**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #1)The facility failed to prevent Resident #1 from sustaining a fall from the bed on 08/28/2025 which resulted in a fractured right femur. The noncompliance was identified as PNC (past noncompliance). The IJ began on 08/28/2025 and ended on 09/02/2025. The facility had corrected the noncompliance before the survey began.This failure could place residents at risk of potential accidents, injuries, harm, or death.Findings included:Record review of Resident #1's face sheet on 09/29/2025 indicated a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including: anoxic brain damage (a medical emergency that occurs when the brain does not get enough oxygen, even when blood flow is adequate), convulsions, aphasia (disorder that affects how you communicate), nonpsychotic mental disorder (a mental health condition that does not involve psychosis and includes anxiety disorders, depression and personality disorders), pseudobulbar affect (inappropriate involuntary laughing and crying due to a nervous system disease), and high blood pressure.Record review of a quarterly MDS dated [DATE] indicated Resident #1 had no speech, sometimes understood others and was sometimes understood, she had a BIMS score of 00 indicating severe cognitive impairment. She required total assistance with ADLs and could not feed herself. She was incontinent of bladder and bowel. She was dependent with mobility and walking unassisted. She had one fall with major injury since the prior MDS assessment. She received a mechanically altered diet. She had a surgical wound.Record review of care plans for Resident #1 indicated she had a care plan initiated on 10/18/2023 and revised on 05/02/2024 which indicated she was at risk for falls due to debility, weakness, and cognitive impairment. Goals included: The resident will be free from falls and/or will not experience significant injuries associated with falls through next review date. Care plan interventions included: bed at appropriate height when unattended and a bolster on mattress for safe boundaries to minimize risk for rolling out of bed.Review of Resident #1's Progress Notes in the electronic record indicated the following:Progress note dated 8/28/2025 at 2:55 PM indicated resident noted lying on her right side on the floor by her bed, laceration noted to face just under left eyebrow, purple bruise noted to right knee, decreased length and internal rotation noted to right lower extremity, resident shows signs and symptoms of pain when she attempts to move, all other extremities have normal ROM, EMS notified and in route, DON, Administrator, NP and family notified, attempted to make resident as comfortable as possible on floor without excessive movement, will continue to observe. Progress note dated 8/28/2025 at 3:08 PM indicated EMS in facility to transfer resident, resident in route to ER, attempted to call report in to hospital, nurse at ER stated she will receive report from EMS.Progress notes dated 8/31/2025 at 6:22 PM indicated Resident came from hospital after right hip surgery. resident currently stable, alert, and without acute distress. Dressing to surgical wound dry and intact. v/s BP 103/56, temp. 99.3 oxygen saturation 100% on room air heart rate 109. Will continue routine care and monitoring.During an observation on 09/29/2025 at 8:20 AM Resident #1 was at the nurses' station in her specialized wheelchair with the back tilted backwards. She was alert to her surroundings and looking about. She was clean and dressed appropriately for the day.During an observation on 09/29/2025 at 2:20 PM Resident #1 was in her bed. The head of the bed was elevated 45 degrees and she was lying on her left side. She opened her eyes when the room was entered but laid her head back down and closed her eyes. The bed was in the low position and bolsters were present on the bed on both sides of the resident. The bolsters were short in length and covered the middle length of the mattress.During an interview on 09/29/2025 at 2:25 PM CNA U was in Resident #1's room and said she had worked at the facility about a year. She said Resident #1 was to have bolsters on her bed when she was in the bed because she moved around a lot and could fall out of bed.During an interview on 09/29/2025 at 3:15 PM, ADON A said she was next door to Resident #1's room on the afternoon of 08/28/2025 and heard a loud bump or thud sound; She said LVN Q was making his start of shift rounds and called to her to come to Resident #1's room. She said the resident was on the floor. She said a wedge cushion was in front of the closet at the foot of the roommate's bed. She said the bed was also left in the higher position where it would normally be during a mechanical lift transfer. She said she did not see any bolsters or wedge cushions on the bed or around the resident. She said the resident required the bolsters because she wiggled and moved about in the bed and had very poor control over her body. During an observation on 09/30/2025 at 9:25 AM Resident #1 was sitting in her specialized wheelchair at the bedside. LVN E was taking the resident's blood pressure prior to administering medications. Resident #1 was calm and alert and did not exhibit any fear. Bolsters were present on both sides of her bed.During an interview on 09/30/2025 at 9:45 AM the DON said CNA B said she had placed a black wedge positioning device under the sheet on Resident#1's bed on 08/28/2025 when she returned her to bed between 1:00 PM-1:30 PM prior to leaving her shift. She said the resident was asleep in bed when she left at 2:00 PM. She said LVN Q told her he did not see the wedge when Resident #1 was found on the floor. She said CNA B demonstrated how she placed the black wedge on the bed. She said CNA B told her the bolsters were not on the bed when she came on shift at 6:00 AM and the black wedge was being used. She said the CNA B said she did not know why the bolsters were not being used as in the past, but she used the wedge like she had seen that morning. The DON said CNA B was suspended immediately pending the results of the investigation. She said the bolsters were found in front of the closet in the resident's room. She said all direct care staff had access to the Kardex through computers on the hall, in the break room and at the nurses' station. She said the Kardex designated care needs and procedures to be done for each individual resident in the facility. She said it was a plan of care and contained everything a staff member may need to know to properly care for a resident including positioning/safety devices. She said she had verified with CNA B she knew how to use the Kardex and she indicated she did. She said the facility immediately began developing an action plan regarding the fall with major injury.During an interview on 09/30/2025 at 4:00 PM LVN Q said he was making his beginning of shift rounds on 08/28/2025 and found Resident #1 on the floor by her bed. He said he could not recall for sure if there was a black positioning wedge present on or around her bed. He said he received assistance from ADON A who happened to be next door. He said the resident had small cuts on her left eyebrow and her right leg was turned inward, and she expressed pain when being repositioned. LVN Q said he along with all staff received in-services on fall prevention and safety, abuse and neglect, resident rights and use of the Kardex. He said he made rounds at least 2-3 times per shift and always at the beginning and end of shift. Record review of a printed form of the Kardex for Resident #1 dated 08/28/2025 indicated under Safety bolster on mattress to for safe boundaries to minimize risk for rolling out of bed and under Monitors bed at appropriate height when left unattended.A review of the facility investigation report indicated the incident occurred on 08/28/2025 at 2:55 PM and was reported to the state agency on 08/28/2025 at 6:16 PM. Resident #1 was found lying on the floor beside her bed. She had a laceration to her left eyebrow and under her left eye. Her right leg was turned inward and she expressed pain and discomfort upon movement. She was immediately sent to the ER and she was diagnosed with a fracture to her right femur. The resident was supposed to have bolsters on the mattress to minimize risk of rolling out of bed. The CNA had used a black wedge instead of the bolsters when the resident was returned to bed prior to her leaving her shift at 2:00 PM. The CNA was immediately suspended during the investigation. Record review of a handwritten statement dated 08/28/2025 CNA B stated she had put Resident #1 to bed after lunch and placed a pad under her.Record review of a handwritten statement dated 08/28/2025 at 7:45 PM by an unknown interviewer indicated CNA B got Resident #1 out of bed for breakfast and she stayed up through lunch. She was put back to bed after lunch, and she inserted a black pad underneath the sheet. The CNA stated the resident was asleep in bed when she left the facility at 2:00 PM.Record review of a handwritten statement dated 08/28/2025 at 9:00 PM by the DON indicated CNA B was interviewed at the facility regarding her activities with Resident #1 on 08/28/2025. The CNA said the resident did not have any special devices in bed with her. When asked about the bolsters she said she used the small one which was the same one on the bed that morning. She said the resident usually had long ones but someone must have taken them off the bed and replaced them with the small one. The DON had the CNA demonstrate how she placed the black wedge on the bed in the room. She asked the CNA about the long bolsters she was referring to and the CNA indicated 2 bolsters half the length of the mattress in front of the closet. When asked why she did not use the bolsters she replied she did not know why and shrugged her shoulders. She said she just put back what had been there that morning. She said she usually used the bolsters but did not because they had been taken off the bed. The CNA was then told she was suspended pending the rest of the investigation.During multiple interviews on 09/30/2025 with nurses, CNAs, and MAs from two shifts (6AM-2PM and 2PM-10PM) (RN D, LVN E, CNA/MA F, CNA G, CNA H, CNA J, CNA/MA K, CNA L, LVN M, CNA N, CNA P, CNA R, CNA/MA S, CNA/MA T, CNA U, CNA V, CNA W, CNA/MA X, CNA Y) from 9:25 AM-11:38 AM and 4:00 PM 4:35 PM indicated they were trained on Fall Prevention and Safety, Abuse and Neglect, Resident Rights, and use of the Kardex. They could explain what information was contained in the Kardex and knew how to access the Kardex for any information regarding residents' care. They were aware Resident #1's need for bolsters when she was in bed and for the bed to be in a low position.The Administrator was informed of PNC IJ on 09/30/2025 at 2:40 PM.The facility completed the following to correct the noncompliance prior to state surveyor entrance:CNA B was immediately suspended pending investigation and terminated 09/02/2025 due to disregard for resident safety.Record review of documentation of training of all staff conducted beginning 08/28/2025 after the fall and completed 09/01/2025 on Fall Prevention and Safety, Abuse and Neglect, Resident Rights, and use of the Kardex.Record review of documentation indicated the MDS Coordinator completed 100% care plan and Kardex audit to validate accuracy of level of care needed with ADLs and transfers was completed 08/28/2025.Record review of documentation of Safe Surveys done on random residents and staff completed 08/29/2025. Residents indicated they felt safe in the facility and had no incidents of mistreatment by staff.Record review of documentation of Monitoring Response indicated: 1) weekly rounds to validate interventions related to fall prevention are in place 1-7 days for 2 months; 2) conduct random skills validation regarding Kardex use 3-7 days a week for 2 months. 3) additional education based on needs observed during this process; 4) all findings to be reported to QAIP during monthly meeting until 100% compliance was met.The noncompliance was identified as PNC. The IJ began on 08/28/2025 and ended on 09/02/2025. The facility had corrected the noncompliance before the survey began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to consult with the resident's physician when there was a significant change in the resident's physical and mental status that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications for 1 of 4 (Resident #1) residents reviewed for resident rights. The facility failed to notify Resident #1's physician of elevated blood sugars resulting in her being sent to the emergency department unresponsive and with a blood sugar of 946 (normal blood sugar ranges are 70-110) This failure resulted in an identification of an Immediate Jeopardy (IJ) at 3:00 p.m. on 10/4/23. While the IJ was removed on 10/6/23 at 10:39 a.m. the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could result in diabetic residents suffering injury, hospitalization, or death related elevated blood sugars. Findings Include: 1. Record review of a face sheet dated 10/6/23 indicated Resident #1 was a [AGE] year-old female admitted to the facility om 3/3/04 with diagnoses including diabetes, dementia, major depressive disorder, and hypertension (elevated blood pressure). Record review of the MDS assessment dated [DATE] indicated Resident #1 was understood by others and usually understood others. The MDS indicated Resident #1 had a BIMS score of 09 and was moderately cognitively impaired. Record review of Resident #1's care plan last updated 8/31/23 indicated Resident #1 had diabetes and was at risk for complications associated with diabetes such as frequent infections, diabetic wounds, vision impairment, and hyper\hypo-glycemia. Interventions included administer medications as recommended by the doctor, monitor labs as indicated, and promptly report abnormal labs results and significant clinical findings to the doctor. Record review of the physician orders dated 10/4/23 indicated Resident #1 had an order for Humalog (a fast-acting insulin to treat diabetes) 100u/ml inject 14 unit subcutaneously before meals related to diabetes starting 9/4/23. The physician orders indicated Resident #1 had an order for Lantus (a long-acting insulin to treat diabetes) 100u/ml Inject 12 unit subcutaneously two times a day for diabetes starting 9/4/23. Record review of the MAR indicated on 9/24/23 Resident #1 had a blood sugar readings of 409 at 7:00 a.m., 502 at 12:00 p.m., and 600 at 5:00 p.m. Record review of the nursing progress notes dated 9/24/23 indicated there had not been physician notification regarding the three elevated blood sugar readings. Record review of the nursing progress note dated 9/25/23 at 3:50 a.m. written by RN A indicated she, received a phone call from the 2:00 p.m.-10:00 p.m. nurse stating that she had forgotten to tell me about [Resident #1's] p.m. blood sugar. Record review of the hospital record dated 9/25/23 indicated Resident #1 admitted to the emergency department via EMS after being found unresponsive at the facility. The hospital records indicated RN A reported Resident #1 had been found unresponsive at approximately 3:00 a.m. The hospital records indicated RN A reported Resident #1 had a blood glucose reading of HI (blood sugar reading greater than 600) and continued to have an undetectable blood glucose reading. The hospital records indicated due to the undetectable blood glucose reading the decision was made to send Resident #1 to the hospital. The hospital records indicated Resident #1 was sedated and intubated. The hospital records indicated Resident #1 had a blood glucose reading of 946. Record review of the hospital Discharge summary dated [DATE] indicated Resident #1 had diagnoses including diabetic ketoacidosis with coma related to diabetes (a process that forms toxic acids known as ketones (measure in the blood or urine and high blood sugar resulting in coma) and non-ST elevated myocardial infarction (heart attack). During an interview on 10/4/23 at 1:49 p.m., the NP said she remembered receiving a phone call at approximately 4:30 a.m. on 9/25/23 regarding Resident #1's blood sugars. The NP said she had not been previously notified of Resident #1 having an elevated blood sugar. The NP said the 10:00 p.m.- 6:00 a.m. nurse had called her and informed her the nurse who had worked 2:00 p.m.-10:00 p.m. the previous shift called the 10:00 p.m.-6:00 a.m. nurse at approximately 3:00 a.m. and told her she had forgot to let her know about Resident #1's elevated blood sugar. The NP said the 10:00 p.m.-6:00 a.m. nurse did not have current vital signs or a current blood sugar for Resident #1 when she called. The NP said the 10:00 p.m.-6:00 a.m. nurse told her she waited 1.5 hours to notify her of Resident #1's elevated blood sugars from the previous shift because she was passing medications. The NP said she gave orders for Resident #1's blood sugar to be checked. The NP said when she received the blood sugar results, she gave an order to administer insulin and recheck in one hour. The NP said when the nurse called her back after re-checking Resident #1's blood sugar an hour later, the nurse informed her Resident #1 was unresponsive. The NP said she gave an order for Resident #1 to be transported to the emergency department for evaluation. The NP said she was not informed of Resident #1's blood sugar being 946 when she arrived at the hospital. The NP said she expected the nurses to notify her of a blood sugar of 400 or greater. During an interview on 10/6/23 at 2:59 p.m., LVN C said she worked a double shift from 6:00 a.m.-10:00 p.m. on 9/24/23. LVN C said she did not notify the physician of Resident #1's elevated blood sugars because she got sidetracked. LVN C said she should have notified the physician and just did not do it. LVN C said she did not think about Resident #1's elevated blood sugars again until approximately 1:00 a.m. LVN C said jumped up and called the night nurse at that time. LVN C said she did not tell the nurse about Resident #1's elevated blood sugars during report due to the fact she had forgotten about it. LVN C said she called back the next morning and found out Resident #1 had been sent to the hospital. During an interview on 10/6/23 at 3:17 p.m., the DON said she expected the nurses to report any blood sugar over 400 to the physician or NP immediately. Record review of the facility's Diabetic Management policy last revised January 2023 indicated, Diabetic Management involves both preventative measures and treatment of complications .The interdisciplinary team assesses the diabetic resident/patient upon admission, validated the orders with the attending physician and initiates plan of care that may include: blood glucose monitoring as ordered .Blood glucose measurements shall be take per the physician order. Results outside of order parameters should be communicated to the physician per orders .Acute Complication Management: It is best practice to avoid hypoglycemic events in the older adult .For acute events, the clinical record shall include the following information: resident's condition indicated clinical presentation, blood glucose test levels, interventions provided, resident's response to treatment or interventions administered, and notification of the physician and any new orders . The Administrator was notified on 10/4/23 at 3:22 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 10/4/23 at 3:26 p.m. The facility's Plan of Removal was accepted on 10/5/23 at 4:48 p.m. and included: Situation: Resident # 1 was discharged to the hospital on 9-5-23 due to a change in condition. Resident was diagnosed and treated for Urinary Sepsis secondary ESBL secondary chronic indwelling foley catheter. Resident re-admitted to facility on 9-10-23 with a diagnosis of Urinary Sepsis as well as Diabetes Mellitus. Resident #1 was being treated with antibiotic therapy and completed the regimen on 9-15-23 as per physician's orders. On 9/24/23 Resident # 1 presented with abnormal blood glucose levels and on 9/25/23 Resident #1 experienced an acute change in condition. Upon identifying the change in condition, the nurse evaluated the patient's condition, notified the physician and at 4:40am nurse received new orders to administer Humalog 10units, at 5:50am the nurse re-checked the blood glucose following the administration of the insulin and the nurse notified the medical provider and received new order to send Resident #1 to the emergency department for evaluation and treatment. Outcome: Resident was admitted and treated in the hospital on 9/25/23, was noted to be at medical and cognitive baseline and has been readmitted to facility on 10/3/23. Regional Nurse Consultant re-educated the Director of Nursing / Assistant Director of Nursing regarding the expected management of a diabetic patient, assessing/evaluating and responding to the urgent needs of the diabetic patient based on presenting symptoms of hyper and hypoglycemia, observing and monitoring a resident's condition, evaluation of the resident's status, reporting changes in condition to the physician, obtaining physician's orders, following physician's recommendations/orders, documenting clinical findings and orders within the medial record (SBAR/progress note) as well as complete and document notifications of the change in status to the MD/PCP and resident/resident's representative accordingly. Date commenced: 10/4/23 Date of completion: 10/4/23 The Director of Nursing Services/Assistant Director of Nursing conducted education to all licensed nurses the expected management of a diabetic patient, how to respond to signs and symptoms of hyper/hypoglycemia, assessing/evaluating and responding to the needs of the diabetic patient based on presenting symptoms of hyper and hypoglycemia, reviewing and validating the plan of care with regards to blood glucose monitoring, sliding scale insulin orders routinely and/or as needed, prescriber's plan of care and management of the diabetic resident and following physician's orders/recommendations. Date completed: 10/4/2023 The Director of Nursing Services/Assistant Director of Nursing conducted and education to all licensed nurses regarding the process for observing and monitoring a resident's condition, proceed with an assessment / evaluation of the resident's status, reporting changes in condition to the physician, obtaining physician's orders, following physician's recommendations/orders, documenting clinical findings and orders within the medial record (SBAR/progress note) as well as complete and document notifications of the change in status to the MD/PCP and resident/resident's representative accordingly. Date commenced: 10/4/23 Date to be completion: 10/4/2023 Risk Response: All residents who are diabetic may potentially be affected by the deficient practice. Administrator and Director of Nursing and Medical Director conducted an Ad Hoc QAPI to review issue and community's response plan in place. Date of Completion: 10/5/2023 Director of Nursing Services/Assistant Director of Nursing Services completed a 100% audit on all residents who receive insulin. Physician orders were audited to ensure blood sugar parameters where in place as well as notifications to the MD/NP with the indicated parameters for all residents who receive insulin. Date completed: 10/4/2023 The Director of Nursing / Assistant Director of Nursing/Licensed Nurse will review all diabetic patients' current plan of care with the attending MD/NP to ensure that the appropriate orders are in place per MD/NP's prescribed plan of care and confirm accuracy of diabetic management orders. The nurse will document the MD/NP's orders should any new or changes in the plan of care be provided by the prescriber. Date Commenced: 10/4/23 Date to be completion: 10/4/2023 Systemic Response: Inservice training & re-education will be provided to all licensed nurses regarding topics: Director of Nursing / Assistant Director of Nursing conducted retraining for all licensed nursing staff prior to assuming next shift/assignment. Inservice topics included but not limited to the following: the expected management of a diabetic patient, how to respond to signs and symptoms of hyper/hypoglycemia. assessing/evaluating and responding to the needs of the diabetic patient based on presenting symptoms of hyper and hypoglycemia, reviewing and validating the plan of care with regards to blood glucose monitoring, sliding scale insulin orders routinely and/or as needed, prescriber's plan of care and management of the diabetic resident and following physician's orders/recommendations. The process for observing and monitoring a resident's condition, proceed with an assessment / evaluation of the resident's status, reporting changes in condition to the physician, obtaining physician's orders, following physician's recommendations/orders, documenting clinical findings and orders within the medial record (SBAR/progress note) as well as complete and document notifications of the change in status to the MD/PCP and resident/resident's representative accordingly. We are using the education on abuse, neglect, and exploitation as an opportunity for our team members. Date completed: 10/4/2023 10:00PM Director of Nursing / Assistant Director of Nursing will ensure all licensed nursing staff to include anyone on leave/agency/PRN staff will be in serviced prior to working next shift. Director of Nursing / Assistant Director of Nursing will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. The trainings will also be conducted with new hires. Date completed 10/4/2023. Director of Nursing / Assistant Director of Nursing in-serviced all C.N.As and M.As prior to assuming their next shift regarding reporting changes in residents' condition to the licensed nurse. Date of completed: 10/5/2023. All staff will be in-serviced on Abuse, Neglect and Exploitation- Prevention, Identification, Protecting and Reporting. This is used for educational purposes. Date Commenced: 10/4/2023 Date to be completion: 10/5/2023 Community Director of Nursing / ADON will ensure all licensed nurses on leave/agency/PRN staff are in serviced prior to working their shift. Community Director of Nursing / Designee will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. Monitoring Response The Director of Nursing/Assistant Director of Nursing will conduct 3 random audits per week of diabetic patients' plan of care and physician orders to validate the prescribed plan of care is being followed specifically reviewing orders for blood glucose monitoring for both labs being monitored and/or routine finger-stick blood glucose accu-checks monitoring as prescribed by the medical provider. The Director of Nursing/Assistant Director of Nursing will conduct random interviews during random shifts to ensure licensed nurses are able to identify signs and symptoms of hyper/hypoglycemia. Director of Nursing/Assistant Director of Nursing will also conduct daily reviews during the clinical start-up meeting (1-7days per week) to review new admissions, new orders for diabetic blood glucose monitoring ordered, review the 24hr report, pertinent progress notes, and SBARs (changes in condition documentation) to ensure that appropriate interventions are in place and to identify additional follow up interventions has been assigned. This plan will remain in place for the next 1-2 months to ensure compliance or to identify any further training needs. Findings of those observations will be reported to the QAPI committee during monthly meeting for the next 1- 2 months. On 10/6/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of the facility's Diabetic Management policy updated 10/4/23 indicated the policy had been updated to include both hyper and hypo-glycemia signs and symptoms and what to do in the event of a resident experiencing hyper or hypo-glycemia. Record review of a random selection of residents with diagnosis of diabetes who receive insulin's orders indicated orders had been updated to include blood glucose parameters and to notify the physician if the resident's blood sugar was outside of the parameters. Record review of the Ad Hoc QAPI meeting sign in sheet dated 10/4/23 indicated a QAPI meeting had been conducted regarding the above failure. Interviews with licensed nurses (LVN D, LVN E, RN F, LVN G, LVN H, and LVN J) on 10/6/23 between 9:17 a.m. and 10:35 a.m. were performed. During these interviews the nurses were able to name signs and symptoms of hyper and hypo-glycemia, blood sugar parameters and when to notify the physician, all types of abuse, what to do in the event of witnessed of reported abuse, and documentation of clinical findings and physician notification. Interviews with CNAs (CNA K, CNA L, CNA M, CNA N, and CNA P) on 10/6/23 between 9:17 a.m. and 10:35 a.m. were performed. During these interviews CNAs were able to identify changes in condition, when to report a change in condition, who to report a change in condition to, all types of abuse and what to do in the event of witnessed or reported abuse. On 10/6/23 at 10:39 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 4 (Resident #1) residents reviewed for quality of care. 1. The facility failed to monitor Resident #1's condition following elevated blood sugar readings. 2. The facility failed to notify Resident #1's physician of elevated blood sugars resulting in her being sent to the emergency department unresponsive and with a blood sugar of 946 (normal blood sugar ranges are 70-110) 3. The facility's Diabetic Management policy failed to address high blood sugars. 4. The facility failed to include blood sugar parameters for physician notification in Resident #1's physician orders. These failures resulted in an identification of an Immediate Jeopardy (IJ) at 3:00 p.m. on 10/4/23. While the IJ was removed on 10/6/23 at 10:39 a.m., the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could result in diabetic residents suffering injury, hospitalization, or death related elevated blood sugars Findings include: Record review of a face sheet dated 10/6/23 indicated Resident #1 was a [AGE] year-old female admitted to the facility om 3/3/04 with diagnoses including diabetes, dementia, major depressive disorder, and hypertension (elevated blood pressure). Record review of the MDS assessment dated [DATE] indicated Resident #1 was understood by others and usually understood others. The MDS indicated Resident #1 had a BIMS score of 09 and was moderately cognitively impaired. Record review of the care plan last updated 8/31/23 indicated Resident #1 had diabetes and was at risk for complications associated with diabetes such as frequent infections, diabetic wounds, vision impairment, and hyper\hypo-glycemia. Interventions included administer medications as recommended by the doctor, monitor labs as indicated, and promptly report abnormal labs results and significant clinical findings to the doctor. Record review of the physician orders dated 10/4/23 indicated Resident #1 had an order for Humalog (a fast-acting insulin to treat diabetes) 100u/ml inject 14 unit subcutaneously before meals related to diabetes starting 9/4/23. The physician orders indicated Resident #1 had an order for Lantus (a long-acting insulin to treat diabetes) 100u/ml Inject 12 unit subcutaneously two times a day for diabetes starting 9/4/23. Record review of the MAR indicated on 9/24/23 Resident #1 had a blood sugar readings of 409 at 7:00 a.m., 502 at 12:00 p.m., and 600 at 5:00 p.m. Record review of the nursing progress notes dated 9/24/23 indicated there had not been physician notification regarding the three elevated blood sugar readings. Record review of the nursing progress note dated 9/25/23 at 3:50 a.m. written by RN A indicated she had, received a phone call from the 2:00 p.m.-10:00 p.m. nurse stating that she had forgotten to tell me about [Resident #1's] p.m. blood sugar. I checked the resident's blood sugar and the reading was HI [blood sugar reading greater than 600] . Call placed to [the physician] and received voicemail that instructed me to text and wait for response. Awaiting response. Record review of the nursing progress dated 9/25/23 at 4:20 a.m. written by RN A indicated Spoke with [the NP]. Order received to recheck blood glucose [on Resident #1]. Blood glucose rechecked and still reads HI. 4:40 a.m. called [the NP] and new order received. 4:50 a.m. [Resident #1] was given 10units of Humalog Insulin. Record review of the nursing progress note dated 9/25/23 at 5:50 a.m. written by RN A indicated Recheck of [Resident #1's] blood glucose revealed glucometer still reading HI. Call placed to [the NP] and was instructed to send resident to hospital. EMS called and resident transferred to [hospital]. Record review of the hospital record dated 9/25/23 indicated Resident #1 admitted to the emergency department via EMS after being found unresponsive at the facility. The hospital records indicated RN A reported Resident #1 had been found unresponsive at approximately 3:00 a.m. The hospital records indicated RN A reported Resident #1 had a blood glucose reading of HI and continued to have an undetectable blood glucose reading. The hospital records indicated due to the undetectable blood glucose reading the decision was made to send Resident #1 to the hospital. The hospital records indicated Resident #1 was sedated and intubated. The hospital records indicated Resident #1 had a blood glucose reading of 946. Record review of the hospital Discharge summary dated [DATE] indicated Resident #1 had diagnoses including diabetic ketoacidosis with coma related to diabetes (a process that forms toxic acids known as ketones (measure in the blood or urine and high blood sugar resulting in coma) and non-ST elevated myocardial infarction (heart attack). During an interview on 10/4/23 at 1:45 p.m. RN B said the facility did not have standing orders to add blood sugar parameters of when to notify the physician for blood sugar readings if too high or too low. RN B said some residents did have individualized parameters in place for when to notify the physician regarding their blood sugars. RN B said blood sugar parameters of when to notify the physician were normally if the blood glucose level was less than 60 or greater than 400. RN B said if she had a resident who had a blood sugar of 400, 500, or 600 she would notify the physician. RN B said physician notification and new orders should have been documented. During an interview on 10/4/23 at 1:49 p.m. The NP said she remembered receiving a phone call at approximately 4:30 a.m. on 9/25/23 regarding Resident #1's blood sugars. The NP said she had not been previously notified of Resident #1 having an elevated blood sugar. The NP said the 10:00 p.m.-6:00 a.m. nurse had called her and informed her the nurse who had worked 2:00 p.m.-10:00 p.m. the previous shift called the 10:00 p.m.-6:00 a.m. nurse at approximately 3:00 a.m. and told her she had forgot to let her know about Resident #1's elevated blood sugar. The NP said the 10:00 p.m.-6:00 a.m. nurse did not have current vital signs or a current blood sugar for Resident #1 when she called. The NP said the 10:00 p.m.-6:00 a.m. nurse told her she waited 1.5 hours to notify her of Resident #1's elevated blood sugars from the previous shift because she was passing medications. The NP said she gave orders for Resident #1's blood sugar to be checked. The NP said when she received to blood sugar results she gave an order to administer insulin and recheck in one hour. The NP said when the nurse called her back after re-checking Resident #1's blood sugar an hour later the nurse informed her Resident #1 was unresponsive. The NP said she gave an order for Resident #1 to be transported to the emergency department for evaluation. The NP said she was not informed of Resident #1's blood sugar being 946 when she arrived at the hospital. The NP said she expected the nurses to notify her of a blood sugar of 400 or greater. During an interview on 10/5/23 at 12:38 p.m. RN A said she was employed at the facility since March 2023. RN A said on 9/25/23 at approximately 4:00 a.m., the nurse who worked the 2:00 p.m.-10:00 p.m. shift on 9/24/23 called and informed her she had forgot to tell her Resident #1's blood sugar was high. RN A said she immediately went to take Resident #1's blood sugar and it only read high. RN A said she called the physician and when he did not answer she waited approximately 30 minutes and then called the on-call for the administration. RN A she spoke RN B who was on-call for administrative call and was told to call the NP. RN A she called the NP and was told to administer 10u of Humalog and recheck in 1 hour RN A said Resident #1 was not very responsive when she administered the Humalog. After re-checking the blood sugar and it was still HI, she reported to NP, and called 911. She said Resident #1 was semi-conscious when she left for the hospital. RN A said she was unsure whether the facility had standing parameters of when to notify a physician regarding blood sugars. RN A said the physician or NP should have been notified if the glucometer read HI when checking a blood sugar. RN A said a glucometer reading of HI was usually over 600. RN A said she would probably notify the physician of a blood sugar reading of 400 or 500. During an interview on 10/6/23 at 2:59 p.m. LVN C worked a double shift from 6:00 a.m.-10:00 p.m. on 9/24/23. LVN C said she did not notify the physician of Resident #1's elevated blood sugars because she got sidetracked. LVN C said she should have notified the physician and just did not do it. LVN C said she did not think about Resident #1's elevated blood sugars again until approximately 1:00 a.m. LVN C said jumped up and called the night nurse at that time. LVN C said she did not tell the nurse about Resident #1's elevated blood sugars during report due to the fact she had forgotten about it. LVN C said she called back the next morning and found out Resident #1 had been sent to the hospital. During an interview on 10/6/23 at 3:17 p.m. the DON said she expected the nurses to report any blood sugar over 400 to the physician or NP immediately. Record review of the undated EvenCare G2 Blood Glucose Monitoring System's Healthcare Professional Operator's Manual indicated a reading of HI meant the patient's blood glucose was greater than 600. Record review of the facility's Diabetic Management policy last revised January 2023 indicated, Diabetic Management involves both preventative measures and treatment of complications .The interdisciplinary team assesses the diabetic resident/patient upon admission, validated the orders with the attending physician and initiates plan of care that may include: blood glucose monitoring as ordered .Blood glucose measurements shall be take per the physician order. Results outside of order parameters should be communicated to the physician per orders .Acute Complication Management: It is best practice to avoid hypoglycemic events in the older adult .For acute events, the clinical record shall include the following information: resident's condition indicated clinical presentation, blood glucose test levels, interventions provided, resident's response to treatment or interventions administered, and notification of the physician and any new orders . The Administrator was notified on 10/4/23 at 3:22 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 10/4/23 at 3:26 p.m. The facility's Plan of Removal was accepted on 10/5/23 at 4:48 p.m. and included: Situation: Resident # 1 was discharged to the hospital on 9-5-23 due to a change in condition. Resident #1 was diagnosed and treated for Urinary Sepsis secondary ESBL secondary chronic indwelling foley catheter. Resident re-admitted to facility on 9-10-23 with a diagnosis of Urinary Sepsis as well as Diabetes Mellitus. Resident #1 was being treated with antibiotic therapy and completed the regimen on 9-15-23 as per physician's orders. On 9/24/23 Resident # 1 presented with abnormal blood glucose levels and on 9/25/23 Resident #1 experienced an acute change in condition. Upon identifying the change in condition, the nurse evaluated the patient's condition, notified the physician and at 4:40am nurse received new orders to administer Humalog 10units, at 5:50am the nurse re-checked the blood glucose following the administration of the insulin and the nurse notified the medical provider and received new order to send Resident #1 to the emergency department for evaluation and treatment. Outcome: Resident was admitted and treated in the hospital on 9/25/23, was noted to be at medical and cognitive baseline and has been readmitted to facility on 10/3/23. Regional Nurse Consultant re-educated the Director of Nursing / Assistant Director of Nursing regarding the expected management of a diabetic patient, assessing/evaluating and responding to the urgent needs of the diabetic patient based on presenting symptoms of hyper and hypoglycemia, observing and monitoring a resident's condition, evaluation of the resident's status, reporting changes in condition to the physician, obtaining physician's orders, following physician's recommendations/orders, documenting clinical findings and orders within the medial record (SBAR/progress note) as well as complete and document notifications of the change in status to the MD/PCP and resident/resident's representative accordingly. Date commenced: 10/4/23. Date of completion: 10/4/23 The Director of Nursing Services/Assistant Director of Nursing conducted education to all licensed nurses regarding the expected management of a diabetic patient, how to respond to signs and symptoms of hyper/hypoglycemia, assessing/evaluating and responding to the needs of the diabetic patient based on presenting symptoms of hyper and hypoglycemia, reviewing and validating the plan of care with regards to blood glucose monitoring, sliding scale insulin orders routinely and/or as needed, prescriber's plan of care and management of the diabetic resident and following physician's orders/recommendations. Date completed: 10/4/2023. The Director of Nursing Services/Assistant Director of Nursing conducted education to all licensed nurses regarding the process for observing and monitoring a resident's condition, proceed with an assessment / evaluation of the resident's status, reporting changes in condition to the physician, obtaining physician's orders, following physician's recommendations/orders, documenting clinical findings and orders within the medical record (SBAR/progress note) as well as complete and document notifications of the change in status to the MD/PCP and resident/resident's representative accordingly. Date commenced: 10/4/2023. Date to be completion: 10/4/2023. Risk Response: All residents who are diabetic may potentially be affected by the deficient practice. Administrator and Director of Nursing and Medical Director conducted an Ad Hoc QAPI to review issue and community's response plan in place. Date to be completed: 10/5/2023. Director of Nursing Services/Assistant Director of Nursing Services completed a 100% audit on all residents who receive insulin. Physician orders were audited to ensure blood sugar parameters where in place as well as notifications to the MD/NP with the indicated parameters for all residents who receive insulin. Date completed: 10/4/2023. The Director of Nursing / Assistant Director of Nursing/Licensed Nurse will review all diabetic patients' current plan of care with the attending MD/NP to ensure that the appropriate orders are in place per MD/NP's prescribed plan of care and confirm accuracy of diabetic management orders. The nurse will document the MD/NP's orders should any new or changes in the plan of care be provided by the prescriber. Date completed: 10/4/2023. Systemic Response: Inservice training & re-education will be provided to all licensed nurses regarding topics: Director of Nursing / Assistant Director of Nursing conducted retraining for all licensed nursing staff prior to assuming next shift/assignment. Inservice topics included but not limited to the following: the expected management of a diabetic patient, how to respond to signs and symptoms of hyper/hypoglycemia. assessing/evaluating and responding to the needs of the diabetic patient based on presenting symptoms of hyper and hypoglycemia, reviewing and validating the plan of care with regards to blood glucose monitoring, sliding scale insulin orders routinely and/or as needed, prescriber's plan of care and management of the diabetic resident and following physician's orders/recommendations. The process for observing and monitoring a resident's condition, proceed with an assessment / evaluation of the resident's status, reporting changes in condition to the physician, obtaining physician's orders, following physician's recommendations/orders, documenting clinical findings and orders within the medial record (SBAR/progress note) as well as complete and document notifications of the change in status to the MD/PCP and resident/resident's representative accordingly. Date completed: 10/4/2023. 10:00PM Director of Nursing / Assistant Director of Nursing will ensure all licensed nursing staff to include anyone on leave/agency/PRN staff will be in serviced prior to working next shift. Director of Nursing / Assistant Director of Nursing will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. The trainings will also be conducted with new hires. Date completed: 10/4/2023. Director of Nursing / Assistant Director of Nursing in-serviced all C.N.As, and M.As prior to assuming their next shift regarding reporting changes in residents' condition to the licensed nurse. Date completed: 10/5/2023 All staff will be in-serviced on Abuse, Neglect and Exploitation, Prevention, Identification, Protecting and Reporting. This is for educational purposes for our employees. Date Commenced: 10/4/2023 Date to be completion: 10/5/2023 Community Director of Nursing / ADON will ensure all licensed nurses on leave/agency/PRN staff are in serviced prior to working their shift. Community Director of Nursing / Designee will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. Monitoring Response for the plan of correction. The Director of Nursing/Assistant Director of Nursing will conduct 3 random audits per week of diabetic patients' plan of care and physician orders to validate the prescribed plan of care is being followed specifically reviewing orders for blood glucose monitoring for both labs being monitored and/or routine finger-stick blood glucose accu-checks monitoring as prescribed by the medical provider. The Director of Nursing/Assistant Director of Nursing will conduct random interviews during random shifts to ensure licensed nurses are able to identify signs and symptoms of hyper/hypoglycemia. Director of Nursing/Assistant Director of Nursing will also conduct daily reviews during the clinical start-up meeting (1-7days per week) to review new admissions, new orders for diabetic blood glucose monitoring ordered, review the 24hr report, pertinent progress notes, and SBARs (changes in condition documentation) to ensure that appropriate interventions are in place and to identify additional follow up interventions has been assigned. This plan will remain in place for the next 1-2 months to ensure compliance or to identify any further training needs. Findings of those observations will be reported to the QAPI committee during monthly meeting for the next 1- 2 months. On 10/6/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of the facility's Diabetic Management policy updated 10/4/23 indicated the policy had been updated to include both hyper and hypo-glycemia signs and symptoms and what to do in the event of a resident experiencing hyper or hypo-glycemia. Record review of a random selection of residents with diagnosis of diabetes who receive insulin's orders indicated orders had been updated to include blood glucose parameters and to notify the physician if the resident's blood sugar was outside of the parameters. Record review of Resident #1's physician orders for insulin indicated she had insulin orders starting 10/4/23 which included diabetic parameters to notify the physician for blood sugar readings of less than 60 or greater than 400. Record review of the Ad Hoc QAPI meeting sign in sheet dated 10/4/23 indicated a QAPI meeting had been conducted regarding the above failure. Interviews with licensed nurses (LVN D, LVN E, RN F, LVN G, LVN H, and LVN J) on 10/6/23 between 9:17 a.m. and 10:35 a.m. were performed. During these interviews the nurses were able to name signs and symptoms of hyper and hypo-glycemia, blood sugar parameters and when to notify the physician, all types of abuse, what to do in the event of witnessed of reported abuse, and documentation of clinical findings and physician notification. Interviews with CNAs (CNA K, CNA L, CNA M, CNA N, and CNA P) on 10/6/23 between 9:17 a.m. and 10:35 a.m. were performed. During these interviews CNAs were able to identify changes in condition, when to report a change in condition, who to report a change in condition to, all types of abuse and what to do in the event of witnessed or reported abuse. On 10/6/23 at 10:39 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.