Health inspection·September 7, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that 1 (R#1) of 30 residents with diagnoses of diabetes reviewed for professional standards, received care in accordance with professional standards of practice and the comprehensive person-centered care plan. Residents Affected - Some During R #1's admission medication reconciliation process and throughout his stay, the facility failed to attempt to attain an order for blood glucose monitoring, despite his daily administration of three different diabetic oral medications and decreased appetite. R #1 became lethargic with an altered mental status on 08/31/23 at approximately 7:30 AM until he was transferred to the hospital at 3:42 PM without appropriate physician intervention. R #1 was admitted to the intensive care unit of the hospital with a blood glucose level of 1160 mg/dL (normal reference range 70-100), required an IV mediation intervention for his low blood pressure, and positive pressure ventilation to assist with his breathing. The facility Administrator and DON were notified on 09/04/23 at 3:42 PM, that an Immediate Jeopardy situation had been identified due to the above failures. While the IJ was removed on 09/07/23 at 11:00 AM, the facility remained out of compliance at a scope of pattern and a severity level of actual harm. This failure could affect residents who resided in the facility who had Diabetes by causing a decline in their quality of care and quality of life due to the effects of lack of diabetic monitoring and medication administration. The findings included: Record review of R#1's Face Sheet, dated 09/02/2023, documented a [AGE] year-old male admitted on [DATE] with the diagnoses of: Type 2 Diabetes Mellitus (a metabolic disease, involving inappropriately elevated blood glucose levels) with Diabetic Polyneuropathy (simultaneous malfunction of many nerves throughout the body), abnormal weight loss, anorexia (an eating disorder that causes people to weigh less than is considered healthy for their age and height, usually by excessive weight loss), and chronic kidney disease (the kidneys are damaged and cannot filter blood as well as they should). Record review of R#1's comprehensive care plan dated 06/05/2023 documented, Focus: I have chronic health conditions & comorbid conditions that have affected my physical function and may further affect my quality of life. Diabetes, Heart disease, Poor Kidney Functioning. Goal: I will be free from complications associated with co-morbid/poor health, medical problems and will maintain quality of life through my next review date. Interventions: administer my medications, treatments, respiratory Page 1 of 31 676313 676313 09/07/2023 Laredo Nursing and Rehabilitation Center 1701 Tournament Trail Dr Laredo, TX 78041

F 0684 Level of Harm - Immediate jeopardy to resident health or safety treatments/therapy and diet as recommend by physician, provide care as tolerated and needed, labs as ordered & report abnormal findings to MD as indicated. Record review of R#1's Minimum Data Set assessment dated [DATE] revealed he: -had clear speech Residents Affected - Some -sometimes understood self and sometimes understood others -had a brief interview of mental status score of 0-severly impaired cognition -required extensive assistance with two-person physical assist for bed mobility and transfers. As well as required extensive assistance with one-person assist with dressing and personal hygiene. -had Diabetes Mellitus Record review of R#1's admission medication reconciliation progress note documented by LVN N dated 05/24/2023 revealed, medication reconciliation clarified with MD: - metFORMIN HCl Oral Tablet 1000 MG Give 1 tablet by mouth two times a day for DM - Tradjenta Oral Tablet 5 MG Give 1 tablet by mouth one time a day for DM - Glimepiride Oral Tablet 4 MG Give 1 tablet by mouth two times a day for diabetes. - There were no blood glucose monitoring included in the reconciliation. Record review of R#1's Medication Administration Record dated 08/01/2023-08/31/2023 revealed Start Date:06/29/2023 Metformin HCl Oral Tablet 500 MG (Metformin HCl) Give 1 tablet by mouth one time a day related to TYPE 2 diabetes mellitus with diabetic polyneuropathy; state date:05/24/2023 Tradjenta Oral Tablet 5 MG (Linagliptin) Give 1 tablet by mouth one time a day for DM and Glimepiride Oral Tablet 4 MG (Glimepiride) Give 1 tablet by mouth two times a day for diabetes, were administered through August 2023. Record review of R#1's Blood Sugar Summary dated 05/23/2023 20:40 (8:40PM) revealed R#1 had a blood sugar reading of 120 mg/dL (reference: High of 99.0 exceeded) Record review of R#1's laboratory results date collected 05/23/2023, date received in lab 05/24/2023, revealed R#1's glucose result of 99mg/dL (reference range 70-100) and A1C result of 8.3 (reference range: less than 6.0) Record review of progress note dated 05/29/2023 documented by GVN A, revealed .Resident noted eating dinner by himself without any difficulty, notified RP and will continue to monitor. Record review of R#1's laboratory results date collected 08/09/2023, date received in lab 08/09/2023, revealed R#1's glucose result of 226 mg/dL (reference range 70-100) and A1C result of 7.3 (reference range: less than 6.0) Record review of progress note dated 08/11/2023 documented by LVN N, documented, MD reviewed lab results done on 8/9/23. no new orders given. RP made aware. 676313 Page 2 of 31 676313 09/07/2023 Laredo Nursing and Rehabilitation Center 1701 Tournament Trail Dr Laredo, TX 78041

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Record review of R#1's progress notes dated 08/31/2023 at 07:30AM documented by LVN D documented the change in condition reported on this CIC Evaluation are/were: Other change in condition at the time of evaluation resident/patient vital signs, weight and blood sugar were: - Blood Pressure: BP 121/79 - 8/31/2023 17:14 - Pulse: P 64 - 8/31/2023 11:14 Pulse Type: Regular - RR: R 18.0 - 7/11/2023 19:50 - Temp: T 97.8 - 7/12/2023 13:07 - Weight: W 153.0 lb - 8/8/2023 13:53 - Pulse Oximetry: O2 100.0 % - 7/12/2023 13:07Method: Room Air - Blood Glucose: BS 120.0 - 5/23/2023 20:40 Relevant medical history is: Dementia Diabetes Chronic Renal Failure/ESRD Code Status: DNR Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were: - Mental Status Evaluation: Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse) - Functional Status Evaluation: Needs more assistance with ADLs - Neurological Status Evaluation: Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse) Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: Telemed Appointment scheduled for the 9/1/23 between 8-12noon to speak to MD NP. - There was no current blood glucose level documented on the evaluation. Record review of R#1's progress notes dated 08/31/2023 at 07:30AM documented by LVN D documented, While SN was passing out medications CNA informed SN that resident does not want to eat breakfast, SN asked if he ate yesterday but was told he did not. Assess, resident is alert, but does not follow command or oriented.SN noticed resident was lethargic but will resist to touch. BP 121/73, HR 79, R 18, T 97.8 and high blood glucose. Lung's sound clear, abdomen soft and non-tender. Called MD office and spoke to medical assistance who schedule a telemed appointment for tomorrow 8/31/23 between 8 and 12 noon for patient to visit MD nurse practitioner. Per RP, resident should be sent to the hospital for further evaluation. Report given to incoming nurse. Record review of R#1's progress notes dated 08/31/2023 at 15:42 (3:42PM), documented by LVN A, revealed Res. picked up by [ambulance company] going to [hospital]. accompanied by family member. Vital 676313 Page 3 of 31 676313 09/07/2023 Laredo Nursing and Rehabilitation Center 1701 Tournament Trail Dr Laredo, TX 78041

F 0684 signs as follows: BP 121/98 P75 R 18 Temp. 97.6 BS 'HI. MD: DON notified. Level of Harm - Immediate jeopardy to resident health or safety Record review of emergency room documentation dated on 08/31/2023 revealed, critical condition(s) addressed for impending deterioration include: airway, respiratory, cardiovascular, central nervous system, metabolic, DKA, and diagnosis' Hypernatremia, Acute kidney injury superimposed on chronic kidney disease, Altered mental, Constipation, Hyperkalemia, Septic shock, DKA (diabetic ketoacidosis). Residents Affected - Some Record review of hospital attending physician's progress note dated 09/02/2023 revealed, R#1 was brought into the emergency department at [NAME] Medical Center on August 31, 2023, in the evening at 6 p.m., sent from the nursing home with report of the patient with altered mental status and high glucose level. Bedside glucometer unable to register the patient's glucose level. On initial presentation to the emergency department, the patient was found to be hypotensive, blood pressure was 80/39. He was severely hyperglycemic, glucose of 1160 with altered mental status. Ketone was positive. The patient initially was admitted with diagnosis of DKA, started on DKA protocol. History according to the wife and the daughter, over the last week prior to this presentation, the patient's mental status has decreased. He was lethargic, less interactive with decreased oral intake. Over the last 3 days, the patient with apparently no oral intake of fluid or food, became nonverbal. On day of presentation, he was unresponsive, delirious, and agitated, brought into the emergency department via ambulance. During an observation on 09/03/2023 at 10:26 AM R#1 was in the ICU, R#1 was in bed, with different fluids running. R#1 had lactated ringer running at 125mL/HR and was also on blood pressure medication assistance Levophed drip. R#1 also had tube feedings running through a nasogastric tube and was on BiPap respiratory support with setting: rate: 20 breath per minute, oxygen:40%. R#1 opened his eyes when ICU Nurse was notifying him that she and her aide were going to turn R#1. Attempted interview with R#1 but did not respond to questions. During an interview on 09/02/2023 at 2:32 PM with the DON, the DON stated if there were a change of condition nurses are expected to perform an assessment and notify physician. The DON stated the expectation of the facility was if any CNAs noticed any change with residents, they would notify the nurse. The DON stated on 08/31/2023 the DON performed an assessment on R#1 and stated vitals were stable, R#1 presented with Altered Mental Status and lethargy. The DON stated the PCP was notified, and stated the facility was told that the PCP's office would schedule tele-med appointment the following day 09/01/2023. The DON stated during her assessment on 08/31/2023, R#1's breathing pattern were stable, and concluded there was not a sense of urgency that warranted an immediate need to send to out to hospital. The DON stated at the request of R#1's spouse, the spouse did not want to wait for the PCP's tele-med appointment that was scheduled for 09/01/23 the following day. The DON stated there were several attempts to call doctor, she stated they called earlier that day of 08/31/2023 and again during lunch on the same day. The DON stated the family initially wanted to send R#1 to the PCP's office, then changed their mind to transfer R#1 to ER due to not wanting to wait till the following day 09/01/2023. The DON determined that there was no need for an immediate need to call 9-1-1 or emergent services but stated something did need to be done for R#1. When asked about the process for medication reconciliation upon admission, the DON stated the admitting nurse will submit referral to the PCP's office, and the PCP's office will either continue home/hospital medications or discontinue medications, it is at the discretion of the physician. The DON stated, when asked about R#1's labs that were taken on 8/9/2023 that resulted a glucose value of 226mg/dL (reference range 70-100), she stated the value was high, and would require insulin in her professional opinion. The DON stated she did not know the blood glucose laboratory results were 226mg/dL and in this case should have inquired to see if physician would give order for glucose checks daily. The DON stated there was no reason 676313 Page 4 of 31 676313 09/07/2023 Laredo Nursing and Rehabilitation Center 1701 Tournament Trail Dr Laredo, TX 78041

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some why he shouldn't have glucose monitoring and theorized that the staff may have been focused on critical values. The DON stated in her professional opinion accu checks (blood glucose monitoring) would be warranted for R#1 due to him taking three anti-diabetic medications. During the interview with the DON, we both concurrently were looking at progress notes, and the DON stated she could not find any progress note that documented an inquiry to the PCP for R#1 to have accu checks. When asked why the facility did not inquire about accu checks, the DON stated the clinical staff follow physician's orders. The DON stated whenever the facility sends out residents during discharges and transfers, as part of the discharge process the facility will perform an accu check and upon R#1's discharge to hospital the glucose monitor read high on 08/31/2023. The DON stated R#1 had a rapid decline and was hospitalized on [DATE]. During an interview on 09/02/2023 at 3:34PM, CNA A stated on Wednesday 08/23/2023 R#1 was bathed in the morning and did not see anything out of ordinary. CNA A stated she noticed a difference in R#1's demeanor and worked with R#1 from 08/24-08/27. CNA A stated on Wednesday 8/30 upon her return to work, she assisted R#1 to eat but saw a difference in eating and demeanor. CNA A stated R#1 was no longer able to hold cutlery or feed self effectively and notified LVN A on 08/30/2023. During an interview on 09/02/2023 at 4:24PM, LVN A stated she took care of R#1 on 08/23 during her 2-10shift. LVN A stated she did not interact with resident for that long when she admitted him to the LTC side on 08/23/23 and when vitals were okay, she left R#1 and attended other patients. LVN A stated she remembers R#1 was non-verbal and stated the only time she knew R#1 was diabetic, was when R#1 left to the hospital on 8/31, and as a discharge practice, the glucose was checked. She stated R#1 did not show signs of hypo/hyper glycemic symptoms on 08/31 upon leaving to hospital. LVN A stated he looked fine on 08/31/23. LVN A stated R#1 was moved to unit on 08/23/23 and was her patient from 08/24-31 and as part of her job was to take care of her residents. LVN A Stated she did not check blood sugar because there was no order from the physician to do and did not inquire to doctor's office for blood sugar reading due to R#1's appearance of looking fine. LVN A stated she was not made aware of R#1 not eating. During an interview on 09/03/2023 at 5:31 PM with LVN D, LVN D stated on 08/31/2023, a CNA notified her that R#1 did not want to eat, and went into R#1's room, assessed R#1, and stated R#1 exhibited signs of lethargy, but would open eyes then close eyes. LVN D stated R#1, during her assessment, R#1 seemed like he was trying to say something, and when she attempted to touch R#1 to arouse resident, he resisted a little bit, then attempted to give juice to R#1 and tolerated a small amount of fluid well. LVN D stated she attempted more than five times on 08/31/23, to speak to the PCP's office, and stated she does not remember at what time she got a hold of the PCP's office. LVN D stated when she did speak to the PCP's office on 08/31/23, LVN D spoke with the PCP's medical assistant, and notified the medical assistant, of R#1's lethargy but normal vital signs, to which the medical assistant told LVN D, she would notify the doctor, but that she was going to schedule a tele-med appointment for the following day 09/01/23, with the Nurse Practitioner. LVN D said she did not request to immediately speak to the physician after she was given the telemed appointment. LVN D stated, during her conversation with the medical assistant on 08/31/2023 she told the medical assistant vital signs and was aware that he was a diabetic patient. LVN D stated she sometimes can check medical history but did not look at R#1's medical history because it was too early in the morning and worked the 6am-2pm shift on 08/31/2023. LVN D stated, when she was speaking with the PCPs office, she attempted to advocate for resident to either get labs, and requested for anything from the PCP's office. LVN D stated she does not know if doctor called back, stated she gave report to the incoming nurse (2pm-10pm). LVN D stated an accu check (glucose monitoring) would have been beneficial to perform to see if resident was hypoglycemic/hyperglycemic but reiterated vitals 676313 Page 5 of 31 676313 09/07/2023 Laredo Nursing and Rehabilitation Center 1701 Tournament Trail Dr Laredo, TX 78041

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some were stable and did not check blood glucose or request an order to check the blood glucose level. LVN D stated the family member of R#1 entered R#1's room in the morning after breakfast, R#1 did not eat, but would drink a little fluid. LVN D stated the family member expressed concern of R#1's lethargic state, to which LVN D stated, she told the family member she called the PCP's office, and was waiting for doctor to get back to LVN D. LVN D stated the family member of R#1 advocated for resident to be sent to hospital. LVN D stated she notified the DON and proceeded to call for an ambulance. LVN D stated she would need a physician's order to send out to hospital. LVN D stated after family member's insistence R#1 was sent to the hospital, LVN D stated she called doctor's office and notified the doctor's office that they were sending R#1 to the hospital, due to the family member asking, and sent R#1 to hospital. LVN D stated the situation with R#1 was her first urgent situation, and stated she was nervous, but that the NF gave her education on how to proceed with a change in condition, notify DON, and RP. LVN D stated she was aware that a medical assistant was not a physician or physician representative that could provide orders or conduct assessments. R #1 continued with a symptom of lethargy, not within his normalcy, for an entire first shift and entering the second shift, without physician awareness and assessment until he was sent to the hospital on [DATE] after 3:00 PM During an interview on 09/04/2023 at 12:08 PM with LVN N, LVN N stated he was made aware by the facility of the reasoning for this interview regarding R#1. LVN N stated he knew R#1 for a while and was R#1's admitting nurse. LVN Nstated the process for medication reconciliation was to fax the medication list that residents enter the facility with, either medications they take at home or medication that are sent with residents from the hospital. LVN N stated once the medication list is faxed, he will follow up and call the PCP's office to go over each medication on the medication reconciliation form and would be given instructions to either continue with the medication regimen the residents enter the facility with or to discontinue regimen. The LVN N stated he knew to call the doctor's office when he needed orders and would call sometimes for emergency orders. LVN N stated he did go over R#1's medications, which did include diabetic medications, and when speaking to the PCP's office, he was instructed to continue with R#1's current medication regimen, including the diabetic medications, and did not receive an order for glucose monitoring and did not ask for glucose monitoring. When LVN N was asked why he did not ask for a glucose monitoring order for R#1, LVN N stated he follows physician orders. LVN N stated he does take care of residents that are diabetic. LVN N stated when he is taking care of residents that are diabetic, he does look for blood sugar monitoring order and diabetic medications. LVN N stated, when asked why he did not inquire about glucose monitoring for R#1, who was taking diabetic medications, he stated he follows doctor's order and will only check blood sugars with residents are on insulin. During an interview on 09/03/2023 at 10:26AM with the ICU Nurse, stated R#1 was admitted on [DATE] into the Emergency Department at the local hospital. ICU nurse stated R#1 was admitted for Diabetic Ketoacidosis, Hyperglycemia, Septic Shock and Acute Kidney Failure. The ICU nurse stated R#1's admitting glucose reading was 1160mg/dL. The ICU Nurse stated R#1 received an xray with findings that showed moderately size Right Lower Lobe Infiltrate (a substance denser than air, such as pus, blood, or protein, which lingers within the lungs), the ICU Nurse stated it could be fluid/pneumonia but could not definitively state what the infiltrate was. Currently, R#1 is on blood pressure support, and has begun to open eyes and was showing attempts of spontaneous responses. ICU Nurse stated upon R#1's admission, R#1's labs on 08/31/23 value for ketones were a moderate amount. ICU Nurse stated the amount of ketones in circulation could potentially have come from body not receiving adequate nutrition, and in response R#1's body could have begun metabolizing R#1's musculature. The ICU Nurse stated, the Nutritionist/Dietician documented that R#1 met the 676313 Page 6 of 31 676313 09/07/2023 Laredo Nursing and Rehabilitation Center 1701 Tournament Trail Dr Laredo, TX 78041

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some criteria of severe protein/calorie malnutrition. The ICU Nurse stated upon admission to the hospital, R#1 was not cognitively aware. During an interview on 09/03/2023 at 2:31PM with the Hospital Attending Physician (HAP), he stated R#1 was sent to the hospital due to R#1 being unresponsive and sugar was over 1000. The HAP stated DKA was very serious, and potentially could have led to death. The HAP stated DKA occurs when there is a high amount of sugar and acid in the body's system. The HAP stated R#1's DKA could have potentially been prevented. The HAP stated as a basic preventative measure for people with diabetes would be to monitor blood sugar and treat with diabetic medications. The HAP stated DKA could potentially affect vital organs and could have led to R#1's Acute Renal Failure on top of R#1's Chronic Kidney Failure. During an interview on 09/03/2023 at 3:22PM the primary care physician (PCP) stated, when a resident is admitted into the nursing facility, the nurses will submit medication reconciliation to doctors' office, and over the phone he will either continue or stop medications. For any additional orders the NF will call his office and notify via phone. The PCP stated he does not know why R#1 was not on glucose monitoring. The PCP stated he knew the resident forever and stated the facility may have called or not for order, but could not recollect, stated he has over 100 patients, and would expect if R#1 was on Diabetes Mellitus (DM) medications, the facility would inquire for glucose monitoring. The PCP stated R#1 has not been a long time diabetic and the lack of glucose monitoring was an oversight on his part. The PCP stated that he expected, as a collaborative effort with the clinical staff at the Nursing Facility (NF), if they see a need for a specific order, whether that's glucose monitoring or diabetic diet, to inquire about and notify him. The PCP stated he expected for the NF to advocate for the safety of all residents. The PCP stated he could not explain why R#1 was not on blood glucose monitoring, due to R#1 taking three DM medications and not on glucose checks, he stated it is a standard of care. The PCP stated if he was made aware of R#1 not having glucose checks, he would have ordered glucose checks for R#1. The PCP stated glucose checks were not only a routine of care but basic standard of care. The PCP stated his expectation of the NF would be to be proactive for patients and advocates for all residents' standard of care. The PCP stated not ordering glucose monitoring was an oversight and takes full responsibility. The PCP stated if R#1's glucose was not monitored, and R#1 was not eating, R#1 could become hypoglycemic which is severe. The PCP stated R#1 could have become too high, an incident like this (DKA) something could raise to an ungodly (critical) amount. The PCP stated he was first notified of R#1's current hospitalization on 09/02/2023. The PCP stated he does not recollect being notified about R#1's transfer to the hospital until 09/02/2023. The PCP stated 1160 blood glucose is absolutely a critical number. The PCP stated there must have been something inciting the incident either a UTI or Pneumonia, something triggered the high sugar. The PCP stated he does not recall being notified of R#1's lethargy or unconsciousness prior to R#1's hospitalization. The PCP stated the NF should have been monitoring glucose. Record review of the facility's Diabetes Management plan date implemented 03/12/19 and date reviewed/revised: January 2023, stated: Purpose: Diabetic Management involves both preventative measures and treatment of complications. Upon admission, the interdisciplinary team works together to implement a plan of care to minimize complications. Assessment: The interdisciplinary team assesses the diabetic resident/patient upon admission, validates the orders with the attending physician and initiates plan of care that may include: 676313 Page 7 of 31 676313 09/07/2023 Laredo Nursing and Rehabilitation Center 1701 Tournament Trail Dr Laredo, TX 78041

F 0684 Blood glucose monitoring as ordered Level of Harm - Immediate jeopardy to resident health or safety Preventative care measures as appropriate Residents Affected - Some Blood glucose measurements shall be taken per the physician order. Results outside of ordered parameters should be communicated to the physician per orders Routine care: 2.For acute events, the clinical record shall include the following information: .Blood glucose test levels . Notification of physician and any new orders. The facility Administrator and DON were notified on 09/04/23 at 3:42 PM, that an Immediate Jeopardy situation had been identified due to the above failures. On 09/06/23 at 12:08 PM, the facility was notified of the acceptance of the Plan of Removal (POR). The facility's Plan of Removal documented: Plan of Removal Immediate Jeopardy Commenced on: 9/4/2023 Situation: Resident # 1 noted with a diagnosis of Type 2 Diabetes Mellitus experienced an acute change in his condition on 8/31/23. The nurse evaluated the patient's condition, identified that he was presenting with s/s altered mental status. The nurse identified as Nurse B, checked Resident's #1 blood glucose level, the meter indicated that the reading was hi. Outcome: On 8/31/23 Nurse B then notified the physician's office of the hi blood glucose reading. Nurse B completed a change in condition SBAR and progress note describing the evaluation findings, physician's recommendations and notifications. [The physician] recommended a telehealth visit for the following day. However, the [family member] wanted the patient to be seen by physician at his office that same day. Since patient did not have an appointment, DON informed [family member] that she could send patient to the ER to which the [family member] agreed. Nurse B immediately sent Resident #1 to the emergency room for evaluation and treatment on 8/31/23. Resident #1 was admitted to the hospital and remains at the hospital. The Director of Nursing Services/Assistant Director of Nursing conducted re-education for the nurse identified as Nurse A regarding reviewing patient's plan of care to include physician's orders and care plan as well as diagnosis in order to identify diabetic patients under the nurse's care. Date commenced: 9/4/23 Date to be completion: 9/5/23 676313 Page 8 of 31 676313 09/07/2023 Laredo Nursing and Rehabilitation Center 1701 Tournament Trail Dr Laredo, TX 78041

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Director of Nursing / Assistant Director of Nursing conducted in-service training for the identified nurse (Nurse B) regarding the expected management of a diabetic patient, assessing/evaluating and responding to the needs of the diabetic patient based on presenting symptoms of hyper and hypoglycemia, and following physician's orders/recommendations. Also in-serviced on 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: 9/4/23 Date to be completion: 9/5/23 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: 9/4/23 Date of completion: 9/4/23 Risk Response: Residents who are diabetic and who are managed by oral medications without routine blood glucose monitoring efforts may potentially be affected by the deficient practice. Director of Nursing / Assistant Director of Nursing conducted retraining for all licensed nursing staff regarding the expected management of a diabetic patient to include: nurses should review patients under their care by review physician's orders, care plan and diagnosis so that diabetic diagnosis are known to ensure appropriate care and that physician's orders are being followed as prescribed, as well as monitoring for and responding to changes in condition for immediate consultation with the MD/NP for appropriate treatment. Evaluating and responding to the needs of the diabetic patient based on presenting symptoms of hyper and hypoglycemia and following physician's orders/recommendations. Also in-serviced on the process for observing and monitoring a resident's condition, conducting follow up evaluation of a resident's condition upon reports of a change of condition or status by a C.N.A., proceeding 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. Director of Nursing / ADON will ensure all licensed nursing staff will be re-educated to include anyone on leave/agency/PRN staff will be in serviced prior to working next shift. Community will 676313 Page 9 of 31 676313 09/07/2023 Laredo Nursing and Rehabilitation Center 1701 Tournament Trail Dr Laredo, TX 78041

F 0684 Level of Harm - Immediate jeopardy to resident health or safety 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 Commenced: 9/4/23 Date to be completion: 9/5/23 Residents Affected - Some 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 orders. The nurse will update the MD/NP's orders should any new or changes in the plan of care be provided by the prescriber. Date Commenced: 9/4/23 Date to be completion: 9/5/23 Administrator and Director of Nursing and Medical Director conducted an Ad Hoc QAPI to review issue and community's response plan in place. Date: 9/4/2023 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 regarding the expected management of a diabetic patient to include: nurses should review patients under their care by review physician's orders, care plan and diagnosis so that diabetic diagnosis are known to ensure appropriate care and that physician's orders are being followed as prescribed, as well as monitoring for and responding to changes in condition for immediate consultation with the MD/NP for appropriate treatment. Evaluating and responding to the needs of the diabetic patient based on presenting symptoms of hyper and hypoglycemia and following physician's orders/recommendations. Also in-serviced on 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, fol[TRUNCATED] 676313 Page 10 of 31 676313 09/07/2023 Laredo Nursing and Rehabilitation Center 1701 Tournament Trail Dr Laredo, TX 78041

F 0710 Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a physician supervised the care of a resident for one (Resident #1) of five residents reviewed for physician services. Residents Affected - Some The facility failed to ensure the physician supervised and monitored Resident #1's blood glucose monitoring since Resident #1 was diagnosed with diabetes and was prescribed and administered three different oral diabetic medications. R #1 became lethargic with an altered mental status on 08/31/23 at approximately 7:30 AM until he was transferred to the hospital at 3:42 PM without any appropriate physician intervention. R #1 was admitted to the intensive care unit of the hospital with a blood glucose level of 1160 mg/dL (normal reference range 70-100), required an IV medication intervention for his low blood pressure, and positive pressure ventilation to assist with his breathing. The facility Administrator and DON were notified on 09/04/23 at 3:42 PM, that an Immediate Jeopardy situation had been identified due to the above failures. While the IJ was removed on 09/07/23 at 11:00 AM, the facility remained out of compliance at a scope of pattern and a severity level of actual harm. This failure could cause a delay in appropriate medical care and a worsening in symptoms, condition or illness up to and including death. The findings included: Record review of R#1's Face Sheet, dated 09/02/2023, documented a [AGE] year-old male admitted on [DATE] with the diagnoses of: Type 2 Diabetes Mellitus (a metabolic disease, involving inappropriately elevated blood glucose levels) with Diabetic Polyneuropathy (simultaneous malfunction of many nerves throughout the body), abnormal weight loss, anorexia (an eating disorder that causes people to weigh less than is considered healthy for their age and height, usually by excessive weight loss), and chronic kidney disease (the kidneys are damaged and cannot filter blood as well as they should). Record review of R#1's comprehensive care plan dated 06/05/2023 documented, Focus: I have chronic health conditions & comorbid conditions that have affected my physical function and may further affect my quality of life. Diabetes, Heart disease, Poor Kidney Functioning. Goal: I will be free from complications associated with co-morbid/poor health, medical problems and will maintain quality of life through my next review date. Interventions: administer my medications, treatments, respiratory treatments/therapy and diet as recommend by physician, provide care as tolerated and needed, labs as ordered & report abnormal findings to MD as indicated. Record review of R#1's Minimum Data Set assessment dated [DATE] revealed he: -had clear speech -sometimes understood self and sometimes understood others -had a brief interview of mental status score of 0-severly impaired cognition 676313 Page 11 of 31 676313 09/07/2023 Laredo Nursing and Rehabilitation Center 1701 Tournament Trail Dr Laredo, TX 78041

F 0710 -required extensive assistance with two-person physical assist for bed mobility and transfers. As well as required extensive assistance with one-person assist with dressing and personal hygiene. Level of Harm - Immediate jeopardy to resident health or safety -had Diabetes Mellitus Residents Affected - Some Record review of R#1's admission medication reconciliation progress note documented by LVN N dated 05/24/2023 revealed, medication reconciliation clarified with MD: - metFORMIN HCl Oral Tablet 1000 MG Give 1 tablet by mouth two times a day for DM - Tradjenta Oral Tablet 5 MG Give 1 tablet by mouth one time a day for DM - Glimepiride Oral Tablet 4 MG Give 1 tablet by mouth two times a day for diabetes. - There was no blood glucose monitoring included in the reconciliation. Record review of R#1's Blood Sugar Summary dated 05/23/2023 at 20:40 (8:40PM) revealed R#1 had a blood sugar reading of 120 mg/dL (reference: High of 99.0 exceeded) Record review of R#1's laboratory results date collected 05/23/2023, date received in lab 05/24/2023, revealed R#1's glucose result of 99mg/dL (reference range 70-100) and A1C result of 8.3 (reference range: less than 6.0) Record review of R#1's laboratory results date collected 08/09/2023, date received in lab 08/09/2023, revealed R#1's glucose result of 226mg/dL (reference range 70-100) and A1C result of 7.3 (reference range: less than 6.0) Record review of R#1's progress note dated 08/11/2023 documented by LVN N, documented, MD reviewed lab results done on 8/9/23. no new orders given. RP made aware. Record review of R#1's progress notes dated 08/31/2023 at 07:30AM documented by LVN D documented the change in condition reported on this CIC Evaluation are/were: Other change in condition at the time of evaluation resident/patient vital signs, weight and blood sugar were: - Blood Pressure: BP 121/79 - 8/31/2023 17:14 - Pulse: P 64 - 8/31/2023 11:14 Pulse Type: Regular - RR: R 18.0 - 7/11/2023 19:50 - Temp: T 97.8 - 7/12/2023 13:07 - Weight: W 153.0 lb - 8/8/2023 13:53 - Pulse Oximetry: O2 100.0 % - 7/12/2023 13:07Method: Room Air - Blood Glucose: BS 120.0 - 5/23/2023 20:40 Relevant medical history is: Dementia Diabetes Chronic Renal Failure/ESRD 676313 Page 12 of 31 676313 09/07/2023 Laredo Nursing and Rehabilitation Center 1701 Tournament Trail Dr Laredo, TX 78041

F 0710 Code Status: DNR Level of Harm - Immediate jeopardy to resident health or safety Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were: Residents Affected - Some - Mental Status Evaluation: Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse) - Functional Status Evaluation: Needs more assistance with ADLs - Neurological Status Evaluation: Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse) Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: Telemed Appointment scheduled for the 9/1/23 between 8-12noon to speak to MD NP. - There was no current blood glucose level documented on the evaluation. Record review of R#1's progress notes dated 08/31/2023 at 07:30AM documented by LVN D documented, While SN was passing out medications CNA informed SN that resident does not want to eat breakfast, SN asked if he ate yesterday but was told he did not. Assess, resident is alert, but does not follow command or oriented.SN noticed resident was lethargic but will resist to touch. BP 121/73, HR 79, R 18, T 97.8 and high blood glucose. Lung's sound clear, abdomen soft and non-tender. Called MD office and spoke to medical assistance who schedule a telemed appointment for tomorrow 8/31/23 between 8 and 12 noon for patient to visit MD nurse practitioner. Per RP, resident should be sent to the hospital for further evaluation. Report given to incoming nurse. Record review of R#1's progress notes dated 08/31/2023 at 15:42 (3:42PM), documented by LVN A, revealed Res. picked up by [ambulance company] going to [hospital]. accompanied by family member. Vital signs as follows: BP 121/98 P75 R 18 Temp. 97.6 BS 'HI. MD: DON notified. Record review of R#1's emergency room documentation dated on 08/31/2023 revealed, critical condition(s) addressed for impending deterioration include: airway, respiratory, cardiovascular, central nervous system, metabolic, DKA, and diagnosis' Hypernatremia, Acute kidney injury superimposed on chronic kidney disease, Altered mental, Constipation, Hyperkalemia, Septic shock, DKA (diabetic ketoacidosis). Record review of hospital attending physician's progress note dated 09/02/2023 revealed, R#1 was brought into the emergency department at [hospital] on August 31, 2023, in the evening at 6 p.m., sent from the nursing home with report of the patient with altered mental status and high glucose level. Bedside glucometer unable to register the patient's glucose level. On initial presentation to the emergency department, the patient was found to be hypotensive, blood pressure was 80/39. He was severely hyperglycemic, glucose of 1160 with altered mental status. Ketone was positive. The patient initially was admitted with diagnosis of DKA, started on DKA protocol. History according to the [family members] , over the last week prior to this presentation, the patient's mental status has decreased. He was lethargic, less interactive with decreased oral intake. Over the last 3 days, the patient with apparently no oral intake of fluid or food, became nonverbal. On day of presentation, he was unresponsive, delirious, and agitated, brought into the emergency department via ambulance. 676313 Page 13 of 31 676313 09/07/2023 Laredo Nursing and Rehabilitation Center 1701 Tournament Trail Dr Laredo, TX 78041

F 0710 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some During an observation and attempted interview on 09/03/2023 at 10:26 AM R#1 was in the ICU, R#1 was in bed, with different fluids running. R#1 had lactated ringer running at 125mL/HR and was also on blood pressure medication assistance Levophed (used for severe low blood pressure , shock, or low heart rate) drip. R#1 also had tube feedings running through a nasogastric tube and was on BiPap respiratory support with setting: rate: 20 breath per minute, oxygen:40%. R#1 opened his eyes when ICU Nurse was notifying him that she and her aide were going to turn R#1. Attempted interview with R#1 but did not respond to questions. During an interview and record review on 09/02/2023 at 2:32 PM with the DON, the DON stated if there were a change of condition nurses are expected to perform an assessment and notify physician. The DON stated the expectation of the facility was if any CNAs noticed any change with residents, they would notify the nurse. The DON stated on 08/31/2023 the DON performed an assessment on R#1 and stated vitals were stable, R#1 presented with Altered Mental Status and lethargy. The DON stated the PCP was notified, and stated the facility was told that the PCP's office would schedule tele-med appointment the following day 09/01/2023. The DON stated during her assessment on 08/31/2023, R#1's breathing pattern were stable, and concluded there was not a sense of urgency that warranted an immediate need to send to out to hospital. The DON stated at the request of R#1's family member, the family member did not want to wait for the PCP's tele-med appointment that was scheduled for 09/01/23 the following day. The DON stated there were several attempts to call doctor, she stated they called earlier that day of 08/31/2023 and again during lunch on the same day. The DON stated the family initially wanted to send R#1 to the PCP's office, then changed their mind to transfer R#1 to ER due to not wanting to wait until the following day 09/01/2023. The DON determined that there was no need for an immediate need to call 9-1-1 or emergent services but stated something did need to be done for R#1. When asked about the process for medication reconciliation upon admission, the DON stated the admitting nurse will submit referral to the PCP's office, and the PCP's office will either continue home/hospital medications or discontinue medications, it is at the discretion of the physician. The DON stated, when asked about R#1's labs that were taken on 8/9/2023 that resulted a glucose value of 226mg/dL (reference range 70-100), she stated the value was high, and would require insulin in her professional opinion. The DON stated she did not know the blood glucose laboratory results were 226mg/dL and in this case should have inquired to see if physician would give order for glucose checks daily. The DON stated there was no reason why he shouldn't have glucose monitoring and theorized that the staff may have been focused on critical values. The DON stated in her professional opinion accu checks (blood glucose monitoring) would be warranted for R#1 due to him taking three anti-diabetic medications. During the interview with the DON, progress notes were reviewed, and the DON stated she could not find any progress note that documented an inquiry to the PCP for R#1 to have accu checks. When asked why the facility did not inquire about accu checks, the DON stated the clinical staff follow physician's orders. The DON stated whenever the facility sends out residents during discharges and transfers, as part of the discharge process the facility will perform an accu check and upon R#1's discharge to hospital the glucose monitor read high on 08/31/2023. The DON stated R#1 had a rapid decline and was hospitalized on [DATE]. During an interview on 09/03/2023 at 5:31 PM with LVN D, LVN D stated on 08/31/2023, a CNA notified her that R#1 did not want to eat, and went into R#1's room, assessed R#1, and stated R#1 exhibited signs of lethargy, but would open eyes then close eyes. LVN D stated R#1, during her assessment, R#1 seemed like he was trying to say something, and when she attempted to touch R#1 to arouse resident, he resisted a little bit, then attempted to give juice to R#1 and tolerated a small amount of fluid well. LVN D stated she attempted more than five times on 08/31/23, to speak to the PCP's office, and stated she does not 676313 Page 14 of 31 676313 09/07/2023 Laredo Nursing and Rehabilitation Center 1701 Tournament Trail Dr Laredo, TX 78041

F 0710 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some remember at what time she got a hold of the PCP's office. LVN D stated when she did speak to the PCP's office on 08/31/23, LVN D spoke with the PCP's medical assistant, and notified the medical assistant, of R#1's lethargy but normal vital signs, to which the medical assistant told LVN D, she would notify the doctor, but that she was going to schedule a tele-med appointment for the following day 09/01/23, with the Nurse Practitioner. LVN D said she did not request to immediately speak to the physician after she was given the telemed appointment. LVN D stated, during her conversation with the medical assistant on 08/31/2023 she told the medical assistant vital signs and was aware that he was a diabetic patient. LVN D stated she sometimes can check medical history but did not look at R#1's medical history because it was too early in the morning and worked the 6am-2pm shift on 08/31/2023. LVN D stated, when she was speaking with the PCPs office, she attempted to advocate for resident to either get labs, and requested for anything from the PCP's office. LVN D stated she does not know if doctor called back, stated she gave report to the incoming nurse (2-10pm). LVN D stated an accu check (glucose monitoring) would have been beneficial to perform to see if resident was hypoglycemic/hyperglycemic but reiterated vitals were stable and did not check blood glucose or request an order to check the blood glucose level. LVN D stated the family member of R#1 entered R#1's room in the morning after breakfast, R#1 did not eat, but would drink a little fluid. LVN D stated the family member expressed concern of R#1's lethargic state, to which LVN D stated, she told the family member she called the PCP's office, and was waiting for doctor to get back to LVN D. LVN D stated the family member of R#1 advocated for resident to be sent to hospital. LVN D stated she notified the DON and proceeded to call for an ambulance. LVN D stated she would need a physician's order to send out to hospital. LVN D stated after family member's insistence R#1 was sent to the hospital, LVN D stated she called doctor's office and notified the doctor's office that they were sending R#1 to the hospital, due to the family member asking, and sent R#1 to hospital. LVN D stated the situation with R#1 was her first urgent situation, and stated she was nervous, but that the NF gave her education on how to proceed with a change in condition, notify DON, and RP. LVN D stated she was aware that a medical assistant was not a physician or physician representative that could provide orders or conduct assessments. R #1 continued with a symptom of lethargy, not within his normalcy, for an entire first shift and entering the second shift, without physician awareness and assessment until he was sent to the hospital on [DATE] after 3:00 PM During an interview on 09/04/2023 at 12:08 PM with LVN N, LVN N stated he was made aware by the facility of the reasoning for this interview regarding R#1. LVN N stated he knew R#1 for a while and was R#1's admitting nurse. LVN Nstated the process for medication reconciliation was to fax the medication list that residents enter the facility with, either medications they take at home or medication that are sent with residents from the hospital. LVN N stated once the medication list is faxed, he will follow up and call the PCP's office to go over each medication on the medication reconciliation form and would be given instructions to either continue with the medication regimen the residents enter the facility with or to discontinue regimen. The LVN N stated he knew to call the doctor's office when he needed orders and would call sometimes for emergency orders. LVN N stated he did go over R#1's medications, which did include diabetic medications, and when speaking to the PCP's office, he was instructed to continue with R#1's current medication regimen, including the diabetic medications, and did not receive an order for glucose monitoring and did not ask for glucose monitoring. When LVN N was asked why he did not ask for a glucose monitoring order for R#1, LVN N stated he follows physician orders. LVN N stated he does take care of residents that are diabetic. LVN N stated when he is taking care of residents that are diabetic, he does look for blood sugar monitoring order and diabetic medications. LVN N stated, when asked why he did not 676313 Page 15 of 31 676313 09/07/2023 Laredo Nursing and Rehabilitation Center 1701 Tournament Trail Dr Laredo, TX 78041

F 0710 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some inquire about glucose monitoring for R#1, who was taking diabetic medications, he stated he follows doctor's order and will only check blood sugars with residents are on insulin. During an interview on 09/03/2023 at 3:22PM the primary care physician (PCP) stated, when a resident is admitted into the nursing facility, the nurses will submit medication reconciliation to doctors' office, and over the phone he will either continue or stop medications. For any additional orders the NF will call his office and notify via phone. The PCP stated he does not know why R#1 was not on glucose monitoring. The PCP stated he knew the resident forever and stated the facility may have called or not for order, but could not recollect, stated he has over 100 patients, and would expect if R#1 was on Diabetes Mellitus (DM) medications, the facility would inquire for glucose monitoring. The PCP stated R#1 has not been a long time diabetic and the lack of glucose monitoring was an oversight on his part. The PCP stated that he expected, as a collaborative effort with the clinical staff at the Nursing Facility (NF), if they see a need for a specific order, whether that's glucose monitoring or diabetic diet, to inquire about and notify him. The PCP stated he expected for the NF to advocate for the safety of all residents. The PCP stated he could not explain why R#1 was not on blood glucose monitoring, due to R#1 taking three DM medications and not on glucose checks, he stated it is a standard of care. The PCP stated if he was made aware of R#1 not having glucose checks, he would have ordered glucose checks for R#1. The PCP stated glucose checks were not only a routine of care but basic standard of care. The PCP stated his expectation of the NF would be to be proactive for patients and advocates for all residents' standard of care. The PCP stated not ordering glucose monitoring was an oversight and takes full responsibility. The PCP stated if R#1's glucose was not monitored, and R#1 was not eating, R#1 could become hypoglycemic which is severe. The PCP stated R#1 could have become too high, an incident like this (DKA) something could raise to an ungodly (critical) amount. The PCP stated he was first notified of R#1's current hospitalization on 09/02/2023. The PCP stated he does not recollect being notified about R#1's transfer to the hospital until 09/02/2023. The PCP stated 1160 blood glucose is absolutely a critical number. The PCP stated there must have been something inciting the incident either a UTI or Pneumonia, something triggered the high sugar. The PCP stated he does not recall being notified of R#1's lethargy or unconsciousness prior to R#1's hospitalization. The PCP stated the NF should have been monitoring glucose. Record review of the facility's Changes in Resident Condition Policy date implemented 05/2017 and date reviewed/revised January 2023 stated: 1. The resident, attending physician and resident representative or designated family member should be notified when there is: c. a significant change in the resident's physical, mental or psychosocial status. 2. Provide assessment information to physician d. a need to alter treatment significantly (i.e., a need form of treatment due to adverse consequences, or to commence a new for of treatment); e. A decision to transfer the resident from the community, g. when laboratory, radiology or other diagnostic results fall outside the clinical reference ranges set by the contracted service provider or per physician orders Record review of the facility's Diabetes Management date implemented 03/12/19 and date 676313 Page 16 of 31 676313 09/07/2023 Laredo Nursing and Rehabilitation Center 1701 Tournament Trail Dr Laredo, TX 78041

F 0710 reviewed/revised: January 2023, stated: Level of Harm - Immediate jeopardy to resident health or safety Purpose: Diabetic Management involves both preventative measures and treatment of complications. Upon admission, the interdisciplinary team works together to implement a plan of care to minimize complications. Residents Affected - Some Assessment: The interdisciplinary team assesses the diabetic resident/patient upon admission, validates the orders with the attending physician and initiates plan of care that may include: Blood glucose monitoring as ordered Preventative care measures as appropriate Routine care: Blood glucose measurements shall be taken per the physician order. Results outside of ordered parameters should be communicated to the physician per orders 2.For acute events, the clinical record shall include the following information: .Blood glucose test levels . Notification of physician and any new orders. The facility Administrator and DON were notified on 09/04/23 at 3:42 PM, that an Immediate Jeopardy situation had been identified due to the above failures. On 09/06/23 at 12:08 PM, the facility was notified of the acceptance of the Plan of Removal (POR). The facility's Plan of Removal documented: Plan of Removal Immediate Jeopardy Situation: Resident # 1 noted with a diagnosis of Type 2 Diabetes Mellitus experienced an acute change in his condition on 8/31/23. The nurse evaluated the patient's condition, identified that he was presenting with s/s altered mental status. The nurse identified as Nurse B, checked Resident's #1 blood glucose level, the meter indicated that the reading was hi. Outcome: On 8/31/23 Nurse B then notified the physician's office of the hi blood glucose reading. Nurse B completed a change in condition SBAR and progress note describing the evaluation findings, physician's recommendations and notifications. [The physician] recommended a telehealth visit for the following day. However, the [family member] wanted the patient to be seen by physician at his office that same day. Since patient did not have an appointment, DON informed [family member] that she could send patient to the ER to which the [family member] agreed. Nurse B immediately sent Resident #1 to the emergency room for evaluation and treatment on 8/31/23. Resident #1 was admitted to the hospital and remains at the hospital. The Director of Nursing Services/Assistant Director of Nursing conducted re-education for the nurse 676313 Page 17 of 31 676313 09/07/2023 Laredo Nursing and Rehabilitation Center 1701 Tournament Trail Dr Laredo, TX 78041

F 0710 Level of Harm - Immediate jeopardy to resident health or safety identified as Nurse A regarding reviewing patient's plan of care to include physician's orders and care plan as well as diagnosis in order to identify diabetic patients under the nurse's care. Date commenced: 9/4/23 Date to be completion: 9/5/23 Residents Affected - Some Director of Nursing / Assistant Director of Nursing conducted in-service training for the identified nurse (Nurse B) regarding the expected management of a diabetic patient, assessing/evaluating and responding to the needs of the diabetic patient based on presenting symptoms of hyper and hypoglycemia, and following physician's orders/recommendations. Also in-serviced on 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: 9/4/23 Date to be completion: 9/5/23 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: 9/4/23 Date of completion: 9/4/23 Risk Response: Residents who are diabetic and who are managed by oral medications without routine blood glucose monitoring efforts may potentially be affected by the deficient practice. Director of Nursing / Assistant Director of Nursing conducted retraining for all licensed nursing staff regarding the expected management of a diabetic patient to include: nurses should review patients under their care by review physician's orders, care plan and diagnosis so that diabetic diagnosis are known to ensure appropriate care and that physician's orders are being followed as prescribed, as well as monitoring for and responding to changes in condition for immediate consultation with the MD/NP for appropriate treatment. Evaluating and responding to the needs of the diabetic patient based on presenting symptoms of hyper and hypoglycemia and following physician's orders/recommendations. Also in-serviced on the process for observing and monitoring a resident's condition, conducting follow up evaluation of a resident's condition upon reports of a change of condition or status by a C.N.A., proceeding with an assessment / evaluation of the resident's status, reporting changes in 676313 Page 18 of 31 676313 09/07/2023 Laredo Nursing and Rehabilitation Center 1701 Tournament Trail Dr Laredo, TX 78041

F 0710 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 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. Director of Nursing / ADON will ensure all licensed nursing staff will be re-educated to include anyone on leave/agency/PRN staff will be in serviced prior to working next shift. Community 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 Commenced: 9/4/23 Date to be completion: 9/5/23 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 orders. The nurse will update the MD/NP's orders should any new or changes in the plan of care be provided by the prescriber. Date Commenced: 9/4/23 Date to be completion: 9/5/23 Administrator and Director of Nursing and Medical Director conducted an Ad Hoc QAPI to review issue and community's response plan in place. Date: 9/4/2023 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 regarding the expected management of a diabetic patient to include: nurses should review patients under their care by review physician's orders, care plan and diagnosis so that diabetic diagnosis are known to ensure appropriate care and that physician's orders are being followed as prescribed, as well as monitoring for and responding to changes in condition for immediate consultation with the MD/NP for appropriate treatment. Evaluating and responding to the needs of the diabetic patient based on presenting symptoms of hyper and hypoglycemia and following physician's orders/recommendations. Also in-serviced on 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: 9/4/2023 Date to be completion: 9/5/23 676313 Page 19 of 31 676313 09/07/2023 Laredo Nursing and Rehabilitation Center 1701 Tournament Trail Dr Laredo, TX 78041

F 0710 All staff will be in-serviced on ANE- Prevention, Identification, Protecting and Reporting. Level of Harm - Immediate jeopardy to resident health or safety Date Commenced: 9/4/2023 Residents Affected - Some 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. Date to be completion: 9/5/23 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 accu-checks monitoring that is prescribed and interview random nurses to review how to identify patients who have diagnosis of diabetes. 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. The surveyor confirmed the facility's Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy that included: Record review: -Facility staff training on documenting in chart change of condition/observation and monitoring change of condition/reviewing resident care plans and physician's orders. -Audit of facility residents with diabetes type II and confirmation of standing orders -Employee record for completion of training -QAPI record of meeting discussing diabetic management protocol and changes in condition with recommendation to re-educate all licensed nurses in these areas and confirm current orders with physicians. Hospital record documented: R #1's Dx: Hypernatremia, Acute Kidney Injury superimposed on chronic kidney disease, Altered Mental Status, Constipation, hyperkalemia, Sepsis; Septic Shock, Diabetic Ketoacidosis. 676313 Page 20 of 31 676313 09/07/2023 Laredo Nursing and Rehabilitation Center 1701 Tournament Trail Dr Laredo, TX 78041

F 0710 R #1's H&P: presented with Altered Mental Status, Dry Mucous Membranes, Distended Abdomen Level of Harm - Immediate jeopardy to resident health or safety V/S @ 8/31/2023 16:09 T 97.3, RR 20, HR 67, B/P 80/39 O2 98% Residents Affected - Some -13 interviews were conducted on 9/6/2023 and 9/7/2023 across 3 shifts with LVN A through LVN M to ensure training was completed. Training began after the facility was notified that the plan of corretion was accepted around noon on 9/6/2023, and was finished the same day on 9/6/2023. Responses were consistent facility training and policy. Interviews: -demonstration of knowledge of documenting in chart change of condition/ observation and monitoring change of condition/reviewing resident care plans and physician's orders. -Interviewed DON on process for m[TRUNCATED] 676313 Page 21 of 31 676313 09/07/2023 Laredo Nursing and Rehabilitation Center 1701 Tournament Trail Dr Laredo, TX 78041

F 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure nursing staff demonstrated appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, for one (R #1) of four residents that were diagnosed with diabetes mellitus. 1. Multiple nursing personnel who cared for R#1 did not consult with R#1's Physician, in attempt to retrieve instructions for blood glucose monitoring. 2. LVN A cared for R#1 for multiple days and stated she did not know he was a diabetic. 3. DON assessed R#1 on 8/31/23 and despite of his change in condition of lethargy and altered level of consciousness, the DON did not conclude that R#1's change in condition was urgent enough to require emergent medical treatment. The facility Administrator and DON were notified on 09/04/23 at 3:42 PM, that an Immediate Jeopardy situation had been identified due to the above failures. While the IJ was removed on 09/07/23 at 11:00 AM, the facility remained out of compliance at a scope of pattern and a severity level of actual harm. This failure to notify and consult with the physician regarding a change of condition, and diabetic management resulted in a delay of appropriate medical treatment and a worsening of R#1's condition. This failure had the potential to affect residents receiving diabetic management who may experience a significant change in condition and or death. The findings included: Record review of R#1's Face Sheet, dated 09/02/2023, documented a [AGE] year-old male admitted on [DATE] with the diagnoses of: Type 2 Diabetes Mellitus (a metabolic disease, involving inappropriately elevated blood glucose levels) with Diabetic Polyneuropathy (simultaneous malfunction of many nerves throughout the body), abnormal weight loss, anorexia (an eating disorder that causes people to weigh less than is considered healthy for their age and height, usually by excessive weight loss), and chronic kidney disease (the kidneys are damaged and cannot filter blood as well as they should). Record review of R#1's comprehensive care plan dated 06/05/2023 documented, Focus: I have chronic health conditions & comorbid conditions that have affected my physical function and may further affect my quality of life. Diabetes, Heart disease, Poor Kidney Functioning. Goal: I will be free from complications associated with co-morbid/poor health, medical problems and will maintain quality of life through my next review date. Interventions: administer my medications, treatments, respiratory treatments/therapy and diet as recommend by physician, provide care as tolerated and needed, labs as ordered & report abnormal findings to MD as indicated. Record review of R#1's Minimum Data Set assessment dated [DATE] revealed he: -had clear speech 676313 Page 22 of 31 676313 09/07/2023 Laredo Nursing and Rehabilitation Center 1701 Tournament Trail Dr Laredo, TX 78041

F 0726 -sometimes understood self and sometimes understood others Level of Harm - Immediate jeopardy to resident health or safety -had a brief interview of mental status score of 0-severly impaired cognition -required extensive assistance with two-person physical assist for bed mobility and transfers. As well as required extensive assistance with one-person assist with dressing and personal hygiene. Residents Affected - Some -had Diabetes Mellitus Record review of R#1's admission medication reconciliation progress note documented by LVN N dated 05/24/2023 revealed, medication reconciliation clarified with MD: - metFORMIN HCl Oral Tablet 1000 MG Give 1 tablet by mouth two times a day for DM - Tradjenta Oral Tablet 5 MG Give 1 tablet by mouth one time a day for DM - Glimepiride Oral Tablet 4 MG Give 1 tablet by mouth two times a day for diabetes. - There were no blood glucose monitoring included in the reconciliation. Record review of R#1's Medication Administration Record dated 08/01/2023-08/31/2023 revealed Start Date:06/29/2023 Metformin HCl Oral Tablet 500 MG (Metformin HCl) Give 1 tablet by mouth one time a day related to TYPE 2 diabetes mellitus with diabetic polyneuropathy; state date:05/24/2023 Tradjenta Oral Tablet 5 MG (Linagliptin) Give 1 tablet by mouth one time a day for DM and Glimepiride Oral Tablet 4 MG (Glimepiride) Give 1 tablet by mouth two times a day for diabetes, were administered through August 2023. Record review of R#1's Blood Sugar Summary dated 05/23/2023 20:40 (8:40PM) revealed R#1 had a blood sugar reading of 120 mg/dL (reference: High of 99.0 exceeded) Record review of R#1's laboratory results date collected 05/23/2023, date received in lab 05/24/2023, revealed R#1's glucose result of 99mg/dL (reference range 70-100) and A1C result of 8.3 (reference range: less than 6.0) Record review of R#1's laboratory results date collected 08/09/2023, date received in lab 08/09/2023, revealed R#1's glucose result of 226mg/dL (reference range 70-100) and A1C result of 7.3 (reference range: less than 6.0) Record review of progress note dated 08/11/2023 documented by LVN N, documented, MD reviewed lab results done on 8/9/23. no new orders given. RP made aware. Record review of R#1's progress notes dated 08/31/2023 at 07:30AM documented by LVN D documented the change in condition reported on this CIC Evaluation are/were: Other change in condition at the time of evaluation resident/patient vital signs, weight and blood sugar were: - Blood Pressure: BP 121/79 - 8/31/2023 17:14 - Pulse: P 64 - 8/31/2023 11:14 Pulse Type: Regular - RR: R 18.0 - 7/11/2023 19:50 676313 Page 23 of 31 676313 09/07/2023 Laredo Nursing and Rehabilitation Center 1701 Tournament Trail Dr Laredo, TX 78041

F 0726 - Temp: T 97.8 - 7/12/2023 13:07 Level of Harm - Immediate jeopardy to resident health or safety - Weight: W 153.0 lb - 8/8/2023 13:53 Residents Affected - Some - Blood Glucose: BS 120.0 - 5/23/2023 20:40 - Pulse Oximetry: O2 100.0 % - 7/12/2023 13:07Method: Room Air Relevant medical history is: Dementia Diabetes Chronic Renal Failure/ESRD Code Status: DNR Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were: - Mental Status Evaluation: Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse) - Functional Status Evaluation: Needs more assistance with ADLs - Neurological Status Evaluation: Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse) Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: Telemed Appointment scheduled for the 9/1/23 between 8-12noon to speak to MD NP. - There was no current blood glucose level documented on the evaluation. Record review of R#1's progress notes dated 08/31/2023 at 07:30AM documented by LVN D documented, While SN was passing out medications CNA informed SN that resident does not want to eat breakfast, SN asked if he ate yesterday but was told he did not. Assess, resident is alert, but does not follow command or oriented.SN noticed resident was lethargic but will resist to touch. BP 121/73, HR 79, R 18, T 97.8 and high blood glucose. Lung's sound clear, abdomen soft and non-tender. Called MD office and spoke to medical assistance who schedule a telemed appointment for tomorrow 8/31/23 between 8 and 12 noon for patient to visit MD nurse practitioner. Per RP, resident should be sent to the hospital for further evaluation. Report given to incoming nurse. Record review of R#1's progress notes dated 08/31/2023 at 15:42 (3:42PM), documented by LVN A, revealed Res. picked up by [ambulance company] going to [hospital]. accompanied by family member. Vital signs as follows: BP 121/98 P75 R 18 Temp. 97.6 BS 'HI. MD: DON notified. Record review of R#1's emergency room documentation dated on 08/31/2023 revealed, critical condition(s) addressed for impending deterioration include: airway, respiratory, cardiovascular, central nervous system, metabolic, DKA, and diagnosis' Hypernatremia, Acute kidney injury superimposed on chronic kidney disease, Altered mental, Constipation, Hyperkalemia, Septic shock, DKA (diabetic ketoacidosis). Record review of Hospital Attending Physician's progress note dated 09/02/2023 revealed, R#1 was brought into the emergency department at [hospital] on August 31, 2023, in the evening at 6 p.m., sent 676313 Page 24 of 31 676313 09/07/2023 Laredo Nursing and Rehabilitation Center 1701 Tournament Trail Dr Laredo, TX 78041

F 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some from the nursing home with report of the patient with altered mental status and high glucose level. Bedside glucometer unable to register the patient's glucose level. On initial presentation to the emergency department, the patient was found to be hypotensive (low blood pressure), blood pressure was 80/39. He was severely hyperglycemic (high blood sugar), glucose of 1160 with altered mental status. Ketone was positive. The patient initially was admitted with diagnosis of DKA, started on DKA protocol. History according to the [family members] , over the last week prior to this presentation, the patient's mental status has decreased. He was lethargic, less interactive with decreased oral intake. Over the last 3 days, the patient with apparently no oral intake of fluid or food, became nonverbal. On day of presentation, he was unresponsive, delirious, and agitated, brought into the emergency department via ambulance. During an observation on 09/03/2023 at 10:26 AM R#1 was in the ICU, R#1 was in bed, with different fluids running. R#1 had lactated ringer running at 125mL/HR and was also on blood pressure medication assistance Levophed drip. R#1 also had tube feedings running through a nasogastric tube and was on BiPap respiratory support with setting: rate: 20 breath per minute, oxygen:40%. R#1 opened his eyes when ICU Nurse was notifying him that she and her aide were going to turn R#1. Attempted interview with R#1 but did not respond to questions. During an interview on 09/02/2023 at 2:32 PM with the DON, the DON stated if there were a change of condition nurses are expected to perform an assessment and notify physician. The DON stated the expectation of the facility was if any CNAs noticed any change with residents, they would notify the nurse. The DON stated on 08/31/2023 the DON performed an assessment on R#1 and stated vitals were stable, R#1 presented with Altered Mental Status and lethargy. The DON stated the PCP was notified, and stated the facility was told that the PCP's office would schedule tele-med appointment the following day 09/01/2023. The DON stated during her assessment on 08/31/2023, R#1's breathing pattern were stable, and concluded there was not a sense of urgency that warranted an immediate need to send to out to hospital. The DON stated at the request of R#1's spouse, the spouse did not want to wait for the PCP's tele-med appointment that was scheduled for 09/01/23 the following day. The DON stated there were several attempts to call doctor, she stated they called earlier that day of 08/31/2023 and again during lunch on the same day. The DON stated the family initially wanted to send R#1 to the PCP's office, then changed their mind to transfer R#1 to ER due to not wanting to wait till the following day 09/01/2023. The DON determined that there was no need for an immediate need to call 9-1-1 or emergent services but stated something did need to be done for R#1. When asked about the process for medication reconciliation upon admission, the DON stated the admitting nurse will submit referral to the PCP's office, and the PCP's office will either continue home/hospital medications or discontinue medications, it is at the discretion of the physician. The DON stated, when asked about R#1's labs that were taken on 8/9/2023 that resulted a glucose value of 226mg/dL (reference range 70-100), she stated the value was high, and would require insulin in her professional opinion. The DON stated she did not know the blood glucose laboratory results were 226mg/dL and in this case should have inquired to see if physician would give order for glucose checks daily. The DON stated there was no reason why he shouldn't have glucose monitoring and theorized that the staff may have been focused on critical values. The DON stated in her professional opinion accu checks (blood glucose monitoring) would be warranted for R#1 due to him taking three anti-diabetic medications. During the interview with the DON, we both concurrently were looking at progress notes, and the DON stated she could not find any progress note that documented an inquiry to the PCP for R#1 to have accu checks. When asked why the facility did not inquire about accu checks, the DON stated the clinical staff follow physician's orders. The DON stated whenever the facility sends out residents during discharges and transfers, as part of the discharge 676313 Page 25 of 31 676313 09/07/2023 Laredo Nursing and Rehabilitation Center 1701 Tournament Trail Dr Laredo, TX 78041

F 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some process the facility will perform an accu check and upon R#1's discharge to hospital the glucose monitor read high on 08/31/2023. The DON stated R#1 had a rapid decline and was hospitalized on [DATE]. During an interview on 09/02/2023 at 4:24PM, LVN A stated she took care of R#1 on 08/23 during her 2-10shift. LVN A stated she did not interact with resident for that long when she admitted him to the LTC side on 08/23/23 and when vitals were okay, she left R#1 and attended other patients. LVN A stated she remembers R#1 was non-verbal and stated the only time she knew R#1 was diabetic, was when R#1 left to the hospital on 8/31, and as a discharge practice, the glucose was checked. She stated R#1 did not show signs of hypo/hyper glycemic symptoms on 08/31 upon leaving to hospital. LVN A stated he looked fine on 08/31/23. LVN A stated R#1 was moved to unit on 08/23/23 and was her patient from 08/24-31 and as part of her job was to take care of her residents. LVN A Stated she did not check blood sugar because there was no order from the physician to do and did not inquire to doctor's office for blood sugar reading due to R#1's appearance of looking fine. LVN A stated she was not made aware of R#1 not eating. During an interview on 09/03/2023 at 10:26AM with the ICU Nurse, stated R#1 was admitted on [DATE] into the Emergency Department at [NAME] Medical Centerthe local hospital. ICU nurse stated R#1 was admitted for Diabetic Ketoacidosis, Hyperglycemia, Septic Shock and Acute Kidney Failure. The ICU nurse stated R#1's admitting glucose reading was 1160mg/dL. The ICU Nurse stated R#1 received an xray with findings that showed moderately size Right Lower Lobe Infiltrate (a substance denser than air, such as pus, blood, or protein, which lingers within the lungs) , the ICU Nurse stated it could be fluid/pneumonia but could not definitively state what infiltrate was. Currently, R#1 is on blood pressure support, and has begun to open eyes and was showing attempts of spontaneous responses. ICU Nurse stated upon R#1's admission, R#1's labs on 08/31/23 value for ketones were a moderate amount. ICU Nurse stated the amount of ketones in circulation could potentially have come from body not receiving adequate nutrition, and in response R#1's body could have begun metabolizing R#1's musculature. The ICU Nurse stated, the Nutritionist/Dietician documented that R#1 met the criteria of severe protein/calorie malnutrition. The ICU Nurse stated upon admission to the hospital, R#1 was not cognitively aware During an interview on 09/03/2023 at 5:31 PM with LVN D, LVN D stated on 08/31/2023, a CNA notified her that R#1 did not want to eat, and went into R#1's room, assessed R#1, and stated R#1 exhibited signs of lethargy, but would open eyes then close eyes. LVN D stated R#1, during her assessment, R#1 seemed like he was trying to say something, and when she attempted to touch R#1 to arouse resident, he resisted a little bit, then attempted to give juice to R#1 and tolerated a small amount of fluid well. LVN D stated she attempted more than five times on 08/31/23, to speak to the PCP's office, and stated she does not remember at what time she got a hold of the PCP's office. LVN D stated when she did speak to the PCP's office on 08/31/23, LVN D spoke with the PCP's medical assistant, and notified the medical assistant, of R#1's lethargy but normal vital signs, to which the medical assistant told LVN D, she would notify the doctor, but that she was going to schedule a tele-med appointment for the following day 09/01/23, with the Nurse Practitioner. LVN D said she did not request to immediately speak to the physician after she was given the telemed appointment. LVN D stated, during her conversation with the medical assistant on 08/31/2023 she told the medical assistant vital signs and was aware that he was a diabetic patient. LVN D stated she sometimes can check medical history but did not look at R#1's medical history because it was too early in the morning and worked the 6am-2pm shift on 08/31/2023. LVN D stated, when she was speaking with the PCPs office, she attempted to advocate for resident to either get labs, and requested for anything from the PCP's office. LVN D stated she does not know if doctor called back, stated she gave report to the incoming nurse (2-10pm). LVN 676313 Page 26 of 31 676313 09/07/2023 Laredo Nursing and Rehabilitation Center 1701 Tournament Trail Dr Laredo, TX 78041

F 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some D stated an accu check (glucose monitoring) would have been beneficial to perform to see if resident was hypoglycemic/hyperglycemic but reiterated vitals were stable and did not check blood glucose or request an order to check the blood glucose level. LVN D stated the family member of R#1 entered R#1's room in the morning after breakfast, R#1 did not eat, but would drink a little fluid. LVN D stated the family member expressed concern of R#1's lethargic state, to which LVN D stated, she told the family member she called the PCP's office, and was waiting for doctor to get back to LVN D. LVN D stated the family member of R#1 advocated for resident to be sent to hospital. LVN D stated she notified the DON and proceeded to call for an ambulance. LVN D stated she would need a physician's order to send out to hospital. LVN D stated after family member's insistence R#1 was sent to the hospital, LVN D stated she called doctor's office and notified the doctor's office that they were sending R#1 to the hospital, due to the family member asking, and sent R#1 to hospital. LVN D stated the situation with R#1 was her first urgent situation, and stated she was nervous, but that the NF gave her education on how to proceed with a change in condition, notify DON, and RP. LVN D stated she was aware that a medical assistant was not a physician or physician representative that could provide orders or conduct assessments. R #1 continued with a symptom of lethargy, not within his normalcy, for an entire first shift and entering the second shift, without physician awareness and assessment until he was sent to the hospital on [DATE] after 3:00 PM. During an interview on 09/04/2023 at 12:08 PM with LVN N, LVN N stated he was made aware by the facility of the reasoning for this interview regarding R#1. LVN N stated he knew R#1 for a while and was R#1's admitting nurse. LVN Nstated the process for medication reconciliation was to fax the medication list that residents enter the facility with, either medications they take at home or medication that are sent with residents from the hospital. LVN N stated once the medication list is faxed, he will follow up and call the PCP's office to go over each medication on the medication reconciliation form and would be given instructions to either continue with the medication regimen the residents enter the facility with or to discontinue regimen. The LVN N stated he knew to call the doctor's office when he needed orders and would call sometimes for emergency orders. LVN N stated he did go over R#1's medications, which did include diabetic medications, and when speaking to the PCP's office, he was instructed to continue with R#1's current medication regimen, including the diabetic medications, and did not receive an order for glucose monitoring and did not ask for glucose monitoring. When LVN N was asked why he did not ask for a glucose monitoring order for R#1, LVN N stated he follows physician orders. LVN N stated he does take care of residents that are diabetic. LVN N stated when he is taking care of residents that are diabetic, he does look for blood sugar monitoring order and diabetic medications. LVN N stated, when asked why he did not inquire about glucose monitoring for R#1, who was taking diabetic medications, he stated he follows doctor's order and will only check blood sugars with residents are on insulin. During an interview on 09/03/2023 at 2:31PM with the Hospital Attending Physician (HAP), he stated R#1 was sent to the hospital due to R#1 being unresponsive and blood sugar level over 1000. The HAP stated DKA was very serious, and potentially could have led to death. The HAP stated DKA occurs when sugar is high and there is high amount of acid in the body's system. The HAP stated R#1's DKA could have potentially been prevented. The HAP stated as a basic preventative measure for people with diabetes would be to monitor blood sugar and treat with diabetic medications. The HAP stated DKA could potentially affect vital organs and could have led to R#1's Acute Renal Failure on top of R#1's Chronic Kidney Failure. During an interview on 09/03/2023 at 3:22PM the primary care physician (PCP) stated, when a resident is admitted into the nursing facility, the nurses will submit medication reconciliation to doctors' office, and over the phone he will either continue or stop medications. For 676313 Page 27 of 31 676313 09/07/2023 Laredo Nursing and Rehabilitation Center 1701 Tournament Trail Dr Laredo, TX 78041

F 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some any additional orders the NF will call his office and notify via phone. The PCP stated he does not know why R#1 was not on glucose monitoring. The PCP stated he knew the resident forever and stated the facility may have called or not for order, but could not recollect, stated he has over 100 patients, and would expect if R#1 was on Diabetes Mellitus (DM) medications, the facility would inquire for glucose monitoring. The PCP stated R#1 has not been a long time diabetic and the lack of glucose monitoring was an oversight on his part. The PCP stated that he expected, as a collaborative effort with the clinical staff at the Nursing Facility (NF), if they see a need for a specific order, whether that's glucose monitoring or diabetic diet, to inquire about and notify him. The PCP stated he expected for the NF to advocate for the safety of all residents. The PCP stated he could not explain why R#1 was not on blood glucose monitoring, due to R#1 taking three DM medications and not on glucose checks, he stated it is a standard of care. The PCP stated if he was made aware of R#1 not having glucose checks, he would have ordered glucose checks for R#1. The PCP stated glucose checks were not only a routine of care but basic standard of care. The PCP stated his expectation of the NF would be to be proactive for patients and advocates for all residents' standard of care. The PCP stated not ordering glucose monitoring was an oversight and takes full responsibility. The PCP stated if R#1's glucose was not monitored, and R#1 was not eating, R#1 could become hypoglycemic which is severe. The PCP stated R#1 could have become too high, an incident like this (DKA) something could raise to an ungodly (critical) amount. The PCP stated he was first notified of R#1's current hospitalization on 09/02/2023. The PCP stated he does not recollect being notified about R#1's transfer to the hospital until 09/02/2023. The PCP stated 1160 blood glucose is absolutely a critical number. The PCP stated there must have been something inciting the incident either a UTI or Pneumonia, something triggered the high sugar. The PCP stated he does not recall being notified of R#1's lethargy or unconsciousness prior to R#1's hospitalization. The PCP stated the NF should have been monitoring glucose. Record review of the facility's Diabetes Management date implemented 03/12/19 and date reviewed/revised: January 2023, stated: Purpose: Diabetic Management involves both preventative measures and treatment of complications. Upon admission, the interdisciplinary team works together to implement a plan of care to minimize complications. Assessment: The interdisciplinary team assesses the diabetic resident/patient upon admission, validates the orders with the attending physician and initiates plan of care that may include: Blood glucose monitoring as ordered Preventative care measures as appropriate Routine care: Blood glucose measurements shall be taken per the physician order. Results outside of ordered parameters should be communicated to the physician per orders 2.For acute events, the clinical record shall include the following information: .Blood glucose test levels . Notification of physician and any new orders. 676313 Page 28 of 31 676313 09/07/2023 Laredo Nursing and Rehabilitation Center 1701 Tournament Trail Dr Laredo, TX 78041

F 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Record review of the facility's Professional Standard of Care Policy date implemented 2017 stated, Nursing Practices: a. Licensed nurses must practice within the constraints of applicable state laws and regulations governing their practice and must follow the guidelines contained in the communities' written policies and procedures. The facility Administrator and DON were notified on 09/04/23 at 3:42 PM, that an Immediate Jeopardy situation had been identified due to the above failures. On 09/06/23 at 12:08 PM, the facility was notified of the acceptance of the Plan of Removal (POR). The facility's Plan of Removal documented: Plan of Removal Immediate Jeopardy Commenced on: 9/4/2023 Situation: Resident # 1 noted with a diagnosis of Type 2 Diabetes Mellitus experienced an acute change in his condition on 8/31/23. The nurse evaluated the patient's condition, identified that he was presenting with s/s altered mental status. The nurse identified as Nurse B, checked Resident's #1 blood glucose level, the meter indicated that the reading was hi. Outcome: On 8/31/23 Nurse B then notified the physician's office of the hi blood glucose reading. Nurse B completed a change in condition SBAR and progress note describing the evaluation findings, physician's recommendations and notifications. [The physician] recommended a telehealth visit for the following day. However, the [family member] wanted the patient to be seen by physician at his office that same day. Since patient did not have an appointment, DON informed the [family member] that she could send patient to the ER to which the spouse agreed. Nurse B immediately sent Resident #1 to the emergency room for evaluation and treatment on 8/31/23. Resident #1 was admitted to the hospital and remains at the hospital. The Director of Nursing Services/Assistant Director of Nursing conducted re-education for the nurse identified as Nurse A regarding reviewing patient's plan of care to include physician's orders and care plan as well as diagnosis in order to identify diabetic patients under the nurse's care. Date commenced: 9/4/23 Date to be completion: 9/5/23 Director of Nursing / Assistant Director of Nursing conducted in-service training for the identified nurse (Nurse B) regarding the expected management of a diabetic patient, assessing/evaluating and responding to the needs of the diabetic patient based on presenting symptoms of hyper and hypoglycemia, and following physician's orders/recommendations. Also in-serviced on 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. 676313 Page 29 of 31 676313 09/07/2023 Laredo Nursing and Rehabilitation Center 1701 Tournament Trail Dr Laredo, TX 78041

F 0726 Date commenced: 9/4/23 Level of Harm - Immediate jeopardy to resident health or safety Date to be completion: 9/5/23 Residents Affected - Some 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: 9/4/23 Date of completion: 9/4/23 Risk Response: Residents who are diabetic and who are managed by oral medications without routine blood glucose monitoring efforts may potentially be affected by the deficient practice. Director of Nursing / Assistant Director of Nursing conducted retraining for all licensed nursing staff regarding the expected management of a diabetic patient to include: nurses should review patients under their care by review physician's orders, care plan and diagnosis so that diabetic diagnosis are known to ensure appropriate care and that physician's orders are being followed as prescribed, as well as monitoring for and responding to changes in condition for immediate consultation with the MD/NP for appropriate treatment. Evaluating and responding to the needs of the diabetic patient based on presenting symptoms of hyper and hypoglycemia and following physician's orders/recommendations. Also in-serviced on the process for observing and monitoring a resident's condition, conducting follow up evaluation of a resident's condition upon reports of a change of condition or status by a C.N.A., proceeding 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. Director of Nursing / ADON will ensure all licensed nursing staff will be re-educated to include anyone on leave/agency/PRN staff will be in serviced prior to working next shift. Community 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 Commenced: 9/4/23 Date to be completion: 9/5/23 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 orders. The nurse will update the 676313 Page 30 of 31 676313 09/07/2023 Laredo Nursing and Rehabilitation Center 1701 Tournament Trail Dr Laredo, TX 78041

F 0726 MD/NP's orders should any new or changes in the plan of care be provided by the prescriber. Level of Harm - Immediate jeopardy to resident health or safety Date Commenced: 9/4/23 Residents Affected - Some 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 completion: 9/5/23 Date: 9/4/2023 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 regarding the expected management of a diabetic patient to include: nurses should review patients under their care by review physician's orders, care plan and diagnosis so that diabetic diagnosis are known to ensure appropriate care and that physician's orders are being followed as prescribed, as well as monitoring for and responding to changes in condition for immediate consultation with the MD/NP for appropriate treatment. Evaluating and responding to the needs of the diabetic patient based on presenting symptoms of hyper and hypoglycemia and following physician's orders/recommendations. Also in-serviced on 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: 9/4/2023 Date to be completion:[TRUNCATED] 676313 Page 31 of 31