order listing report in [the facility's EMR] to monitor for new orders for blood sugar checks and ensure that parameters are added. This will include new orders for current residents, new admissions, and readmissions. This was initiated on [DATE] continue x 4 weeks. - At least 5 times per week nursing administration will review the previous days TARS and the medical record to ensure that blood sugar checks were performed as ordered and the MD or NP was notified if it was outside the ordered parameters. This was initiated on [DATE] and will continue x 4 weeks. - Nursing Administration will ask at least 10 nursing staff per week a situational question regarding if a resident presented with hyper or hypoglycemia and what they would do. This was initiated on [DATE] and will continue x 4 weeks. - DON/Designee will review 5-8 residents slide scale results for proper notification to MD if outside parameters weekly. This will be initiated on [DATE] and continue x 4 weeks. - DON/Designee will monitor all blood sugars outside parameters of slide scale for notification to MD weekly x 4 weeks. This was initiated [DATE] and will continue x 4 weeks. - Regional Compliance Nurse will monitor for compliance weekly x 4 weeks starting on [DATE]. - The QA (Quality Assurance) Committee will review findings and Physician Notification Policy and will make changes as needed monthly. This will occur during the next QAPI (Quality Assurance and Performance Improvement) meeting on [DATE]. Monitoring of the plan of removal included: Interviews were conducted on [DATE] from 02:50 p.m. to 07:47 p.m. with 2 RNs (RN Z and RN AA) of 2 and 9 LVNs (LVN K, LVN L, LVN M, LVN N, LVN O, LVN P, LVN Q, LVN R, and LVN S) of 9, who worked multiple shifts, revealed they had all been trained on the facility policy, Notifying the Physician of Change in Status. The nursing staff were knowledgeable on the requirement that all blood sugar monitoring orders must include blood sugar parameters, and on the protocols to follow including what to document and who to notify if a blood sugar was outside parameters or a resident was showing signs or symptoms of being hypo or hyperglycemic. The staff were able to identify when it would be appropriate to administer glucagon and how to report and document glucagon administration. Interviews were conducted on [DATE] from 03:13 p.m. to 08:37 p.m. with 6 CNAs (CNA A, CNA B, CNA C, CNA D, CNA E, and CNA F) of 9, 3 HAs (HA H, HA I, and HA J) of 3, 2 MAs (MA T and MA U) of 3, and 6 SNAs (SNA AB, SNA AC, SNA AD, SNA AE, SNA AF, and SNA AG) of 8; and on [DATE] at 10:32 a.m. with 1 CNA (CNA G). Interviews revealed they worked multiple shifts, had all been trained and were able to identify signs and symptoms of hypo and hyperglycemia, and were knowledgeable on who they needed to report to. In an interview and record review with the RCN on [DATE] at 03:55 p.m., she revealed she had started and was conducting the staff in-services. The RCN confirmed the ADMIN, with her present, had notified the facility's medical director of the Immediate Jeopardy (IJ). The RCN revealed the plan for the facility administration to monitor every new blood sugar order, ensuring that every new order included parameters was to review the previous day's (or days' for new orders over the weekends and holidays) orders by printing out an Order Listing Report from the facility's EMR, which would show all of the previous days' orders. The RCN revealed she had completed the initial blood sugar monitoring audit on [DATE]. She revealed that she had discovered a few residents without parameters on their orders. The RCN revealed she called the residents' physicians to add the parameters, asked the physicians about glucagon orders if not currently included in the residents' active order list, and added the orders with parameters per the physician's order. The RCN indicated the facility's monitoring document, labeled with At least 5 times per week nursing administration will review the previous days orders using the order listing report in [EMR system name] to monitor for new orders for blood sugar checks and ensure that parameters were added., was the monitoring document the facility would use to track their completion of this monitor. The document revealed this monitor was to be tracked 5 times a week for 4 weeks and that the monitor had been completed on [DATE], [DATE], and [DATE] for week 1. The RCN revealed the plan for facility administration to monitor each resident's blood sugar, that had a blood sugar monitoring order, for being completed per order and to verify the resident's MD or NP was notified if the blood sugar was outside parameters was by printing out the previous day's (or days' if after a weekend and/or holiday) Weights and Vitals Summary report from the facility's EMR, which would show all the previous days' blood sugar results, identify any blood sugars outside parameters, and review the resident's progress notes for a note on notification to the physician and/or nurse practitioner for any blood sugar results outside parameters. The RCN indicated the facility's monitoring document, labeled with At least 5 times per week nursing administration will review the previous days TARs and the medical record to ensure that blood sugar checks were performed as ordered and the MD or NP was notified if it was outside the ordered parameters., was the monitoring document the facility would use to track their completion of this monitoring. The document revealed this monitoring was to be tracked 5 times per week for 4 weeks and that the monitoring had been completed on [DATE], [DATE], and [DATE] for week 1. Weights and Vitals Summary reports for dates [DATE], [DATE], and [DATE] were provided and revealed initials on each page to indicate it had been reviewed and check marks next to each blood sugar out of parameters to indicate a corresponding progress note had been confirmed to indicate the MD or NP had been notified. The RCN revealed the ADON would be responsible for completing the review of the 5-8 residents with sliding scale insulin orders for proper notification of the MD if the blood sugar was outside parameters. The RCN stated that this monitor was the same process or intervention as the intervention for reviewing the TARs for residents with orders for blood sugar monitoring. The RCN revealed the plan for the facility administration to ask at least 10 nursing staff situational questions regarding if a resident had high or low blood sugars and what they would do was to utilize the monitoring document, labeled with Nursing administration will ask at least 10 nursing staff per week a situational question ., mark Yes or No if the staff member answered the question correctly or incorrectly, and if incorrect, document how they answered the question incorrectly and what the nursing administration's plan was for correcting the incorrect answer (ex. in-service training). The document revealed this monitoring was to be completed 10 times per week for 4 weeks, had a spot to put the date, indicate if the answer was correct or incorrect, the staff name of the person questioned, and the name of the interviewer. The document revealed two staff members had been questioned, both on [DATE], and both had answered correctly. The RCN revealed the plan for her to monitor that the facility administration and DON/designee were compliant with the other interventions/monitors for 4 weeks was for her to come to the facility at least one time per week, review the other monitoring forms to ensure they are up to date, review the related Weights and Vitals Summary reports and Order Listing Report that the facility will be maintaining in a specified binder, and to mark Yes or No on the monitoring document, labeled with Regional Compliance Nurse and/or ADO (ADON) compliance monitoring:. The document revealed this monitoring was to be completed for 4 weeks and did not have any weeks marked as completed at the time of the interview. In an interview with the ADON on [DATE] at 04:08 p.m., she revealed she had received training on the facility policy, Notifying the Physician of Change in Status, blood sugar checks procedure, administering glucagon per order, reporting blood sugars to the resident's physician or NP immediately if outside parameters or when symptomatic, documenting physician notifications and new orders, and verifying that all new blood sugar monitoring orders included parameters on [DATE]. The ADON revealed she was to print out the Weights and Vitals report and document for new orders daily. The ADON revealed she was to review the reports for new orders and to review the blood sugars to identify if any residents had blood sugars less than 60 or over 400. She revealed that she was to review the progress notes and the 24-hour or 72-hour report to confirm the nurse notified and documented that they notified the physician of a blood sugar outside parameters. The ADON revealed she was to ask CNAs from different shifts to determine if they could recognize signs and symptoms of a hyper or hypoglycemia and what they were supposed to do if they observed those signs or symptoms. The ADON revealed she planned to in-service the staff member if they answered incorrectly and document on the monitoring form

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure that based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 13 residents (Resident #1) reviewed for quality of care, in that: The facility failed to ensure Resident #1's received timely treatment and care for the resident's Type II Diabetes when the resident went multiple days of blood sugar readings above 400 with no interventions, resulting in the resident being hospitalized on [DATE] and expired on [DATE]. An immediate jeopardy (IJ) was identified on [DATE] at 01:27 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of isolated due to the facility still monitoring the effectiveness of their Plan of Removal. This deficient practice could place residents at risks for a delay in medical treatment, which could lead to worsening of their condition, hospitalization, or death. Findings included: Record review of Resident #1's Administration Record, dated [DATE], revealed an [AGE] year-old male who originally admitted to the facility on [DATE] and last re-admitted on [DATE]. Resident #1 was noted to have discharged [DATE] to an acute care hospital. Resident #1 had diagnoses which included the following: diabetes mellitus (a condition that develops with the way the body regulates and uses sugar as fuel), chronic kidney disease (a condition where the kidneys lose their ability to filter blood and remove wastes), and heart failure. Record review of Resident #1's Quarterly MDS assessment, dated [DATE], revealed a BIMS score of 04, which indicated Resident #1's cognition was severely impaired. The MDS revealed Resident #1 was diabetic and received insulin injections. Further review revealed Resident #1 was dependent with mobility in rolling left to right, sit to lying, lying to sitting on side of bed, and sit to stand. Resident #1 required substantial to maximal assistance with chair to bed transfer, toilet transfer, and tub or shower transfer. Resident #1 was noted to have had an indwelling catheter (a tube that drains urine from the bladder into a bag outside the body) and always bowel incontinent. Record review of Resident #1's Care Plan, dated as last reviewed [DATE], reflected Resident #1 had diagnosed diabetes mellitus with other neurological complications (date initiated: [DATE] and date revised: [DATE]) and the interventions included: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. and Fasting Serum Blood Sugar as ordered by doctor, report any abnormal levels. The Care Plan reflected Resident #1 had an altered endocrine system (a network of glands and organs in the body that use hormones to control and regulate many of the body's functions) status related to chronic kidney disease (date initiated and revised: [DATE]) and the interventions included: Fasting Blood Glucose as ordered by MD, Monitor/document/report to MD PRN any s/sx (signs and symptoms) of behavioral changes: nervousness, increased irritability, emotional lability (change or inconsistency), insomnia, extreme fatigue, confusion, disorientation, delirium, psychosis, stupor, coma. and Monitor/document/report to MD PRN for s/sx of hyperglycemia (elevated or high blood sugar): increased thirst and appetite, weight loss, fatigue, dry skin, poor healing, muscle cramps, abdominal pain, deep labored breathing (Kussmaul), acetone (fruity) breath, stupor, coma. Record review of Resident #1's Order Summary Report, order date range: [DATE] - [DATE], revealed Resident #1 had active blood glucose check orders which included: Glucose Check BID x 7 days then report to PCP on 02/22 two times a day (repeated direction to check blood sugars twice a day) related to type 2 diabetes mellitus with hyperglycemia, ordered and start date: [DATE], Monitor for signs or symptoms of hypoglycemia or hyperglycemia Q shift. Every day and night shift related to type 2 diabetes mellitus with diabetic polyneuropathy (damage to the nerves that control arm and leg movement), ordered [DATE] and started [DATE], and Monitor resident for confusion, combativeness, and restlessness. If resident is experiencing any of these, check blood sugar, every day and night shift related to type 2 diabetes mellitus with diabetic polyneuropathy, ordered [DATE] and started [DATE]. Active blood glucose check orders found to not include blood sugar parameters, directing staff when they were to notify the physician of blood sugars below or above the expected range. Resident #1 had active diabetes medication orders which included: Glucagon Emergency Injection Kit 1 MG .Inject 1 mg subcutaneously (between the skin and muscle) as needed for signs or symptoms of hypoglycemia related to type 2 diabetes mellitus with other diabetic neurological complication, ordered and started [DATE] and Trulicity Subcutaneous Solution Pen-injector 0.75 mg/0.5 mL .Inject 0.75 mg subcutaneously one time a day every 7 days(s) related to Type 2 diabetes mellitus with hyperglycemia, ordered [DATE] and started [DATE]. Active diabetes medication orders found to not include an active order for insulin. Record review of Resident #1's TAR, dated [DATE] - [DATE], revealed Resident #1's blood sugar checks BID which included: - a blood sugar of 577 mg/dL (high) on [DATE] at 08:00 p.m. by the ADON, - a blood sugar of 432 mg/dL (high) on [DATE] at 07:00 a.m. by RN Z, - a blood sugar of 550 mg/dL (high) on [DATE] at 08:00 p.m. by the ADON, - a blood sugar of 487 mg/dL (high) on [DATE] at 07:00 a.m. by LVN R, - a blood sugar of 498 mg/dL (high) on [DATE] at 08:00 p.m. by LVN P, - a blood sugar of 502 mg/dL (high) on [DATE] at 07:00 a.m. by LVN R, - a blood sugar of 486 mg/dL (high) on [DATE] at 08:00 p.m. by LVN P, - a blood sugar of 424 mg/dL (high) on [DATE] at 07:00 a.m. by LVN R, - a blood sugar of 492 mg/dL (high) on [DATE] at 08:00 p.m. by LVN P, - a blood sugar of 498 mg/dL (high) on [DATE] at 07:00 a.m. by RN Z, and - the blood sugar check coded as not taken due to hospitalization by LVN M. Record review of Resident #1's progress notes, dated [DATE] at 07:00 p.m., revealed the following note by the ADON, [Resident #1's PCP] notified of resident with blood sugar 577. Asymptomatic (no symptoms). No new orders. Record review of Resident #1's progress notes, dated [DATE] at 10:00 a.m., revealed the following note by RN Z, [Resident #1's PCP] is aware of blood sugar this AM (morning) 432; no new orders at this time. Record review of Resident #1's progress notes, dated [DATE] at 12:55 p.m., revealed the following note by LVN 1, .[MD X] will no longer be PCP for [Resident #1]. She (Resident #1 RP) stated [MD W] will now be his primary care physician. I informed [MD X], and notified [MD W]'s nurse of change effective today. Record review of Resident #1's progress notes, dated from [DATE] at 10:01 a.m. to [DATE] at 03:53 p.m., revealed no progress notes mentioning blood sugar results or notification to physician. Record review of Resident #1's progress notes, dated [DATE] at 03:54 p.m., revealed the following note by RN Z, one week of blood sugar results sent to [Resident #1's PCP]. Pending response. Record review of Resident #1's progress notes, dated [DATE] at 04:00 p.m., revealed the following note by RN Z, called into room by CNAs. Res (resident) was lying in bed with eyes closed, respirations shallow, difficult to arouse. Unresponsive to tactile stimuli. Upon assessment .blood sugar too high to register on glucometer (machine used to test blood sugar). Immediately contacted [Resident #1's PCP]. New orders received to send to [local hospital] ER (emergency room) for further eval (evaluation) and tx (treatment) . Record review of Resident #1's progress notes, dated [DATE] at 04:09 p.m., revealed the following note by LVN N, [Resident #1] was transferred to a hospital on [DATE] 4:05 PM related to High blood sugar, unresponsive. Record review of Resident #1's progress notes, dated [DATE] at 11:40 a.m., revealed the following note by RN Z, Res (resident) is admitted to [hospital name and location]; ICU (intensive care unit) DX (diagnoses): Hyperglycemia, Altered Mental Status. Record review of Resident #1's hospital records, dated [DATE], reflected Resident #1 was admitted to the ER on [DATE] at 05:44 p.m. The records reflected Resident #1 was discharged from the ER on [DATE] to an alternate hospital. The ER notes dated [DATE] reflected Resident #1's chief complaint was hyperglycemia and an altered mental status. Resident #1 noted to had started seizing when on bed with no prior history of seizures. Resident #1 was intubated and placed on a mechanical ventilator, diagnosed with altered mental status, hyperglycemia (high blood glucose/sugar), hyperosmolar hyperglycemic state (HHS; a life-threatening complication of diabetes when the blood glucose or blood sugar levels are too high for a long period, leading to severe dehydration and confusion), seizure, respiratory failure, GI (gastrointestinal) bleed, sepsis (a condition in which the body's extreme response to an infection become life-threatening), urinary tract infection, and an electrolyte disorder. Glucose level measured at 798 mg/dL on [DATE] at 05:52 p.m. Record review of addendum to facility self-report to HHSC Complaint and Incident Intake, dated [DATE] at 03:53 p.m., revealed the following note by the ADMIN, He (Resident #1) passed away on [DATE] at 10:37 p.m. We (the facility) do not have a cause of death at this time. Interview with RN Z on [DATE] at 03:01 p.m. revealed she had reviewed Resident #1's weekend blood sugars when she came in to work on Monday, [DATE], seen that they were elevated, and sent the blood sugar results to Resident #1's physician. RN Z stated she had reported his high blood sugar that morning but Resident #1 was awake, alert, and up in the dining room for breakfast and lunch. RN Z stated Resident #1's change in condition started right before she had sent him out, after lunch. RN Z stated she did not hear back from Resident #1's physician when reporting the initial high blood sugar but called the physician again for the change of condition and transfer out to the hospital. RN Z did not state the time for the second call to Resident #1's physician. RN Z described Resident #1's change as condition as being slower to respond, not really answering staff, and just not himself. Interview with SNA AC on [DATE] at 03:17 p.m., revealed she had been taking care of Resident# 1 on Sunday, [DATE] and around 05:30 p.m. observed a concern about how Resident #1 was positioned in bed and that Resident #1 was not breathing as good as he normally did. SNA AC stated she had reported her observations to the nurse. SNA AC stated she had worked at the facility for less than a month and had not yet been trained on how to document in the facility's EMR. Interview with CNA A on [DATE] at 03:28 p.m., revealed she had been taking care of Resident #1 on Monday, [DATE] during the day. CNA A revealed she had observed Resident #1 to have been behaving normally, chatty and responsive that morning. CNA A stated after lunch, she had reported to Resident #1's nurse (RN Z) that when she and another CNA (CNA B) went into Resident #1's room to get him up from an after-lunch nap, he was not as responsive as normal. CNA A stated she had tried physical stimulus (rubbing Resident #1 wrist), which he did not respond to. CNA A stated she also observed an unknown purple substance around Resident #1's mouth, which she had cleaned off when the nurse came in to check Resident #1's vitals. CNA A did not state she documented her observations in the facility EMR or notify the nurse of the purple substance during the interview as part of her recollection of events. Interview with CNA B on [DATE] at 03:37 p.m., revealed she had observed Resident #1 during Monday, [DATE] and had noted that he was his normal responsiveness and able to have a conversation with her that morning. CNA B stated that after lunch Resident #1 started to be different, dazed. CNA B revealed she reported her observations to Resident #1's nurse (RN Z). Interview with the ADON on [DATE] at 04:08 p.m., revealed she had worked [DATE] for the 08:00 p.m. blood sugar check shift. The ADON stated that Resident #1 had looked fine, was acting his normal or not any different than he has been since his recent stroke. The ADON stated that for one of her shifts that week Resident #1 had a very high blood sugar and she had called Resident #1's physician who said he did not want to do anything if the resident was asymptomatic (without symptoms). The ADON stated she did not call Resident #1's physician again because when she had called on [DATE], the physician said that if Resident #1 was asymptomatic he was not going to do anything. Interview with MD W on [DATE] at 04:37 p.m., revealed he had been notified of changes in Resident #1's blood sugar medications, including the approval of diabetic medication Trulicity by Resident #1's insurance and that Resident #1's prior PCP had wanted to decrease Resident#1's insulin, but had not received any calls regarding Resident #1's high blood sugars until Monday morning, [DATE]. MD W revealed his expectation was for the facility to call him if a resident's blood sugar was below 60, over 400, or symptomatic (having symptoms). MD W stated he believed Resident #1's comorbidities (having more than one medical condition at the same time) were contributing to Resident #1's blood sugar problems. MD W revealed he was not sure that if the facility had contacted him sooner regarding Resident #1's elevated blood sugars, if it would have made a difference but it would have been ideal for the facility to have had contacted him sooner. Interview with LVN P on [DATE] at 05:37 p.m., revealed her observations for Resident #1 during her shifts on [DATE]- [DATE] were that he was fine when he had high blood sugars. His behaviors were fine and happy. He was back to his normal self. LVN P stated when Resident #1 had low blood sugars he would become confused and combative. LVN P stated she reported to Resident #1's physician when Resident #1 was experiencing lows but could not remember if she had called the physician for the high blood sugars. LVN P revealed Resident #1 did not have symptoms when his blood sugars were high. LVN P stated Resident #1's respirations were great, he was sleeping well, and he was his normal self. LVN P revealed she felt the physician would have known Resident #1 was having high blood sugars since the physician discontinued Resident #1's insulin. Interview with LVN R on [DATE] at 06:11 p.m., revealed her observations for Resident #1 during her shifts on [DATE] - [DATE] were that Resident #1 was good, just tired which was not abnormal for him recently. LVN R stated that she could recall that Resident #1 had an order during that time to monitor Resident #1's blood sugars and then to report it in 7 days, which she believed was either that following Monday ([DATE]) or Tuesday ([DATE]). LVN R stated she did not report Resident #1's high blood sugars during her shifts because of the monitoring order with instruction to report in 7 days and she had reviewed Resident #1's previous blood sugars and found them to be consistent with the blood sugars she had collected. LVN R stated Resident #1's blood sugars were all the same, all in the 400's and not fluctuating, such as from the 100's to the 400's. LVN R also revealed Resident #1 was not showing symptoms, which he did when experiencing a low blood sugar and that she did not have any concerns. Interview with MD X on [DATE] at 11:20 a.m., revealed Resident #1's blood sugars had been fluctuating quite a bit due to Resident #1's renal (kidney) failure, which was causing his blood sugars to become difficulty to control. MD X revealed that he did recall the facility's nursing staff contacting him regarding Resident #1's blood sugars but could not recall when without his notes. MD X stated the facility contacted him regarding Resident #1's change in physician on [DATE] and that was the last contact he received from the facility for Resident #1's care. MD X stated prior to the change in physician, he was trying to make chronic (long-term) changes and did not want to make acute (immediate) changes in regulating Resident #1's blood sugar. MD X revealed his expectation for the facility staff to notify him for blood sugars was for them to call if a resident's blood sugar was at 500. MD X revealed that if a resident was at 500 and symptomatic, he would order adjustments and send the resident out to the hospital, but if not symptomatic, he would just make adjustments to the insulin order. MD X revealed Resident #1's insulin orders had been discontinued due to Resident #1 having had bottomed out (experienced a low blood sugar episode) earlier that month (early February), Resident #1 was very brittle, and Resident #1's blood sugars had been going in the wrong direction (blood sugar dropped) with insulin. Interview with the RCN on [DATE] at 02:16 p.m., revealed the facility procedure for a blood sugar outside parameters (the expected range) was to follow the order, including to hold the medication, give an additional medication, re-check, and/or immediately contact the physician per the doctor's orders. She stated that staff are expected to contact the physician if there is a pattern in a resident's blood sugars being outside the blood sugar parameters or a pattern of refusals by the resident. She revealed that if a resident was experiencing a high blood sugar, the doctor was to tell them what they are to give to the resident and when to re-check the resident's blood sugar. The RCN stated that the nurse was responsible for entering the physician's order into the facility's EMR, documenting the order and interventions in a progress note, and reporting any changes to the resident's RP. She revealed that reporting high and low blood sugars is important for tracking the resident's blood sugar trends and that if a resident was running a high blood sugar all the time, their medications would need to be adjusted to limit the long-term effects it could have, which may be harmful if not treated. The RCN stated that facility staff should monitor blood sugars as ordered, notify the resident's physician immediately if outside parameters and follow the orders that the physician gives. Interview with the ADMIN on [DATE] at 02:34 p.m., revealed reporting any change of condition is important, to let the physician know and be aware of it. The ADMIN revealed his expectation was that staff call the resident's physician, report that they had contacted the physician, make the changes per the physician, and make notifications to the resident's family for any changes of condition. The ADMIN revealed that this was standard nursing practice and an order. Record review of facility policy, Notifying the Physician of Change in Status, dated revised [DATE], revealed The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgement deem it necessary for immediate medical attention .1. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record .11. Abnormal lab, x-ray and other diagnostic reports require physician notification. Record review of facility policy, Medication Administration Procedures, dated 2003, revealed 13. When ordered or indicated, include specific item(s) to monitor (e.g., blood pressure, pulse, blood sugar, weight), frequency (e.g., weekly, daily), timing (e.g., before or after administering the medication), and parameters for notifying the prescriber. This failure resulted in an identification of an immediate jeopardy on [DATE] at 01:27 p.m. The administrator was informed and provided the IJ template on [DATE] at 06:00 p.m. and a plan of removal (POR) was requested. The plan of removal reflected: [DATE] Plan of Removal- [Citation Number] Notify of Changes Interventions: - 100% blood sugar audit completed on [DATE] by Regional Compliance Nurse - Blood sugar checks were assessed on [DATE] to ensure that blood sugar parameters were in place, if not, parameters were requested by attending physician and added. - 100% of residents with blood sugar checks were audited on [DATE] and Physician(s) were notified of all blood sugars outside of parameters or were excessively high or low. Date completed [DATE]. - The following in-services were initiated [DATE] by Regional Compliance Nurse. Inservice 100% of staff completion date: [DATE]. Inservice has been added to new-hire packets for all new hires and agency staff to ensure all staff is in-serviced prior to start of their first shift. - Perform blood sugar checks as ordered. - Ensure any resident who has blood sugar checks has a parameter to the physician or nurse practitioner (NP). This includes when to report new orders for current residents, new admissions, and readmissions. - To report to the MD or NP if a blood sugar check is outside the ordered parameters immediately and to initiate any new orders. - If resident(s) has an order for glucagon, follow the prescriber's orders. - Policy on Notifying the Physician of Change in Status - The following in-services were initiated on [DATE] for all NA/CNAs by nursing administration and/or Regional Compliance Nurse. Inservice 100% of NA/CNA completion date [DATE]. - Hyperglycemia - excessive thirst/dry mouth, excessive urine, increased fatigue/weakness, blurred vision - Hypoglycemia-sweating, dizzy, shaking, increased confusion, anxiety, drowsy, change in mental status, slurred speech, nausea, lightheaded, loss of coordination. - Notified Medical Director of IJ situation on [DATE] at 6:17 pm. Monitoring: - At least five (5) times per week, nursing administration will review the previous days orders using the order listing report in [the facility's EMR] to monitor for new orders for blood sugar checks and ensure that parameters are added. This will include new orders for current residents, new admissions, and readmissions. This was initiated on [DATE] continue x 4 weeks. - At least 5 times per week nursing administration will review the previous days TARS and the medical record to ensure that blood sugar checks were performed as ordered and the MD or NP was notified if it was outside the ordered parameters. This was initiated on [DATE] and will continue x 4 weeks. - Nursing Administration will ask at least 10 nursing staff per week a situational question regarding if a resident presented with hyper or hypoglycemia and what they would do. This was initiated on [DATE] and will continue x 4 weeks. - DON/Designee will review 5-8 residents slide scale results for proper notification to MD if outside parameters weekly. This will be initiated on [DATE] and continue x 4 weeks. - DON/Designee will monitor all blood sugars outside parameters of slide scale for notification to MD weekly x 4 weeks. This was initiated [DATE] and will continue x 4 weeks. - Regional Compliance Nurse will monitor for compliance weekly x 4 weeks starting on [DATE]. - The QA (Quality Assurance) Committee will review findings and Physician Notification Policy and will make changes as needed monthly. This will occur during the next QAPI (Quality Assurance and Performance Improvement) meeting on [DATE]. Monitoring of the plan of removal included: Interviews were conducted on [DATE] from 02:50 p.m. to 07:47 p.m. with 2 RNs (RN Z and RN AA) of 2 and 9 LVNs (LVN K, LVN L, LVN M, LVN N, LVN O, LVN P, LVN Q, LVN R, and LVN S) of 9, who worked multiple shifts, revealed they had all been trained on the facility policy, Notifying the Physician of Change in Status. The nursing staff were knowledgeable on the requirement that all blood sugar monitoring orders must include blood sugar parameters, and on the protocols to follow including what to document and who to notify if a blood sugar was outside parameters or a resident was showing signs or symptoms of being hypo or hyperglycemic. The staff were able to identify when it would be appropriate to administer glucagon and how to report and document glucagon administration. Interviews were conducted on [DATE] from 03:13 p.m. to 08:37 p.m. with 6 CNAs (CNA A, CNA B, CNA C, CNA D, CNA E, and CNA F) of 9, 3 HAs (HA H, HA I, and HA J) of 3, 2 MAs (MA T and MA U) of 3, and 6 SNAs (SNA AB, SNA AC, SNA AD, SNA AE, SNA AF, and SNA AG) of 8; and on [DATE] at 10:32 a.m. with 1 CNA (CNA G). Interviews revealed they worked multiple shifts, had all been trained and were able to identify signs and symptoms of hypo and hyperglycemia, and were knowledgeable on who they needed to report to. In an interview and record review with the RCN on [DATE] at 03:55 p.m., she revealed she had started and was conducting the staff in-services. The RCN confirmed the ADMIN, with her present, had notified the facility's medical director of the Immediate Jeopardy (IJ). The RCN revealed the plan for the facility administration to monitor every new blood sugar order, ensuring that every new order included parameters was to review the previous day's (or days' for new orders over the weekends and holidays) orders by printing out an Order Listing Report from the facility's EMR, which would show all of the previous days' orders. The RCN revealed she had completed the initial blood sugar monitoring audit on [DATE]. She revealed that she had discovered a few residents without parameters on their orders. The RCN revealed she called the residents' physicians to add the parameters, asked the physicians about glucagon orders if not currently included in the residents' active order list, and added the orders with parameters per the physician's order. The RCN indicated the facility's monitoring document, labeled with At least 5 times per week nursing administration will review the previous days orders using the order listing report in [EMR system name] to monitor for new orders for blood sugar checks and ensure that parameters were added., was the monitoring document the facility would use to track their completion of this monitor. The document revealed this monitor was to be tracked 5 times a week for 4 weeks and that the monitor had been completed on [DATE], [DATE], and [DATE] for week 1. The RCN revealed the plan for facility administration to monitor each resident's blood sugar, that had a blood sugar monitoring order, for being completed per order and to verify the resident's MD or NP was notified if the blood sugar was outside parameters was by printing out the previous day's (or days' if after a weekend and/or holiday) Weights and Vitals Summary report from the facility's EMR, which would show all the previous days' blood sugar results, identify any blood sugars outside parameters, and review the resident's progress notes for a note on notification to the physician and/or nurse practitioner for any blood sugar results outside parameters. The RCN indicated the facility's monitoring document, labeled with At least 5 times per week nursing administration will review the previous days TARs and the medical record to ensure that blood sugar checks were performed as ordered and the MD or NP was notified if it was outside the ordered parameters., was the monitoring document the facility would use to track their completion of this monitoring. The document revealed this monitoring was to be tracked 5 times per week for 4 weeks and that the monitoring had been completed on [DATE], [DATE], and [DATE] for week 1. Weights and Vitals Summary reports for dates [DATE], [DATE], and [DATE] were provided and revealed initials on each page to indicate it had been reviewed and check marks next to each blood sugar out of parameters to indicate a corresponding progress note had been confirmed to indicate the MD or NP had been notified. The RCN revealed the ADON would be responsible for completing the review of the 5-8 residents with sliding scale insulin orders for proper notification of the MD if the blood sugar was outside parameters. The RCN stated that this monitor was the same process or intervention as the intervention for reviewing the TARs for residents with orders for blood sugar monitoring. The RCN revealed the plan for the facility administration to ask at least 10 nursing staff situational questions regarding if a resident had high or low blood sugars and what they would do was to utilize the monitoring document, labeled with Nursing administration will ask at least 10 nursing staff per week a situational question ., mark Yes or No if the staff member answered the question correctly or incorrectly, and if incorrect, document how they answered the question incorrectly and what the nursing administration's plan was for correcting the incorrect answer (ex. in-service training). The document revealed this monitoring was to be completed 10 times per week for 4 weeks, had a spot to put the date, indicate if the answer was correct or incorrect, the staff name of the person questioned, and the name of the interviewer. The document revealed two staff members had been questioned, both on [DATE], and both had answered correctly. The RCN revealed the plan for her to monitor that the facility administration and DON/designee were compliant with the other interventions/monitors for 4 weeks was for her to come to the facility at least one time per week, review the other monitoring forms to ensure they are up to date, review the related Weights and Vitals Summary reports and Order Listing Report that the facility will be maintaining in a specified binder, and to mark Yes or No on the monitoring document, labeled with Regional Compliance Nurse and/or ADO (ADON) compliance monitoring:. The document revealed this monitoring was to be completed for 4 weeks and did not have any weeks marked as completed at the time of the interview. In an interview with the ADON on [DATE] at 04:08 p.m., she revealed she had received training on the facility policy, Notifying the Physician of Change in Status, blood sugar checks procedure, administering glucagon per order, reporting blood sugars to the resident's physician or NP immediately if outside parameters or when symptomatic, documenting physician notifications and new orders, and verifying that all new blood sugar monitoring orders included parameters on [DATE]. The ADON revealed she was to print out the Weights and Vitals report and document for new orders daily. The ADON revealed she was to review the reports for new orders and to review the blood sugars to identify if any residents had blood sugars less than 60 or over 400. She revealed that she was to review the progress notes and the 24-hour or 72-hour report to confirm the nurse notified and documented that they notified the physician of a blood sugar outside parameters. The ADON revealed she was to ask CNAs from different shifts to determine if they could recognize signs and symptoms of a hyper or hypoglycem[TRUNCATED]