Every finding on record at Autumn Care of Madison

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent. A total of three errors occurred out of 31 opportunities for error due to residents not receiving their medication for two residents (Resident (R)19 and R84) out of six residents observed for medication administration. In addition, one of six residents (R27) received a partial dose of medication. The facility medication error rate was 9.68%. This failure had the potential to affect the accurate dosing of medication administered to the residents and for residents not to receive the full beneficial effects of the prescribed medications.Findings include:1. Observations during medication administration on 04/23/26 at 8:16 AM, revealed Registered Nurse (RN) 1 failed to administer R84's bumetanide (a medication used to treat excess fluid retention) 1 [one] milligram (mg) one tablet. Review of R84's Physician Orders, dated April 2026 and located under the Orders tab of the electronic medical record (EMR), indicated there was a physician's order for bumetanide 1 mg every day at 9:00AM. 2. Observations during medication administration on 04/23/26 at 8:55 AM revealed that RN2 failed to administer R19's Salon Pas 4% lidocaine adhesive patch (a pain-relieving patch). Review of R19's Physician Orders, dated April 2026 and located under the Orders tab in the EMR, indicated there was a physician's order for Salon Pas 4% lidocaine adhesive patch twice a day at 7:00AM-11:00 AM and 19:00-23:00 [7:00 PM to 11:00 PM]. 3. Observations during medication administration on 04/23/26 at 8:39 AM, revealed Licensed Practical Nurse/Unit Manager (LPNUM) administered R27's Geri-Kot 8.6 mg [a medication used to help you have a bowel movement] 1 [one] tablet. Review of R27's Physician Orders, dated April 2026 located under the Orders tab of the EMR, indicated there was a physician's order for Senna 8.6 mg 2 [two] tablets, twice a day at 7:00AM-11:00AM and 19:00-23:00 [7:00 PM to 11:00 PM]. During an interview on 04/23/24 at 3:15PM, RN1 stated I gave it [referring to the bumetanide], let's go look on the cart. RN1 went to medication cart with the Surveyor and was unable to find a medication card for bumetanide. Further research revealed the pharmacy had not delivered the medication. During an interview on 04/23/24 at 3:45 PM, RN2 stated We are out of the patches. I checked in both medication rooms and there weren't any here when I worked Sunday either. During an interview on 04/23/24 at 4:10 PM, LPNUM was asked about only giving one Geri-Kot (senna tablet) instead of two. LPNUM stated, I thought I did give two. During an interview on 04/23/26 at 4:30 PM, the Director of Nursing (DON) stated, staff should never mark medications as given when they weren't available, and that she should be made aware of missing medications so they can be gotten from the pharmacy. Review of the facility policy titled, Medication Shortages/Unavailable Medications, dated 12/01/07, last revision date 08/01/24, revealed, . 1. Upon discovery that Facility has an inadequate supply of medication to administer to a resident, Facility staff should immediately initiate action to obtain medication from pharmacy. If medication shortage is discovered at the time of medication administration, facility staff should immediately notify the pharmacy.

Based on staff interview and clinical record review, it was determined the facility staff failed to maintain a complete and accurate clinical record for one of four residents in the survey sample, Resident #1. The findings include: Resident #1 was admitted to the facility on [DATE]. The resident was transferred to the hospital on 6/29/24 and did not return to the facility after her stay in the hospital. Resident was transferred elsewhere. Review of the clinical record revealed documented a physician note dated, 7/23/24, documented in part, Patient seen and evaluated for continuity of necessity of rehabilitation stay/skilled nursing/medication order review. Nurses' notes/vitals reviewed in PCC (initials of computer program), discussed patient status/progress with nursing staff. A second physician note dated, 8/27/24, documented in part, Patient seen and evaluated for continuity of necessity of rehabilitation stay/skilled nursing/medication order review. Nurses' notes/vitals reviewed in PCC, discussed patient status/progress with nursing staff. The physician was not available for interview at this time. On 2/5/25 at 2:27 p.m., The above was shared with ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional director of operations ASM #3 stated, They have reached out to the physician regarding this. No further information was provided prior to exit.

Based on staff interview and clinical record review, it was determined the facility staff failed to notify the physician and the responsible party of changes in condition for one of four residents in the survey sample, Resident # 3. The findings include: For Resident #3, the facility staff failed to notify the responsible party of a bruise on 12/19/24 and a fall on 12/25/24. The nurse's note dated 12/19/24 at 6:47 p.m. documented, Hospice CNA (certified nursing assistant) reported to this speaker that resident has bruising to R. (right) buttock. There is no documentation the physician or responsible party were notified of the bruise. The nurse's note dated 12/25/24 at 6:47 p.m. documented, Resident had unwitnessed fall in bathroom located beside commode, resident was sitting upward, Resident (+) (positive for) PEERLA (pupils, equal, round, reactive to light and accommodation), upper and lower extremities move at previous levels, respirations even and resident abdomen soft and non-tender resident denies pain and discomfort. There is no documentation the physician or responsible party were notified of the fall. On 2/5/25 at 1:46 p.m., An interview was conducted with RN (registered nurse) #,1 RN #1 stated When there is a fall, bruise or any change in condition, the nurse should notify the doctor, family and the director of nursing. On 2/5/25 at 2:16 p.m., ASM (administrative staff member) #2, the director of nursing, stated, They did not have any documentation that the provider and/or responsible party was notified of the above. The facility policy, Incident/Accident Policy documented in part, 5. The incident will be reported to the provider as soon as practicably possible .6. The incident will be reported to the resident's responsible party as soon as practicably possible, including any known injury and provider orders. ASM #1, the administrator, ASM #2, and ASM #3, the regional director of operations. No further information was provided prior to exit.

Based on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to implement a complete pain management program for one of 28 residents in the survey sample, Resident # 49 (R49). The findings include: For (R49) the facility staff failed to attempt non-pharmacological interventions prior to the administration of a prn (as needed) pain medications, hydromorphone (1) and Tylenol (2) and failed to clarify the physician's orders for the use of the PRN pain medications. (R49) was admitted to the facility with a diagnosis that included but was not limited to chronic pain. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 02/03/2023, (R49) scored 15 out of 15 on the BIMS (brief interview for mental status), indicating (R49) was cognitively intact for making daily decisions. Under J0600. Pain Intensity it documented, A. Numeric Rating Scale (00-10). (R49) was coded a 7 (seven). The physician's order for (R49) documented in part, Hydromorphone HCl Tablet 2 MG (milligrams). Give 2 tablet by mouth every 6 hours as needed for chronic pain. Order Date: 09/16/202 and Tylenol Tablet 325 MG (Acetaminophen). Give 975 mg by mouth every 6 hours as needed for pain. Order date: 08/29/2022. Further review of the physician's orders failed to evidence pain level parameters for the administration of the above prn pain medications. The eMAR (electronic medication administration record) for (R49) dated January 2023 documented the physician's orders as stated above. The eMAR revealed that (R49) received 2 mgs of hydromorphone on the following dates and times, with no evidence of non-pharmacological interventions being attempted: 01/03/2023 at 10:16 a.m., 01/04/2023 at 10:53 a.m., 01/06/2023 at 2:47 p.m., 01/07/2023 at 10:17 a.m., 01/11/2023 at 8:28 a.m. and at 3:54 p.m., 01/12/2023 at 9:03 a.m. and at 4:29 p.m., 01/13/2023 at 8:31 a.m. and at 3:54 p.m., 01/14/2023 at 12:53 p.m., 01/17/2023 at 7:39 a.m., 01/20/2023 at 11:37 a.m., 01/21/2023 at 4:51 p.m., 01/22/2023 at 9:05 a.m., 01/26/2023 at 8:00 a.m. and at 3:54 p.m., 01/27/2023 at 1:01 p.m. and at 7:07 p.m., and on 01/31/2023 at 12:32 p.m. Further review of the eMAR revealed that (R49) received 975 mg of Tylenol on the following dates and times, with no evidence of non-pharmacological interventions being attempted on: 01/11/2023 at 8:28 a.m., 01/13/2023 at 10:18 a.m., 01/14/2023 at 12:55 p.m., 01/21/2023 at 4:52 p.m., 01/22/2023 at 9:06 a.m., 01/24/2023 at 11:24 a.m., and on 01/26/2023 at 11:34 a.m. The eMAR for (R49) dated February 2023 documented the physician's orders as stated above. The eMAR revealed that (R49) received 2 mgs of hydromorphone on the following dates and times, with no evidence of non-pharmacological interventions being attempted: 02/01/2023 at 7:38 a.m. and at 2:33 p.m., 02/10/2023 at 9:58 a.m. and at 4:32 p.m., and on 02/15/2023 at 2:09 p.m. Further review of the eMAR revealed that (R49) received 975 mg of Tylenol on the following dates and times, with no evidence of non-pharmacological interventions being attempted on: 02/08/2023 at 5:36 a.m. and on 02/15/2023 at 2:09 p.m. On 02/21/23 at approximately 11:45 a.m., an interview was conducted with (R49). When asked if they have pain (R49) stated they have chronic pain. When asked when they receive as needed pain medication, if the staff try to alleviate their pain before administering their pain medication, (R49) stated no. The comprehensive care plan for (R49) dated 08/16/2022 documented in part, The resident has pain r/t (related to) Neuropathy (3) and PVD (peripheral vascular disease) (4). Has hx (history) of chronic pain to lower back and legs. Date Initiated: 08/16/2022. Under Interventions it documented in part, Staff to offer/implement non-pharmacological interventions for pain relief .Date Initiated: 08/16/2022. On 02/22/2023 at approximately 12:55 p.m., an interview was conducted with LPN (licensed practical nurse) #7. When asked to describe the procedure when administering as needed pain medication LPN #7 stated that the nurse assesses the resident's pain by obtaining the severity of the resident's pain on a scale of zero to ten, with ten being the worse pain, the location of the pain and the type of pain. LPN #7 stated that the nurse would start with non-pharmacological interventions such as repositioning and if that did not alleviate the resident's pain, they would administer the prescribe medication. When asked how often non-pharmacological interventions should be attempted, LPN #7 stated that it should be attempted each time before the as needed pain medication is administered. When asked to describe the procedure they follow when a resident is prescribed two prn pain medications without pain level parameters LPN #7 stated they would clarify the orders. After reviewing the physician's orders for the prn pain medications stated above, LPN #7 was asked how they determine which pain medication they administer when (R49) tells them they are in pain. LPN #7 stated that (R49) will tell them which pain medication the want. On 02/22/2023 at approximately 1:15 p.m., an interview was conducted with ASM (administrative staff member #2, director of nursing. After reviewing the physician's orders for the prn pain medications stated above, ASM #2 was asked how they determine which pain medication they would administer when (R49) tells them they are in pain. ASM #2 stated that the physician's order should have been clarified. ASM #2 was asked to review the dates and times stated above on the eMARS to determine if there was documentation of non-pharmacological interventions attempted prior to the administration of (R49's) prn pain medications. At approximately 2:05 p.m., ASM #2 stated that there was no documentation of non-pharmacological interventions attempted for the dates and times stated above. The facility's policy Pain Management Protocol documented in part, Non-pharmacological intervention[s] will be attempted prior to the administration of PRN pain medications. When it is determined the resident's pain will need pharmacological interventions: a. Documentation of administration of medications will be located in the electronic medication record (eMAR). b. The effectiveness of the medication(s) will be identified on the eMAR. On 02/22/2023 at approximately 4:49 p.m., ASM #1, administrator, and ASM #2, director of nursing, ASM #3, assistant director of nursing, and ASM #4, business office manager/administrator in training, were made aware of the above findings. No further information was provided prior to exit. References: (1) Used to relieve severe pain. This information was obtained from the website: Hydromorphone: MedlinePlus Drug Information. (2) Used to relieve mild to moderate pain. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a681004.html. (3) Nerve damage. This information was obtained from the website: https://www.google.com/#q=neuropathy+nih. (4) Arteries can become thick and stiff, a problem called atherosclerosis. Blood clots can clog vessels and block blood flow to the heart or brain. Weakened blood vessels can burst, causing bleeding inside the body.) This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/vasculardiseases.html.

Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide the required written documentation for a facility-initiated transfer, for one of 28 residents in the survey sample, Resident # 64 (R64). The findings include: For (R64), the facility staff failed to evidence that written notification was provided to (R64) and (R64's) responsible party for a facility-initiated transfer on 02/10/2023. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 01/20/2023, (R64) scored three out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely impaired of cognition for making daily decisions. The facility's progress noted for (R64) dated 2/10/2023 at 7:35 a.m., documented in part, Situation: The Change In Condition/s reported on this CIC (change in condition) Evaluation are/were: Nausea/Vomiting . A. Recommendations: If resident has additional n/v (Nausea/Vomiting) please send to hospital for evaluation. The facility's progress noted for (R64) dated 2/10/2023 at 10:05 a.m., documented. RT (Resident) sent to (Name of Hospital) at 0700 (7:00 a.m.) for vomiting and abnormal VS (vital signs). Review of the clinical record and the EHR (electronic health record) for (R64) failed to evidence written notification of the discharge was provided to (R64) and (R64's) representative for the facility-initiated transfer on 02/10/2023. On 02/22/2023 at approximately 3:58 p.m., an interview was conducted with OSM (other staff member) #1, director of social services. When asked about providing a written notification to the resident and the resident's RP regarding the transfer, OSM stated they mail a copy of the letter and scan it into the resident's electronic health record. On 02/22/2023 at approximately 4:49 p.m., ASM (administrative staff member) #1, administrator, stated that they did not have evidence of providing written notification provided to (R64) and (R64's) responsible party for a facility-initiated transfer on 02/10/2023. The facility's policy Resident Discharge / Transfer Letter Policy documented in part, E) Social Services or designee will assure the original discharge/transfer letter is given to resident or guardian/sponsor, id applicable. 1. Copies will be sent to Department of Health, Ombudsman Office, and filed in the business file and/or scanned into PCC (point click care - electronic health record) documents tab with administrator/designee signature, with certified receipt if applicable. On 02/23/2023 at approximately 11:10 a.m., ASM #1, administrator, and ASM #2, director of nursing, and ASM #5, regional director of clinical services, were made aware of the above findings. No further information was provided prior to exit

Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed provide a bed hold policy notice to the resident or the resident's representative, for a facility-initiated transfer of one of 28 residents in the survey sample, Resident #64 (R64). The findings include: For (R64), the facility staff failed to evidence that a bed hold policy notice was provided to (R64) and (R64's) responsible party for a facility-initiated transfer on 02/10/2023. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 01/20/2023, (R64) scored three out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely impaired of cognition for making daily decisions. The facility's progress noted for (R64) dated 2/10/2023 at 10:05 a.m., documented. RT (Resident) sent to (Name of Hospital) at 0700 (7:00 a.m.) for vomiting and abnormal VS (vital signs). Review of the clinical record and the EHR (electronic health record) for (R64) failed to evidence a bed hold policy was provided to (R64) and (R64's) representative for the facility-initiated transfer on 02/10/2023. On 02/22/2023 at approximately 3:58 p.m., an interview was conducted with OSM (other staff member) #1, director of social services. When asked about the procedure to provide a bed hold policy for a facility-initiated transfer, OSM #1 stated the hold policy is given to the resident when they to go to emergency room and then it is scanned into the resident's electronic health record. On 02/22/2023 at approximately 4:49 p.m., ASM (administrative staff member) #1, administrator, stated that they did not have evidence of providing a bed hold policy to (R64) and (R64's) responsible party for a facility-initiated transfer on 02/10/2023. The facility's policy Resident Discharge / Transfer Letter Policy documented in part, G) The resident or responsible party will receive a bed hold policy notice along with the discharge / transfer letter, when applicable. Bed hold notices can be found within PCC (point click care - electronic health record) under Document Manager . On 02/23/2023 at approximately 11:10 a.m., ASM #1, administrator, and ASM #2, director of nursing, and ASM #5, regional director of clinical services, were made aware of the above findings. No further information was provided prior to exit

Based on clinical record review and staff interview it was determined that the facility staff failed to maintain an accurate MDS (minimum data set) assessment for one of 28 residents in the survey sample, Resident #38. The findings include: For Resident #38 (R38), the facility staff failed to code the quarterly MDS assessment with an ARD (assessment reference date) of 1/2/2023 for hospice services received during the assessment period. Review of the clinical record for R38 revealed the most recent MDS assessment to be a quarterly MDS with an ARD of 1/2/2023. Section O of the assessment failed to document R38 receiving hospice services during the assessment period. The physician orders for R38 documented in part, Admit to [Name of hospice] - Do Not Give Antibiotics, No Vital Signs or Weights, Do Not Send To ER (emergency room ) or Hospital, Do Not Draw Blood, Collect Urine or XR (x-ray) Testing, Do Not Give Tube Feedings. Order Date: 06/28/2021. The comprehensive care plan for R38 documented in part, HOSPICE SERVICES: Resident is on Hospice services, (Name of hospice) (phone number]) Date Initiated: 06/28/2021 . On 2/22/2023 at 2:00 p.m., an interview was conducted with LPN (licensed practical nurse) #1, MDS coordinator. LPN #1 stated that they used the RAI (resident assessment instrument) manual as their guide when completing the MDS assessments. LPN #1 stated that R38 received hospice services and the MDS should be coded for the services. LPN #1 reviewed the quarterly MDS with the ARD of 1/2/2023 and stated that it was not coded for hospice and should have been and it would be corrected. According to the RAI Manual, Version 1.16, dated October 2018, section O0100 documented in the steps for assessment, 1. Review the resident's medical record to determine whether or not the resident received or performed any of the treatments, procedures, or programs within the last 14 days .O0100K, Hospice Care, Code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions. The hospice must be licensed by the state as a hospice provider and/or certified under the Medicare program as a hospice provider . On 2/22/2023 at 4:47 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing/infection preventionist, ASM #4, the business office manager/administrator in training and ASM #5, the regional director of clinical services were made aware of the concern. No further information was provided prior to exit.

Based on resident interview, staff interview, facility policy review, and clinical record review, it was determined the facility staff failed to implement the comprehensive care plan for two of 28 residents in the survey sample, Residents #33 and #49. The findings include: 1. The facility staff failed to implement the care plan for obtaining weights per the physician orders for Resident #33 (R33). On the most recent MDS (minimum data set) assessment, a quarterly/Medicare five-day assessment, with an assessment reference date of 1/2/2023, the resident scored an eight out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired for making daily decisions. R33 has a diagnosis of congestive heart failure (CHF). The comprehensive care plan dated, 9/14/2022 and revised on 10/13/2022, documented in part, Focus: The resident has a potential nutritional problem r/t (related to) risk for malnutrition r/t depression, celiac disease, Vitamin deficiency, and duodenal ulcer. The Interventions documented in part, Weights per orders/routine/prn (as needed). The physician order dated, 11/17/2022, documented, Daily Weight. The December 2022 and January 2023, MAR (medication administration record) documented the above order for daily weights. The following dates were blank: 12/29/2022, 12/20/2022, 1/3/2023, 1/4/2023, 1/29/2023. Review of the Weights tab in the electronic medical record failed to evidence documentation of weights obtained on the above dates. An interview was conducted with LPN (licensed practical nurse) #3 on 2/22/2023 at 3:30 p.m. When asked the purpose of the care plan, LPN #3 stated, It is to make sure we are doing the right things for our folks. It should have new orders, falls, treatments, ADLs (activities of daily living), and code status. LPN #3 stated it is individualized [care plan] for each resident, as each resident is different in their care needs. When asked if it should be followed, LPN #3 stated, yes. The facility policy, Comprehensive Care Planning Policy documented in part, POLICY: An interdisciplinary plan of care will be established for every resident and updated in accordance with state and federal regulatory requirements and on an as needed basis. In states where pre-admission screening applies, this will be coordinated with the facility assessment. Goals must be measurable and objective . D) All staff must be familiar with each resident's Care Plan and all approaches must be implemented. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM # 5, the regional director of clinical services, were made aware of the above finding on 2/23/2023 at 11:15 a.m. No further information was provided prior to exit. 29843 2. For Resident #49 (R49) the facility staff failed to implement the comprehensive care plan for the use of non-pharmacological interventions prior to the administration of a prn (as needed) pain medications, (R49) was admitted to the facility with a diagnosis that included but was not limited to chronic pain. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 02/03/2023, (R49) scored 15 out of 15 on the BIMS (brief interview for mental status), indicating (R49) was cognitively intact for making daily decisions. Under J0600. Pain Intensity it documented, A. Numeric Rating Scale (00-10). (R49) was coded a 7 (seven). The physician's order for (R49) documented in part, Hydromorphone HCl Tablet 2 (two) MG (milligrams). Give 2 tablet by mouth every 6 (six) hours as needed for chronic pain (1). Order Date: 09/16/202, and Tylenol Tablet 325 MG (Acetaminophen). Give 975 mg by mouth every 6 hours as needed for pain (2). Order date: 08/29/2022. Further review of the physician's orders failed to evidence pain level parameters for the administration of the above prn pain medications. The comprehensive care plan for (R49) dated 08/16/2022 documented in part, The resident has pain r/t (related to) Neuropathy (3) and PVD (peripheral vascular disease) (4). Has hx (history) of chronic pain to lower back and legs. Date Initiated: 08/16/2022. Under Interventions it documented in part, Staff to offer/implement non-pharmacological interventions for pain relief .Date Initiated: 08/16/2022. The eMAR (electronic medication administration record) for (R49) dated January 2023 documented the physician's orders as stated above. The eMAR revealed that (R49) received 2 mgs of hydromorphone on the following dates and times, with no evidence of non-pharmacological interventions being attempted: 01/03/2023 at 10:16 a.m., 01/04/2023 at 10:53 a.m., 01/06/2023 at 2:47 p.m., 01/07/2023 at 10:17 a.m., 01/11/2023 at 8:28 a.m. and at 3:54 p.m., 01/12/2023 at 9:03 a.m. and at 4:29 p.m., 01/13/2023 at 8:31 a.m. and at 3:54 p.m., 01/14/2023 at 12:53 p.m., 01/17/2023 at 7:39 a.m., 01/20/2023 at 11:37 a.m., 01/21/2023 at 4:51 p.m., 01/22/2023 at 9:05 a.m., 01/26/2023 at 8:00 a.m. and at 3:54 p.m., 01/27/2023 at 1:01 p.m. and at 7:07 p.m., and on 01/31/2023 at 12:32 p.m. Further review of the eMAR revealed that (R49) received 975 mg of Tylenol on the following dates and times, with no evidence of non-pharmacological interventions being attempted: 01/11/2023 at 8:28 a.m., 01/13/2023 at 10:18 a.m., 01/14/2023 at 12:55 p.m., 01/21/2023 at 4:52 p.m., 01/22/2023 at 9:06 a.m., 01/24/2023 at 11:24 a.m., and on 01/26/2023 at 11:34 a.m. The eMAR for (R49) dated February 2023 documented the physician's orders as stated above. The eMAR revealed that (R49) received 2 mgs of hydromorphone on the following dates and times, with no evidence of non-pharmacological interventions being attempted: 02/01/2023 at 7:38 a.m. and at 2:33 p.m., 02/10/2023 at 9:58 a.m. and at 4:32 p.m., and on 02/15/2023 at 2:09 p.m. Further review of the eMAR revealed that (R49) received 975 mg of Tylenol on the following dates and times, with no evidence of non-pharmacological interventions being attempted: 02/08/2023 at 5:36 a.m. and on 02/15/2023 at 2:09 p.m. On 02/21/23 at approximately 11:45 a.m., an interview was conducted with (R49). When if they have pain (R49) stated they have chronic pain. When asked if they receive as needed pain medication, does the staff try to alleviate their pain before administering their pain medication (R49) stated no. On 02/22/2023 at approximately 1:15 p.m., an interview was conducted with ASM (administrative staff member) #2, director of nursing. ASM #2 was asked to review the dates and times stated above on the eMARS to determine if there was documentation of non-pharmacological interventions attempted prior to the administration of (R49's) prn pain medications. At approximately 2:05 p.m., ASM #2 stated that there was no documentation of non-pharmacological interventions attempted for the dates and times stated above. On 02/23/2023 at approximately 8:55 a.m., an interview was conducted with ASM #2. After reviewing (R49's) comprehensive care plan as stated above, ASM #2 was asked if the care plan was being implemented if there was no evidence of non-pharmacological interventions attempted. ASM # 2 stated no. The facility's policy Comprehensive Care Planning Policy documented in part, D) All staff must be familiar with each resident's Care Plan and all approaches must be implemented. On 02/23/2023 at approximately 9:00 a.m., ASM #2, director of nursing, was made aware of the above findings. No further information was provided prior to exit. References: (1) Used to relieve severe pain. This information was obtained from the website: Hydromorphone: MedlinePlus Drug Information. (2) Used to relieve mild to moderate pain. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a681004.html. (3) Nerve damage. This information was obtained from the website: https://www.google.com/#q=neuropathy+nih. (4) Arteries can become thick and stiff, a problem called atherosclerosis. Blood clots can clog vessels and block blood flow to the heart or brain. Weakened blood vessels can burst, causing bleeding inside the body.) This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/vasculardiseases.html.

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed follow the physician's order for obtaining daily weights for one of 28 residents in the survey sample, Resident #33. The findings include: For Resident #33 (R33), the facility staff failed to obtain daily weights twice in December 2022 and three times in January 2023. On the most recent MDS (minimum data set) assessment, a quarterly/Medicare five day assessment, with an assessment reference date of 1/2/2023, the resident scored an eight out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired for making daily decisions. R33 has a diagnosis of congestive heart failure (CHF). The physician order dated, 11/17/2022, documented, Daily Weight. The December 2022 and January 2023, MAR (medication administration record) documented the above order for daily weights. The following dates were blank: 12/29/2022, 12/20/2022, 1/3/2023, 1/4/2023, 1/29/2023. Review of the Weights tab in the electronic medical record failed to evidence documentation of weights obtained on the above dates. The comprehensive care plan dated, 9/14/2022 and revised on 10/13/2022, documented in part, Focus: The resident has a potential nutritional problem r/t (related to) risk for malnutrition r/t depression, celiac disease, Vitamin deficiency, and duodenal ulcer. The Interventions documented in part, Weights per orders/routine/prn (as needed). An interview was conducted with LPN (licensed practical nurse) #5 on 2/23/2023 at 9:26 a.m. When asked where daily weights are documented and why they are done, LPN #5 stated they are documented on the MAR and typically done for residents with CHF. When asked if there is a blank on the MAR for a day, what does that indicate, LPN #5 stated, if it's not documented it wasn't done. The facility policy, Weights Policy documented in part, POLICY: Weights will be obtained routinely in order to monitor parameters of nutrition over time. Each individual's weight will be determined upon admission/readmission to the facility, weekly for the first four weeks after admission/readmission, and monthly or more often if risk is identified. Obtaining accurate weights is vital for the nutritional assessment of each resident and can be used as a basis for medical and nutritional intervention. Nursing is responsible for the determination of each individual's weight. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM # 5, the regional director of clinical services, were made aware of the above finding on 2/23/2023 at 11:15 a.m. No further information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to ensure a new heel wound was assessed accurately, and a treatment was obtained and implemented timely, for one of 28 residents in the survey sample, Resident #33 (R33). The findings include: For R33, the facility staff failed to obtain a physician's order for a treatment to an opened heel blister, and, the heel blister was not assessed and staged as a pressure injury per the National Pressure Injury Advisory Panel (NPIAP) guidelines. On the most recent MDS (minimum data set) assessment, a quarterly/Medicare five-day assessment, with an assessment reference date of 1/2/2023, the resident scored an eight out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired for making daily decisions. In Section M - Skin Conditions, R33 was not coded as having any pressure ulcers. The Weekly Wound assessment dated [DATE], documented in part, Wound type: other. Other wound type: open blister. Stage: N/A (not applicable). Wound location: right heel. Length: 5.0 cm (centimeters). Width: 6 cm. Depth: 0.2 cm. Location where wound was acquired: in house. Date wound identified: 2/10/2023. Wound status: New Wound. Treatment: area cleaned and dressing applied. Comments: Call placed to on call doctor, awaiting return call. The nurse who documented the wound was not available for interview. Per the NPIAP: Stage 2 Pressure Injury: Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel . (1) The Wound Care Specialist Note dated, 2/14/2023, documented in part, Wound: Right heel (+) full-thickness wound that measures 5.0 x 6.0 x 0.2 cm. Wound base 40% purple/maroon tissue, 60% granular, (+) surface induration, edges adherent to the wound base, moderate non-odorous serous drainage, Peri wound without erythema, induration or signs of cellulitis. Patient does not demonstrate evidence of pain when area palpated .Wound care to right heel as follows: Cleanse with normal saline or wound cleanser, pat dry. Apply Alginate to wound bed. Cover with gauze and kerlix dressing. Change dressing every day and as needed for saturation or soilage. Review of the physician orders failed to evidence documentation of the wound care specialist directions. Review of the TAR (treatment administration record) for February, failed to evidence documentation of any dressing changes from 2/10/2023 through 2/14/2023 or 2/15/23 through 2/20/2023. The physician order dated, 2/21/2023, documented, Cleanse right heel with wound cleanser and apply xeroform and dressing daily to open blister. The comprehensive care plan dated, 9/13/2022, documented in part, Focus: Skin Integrity/Pressure Ulcer Development: The resident has potential for skin breakdown including pressure ulcer development r/t (related to) decrease in mobility. Resident refuses treatments at times. 2/20/2023 - Left heel wound (area is on his right heel). The Interventions dated 9/13/2022, documented in part, Administer treatments as ordered and monitor for effectiveness. Assess/document/report to MD (medical doctor) PRN (as needed) changes in skin status. On 2/23/2023 at 9:15 a.m., ASM (administrative staff member) #2, the director of nursing, was asked if there was any documentation of any treatments between 2/10/2023 and 2/20/2023, ASM #2 stated there was no documentation of any wound treatment between 2/10/2023 and 2/20/2023. The Wound Care Specialist recommendations for wound care on 2/14/2023 was reviewed with ASM #2. ASM #2 stated the orders were never transferred over to the TAR. On 2/23/2023 at 9:15 a.m., R33 was observed in bed with an air mattress in use on the bed. R33 was lifting both of his legs around in the bed. During the wound care observation at that time, the resident was able to lift his leg independently for the nurse to perform the dressing change. A dressing was observed on the heel prior to the dressing change. An interview was conducted with LPN (licensed practical nurse) #5 on 2/23/2023 at 9:26 a.m. When asked the process for assessing and treating a new pressure wound, LPN #5 stated, the nurse should do a head-to-toe assessment, if any new areas are found, they complete the Weekly Wound Assessment form which documents the type of wound, location of wound, measurements and notification of the doctor and RP (responsible party), the new orders received from the doctor or nurse practitioner. When asked if there should be a treatment for an open blister, LPN #5 stated, yes. When asked what the process is for after the wound care specialist sees a resident with a pressure area, LPN #5 stated, typically the nurse practitioner will give a verbal order at the time she sees the resident. If she doesn't give a verbal order, her notes are faxed over to the facility in the evening after she was in the building. LPN #5 stated, typically the resident is reviewed the next day to ensure there are appropriate orders in place. The copy of the wound care specialist notes are printed and given to the nurse on the unit. The nurse is to transcribe the orders into the computer record. LPN #5 reviewed the February TAR. When asked if she saw any treatment documented between 2/10/2023 and 2/20/2023, LPN #5 stated, she didn't see anything The facility policy, Skin and Wound Care Best Practices documented in part, Pressure Injury and Wound Treatment: steps initiated based on skin assessment findings: Pressure injuries and wounds will be treated with evidence-based interventions as ordered by the provider. See Wound Product Selection Guide for guidance on wound type/stage identification and suggested treatment approaches. Conduct comprehensive pain assessment for those with pressure injury. Communities may engage the services of a consulting wound care provider. Use of a consulting wound care provider for management of wounds is recommended for the following: A stage 3 or greater pressure injury, complicated vascular wounds, complicated diabetic wounds, wounds which are worsening, wounds which are not healing even with treatment changes, infected wounds, when assistance with correctly staging or categorizing a wound is needed. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM # 5, the regional director of clinical services, were made aware of the above finding on 2/23/2023 at 11:15 a.m. No further information was provided prior to exit. Reference obtained from: (1) https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf

Based on observation, resident interview, clinical record review, staff interview and facility document review it was determined that the facility staff failed to provide foot care for two of 28 residents, Resident #43 and Resident #7. The findings include: 1. For Resident #43 (R43), the facility staff failed to provide foot care services. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/19/2023, the resident scored 11 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was moderately impaired for making daily decisions. Section G documented R43 requiring extensive assistance of one staff member for personal hygiene. Section I documented R43 having diagnoses including but not limited to Diabetes Mellitus (1). On 2/21/2023 at 12:29 p.m., R43 was observed lying in bed asleep. R43's right foot was observed outside of the blanket uncovered. The toenail on the great toe was observed to be uneven with thick jagged edges which extended past the toe. The nails on the other toes were observed to be long but not jagged. Additional observations of R43 on 2/21/2023 at 2:50 p.m. revealed to same observation of the right foot uncovered outside of the blanket. An interview was attempted with R43 however due to their cognitive status it was not completed. On 2/22/2023 at 9:29 a.m., an observation was made of R43 in bed with both of R43's uncovered and visible. Observation of the left foot revealed the great toenail to be thick and long with jagged edges which extended past the toe. The nails on the other toes were observed to be long but not jagged. The comprehensive care plan for R43 documented in part, ADL (activities of daily living) Functional Status: The resident has an ADL self care performance deficit r/t (related to) general weakness, morbid obesity, adult failure to thrive and neuropathy. Requires staff to assist with completing adl's daily. Date Initiated: 10/13/2022 . On 2/22/2023 at 2:38 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that the facility had a podiatrist that came in but they were not sure how often they came in the building or their schedule. LPN #3 stated that there was a podiatrist list kept at the nurses station and they could add residents to be seen as needed. LPN #3 stated that the CNA's (certified nursing assistants) could trim fingernails of residents unless they were diabetic and the nurses could trim the fingernails and toenails of all residents. LPN #3 stated that the nurses would trim or file the residents toenails and if they were too long, painful or too thick they would have the podiatrist see them because they did not have the proper equipment. LPN #3 observed R43's toenails and agreed that they were long and jagged and needed to be trimmed up. On 2/22/2023 at 4:33 p.m., an interview was conducted with ASM (administrative staff member) #3, the assistant director of nursing, infection preventionist. ASM #3 stated that they were responsible for the podiatry schedule at the facility. ASM #3 stated that the podiatrist came to the facility every three months and more frequently if needed. ASM #3 stated that the nurses trimmed the toenails of diabetic residents. ASM #3 stated that the podiatrist preferred to have 10 to 15 residents to see when they came in the building but came in to see one resident if there was a need or a consult within 48-72 hours or they sent residents out to see a podiatrist. On 2/22/2023 at 4:47 p.m., ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing/infection preventionist, ASM #4, the business office manager/administrator in training and ASM #5, the regional director of clinical services were made aware of the concern. On 2/23/2023 at 11:10 a.m., ASM #5, the regional director of clinical services stated that the facility did not have a policy regarding foot care or podiatry services and that they followed Lippincott as their nursing standard of practice. On 2/23/2023 at 11:41 a.m., ASM #5 provided the title page of Lippincott Manual of Nursing Practice, Eleventh Edition. According to Lippincott Manual of Nursing Practice, 10th Edition, it documented in part, Diabetes Mellitus and Related Disorders .Foot Care Guidelines .6. Go to a podiatrist on a regular basis if corns, calluses, and ingrown toenails are present. 6.a. Trim toenails straight across to prevent ingrown toenails. b. File any rough corners with an emery board . No further information was provided prior to exit. (1) Diabetes Mellitus Diabetes is a disease in which your blood glucose, or blood sugar, levels are too high. Glucose comes from the foods you eat. Insulin is a hormone that helps the glucose get into your cells to give them energy. With type 1 diabetes, your body does not make insulin. With type 2 diabetes, the more common type, your body does not make or use insulin well. Without enough insulin, the glucose stays in your blood. You can also have prediabetes. This means that your blood sugar is higher than normal but not high enough to be called diabetes. Having prediabetes puts you at a higher risk of getting type 2 diabetes. Over time, having too much glucose in your blood can cause serious problems. It can damage your eyes, kidneys, and nerves. Diabetes can also cause heart disease, stroke and even the need to remove a limb. This information was obtained from the website: https://medlineplus.gov/diabetes.html 2. For Resident #7 (R7), the facility staff failed to provide foot care services. On the most recent MDS (minimum data set), a five day admission assessment with an ARD (assessment reference date) of 1/4/2023, the resident scored 12 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was moderately impaired for making daily decisions. Section G documented R7 requiring extensive assistance of one staff member for personal hygiene. R7 was not documented as being a diabetic. On 2/21/2023 at 12:15 p.m., an interview was conducted with R7 in their room. R7 stated that they had a lot of pain in their left foot from their toenails. R7 stated that they had been having pain for a long time. R7 stated that a nurse had looked at their toenails and told them the doctor was going to trim them but no one had been in. R7 stated that the nursing staff had told them that they were not allowed to trim their toenails. R7 stated that the toenails were so long that it was hurting their feet and they could not wear their shoes because it hurt. R7 was observed wearing non-slip socks on their feet. R7 stated that they were unable to trim their toenails themselves and required someone to do this for them. Additional observations of R7 on 2/21/2023 at 2:55 p.m. revealed R7 in the hallway in a wheelchair wearing non-slip socks. The comprehensive care plan for R7 documented in part, ADL (activities of daily living) self care deficit: The resident has an ADL self care performance deficit r/t (related to) pain, BLE (bilateral lower extremity) edema (swelling), CHF (congestive heart failure), DJD/DDD (degenerative joint disease/degenerative disc disease), gen. (general) weakness. Date Initiated: 12/29/2022 . The progress notes for R7 documented in part, - 1/13/2023 10:38 (10:38 a.m.) Physician/PA (physician assistant)/NP (nurse practitioner) Progress note . History of Present Illness: Asked to see patient to evaluate pain. Nursing reports patient complaining of left great toe pain. Patient interviewed. Reports having difficulty with her toes and needing them trimmed. Patient also reports pain and discomfort to left great toe .Skin: Warm and dry, normal color for ethnicity. **Hypertrophic thick and discolored toenails noted .Assessment/Plan (reviewed w/ (with) patient): 1) Left great toe pain- Acute. Most likely related to hypertropic [sic] nails. Patient placed on Podiatry list. 2) Hypertropic [sic] toenails- Acute. Consult Podiatry to evaluate and treat . On 2/22/2023 at 2:38 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that the facility had a podiatrist that came in but they were not sure how often they came in the building or their schedule. LPN #3 stated that there was a podiatrist list kept at the nurses station and they could add residents to be seen as needed. LPN #3 stated that the CNA's (certified nursing assistants) could trim fingernails of residents unless they were diabetic and the nurses could trim the fingernails and toenails of all residents. LPN #3 stated that the nurses would trim or file the residents toenails and if they were too long, painful or too thick they would have the podiatrist see them because they did not have the proper equipment. An observation of R7's toenails was requested with LPN #3. Observation of R7's toenails revealed the left and right great toenails to be long, thick and curved over growing towards the second toe. The additional toenails were observed to be long, thick and curved downward under the toes. LPN #3 agreed that they were long, thick, curved into the toes next to them and needed to be trimmed. LPN #3 stated that if R7 had been complaining of pain from the toenails they should have seen the podiatrist at the facility or been sent out to see a podiatrist. On 2/22/2023 at 4:33 p.m., an interview was conducted with ASM (administrative staff member) #3, the assistant director of nursing, infection preventionist. ASM #3 stated that they were responsible for the podiatry schedule at the facility. ASM #3 stated that the podiatrist came to the facility every three months and more frequently if needed. ASM #3 stated that the CNA's could trim toenails of non-diabetic residents however the nurses preferred to do them to assess each residents feet. ASM #3 stated that the podiatrist preferred to have 10 to 15 residents to see when they came in the building but came in to see one resident if there was a need or a consult within 48-72 hours or they sent residents out to see a podiatrist. ASM #3 stated that the nurses were responsible for arranging the appointments for residents to go to a podiatrist outside of the facility. On 2/22/2023 at 4:47 p.m., ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing/infection preventionist, ASM #4, the business office manager/administrator in training and ASM #5, the regional director of clinical services were made aware of the concern. No further information was provided prior to exit.

Based on observation, resident interview, clinical record review, staff interview and facility document review it was determined that the facility staff failed to provide respiratory care and services consistent with professional standards of practice for two of 28 residents, Resident #43 and Resident #45. The findings include: 1. For Resident #43 (R43), the facility staff failed to properly store a BiPAP (1) mask in a sanitary manner when not in use. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/19/2023, the resident scored 11 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was moderately impaired for making daily decisions. Section I documented R43 having diagnoses including but not limited to Obstructive Sleep Apnea. On 2/21/2023 at 12:29 p.m., an observation was made of R43 in their room. A BiPAP machine was observed on the nightstand to the right side of R43's bed. A mask with tubing was attached to the machine. The mask was observed to be uncovered and laying on the nightstand surface. Additional observation of R43 on 2/21/2023 at 2:50 p.m. revealed the BiPAP mask uncovered on the nightstand surface. An interview was attempted with R43 however due to their cognitive status it was not completed. On 2/22/2023 at 9:29 a.m., the BiPAP mask was observed uncovered on the nightstand surface. The comprehensive care plan for R43 documented in part, Respiratory Status: COPD (chronic obstructive pulmonary disease), OSA (obstructive sleep apnea). Resident has altered pulmonary status R/T (related to) COPD and Obstructive Sleep Apnea. Resident has use of BIPAP. Date Initiated: 10/13/2022 . The physician orders for R43 documented in part, BIPAP q (every) HS (bedtime) .Order Date: 10/12/2022 . The eMAR (electronic medication administration record) dated 2/1/2023-2/28/2023 for R43 documented the use of the BiPAP each night at 8:00 p.m. from 2/1/2023 through 2/21/2023 with the exception of 2/2/2023, 2/3/2023 and 2/8/2023 when R43 refused to wear the BiPAP. On 2/22/2023 at 2:38 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that BiPAP masks should be washed with soap and water and stored in a bag after they were dried to keep them clean. LPN #3 stated that the bags were changed every week. LPN #3 observed R43's BiPAP mask uncovered on the nightstand and stated that at times R43 refused to wear it but it should be covered to keep it clean. The facility policy, BiPAP/CPAP Policy effective 1/24/2017 and revised 10/20/2021 documented in part, .Mask: wash mask with soap and water or CPAP masks after each use, let air dry. Once dry store mask in a plastic bag to keep it clean . On 2/22/2023 at 4:47 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing/infection preventionist, ASM #4, the business office manager/administrator in training and ASM #5, the regional director of clinical services were made aware of the concern. No further information was provided prior to exit. Reference: (1) Bi-Pap Positive airway pressure (PAP) treatment uses a machine to pump air under pressure into the airway of the lungs. This helps keep the windpipe open during sleep. The forced air delivered by CPAP (continuous positive airway pressure) prevents episodes of airway collapse that block the breathing in people with obstructive sleep apnea and other breathing problems Bilevel positive airway pressure (BiPAP or BIPAP) has a higher pressure when you breathe in and lower pressure when you breathe out. This information was obtained from the website: https://medlineplus.gov/ency/article/001916.htm 27660 2. The facility staff failed to provide oxygen per the physician order for Resident #45 (R45). On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 12/12/2022 the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. In Section O - Special Treatments, Procedures and Programs, the resident was not coded as using oxygen. The physician order dated 2/10/2022 read: Oxygen at 2 LPM for acute respiratory failure for 7 days. Observation was made of R45 on 2/21/2023 at 1:30 p.m., 3:12 p.m. and 4:49 p.m., sitting in their bed with oxygen on via a nasal cannula. The oxygen concentrator was set at 3 LPM (liters per minute). On 2/21/2023 at 4:59 p.m. R45 was asked if they adjusted the oxygen rate on the concentrator, R45 stated, no, they can hardly reach where the machine is. Another observation was made on 2/22/2023 at 8:50 a.m. The resident was in bed with the oxygen on via the nasal cannula. The oxygen concentrator was set at 3 LPM. On 2/22/2023 at 2:38 p.m. an observation of the concentrator was made with LPN (licensed practical nurse) #3. The oxygen concentrator was set at 2 LPM. LPN #3 stated she had adjusted it in the morning as it was set incorrectly at 3 LPM. Review of the February MAR (medication administration record) and TAR (treatment administration record) failed to evidence documentation of the use of oxygen for February 21 - 22, 2023. The comprehensive care plan dated 2/14/2023, documented in part, Focus: Resident has infection R/T (related to) pneumonia, oxygen use as directed. The Interventions documented in part, Oxygen as directed. An interview was conducted with LPN #3 on 2/22/2023 at 3:30 p.m. When asked where she signed off the resident is using oxygen, LPN #3 stated, on the TAR or MAR. When asked if R45 has a current order for oxygen, LPN #3 proceeded to review the physician orders for R45 in the computer. After reviewing the orders, LPN #3 stated, She does not have a current order for oxygen at this time. When asked should there be an order, LPN #3 stated, yes. The facility policy, Oxygen Administration Policy, documented in part, POLICY: Licensed clinicians with demonstrated competence will administer oxygen via the specified route as ordered by a provider. In an emergency, clinicians may administer oxygen and obtain a provider's order as soon as practicably possible after patient stabilization or transfer .PROCEDURE: 1. Verify provider order. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #4, the business office manager/administrator in training, and ASM # 5, the regional director of clinical services, were made aware of the above finding on 2/22/2023 at 4:55 p.m. No further information was provided prior to exit

Based on staff interview, facility document review and clinical record review, the facility staff failed to notify a resident's responsible party of a change in condition for one of 28 residents in the survey sample, Resident #223. The findings include: For Resident #223 (R223), the facility staff failed to notify the resident's RP (responsible party) of a new physician's order for melatonin. A review of R223's clinical record revealed a note signed by the nurse practitioner on 1/27/23 that documented, 4) Insomnia - Acute. New recommendations given . A physician's order dated 1/27/23 documented an order for melatonin 5 milligrams by mouth at bedtime for insomnia. Further review of R223's clinical record failed to reveal the resident's RP was made aware of the resident's insomnia and new medication order. On 2/23/23 at 8:52 a.m., an interview was conducted with LPN (licensed practical nurse) #8. LPN #8 stated a resident's RP should be notified regarding any change in condition and new medication order. LPN #8 stated, You want the RP to know a change was made and this is a reason for what the doctor is doing. On 2/23/23 at approximately 11:15 a.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Resident Change in Condition Policy documented, 5. The Resident/Physician or Provider/Family/Responsible Party will be notified when there has been .e. A need to alter the resident's medical treatment, including a change in provider orders.

Based on observation, staff interview, and clinical record review, it was determined the facility staff failed to maintain effective infection control for one of 28 residents in the survey sample, Resident #33. The findings include: For Resident #33 (R33), the facility staff failed to provide a treatment to a pressure ulcer in a manner to prevent infection. The physician order dated, 2/21/2023, documented, Cleanse right heel with wound cleanser and apply xeroform and dressing daily to open blister. On 2/23/2023 at 9:15 a.m., LPN (licensed practical nurse) #4 was observed providing a treatment to R33's right heel. LPN #4 was at the treatment cart where she got a 4x4 gauze packet, opened the packet by tearing it across one corner, used her hands to pull the gauze out of the packet and placed in on the outside of the packet. She proceeded to spray the gauze pad with wound cleanser. LPN #4 gathered the rest of her supplies; a xeroform dressing, a bordered gauze dressing, a 4x4 gauze pad, a red plastic bag, and a sterile field packet. LPN #4 entered the room. She placed the supplies on the overbed table that contained a container of thickened liquids on it. LPN #4 did not clean the table. LPN #4 then washed her hands, put on clean gloves, then proceeded to remove the current dressing from the right heel and placed it in the red bag. She then took the gauze pad, that had the wound cleanser on it and wiped the wound. She did not change gloves or perform hand hygiene between the dirty dressing and clean dressings. She then opened the clean 4x4 gauze pad by tearing it open, not using the edges to open it up. Dried the wound. Opened the xeroform dressing according to package directions, took a pair of scissors out of her pocket and proceeded to cut the xeroform dressing. She did not clean her scissors after removing them from her pocket. She placed the xeroform dressing on the wound. LPN #4 took the bordered dressing packet and tour it open and placed it on the resident's right heel. She took a marker out of her pocket which was the same pocket where the scissors were, and wrote the date and her initials on the dressing. LPN #4 removed her gloves, washed her hands and gathered the sterile field packet and returned to the treatment cart. The above observations were reviewed with LPN #4, she concurred that she did not set up a clean field or used the sterile field packet, failed to change her gloves between taking the dressing off and putting on the new dressing, failed to clean her scissors, and failed to write the date and her initials prior to placing the dressing on the resident's heel. A policy was requested for dressing application. The facility staff stated they did not have a policy; they follow standards of care. Wound Care: Preventing Infection: Gather supplies (dressings, tape, scissors, sterile saline solution, cotton swabs, extra gauze and culture materials if indicated). Wash your hands thoroughly and don gloves. Ensure strict aseptic technique during dressing changes. Lippincott Manual of Nursing Practice, 11th Edition, Wolters and Kluwer, page 104. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM # 5, the regional director of clinical services, were made aware of the above finding on 2/23/2023 at 11:15 a.m.

Based on staff interview, clinical record review, and facility document review, it was determined that facility staff failed to revise the comprehensive care plan for one of 28 residents in the survey sample, Resident #49. The findings include: For Resident #49 (R49) the facility staff failed to update the comprehensive care plan for activities to include (R49's) preference of being outside when the weather is good. (R49's) most recent comprehensive MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 01/12/2023, coded (R49) as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0-15, with 15 being cognitively intact for making daily decisions. Under F0500. Interview for Activity Preferences it coded (R49) as it being Very important to go outside to get fresh air when the weather is good. The comprehensive care plan for (R49) dated 08/22/2022 documented in part, Focus: Activities: Resident prefers/enjoys the following activities: watching tv, spending time on social media and phone. Date Initiated: 08/22/2022. Under Interventions it documented, Engage resident in group activities Date Initiated: 08/22/2022. Monitor independent activities prn (as needed). Date Initiated: 08/22/2022. On 02/23/2023 at approximately 8:45 a.m., an interview was conducted with LPN (licensed practical nurse) #6, MDS assistant coordinator. After reviewing section F0500 of (R49's) significant change MDS and their comprehensive care plan for activities, LPN #6 stated that (R49's) care plan was revised to include their activity preference of being outside when the weather is good. When asked to describe the procedure for ensuring the care plan reflects the resident's preferences for activities LPN #6 stated that they follow the RAI (resident assessment instrument) manual. On 02/23/2023 at approximately 11:10 a.m., ASM #1, administrator, and ASM #2, director of nursing, and ASM #5, regional director of clinical services, were made aware of the above findings. No further information was provided prior to exit

Based on resident interview, clinical record review, staff interview and facility document review, it was determined the facility staff failed to evidence consistent communication to the hemodialysis (1) center for one of 28 residents in the survey sample, Resident #35. The findings include: For Resident #35 (R35), the facility staff failed to evidence communication to the dialysis facility for nine of 32 dialysis appointments between 12/10/2022-2/23/2023. There was no evidence of dialysis communication from the facility to the dialysis center on 12/27/2022, 1/5/2023, 1/10/2023, 1/14/2023, 1/17/2023, 1/19/2023, 2/7/2023, 2/11/2023 and 2/16/2023. On the most recent MDS (minimum data set) assessment, an admission assessment with an ARD (assessment reference date) of 12/17/2022 the resident scored 12 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was moderately impaired for making daily decisions. Section O documented R35 receiving dialysis services while a resident at the facility. On 2/22/2023 at 9:22 a.m., an interview was conducted with R35. R35 stated that the staff send a communication book with them when they go to dialysis. R35 stated that the book was kept at the nurses station. On 2/23/2023 at 8:07 a.m., a review of R35's dialysis communication book revealed printed facility dialysis communication forms dated 1/26/2023, 1/31/2023, 2/2/2023, 2/4/2023, 2/14/2023, 2/18/2023 and 2/23/2023. Review of R35's clinical record failed to evidence dialysis communication for the dialysis appointments on 12/27/2022, 1/5/2023, 1/10/2023, 1/14/2023, 1/17/2023, 1/19/2023, 2/7/2023, 2/11/2023 and 2/16/2023. The comprehensive care plan for R35 documented in part, DIALYSIS: ESRD (end stage renal disease). Resident receives dialysis treatments 3 times weekly. ESRD. Dialysis at [Name of dialysis center] on TU-TH-SA .Date Initiated: 12/12/2022 . The physician orders for R35 documented in part, May attend dialysis at [Name of dialysis center] on Tuesday/Thursday/Saturday. pick-up time 12:15pm for chair time 1:00pm [Name, address, phone number of dialysis center]. Order Date: 01/30/2023 . On 2/23/2023 at approximately 8:30 a.m., a request was made to ASM (administrative staff member) #2, the director of nursing for evidence of dialysis communication from the facility for the dialysis appointments on 12/27/2022, 1/5/2023, 1/10/2023, 1/14/2023, 1/17/2023, 1/19/2023, 2/7/2023, 2/11/2023 and 2/16/2023 for R35. On 2/23/2023 at 9:52 a.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated that they completed the dialysis communication forms in the electronic medical record prior to R35 leaving for dialysis with current vital signs and any pertinent information on it to send with the resident in the dialysis communication book. LPN #2 stated that after they completed the dialysis communication form they printed it out and placed it in the book so that it was ready when transport came to pick the resident up. LPN #2 stated that dialysis sent the book back with any communication to them each treatment. On 2/23/2023 at 11:11 a.m., ASM #2 stated that they did not have any evidence of dialysis communication for R35 for 12/27/2022, 1/5/2023, 1/10/2023, 1/14/2023, 1/17/2023, 1/19/2023, 2/7/2023, 2/11/2023 and 2/16/2023 to provide. The facility policy, Hemodialysis Care Policy effective 6/16/2017 with a revision date of 4/20/2022 documented in part, Policy: Licensed staff with demonstrated competence will care for residents who require hemodialysis (via onsite third-party providers or who travel to an outpatient setting). Communication between the dialysis provider and facility staff will occur before and after each hemodialysis treatment and as needed . The policy further documented, Pre-dialysis process: .Document assessment in the Dialysis Communication Tool. Assessment includes: - Vital signs. - Pre-treatment weight (unless performed at dialysis). - Medications administered before treatment. - Time of last meal. - Fluid intake. - Any additional alerts or information. Print the Tool and send with resident to dialysis (if off-site) . On 2/23/2023 at approximately 11:15 a.m., ASM #1, the administrator, ASM #2, the director of nursing and ASM #5, the regional director of clinical services were made aware of the findings. No further information was provided prior to exit. (1) hemodialysis When your kidneys are healthy, they clean your blood. They also make hormones that keep your bones strong and your blood healthy. When your kidneys fail, you need treatment to replace the work your kidneys used to do. Unless you have a kidney transplant, you will need a treatment called dialysis. There are two main types of dialysis. Both types filter your blood to rid your body of harmful wastes, extra salt, and water.: Hemodialysis uses a machine. It is sometimes called an artificial kidney. You usually go to a special clinic for treatments several times a week. Peritoneal dialysis uses the lining of your abdomen, called the peritoneal membrane, to filter your blood. This information was obtained from the website: https://medlineplus.gov/dialysis.html

Based on observation, staff interview, and facility document review it was determined facility staff failed to store food in the kitchen in accordance with professional standards for food service safety. The facility failed to properly dispose of dry goods that were past their expiration date, dispose of milk past it expiration date and date/label refrigerated juice not stored in it's original container. The findings include: On [DATE] at approximately 11:00 a.m., an observation of the facility's kitchen was conducted. Observation of the kitchen's dry storage area revealed an opened 24 ounce bag of french fried onions approximately three-quarters full with no open date on the package and a manufacturer's date on the package documenting Best used by 19:35 Jun (June) 24 2021. A second 24 ounce bag of french fried onions was observed on the shelf unopened with a manufacturer's date on the package documenting Best used by 19:33 Jun 24 2021. Observations of the kitchen's walk in refrigerator revealed an approximately two quart sized clear plastic pitcher filled with a red liquid approximately ,d+[DATE] full. No label documenting what the pitcher contained or the date it was poured was observed. Further observation of the walk in refrigerator revealed 14 half-pint whole milk cartons with a manufacturer's date of sep (September) 12 observed in a crate with other half-pint milk cartons dated sep 20. On [DATE] at approximately 11:30 a.m., an interview was conducted with OSM (other staff member) #6, the dietary manager. OSM #6 stated that opened dry good stored in the dry storage area were dated with the opened date. OSM #6 stated that the french fried onions were out of date and should have been discarded. OSM #6 stated that the opened bag of french fried onions should have been dated when it was opened and thrown away when it expired. OSM #6 stated that the staff always checked the milk cartons when they retrieved them from the walk-in refrigerator before they were served but the 14 cartons of whole milk expired on [DATE] and should not have been available for use in the refrigerator. OSM #6 stated that they received deliveries of milk every Monday and staff were supposed to go through the milk and discard any expired products. OSM #6 stated that it appeared someone had just placed the 14 milk cartons on top of the new ones in the milk crate. OSM #6 stated that the red liquid in the pitcher was V8 (tomato) juice and should have been labeled so they would know when it was poured and when to discard it. OSM #6 stated that the juice needed to be discarded. On [DATE] at approximately 5:15 p.m., a request was made to ASM (administrative staff member) #1, the administrator for the facility policy for storage of dry goods, discarding expired foods and storage of refrigerated foods in the facility. The facility policy Storage of Dry Food Policy dated [DATE] documented in part, Food and Nutrition Services will store dry goods in a manner which avoids contamination, optimizes food safety, and protects food quality . The facility policy Storage of Refrigerated Food Policy dated [DATE] documented in part, .Refrigerated items must have a label showing the name of the food and the date it should be consumed, or discarded . The policy further documented, Create a schedule to check food dates on a regular basis. If a food item has not been used by a specific date, throw it out, then clean and sanitize the container if it is a re-usable container. On [DATE] at approximately 5:20 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional director of clinical services were made aware of the findings. No further information was provided prior to exit.

Based on observation, clinical record review, staff interviews and facility document review it was determined that the facility staff failed to ensure an injury of unknown origin was immediately reported to the administrator, State Agency and other officials for one of 34 residents in the survey sample, Resident #609. The facility staff failed to immediately report an injury of unknown origin for Resident #609 that was first observed on 12/23/2020. The injury of unknown origin was not reported to the director of nursing until 12/24/2020 and the director of nursing failed to immediately report the injury to the administrator. Resident #609's injury of unknown origin was not reported to the administrator until 12/28/20 and to the appropriate agencies or the responsible party until 12/28/2020. The findings include: Resident #609 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #609's most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 8/28/2021, documented Resident #609 as scoring a one on the brief interview for mental status (BIMS) of a score of 0 - 15, one - being severely impaired for making daily decisions. Section G documented Resident #609 requiring extensive assistance of one person for bed mobility and total assistance of two or more persons for transfers. Section J documented a fall in the last month prior to admission/entry or reentry. The comprehensive care plan for Resident #609 documented in part, FALL RISK: Resident is at risk for falls characterized by history of falls, multiple risk factors related to: bladder incontinence, bowel incontinence, dementia, unaware of safety need, rolled out of right side of bed 3/4/21, 3/21/21- fall out of bed, 6/11/21-Fall w/ (with) laceration, 8/15/21-Fall/ sent to ER (emergency room ) 8/17-with leg pain and bruising=admitted subdural hematoma (3), 9/2/21-Fall out of bed. Date Initiated: 08/25/2021 . The progress notes for Resident #609 documented in part, - 12/22/2020 17:38 (5:38 p.m.) physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Necessity for Skilled Nursing home stay visit. Medications and allergies reviewed, continue as ordered. The current medical regimen and psycho-social regimen reviewed, assessed and evaluated. Continue plan of care discuss with staffs. Chart reviewed for continued appropriateness of meds/ (medications) dosages. Allergies reviewed. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Currently doing well without acute medical concerns per nursing staff. Comfortable beside [Sic.] with no apparent clinical complaints .Skin: no rash, itching. HEENT (head, eyes, ears, nose, throat): no runny nose, nasal congestion or sore throat . - 12/23/2020 08:00 (8:00 a.m.) Nursing note: Late Entry: Note Text: on 12/23/2020 before breakfast around 0800 hrs. The NP (nurse practitioner) noted a hematoma (4) in the residents forehead and asked for vitals I took them and handed them to her. Resident is usually out of bed by 0700 when our shift begins. I had not noticed this or been told about any injuries or accidents during my on shift report. Until the NP told me. - 12/27/2020 06:51 (6:51 a.m.) Nursing note: Note Text: CNA (certified nursing assistant) called this nurse in residents room, This nurse noted old bruising around eyes and forehead, bruising yellow/green in color. Multiple areas about face. Resident does not know what happened and denies any pain at all. Oncoming Nurse made aware. - 12/28/2020 18:55 (6:55 p.m.) Head to toe Eval. (evaluation) Late Entry: Overview: This note is a follow up to bruising to face .NP (nurse practitioner) and RP (responsible party) notified - Resident with continued bruising to forehead, nose, eyes, and cheeks. Bruising is fading down her face. No pain or tenderness. - 12/28/2020 19:46 (7:46 p.m.) Family/Responsible Party Contact Note. Note Text: Notified daughter (emergency contact #1) about hematoma and bruising found on resident's face on 12/23/2020. No concerns were expressed at this time to me. - 12/29/2020 10:59 (10:59 a.m.) Nursing note: Late Entry: Note Text: Resident discussed by IDT (interdisciplinary) this morning r/t (related to) hematoma and bruising to the face. Resident could have hit her head on her grab bars while in bed, or she may have hit her forehead on the footboard of her bed. She was previously observed sitting in her wheelchair with her head resting on the top of the footboard. IDT recommended that resident be reassessed for the use of grab bars, pad the top of her footboard, and place a concave mattress on her bed. She has no complaints of pain. - 12/29/2020 15:04 (3:04 p.m.) Social Services note. Note Text: Writer visited resident today R/T recent incident. Resident displayed no ill effects from the incident. Resident was not fearful when writer visited. Resident noted to be at baseline as to talking to her baby doll while up in W/C (wheelchair) sitting near her door way. - 1/1/2021 20:00 (8:00 p.m.) Head to Toe eval. Overview: This note is a follow up to bruising to face with unknown cause . no c/o pain from bruising to face Review of the Facility Reported Incidents (FRI) provided upon survey entrance documented a FRI dated 12/28/2020 for Resident #609 which documented in part, Report Date: 12/28/2020, Incident Date: 12/23/2020. Resident Involved: [Resident #609], Injuries: No, Injury of unknown origin, on 12/23/2020 resident was seen by NP (nurse practitioner) before breakfast and she noted a large hematoma to the right side forehead. Resident has history of being combative with ADL (sanctities of daily living) care and is noted to lay on footboard of bed when in room. Resident has no complaints of pain and has severe dementia and unable to be interviewed. Staff are being interviewed and statements obtained. Investigation underway and final outcome to follow .If applicable, date notification provided to: Responsible party 12/28/2020, Physician 12/23/2020, APS (adult protective services) 12/28/2020 . Attached to the FRI document were 12 facsimile transmission reports starting on 12/28/2020 at 19:17 (7:17 p.m.) with a successful transmission of the FRI on 12/29/2020 at 12:50 (12:50 p.m.). Included in the FRI folder for Resident #609 dated 12/28/2020 was an incident report dated 12/23/2020 0800 (8:00 a.m.) for Resident #609 which documented in part, Incident Description: 0800 NP saw resident on 12/23 and noted hematoma on right side of forehead and reported to the nurse at this time. This resident is unable to tell how hematoma occurred due to dementia, she does have history of thrashing around in bed when care provided. She also will lay her forehead on footboard when up in w/c and leans forward. 12/25/2020 skin assessment noted bruising around eyes and hematoma. Hematoma is resolving and the bruising is showing up around eyes. She was observed leaning head also on footboard, that is noted on the skin check. 12/27/2020 Nurse's note that indicates that bruising is resolving around the eyes and forehead. Denies any pain. Resident description: Resident unable to give description .Agencies/People Notified: Responsible party: [Name of RP] 12/28/2020 16:52 (4:52 p.m.), physician [Name of NP] 12/23/2020 08:01 (8:01 a.m.). Included in the FRI folder for Resident #609 dated 12/28/2020 was a document titled Abatement Plan for Late Reporting on 12/28/2020. It documented in part, Problem: Incident reported to Admin (administrator) on 12/27 (12/27/2020). 0800 NP saw resident on 12/23 and noted hematoma on right side of forehead and reported to the nurse at this time. The nurse did not document in an incident report or in nurses notes on 12/23/2020. Late entry placed on 12/28/2020. The resident is unable to tell how hematoma occurred due to dementia, she does have history of thrashing around in bed when care provided. 12/24/2020 DON (director of nursing) was aware of bruise and began questioning staff. COVID (5) testing as well and had positive resident that needed to be moved and setting up unit. Follow through and reporting timely was not done .12/28/2020 No abuse indicated. No psychosocial harm noted, not fearful of staff when speaking to. FRI completed and sent to OLC (office of licensure and certification), Ombudsman, APS (adult protective services). RP notified. Gathering statements from staff that worked 12/22 and 12/23/2020. Statements from 11-7 (11:00 p.m.-7:00 a.m.) aide indicates that resident was combative with care on morning of 12/23/2020 and may have hit head on side rail at that time. The hematoma was noted by the NP on 12/23/2020 on AM (morning) rounds. 12/29/2020 Padded footboard as leans head on when up in w/c. 12/29/2020 Side rail asst. (assessment) redone to assess for need for SR (side rail) and side rails were removed. Believe hit head on footboard or rails, no abuse indicated. Interventions: 12/28/2020 FRI was done to all required agencies. RP notification. Care plan updated. Chart reviewed. Employee interviews performed. Resident is non-interviewable. Education to staff started for Abuse policy, documentation, and reporting. DON and ADMIN (administrator) education completed for timely reporting. RDCS (regional director of clinical services) and Administrator went and saw resident and resident was pleasantly confused and did not appear fearful at time of visit. No apparent psychosocial harm seen. She was holding doll baby and talking to us in non-coherent speech r/t her severe dementia. Looked at like residents. All residents with BIMS 9 and below that have side rails were reviewed and re-assessed for needs of side rails. If not needed, rails removed. 12/29/2020 Padded foot board as she leans forward in chair and lays head on edge of footboard. Side rails removed as re-assessed and found that resident does not need. She was given a concave mattress to help define the perimeters of the bed. Bed in low position for safety. Social services saw resident to ensure no psychosocial harm. Social services to see resident weekly for 4 weeks and document to ensure doing well. Education completed. Adhoc QAPI (quality assessment performance improvement) held. Audits: All incidents will be reviewed in AM clinical meeting 5 times a week for next 3 months to indicate if incident is reportable. Report as per the regulation and policy. The findings will be reported to monthly QAPI for the next 3 months. Administrator will be in charge of this audit tool in the AM meeting. Findings: The facility can substantiate that they failed to report this incident timely and that the injury remains unknown, but is believed not due to any type of abuse. The resident has history of combative behaviors with ADL: care. She has history of thrashing around in the bed when care provided and had 1/4 side rails that she could have hit on during care. 11-7 aide statement that says she was combative with car eon the AM on 12/23/2020. The are [sic] on right forehead was not noted until the AM by the NP on early AM rounds. Side rails have been removed for no further injury of this nature can occur and also padded the edge of the foot board as she also likes to lay head on edge of when up in wheelchair. Education has been provided to all nurses, Aides, DON, and Administrator on reporting and documentation. An education sign-in sheet dated 12/28/2020 documented the director of nursing and administrator who were employed at the facility at that time being educated on timely reporting. It documented, Any incident of unknown origin has to be reported timely. Injury [within] 2 (hours) & if 0 (not) [within] 24 (hours) as soon as notification of an incident you have to report to RDCS (regional director of clinical services), FRI, Quick response . Included with the document was documentation of nursing staff inservice completed on 12/28/2021 at 10:30 a.m., 11:30 a.m., 2:00 p.m., 3:30 p.m., 12/29/2021 at 7:15 a.m., 1:00 p.m., 3:15 p.m., and 12/30/2021 at 8:00 a.m., 12:00 p.m., and 4:00 p.m. on Documentation requirements and reporting policy of Injury of unknown origin. Abuse/reporting policy. The QAPI (quality assessment and performance improvement) action plan dated 12/29/2020 documented a meeting focusing on late reporting of an injury of unknown origin to the state and the RP (responsible party), the incident report not completed timely and late entry documentation in the nurse's notes. The QAPI action plan documented in part, staff education, correction action interventions specific to Resident #609, identification and assessment of similar residents with potential for injury of unknown origin and the facility plan to audit and monitor performance with an actual completion date of 12/29/2020 and onging audits for three months. The staff sign-in sheets for the timely reporting, documentation of incidents, reporting and Abuse policy were reviewed and verified by multiple staff interviews. The other points of the plan of correction as described in this writing were verified with facility document review, observations, and clinical record reviews and staff interviews. No concerns were identified. On 9/15/2021 at 3:45 p.m., an interview was conducted with ASM (administrative staff member) #1, the administrator. ASM #1 stated that the former administrator and former director of nursing were employed at the time of the injury of unknown origin FRI reported for Resident #609. ASM #1 stated that any injuries of unknown origin were investigated to determine a possible cause. ASM #1 stated that staff reported any injuries to them or the DON who investigated and reported them to the appropriate agencies. ASM #1 stated that immediately upon discovery the staff completed a full body assessment, vital signs, and neurological checks. ASM #1 stated that if the residents was interviewable they would ask them what happened and get statements. ASM #1 stated that in the case of Resident #609 they would not be able to say what happened and was not witnessed so they could only guess at the possible cause. ASM #1 stated that after speaking with any witnesses and getting a statement from the resident they would report the incident as an injury of unknown origin immediately to the appropriate agencies. ASM #1 stated that they had extending the QAPI for reviewing all incidents and accidents through January of 2022. ASM #1 stated that their understanding of why the FRI was sent in late to the state agency was that the DON did not report it to the administrator. ASM #1 stated that the FRI folder documented all nursing staff including CNA's (certified nursing staff) were educated on timely reporting, documentation and the abuse policy. The facility policy Abuse, Neglect and Exploitation with a revision date of 7/14/2020 documented in part, It is the facility's policy to investigate all allegations, suspicions and incidents of abuse, neglect, involuntary seclusion, exploitation of residents, misappropriation of resident property and injuries of unknown source. Facility staff must immediately report all such allegations to the Administrator/Abuse coordinator. The Administrator/Abuse coordinator will immediately begin an investigation and notify the applicable local and state agencies in accordance with the procedures in this policy . It further documented, .Documentation in the nurses' notes should include the results of the resident's ROM (range of motion), body assessment, vital signs, the notification of the physician and the responsible party and treatment provided. Appropriate quality assurance documentation should be completed as well. Initial Reports. Timing. All allegations of Abuse, Neglect, Involuntary Seclusion, Injuries of Unknown Source, and Misappropriation of resident property must be reported immediately to the Administrator, Director of Nursing (DON) and to the applicable state agency . On 9/15/2021 at approximately 5:20 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional director of clinical services were made aware of the concern. PAST NONCOMPLIANCE References: 1. [CONDITION(S)]- Makes your bones weak and more likely to break. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/[CONDITION(S)].html. 2. Dementia A loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. This information was obtained from the website: https://medlineplus.gov/ency/article/ 9.htm. 3. Subdural hematoma A subdural hematoma is a collection of blood between the covering of the brain (dura) and the surface of the brain. This information was obtained from the website: https://medlineplus.gov/ency/article/ 3.htm. 4. Hematoma A bruise is an area of skin discoloration. A bruise occurs when small blood vessels break and leak their contents into the soft tissue beneath the skin. This information was obtained from the website: https://medlineplus.gov/ency/article/ 3.htm. 5. COVID-19 COVID-19 is caused by a coronavirus called [CONDITION(S)]-CoV-2. Coronaviruses are a large family of viruses that are common in people and may different species of animals, including camels, cattle, cats, and bats. Rarely, animal coronaviruses can infect people and then spread between people. This occurred with [NAME]-CoV and [CONDITION(S)]-CoV, and now with the virus that causes COVID-19. The [CONDITION(S)]-CoV-2 virus is a betacoronavirus, like [NAME]-CoV and [CONDITION(S)]-CoV. All three of these viruses have their origins in bats. The sequences from U.S. patients are similar to the one that China initially posted, suggesting a likely single, recent emergence of this virus from an animal reservoir. However, the exact source of this virus is unknown. This information was obtained from the website: https://www.cdc.gov/coronavirus/2019-ncov/faq.html#How-COVID-19-Spreads.

Based on resident interview, staff interview and clinical record review it was determined that the facility staff failed to submit an accurate MDS (minimum data set) assessment for one of 34 residents in the survey sample, Resident #49. Resident #49's quarterly MDS assessment with an ARD of 8/20/2021, in Section O failed to code Resident #49 as receiving oxygen during the assessment period. The findings include: Resident #49 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #49's most recent MDS, a quarterly assessment with an ARD of 8/20/2021, coded Resident #49 as scoring a 14 on the brief interview for mental status (BIMS) of a score of 0 - 15, 14 - being cognitively intact for making daily decisions. Section O failed to coded Resident #49 receiving oxygen during the assessment period. On 9/14/2021 at 2:08 p.m., an interview was conducted with Resident #49. Resident #49 was observed in bed wearing a nasal cannula attached to an oxygen concentrator. Resident #49 stated that they wore the oxygen all the time and needed it because they had lung problems. Review of the clinical record revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] @2 [sic] lpm (liters per minute) via NC (nasal cannula) every shift related to acute and chronic respiratory failure with [CONDITION(S)] (3). The eMAR (electronic medication administration record) for Resident #49 dated 8/1/2021-8/31/2021 and 9/1/2021-9/30/2021 documented O2 at 2 lpm received by nasal cannula every shift each day from 8/1/2021 through the current date. The comprehensive care plan for Resident #49 dated 3/12/2021 documented in part, Oxygen use: Resident requires oxygen R/T (related to) [CONDITION(S)] ([CONDITION(S)]) . Date Initiated: 03/12/2021; Revision on: 06/28/2021. On 9/15/2021 at 11:51 a.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated that Resident #49 received oxygen by nasal cannula at all times and they documented this on the medication administration record. On 9/16/2021 at 7:40 a.m., an interview was conducted with LPN #7, the MDS nurse. LPN #7 stated that they reviewed the resident's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #7 stated that oxygen use was documented on the MDS assessment. When asked about Resident #49's quarterly MDS with the ARD of 8/20/2021 documenting oxygen use, LPN #7 stated that if Resident #49 was wearing the oxygen, had an order and it was documented on the administration record it should be documented on the MDS. LPN #7 stated that they were going to review the MDS to see if it was documented. On 9/16/2021 at 8:05 a.m., LPN #7 reviewed Resident #49's quarterly MDS with the ARD of 8/20/2021 assessment and stated that oxygen was not documented and they would do a correction to add it. LPN #7 stated that they followed the RAI (resident assessment instrument) manual when completing the MDS assessments. According to the RAI Manual, Version 1.16, dated October 2018, section O0100 documented in part, .Review the resident's medical record to determine whether or not the resident received or performed any of the treatments, procedures, or programs within the last 14 days .Check all treatments, procedures, and programs received or performed by the resident after admission/entry or reentry to the facility and within the 14-day look-back period . On 9/16/2021 at approximately 8:40 a.m., ASM (administrative staff member) #1, the administrator was made aware of the findings. No further information was provided prior to exit. References: 1. [CONDITION(S)]: A condition in which the heart can't pump enough blood to meet the body's needs. Heart failure does not mean that your heart has stopped or is about to stop working. It means that your heart is not able to pump blood the way it should. It can affect one or both sides of the heart. This information was obtained from the website: https://medlineplus.gov/heartfailure.html 2. [CONDITION(S)] ([CONDITION(S)]): Disease that makes it difficult to breath that can lead to shortness of breath. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/[CONDITION(S)].html. 3. Respiratory failure: When not enough oxygen passes from your lungs into your blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/respiratoryfailure.html.

Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to follow professional standards of practice for one of 34 residents in the survey sample, Resident #42. The facility staff failed to clarify a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Resident #42 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #42's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #42's significant change in status minimum data set assessment with an assessment reference date of 8/19/21, coded the resident's cognition as moderately impaired. Section H coded Resident #42 as having a urinary catheter. Review of Resident #42's clinical record revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of all physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #42's comprehensive care plan revised on 3/20/20 documented, Foley (size) 14F (French) 5cc (cubic centimeters) (balloon). On 9/15/21 at 1:02 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #2 stated physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/15/21 at 2:03 p.m., another interview was conducted with LPN #2. LPN #2 reviewed Resident #42's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #2 stated the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/15/21 at 5:27 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. On 9/16/21 at 7:39 a.m., an interview was conducted with LPN #7, the nurse who documented the catheter size on Resident #42's comprehensive care plan. LPN #7 stated Resident #42 went to the hospital to have his catheter replaced and she thought she obtained the size information from hospital documentation but would check. LPN #7 stated there should at least be a nurse's note but the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/16/21 at approximately 7:50 a.m., LPN #7 stated she obtained the catheter size information from a nurse's note. The nurse's note dated 11/22/19 documented, Resident returned from (name of hospital) with 14fr (French) Foley intact draining yellow colored urine, no c/o (complaint of) pain or discomfort, no new orders. The facility policy titled, Physician/Provider Orders documented, POLICY: The Charge Nurse shall transcribe and review all physician/provider orders . The facility standard of practice LIPPINCOTT MANUAL OF NURSING PRACTICE 11th Edition, 2019 documented, 1. Integral to the practice of any profession is the inherent need to be responsible for actions taken and for omissions. 2. The professional nurse must be proactive and take all appropriate measures to ensure that professional practice is not lacking, remiss, or deficient in any area or way .e. Examine the quality (accuracy and completeness) of documentation. No further information was presented prior to exit. Reference: (1) A urinary catheter is a tube placed in the body to drain and collect urine from the bladder. This information was obtained from the website: https://medlineplus.gov/ency/article/ 1.htm

Based on observation, staff interview, facility document review, and in the course of a complaint investigation, it was determined the facility staff failed to provide care and services for the prevention and treatment of [REDACTED].#18. The facility staff failed to identify a pressure injury on Resident #18's fourth left toe until it was at an advanced stage. The pressure sore was found on 8/26/18, and was assessed and staged by staff on 8/27/18, as a Stage III wound, measuring 1.0 (centimeters) by 0.8 cm (centimeters) with a depth of 0.2 cm., with yellow tissue in the wound bed and a scant amount of purulent drainage, resulting in harm. The facility staff also failed to ensure complete skin assessments including measurements, descriptions of the area on Resident #18's fourth left toe, prior to the staff identifying the stage III Pressure sore. The findings include: Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 8/14/18, coded the resident as scoring a 15 on the BIMS (brief interview for mental status) score, indicating she was capable of making her own daily cognitive decisions. The resident was coded as requiring limited to extensive assistance for most of her activities of daily living except eating as she only required supervision. In Section M - Skin Conditions, the resident was coded as being at risk for developing pressure ulcers but as not having any current unhealed ulcers. During the entrance conference, a list of residents with pressure injuries was requested from the administrator (administrative staff member- ASM #1). Resident #18 was listed as having a pressure injury that was facility acquired on 8/26/18. The pressure injury was documented as being located on the left foot 4th digit (toe). The pressure injury was staged as a Stage III pressure injury. A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. (3). Stage 3 Pressure Injury: Full-thickness skin loss: Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. (4) The Admission Evaluation dated, 8/7/18, documented in part, Braden Score - 21. A total score of 12 or less indicates a high risk for developing pressure injuries. A score of 19 or above indicates a low risk of developing pressure injuries. (5) The Bi-Weekly Skin Check sheet dated 8/7/18, documented in part, Does the resident have current Skin Issues. A mark was made next to Yes. The Description documented, left 4th toe [MEDICAL CONDITION]. The nurse's note dated, 8/7/18 at 2:20 p.m. documented in part, While doing skin assessment noted resident to have on her left foot fourth toe there was a sore that was swollen red and warm to touch doctor here on rounds new order received. (Sic. Sentence typed as is written in the clinical record). The nurse's note dated, 8/8/18 at 12:06 a.m. documented in part, Resident is currently on antibiotic therapy. Currently taking [MEDICATION NAME] (antibiotic) [MEDICAL CONDITION] to 4th toe. Resident is having no adverse effects from antibiotic. The nurse practitioner note dated, 8/8/18 at 4:10 p.m. documented in part, Skin: warm, dry .Assessment/plan: 8. [MEDICAL CONDITION], acute - [MEDICATION NAME] as ordered. The nurse's note dated, 8/9/18 at 12:06 a.m. documented in part, Resident is currently on antibiotic therapy. currently (Sic.) taking [MEDICATION NAME] (antibiotic) [MEDICAL CONDITION] to 4th toe. Resident is having no adverse effects from antibiotic. The nurse's note dated, 8/10/18 at 12:06 a.m. documented in part, Resident is currently on antibiotic therapy. currently (Sic.) taking [MEDICATION NAME] (antibiotic) [MEDICAL CONDITION] to 4th toe. Resident is having no adverse effects from antibiotic. The nurse's note dated, 8/10/18 at 12:06 p.m. documented in part, Resident continues to receive [MEDICATION NAME] for [MEDICAL CONDITION]. No s/s (signs or symptoms) adverse reactions noted. The Bi-Weekly Skin Check dated, 8/10/18 at 8:06 p.m. documented in part, Does the resident have current Skin Issues. A mark was made next to Yes. The Description documented, L (left) 4th toe [MEDICAL CONDITION]. ABTX (antibiotic treatment) continues. The Shower/Tub bath/ Bed Bath Sheet completed by the CNA (certified nursing assistant), dated, 8/10/18, documented the resident didn't want shower, wanted to get washed up in her room. The form documented the resident had no rashes, bruises, or redness and the skin was intact. The Bi-Weekly Skin Check dated, 8/13/18 at 8:06 p.m. documented in part, Does the resident have current Skin Issues. A mark was made next to Yes. The Description documented, 4th toe red and swelling ([MEDICAL CONDITION]). The Shower/Tub bath/ Bed Bath Sheet completed by the CNA (certified nursing assistant), dated, 8/13/18, documented the resident had no rashes or bruises. The resident was documented as having redness on her 4th toe and the skin was intact. The physician note dated, 8/14/18 at 1:57 p.m. documented in part, Skin: warm, dry .Assessment/Plan: [MEDICAL CONDITION], acute - [MEDICATION NAME] as ordered. The Bi-Weekly Skin Check dated, 8/16/18 at 8:06 p.m. documented in part, Does the resident have current Skin Issues. A mark was made next to Yes. The Description documented, 4th toe. The Shower/Tub bath/ Bed Bath Sheet completed by the CNA (certified nursing assistant), dated, 8/17/18, documented the resident had no rashes or bruises and the skin was intact. The resident was documented as having redness but nothing was documented as to where the redness was. The Bi-Weekly Skin Check dated, 8/19/18 at 8:06 p.m. documented in part, Does the resident have current Skin Issues. A mark was made next to Yes. The Description documented, fourth toe. The Shower/Tub bath/ Bed Bath Sheet completed by the CNA (certified nursing assistant), dated, 8/20/18 documented the resident had no rashes, bruises or redness and the skin was intact. The Bi-Weekly Skin Check dated, 8/22/18 at 8:06 p.m. documented in part, Does the resident have current Skin Issues. A mark was made next to No. The Shower/Tub bath/ Bed Bath Sheet completed by the CNA (certified nursing assistant), dated, 8/24/18 documented the resident had no rashes, bruises, redness and the skin was intact. The nurse practitioner note dated, 8/24/18 at 2:56 p.m. failed to evidence documentation related to the resident's left fourth toe. There were no further nurse's notes documenting anything related to the toe until 8/27/18. The Shower/Tub bath/ Bed Bath Sheet completed by the CNA (certified nursing assistant), dated, 8/27/18 documented the resident refused her shower. There was no documentation related to the skin assessment by the CNA. The Weekly Wound assessment dated [DATE] documented, Wound type: Pressure. Stage - 3. Wound location: left foot 4th digit. Length - 1.0 (centimeters). Width - 0.8 cm (centimeters). Depth - 0.2 cm. Location where wound was acquired: In house. Date wound identified: 8/26/18. Drainage - Purulent. Drainage amount - scant. Wound bed appearance - Yellow. Odor - none. Periwound appearance - macerated. Wound status - new wound. Comments: .Resident informed not to wear shoe at this time. The Bi-Weekly Skin Check dated, 8/28/18 at 8:06 p.m. documented in part, Does the resident have current Skin Issues. A mark was made next to Yes. The Description documented,4th digit. The Shower/Tub bath/ Bed Bath Sheet completed by the CNA (certified nursing assistant), dated, 8/10/18, documented the resident didn't want shower, wanted to get washed up in her room. The form documented the resident had no rashes, bruises, or redness and the skin was intact. The comprehensive care plan dated, 8/7/18 documented, Focus: SKIN INTEGRITY/PRESSURE ULCER RISK: The resident has potential for pressure ulcer development r/t (related to) dementia, depression, [MEDICAL CONDITION], anxiety and requires assistance from staff to remind and assist with positioning. The revision on 8/27/18, documented, Stage 3 t left foot 4th digit. The Interventions documented, 8/7/18 - Assess. Document/report to MD (medical doctor) PRN (as needed) changes in skin status. Inform the resident/family/ and/or caregivers of any new area of skin breakdown as needed. Monitor nutritional status. Serve diet as ordered, monitor intake and record. On 8/27/18, the care plan was revised to include, Pressure reducing mattress to bed. Supplement therapy for wound, no shoe till (Sic.) heals. TX (treatment) as directed. Observation was made of Resident #18's wound, on 8/30/18 at 9:06 a.m. accompanied by LPN (licensed practical nurse) #2. The resident was observed with slip on tennis like shoes on. The resident's foot was observed with multiple deformities in bone structure. The wound was measured by LPN #2 as follows: width 1 cm, length 1.2 cm, depth 0.2 cm. When LPN #2 was asked about the stage of the wound, LPN #2 stated it was a stage 2 pressure injury. In the middle of the wound, yellow slough was observed. The edges appeared macerated. LPN #2 further stated, She came in with a black scab on her toe. The toe was warm to touch. They treated it for [MEDICAL CONDITION]. This was caused by the shoes she wore. An interview was conducted with the nurse practitioner, administrative staff member (ASM) #3, on 8/30/18 at 9:50 a.m. When asked her knowledge of the resident's [MEDICAL CONDITION] on admission, ASM #3 stated that it had resolved. ASM #3 stated the nurse manager had notified her this week of a pressure ulcer on the same toe. When asked if she had observed the pressure ulcer, ASM #3 stated that she had not seen it. When asked if upon admission the area on the fourth toe had an open area on it, ASM #3 stated, that it did not. ASM #3 stated if she doesn't have, it (open wound) documented then it's a no. ASM #3 stated, It wasn't a pressure ulcer on admission, it was a [MEDICAL CONDITION], (LPN # 1) felt it was from her shoes. When asked if she has assessed the wound since her first assessment of the [MEDICAL CONDITION], ASM #3 stated she did not take the resident's shoes off for her second visit (8/24/18 *see note above) with the resident. An interview was conducted with LPN #1, the unit manager, on 8/30/18 at 10:12 a.m. When asked to describe Resident #18's fourth toe on admission, LPN #1 stated, There was a scab on the toe, it was red and inflamed on the outside. It looked like it had a sore and it scabbed over. (Name of Medical Doctor) was in the house, so I had him look at it. He felt it was [MEDICAL CONDITION]. When asked the next time the 4th toe was observed after the [MEDICATION NAME] was finished, LPN #1 stated, The CNAs (certified nursing assistants) look at the resident during their showers. When asked how often a nurse checks the skin, LPN #1 stated, twice a week. The above Biweekly skin sheets were reviewed with LPN #1. LPN #1 stated, They don't tell you anything. When asked how she was notified the resident needed to be seen, LPN #1 stated, I was told by the evening supervisor from the weekend. I went in to assess it (pressure sore on the 4th left toe) on Monday. When asked what the facility policy says about completing the Bi-Weekly skin checks, LPN #1 stated, They should have a description other than 4th toe. They failed to do a thorough weekly assessment. When asked why it is important to do a thorough assessment of the area, LPN #1 stated, It has to be a complete assessment so we can evaluate the wound. When asked if she was certified in wound care, LPN #1 stated she was not a trained wound nurse but I have been doing it for many years of my nursing and worked closely with several wound doctors. When asked why there would be concerns about Resident #18's wound, LPN #1 stated, We didn't follow our policies and have more of a description of her wound prior to finding it at the stage 3. The nurse practitioner, ASM #3, returned on 8/30/18 at 10:38 a.m. and stated the wound was a stage III pressure area with yellow slough around the edge, like a crescent moon, from the 3 o'clock position to the 7 o'clock position. There was no necrosis and the rest of the wound bed was pink. ASM #3 stated, She is at high risk for pressure injury development due to her deformities of her feet. On 8/30/18 at 10:50 a.m. the administrator and the director of nursing, (administrative staff member - ASM) #2, were made aware of the concern for harm. When asked if the staff should do a full assessment and include a full description of the area, for a skin concern, ASM #2, the director of nursing stated, Yes. When asked about the process staff follows for new skin areas identified, ASM #2 stated, The unit manager goes in the next day and assesses the wound. She contacts the doctor or nurse practitioner and gets orders to treat. When asked why it is important to document a description of the area on the wound assessments and skin assessments, ASM #2 stated, It's so we can assure we are treating it properly. An interview was conducted with LPN #3 on 8/30/18 at 12:50 p.m. When asked about the process staff follows for completing skin assessments, LPN #3 stated, It (skin assessment) pops up weekly or sometimes more often on the computer. I look at the whole entire body. If there are old issues I answer a yes. When asked if she was describing an area would she document, left fourth toe, LPN #3 stated, We should describe what we see. I was told today that I should but I wasn't doing it that was before today. The facility policy, Wound Management documented in part, Policy: It is the policy of (Name of Corporation) based on the comprehensive assessment of a resident; the facility must ensure that a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing Monitoring - 3. Twice weekly, on bath/shower days, the nursing assistant will look at the resident's skin and place the identified area on the shower sheet. The nursing assistant will report any reddened and/or areas of concern to the licensed nurse. 4. The licensed nurse will complete a head to toe body review twice a week as well. This head to toe body review is inn additions to the nursing assistant's skin review. The Pressure Ulcer Treatment Quick Reference Guide by NPUAP states on page 8 concerning pressure ulcer assessment, Assess and accurately document physical characteristics such as location, Category/Stage, size, tissue type (s), wound bed and periwound condition, wound edges, sinus tracts, undermining, tunneling, exudate, necrotic tissue, odor, presence/absence of granulation tissue, and [MEDICATION NAME]. Page 10 of this reference states, Re-evaluate the pressure ulcer, the plan of care, and the individual if the pressure ulcer does not show progress toward healing within 2 weeks (or as expected given the individual's overall condition and ability to heal) .Signs of deterioration should be addressed immediately. This information was obtained from: National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Pressure Ulcer Prevention and Treatment: Clinical Practice Guideline. Washington, DC: National Pressure Ulcer Advisory Panel, Second edition published 2014. No further information was provided prior to exit. (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 522. (2) [MEDICAL CONDITION] is a condition characterized by rapid and random contraction of the atria of the heart causing irregular beats of the ventricles and resulting in decreased heart output and frequently clot formation in the atria. This information was obtained from: Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 55. (3) This information was obtained from the following website: http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ (4) This information was obtained from the following website: http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ (5) This information was obtained from the following website: https://www.in.gov/isdh/files/Braden_Scale.pdf

Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to ensure that 1 of 4 residents in the survey sample; Resident #1, was free of unnecessary medication. Resident #1 was administered [MEDICATION NAME] (an anticoagulant medication) without adequate and timely monitoring of laboratory test for PT / INR ([MEDICATION NAME]/International Normalized Ratio) levels, for which dosing was dependent on. When the laboratory results were not received, the facility staff failed to follow up with the lab regarding the results, and Resident #1's [MEDICATION NAME] dose was not readjusted accordingly, resulting in toxic levels of the medication for the resident, that required hospitalization . The findings include: Resident #1 was admitted to the facility on [DATE] and discharged on [DATE]. The resident was admitted with the [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) was a 5-day assessment post readmission (1/11/17 after brief re-hospitalization ) with an ARD (Assessment Reference Date) of 1/18/17. The resident was coded as being cognitively intact in ability to make daily life decisions, scoring a 15 out of a possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #1 was coded as requiring total assistance for transfers; extensive assistance for hygiene, toileting, and dressing; supervision for eating; and as incontinent of bowel and bladder. Review of the hospital record for the hospitalization leading to the resident's initial admission of 12/31/16 revealed the following: A review of the hospital record dated 12/31/16 revealed a discharge summary which documented, Principle Discharge Diagnosis: [REDACTED].o. (year old) female with a history of poorly controlled DM (diabetes) c/b (complicated by) [MEDICAL CONDITION] and right BKA (below knee amputation), hypertension (high blood pressure), [MEDICAL CONDITIONS] s/p (status [REDACTED].No history of stroke. Reports compliance with [MEDICATION NAME]. Takes 4 mg (milligrams) nightly (at 6 pm) but had been off all medications, including [MEDICATION NAME], for a year due to insurance issues Continue full anticoagulation for history of recurrent PEs with [MEDICATION NAME] (also known as [MEDICATION NAME] (2)). Check INR (International Normalized Ratio (3)) in 1-2 days after discharge. Restart [MEDICATION NAME] at 1 mg (milligram) daily once INR is between 2-3. Continue [MEDICATION NAME] 1 mg daily for the duration of antibiotic therapy with Bactrim (an antibiotic (4)). After Bactrim is completed, would recommend close INR monitoring and readjustment of her [MEDICATION NAME] to higher doses. In addition, the above dated hospital record documented that on 12/29/16, the resident's INR was 2.9 (normal range was identified as 0.9 to 1.2). The [MEDICATION NAME] (PT) level was high at 32.9. Documented normal range was 9.8 to 12.6 A review of the facility physician's orders dated 12/31/16 and 1/1/17 revealed that, per the discharge summary above, Resident #1 was not yet started on the [MEDICATION NAME] at the time of admission to the facility on [DATE]. On 1/3/17, the resident was sent from the facility to the hospital for suspected [MEDICAL CONDITION] related to complaints of chest pain. The hospital record for this visit contained an INR result of 1.4, which was still elevated above the normal range. The PT was documented as 15.6, which was also still above the normal range. The resident was released back to the facility the same day. The discharge paperwork documented, [MEDICATION NAME] 1 mg please wait till INR is between 2 - 3 to resume. On 1/4/17 the facility obtained an INR level, which the results were 1.5. The facility's laboratory ranges for this documented normal range as being 0.80 to 3.50. A PT result was documented as 12.1. The facility's laboratory documented normal range as being 10.5 to 12.0. (NOTE: variances in normal ranges and results vary by laboratory, based on equipment used, procedures used, laboratory policy, and standard deviation. (6)). The nurse practitioner notated the lab results on 1/5/17. There were no further labs or medication changes until 1/9/17. Up to this date, the facility had not ordered any [MEDICATION NAME] / [MEDICATION NAME] for the resident. In the approximately 10 days the resident was in the facility, the PT and INR had been checked twice (1/3/17 at the hospital and 1/4/17 at the facility). Review of the clinical record revealed that on 1/9/17, Resident #1 was again sent to the hospital, for altered mental status related to [DIAGNOSES REDACTED]. Resident #1 was admitted , and was discharged back to the facility on [DATE]. The hospital record documented the following: PT normal ranges 9.6 to 11.0. INR normal ranges (not provided). On 1/8/17 the resident's PT was 11.5 and INR was 1.12. On 1/10/17 the PT was 12.7 and the INR was 1.22. On 1/11/17 the PT was 13.9 and the INR was 1.34. The hospital record further documented, Discussion: 5. [MEDICAL CONDITION]/PE ([MEDICAL CONDITION]/pulmonary [MEDICAL CONDITION]) history. Patient not currently on anticoagulation despite being continued at discharge recently; will start a [MEDICATION NAME] (7) bridge to [MEDICATION NAME]. The resident was readmitted to the facility on [DATE]. A physician's order dated 1/12/17 documented [MEDICATION NAME] 4 mg in the evening. A review of the MAR (Medication Administration Record) for the month of January 2017 revealed that Resident #1 received [MEDICATION NAME], 4 mg every evening through 1/19/17. There were no further labs for PT / INR obtained until 1/19/17. On 1/19/17, a PT / INR were drawn. The results were: PT 13.5 (normal ranges 10.0 - 12.0) and INR 1.28 (normal ranges 0.80 - 3.5). Review of the clinical record revealed that on 1/20/17 a PT / INR were drawn. The results were PT 12.8 and INR 1.22. The nurse practitioner documented on the lab results to check (labs) on Monday (1/23/17) and to increase the [MEDICATION NAME] to 6 mg every evening. A review of the physician's orders revealed one dated 1/20/17 for [MEDICATION NAME] 6 mg in the evening. A review of the MAR for January 2017 revealed the resident received this medication as prescribed each evening from 1/20/17 through 1/26/17. On 1/23/17 a PT / INR were drawn. The results were: PT 14.0 and INR 1.33. The nurse practitioner documented on the results on 1/25/17 to check (labs) on Friday (1/27/17) and to increase the [MEDICATION NAME] to 8 mg. A review of the physician's orders revealed no new orders at this time. The medication dose did not change. Review of the MARs revealed the resident remained on the previous dose of 6 mg every evening through 1/26/17. On 1/25/17 a PT / INR were drawn. The results were: PT 16.9 and INR 1.59. It was unclear as to why the results were drawn on this date as there was not an order to do so. However, the nurse practitioner initialed the results on 1/26/17 and hand written on the results was a notation to increase the [MEDICATION NAME] to 8 mg and recheck the INR on 2/1/17. A review of the physician's orders revealed one dated 1/27/17 for [MEDICATION NAME] 4 mg tabs, give 2 tabs (8 mg) every morning. A review of Resident #1's January MAR indicated [REDACTED]. Up to this point, the medication was being administered at night. On 1/27/17, when the above order was written for 4 mg [MEDICATION NAME], give 2 tabs (8 mg) in the morning, it was before the resident's evening dose was due, thus an order for [REDACTED]. On 2/1/17 a PT / INR were drawn. The results were PT 13.4 and INR 1.28. The nurse practitioner initialed the results on 2/2/17 and handwritten on the results was the notation for 12 mg tonight (2/1/17), 10 mg Thurs (Thursday, 2/2/17) and recheck the labs on Monday (2/6/17). A review of the physician's orders revealed one dated 2/1/17 for [MEDICATION NAME] 12 mg one time only and an order also dated 2/1/17 for [MEDICATION NAME] 10 mg in the evening. A review of Resident #1's February MAR indicated [REDACTED]. It was noted that this order was, once again, scheduling the medication for an evening administration. On 2/6/17 a PT and INR were drawn. The results were: PT 24.1 and INR 2.24. Hand written on the results was Now 10 mg [MEDICATION NAME] and check Wednesday (2/8/17). The nurse practitioner initialed the results on 2/8/17. There was no evidence of an order written [REDACTED]. It was unclear if that was the intent of the notation, as the resident was already on 10 mg every evening at that time. On 2/8/17 a PT / INR were drawn. The results were: PT 41.1 and INR 3.74. The nurse practitioner wrote on the results to decrease ([MEDICATION NAME]) to 8 mg and hold x 2dy (it was unclear if this meant today or for 2 days.) A review of Resident #1's physician's orders revealed one dated 2/8/17 that documented, [MEDICATION NAME] 8 mg in the evening, start 2/10/17. A review of Resident #1's February 2017 MAR indicated [REDACTED]. The physician's orders did not specify to hold any doses even though the notation on the lab results documented to hold x 2 days. Further review of the MAR indicated [REDACTED]. Review of the clinical record failed to reveal the results of the PT / INR that were to be drawn on 2/10/17. A review of the facility lab order sheet revealed that a PT / INR were ordered to be drawn on 2/10/17 and the lab tech (technician) initialed that the labs were drawn. However, to date of the survey (3/23/17), the results were never provided to the facility from the lab company. There was no evidence the facility attempted to follow up with the lab regarding this lab test results until after Resident #1 was discharged to the hospital for [MEDICATION NAME] toxicity on 2/27/17. On 2/15/17 (a Wednesday) the nurse practitioner saw the resident. The NP note dated 2/15/17 did not document anything regarding the missing PT/INR results that were drawn on 2/10/17. A notation was made that documented INR on Wednesdays indicating that the lab was performed on Wednesdays. There were no orders written dated 2/15/17 for a PT/INR to be drawn, or for a dose change in the medication. On 2/21/17 Resident #1 was transferred to a different unit in the facility. Review of the February 2017 MAR indicated [REDACTED]. There were no further PT / INR orders obtained until 2/24/17. On 2/23/17 the NP saw the resident. The note documented, (illegible) INR still (illegible). Review of the physician's orders revealed one dated 2/23/17 for CBC (complete blood count (15)), BMP (basic metabolic panel (16)), Mag (magnesium (17)) level, Phos (phosphorous (18)) level and d-dimer (test used to check for blood clotting problems (8)) in A.M. Also dated 2/23/17 was an order for [REDACTED]. In an interview conducted with LPN #2 (Licensed Practical Nurse #2) on 3/23/17 at 10:24 a.m., she stated that on 2/23/17 she realized the results were never obtained from the 2/10/17 PT/INR lab draw and notified the nurse practitioner. LPN #2 stated the nurse practitioner saw the resident and ordered Labs for PT / INR and a D-Dimer (8). A review of the labs dated 2/24/17 revealed that the d-dimer could not be performed due to a problem with the sample and was going to be redrawn. There was no evidence the PT/INR was drawn with the other labs drawn the morning of 2/24/17. A review of the lab order slips revealed one dated 2/24/17 that documented PT/INR, d-dimer, re-collect. On 2/24/17 the NP saw the resident again. The note documented, INR (illegible) .INR still not in (illegible) .INR results (illegible) 2-3 . On 3/22/17 at 3:28 p.m., in an interview with LPN #3, she stated that the lab called her on 2/24/17 regarding labs drawn that morning and reported that there was something wrong with the sample for the d-dimer and PT/INR and that they would be back later that day to redraw these labs. On 3/22/17 at 4:57 p.m., an interview was conducted with LPN #4. She stated that she worked evening shift on 2/24/17 and saw the lab tech in the building and going into Resident #1's room to redraw the labs. LPN #4 stated that she inquired of the lab tech about the labs she was drawing because she was not made aware from day shift, to be expecting any labs to be drawn that evening. She stated the lab tech was drawing a PT/INR and d-dimer. A review of the labs drawn 2/24/17 revealed the d-dimer was 738. The normal range documented on the lab results was 0-243. Further review of the clinical record failed to reveal any evidence that the facility followed up with the lab regarding the results of the PT / INR that were drawn. Review of the nurses' notes documented the following entries: - 2/25/17 at 11:00 a.m., documented the resident's skin tone was normal, and warm and dry, and that stool was soft and formed. - 2/26/17 at 10:30 a.m., documented the resident's skin tone was normal and skin was warm and dry. - 2/26/17 at 5:15 p.m., Resident c/o pain dramatically crying out into hall. She c/o pain in ribs, neck, and arms. When I took the resident some Tylenol (9) down she refused it stating, I am not going to even take it anymore, it doesn't help. She stopped crying out as soon as I left the room. Note left for MD (medical doctor) to evaluate her pain. Will continue to monitor - 2/27/17 at 3:30 a.m., documented, .Resident skin tone is normal. Skin is warm and dry .Last BM (bowel movement) 02/26/17. Stool appearance is soft and formed - 2/27/17 at 10:34 a.m., documented, Resident c/o chest pain at 08:40 A.M. Crying out during the episode. V/S (vital signs) are 97.6 (temperature), 75 (pulse), 17 (respirations), 159/85 (blood pressure) with an 02 sat (oxygen saturation) of 95% on RA (room air). Took her meds and is calmer at this time. A note by the nurse practitioner on 2/27/17 at 11:26 a.m., documented, f/u (follow up) CP (complaints of pain), with elevated dimer, no inc (sic - INR) as of yet, getting stat today as not returned prior per report to me, pt (patient) declining ED (emergency department) visit as I stated multiple times that she should be evaluated, is oriented and able to make decisions, ekg (electrocardiogram) looked ok, no nausea, no bleeding, no sob (shortness of breath) Physical Exam: Skin: no rash, turgor normal, warm, dry A/P: (assessment/plan) 1. CP improved, pt awake and alert, could suspect PE (pulmonary [MEDICAL CONDITION]), need INR returned asap (as soon as possible), nurse to call me, pt (patient) declines ED visit and understands risks. 2. [MEDICAL CONDITION]/debility, cont LTC (continue long term care). 3. URI (upper respiratory infection), on antibiotic. A nurse's note dated 2/27/17 at 6:15 p.m., documented the resident was given Tylenol 2 tabs for pain, and a follow up note documented that the medication was ineffective. A routine weekly skin assessment completed on 2/27/17 at 4:14 p.m., documented no changes in skin condition or areas of concern. A nurse's note dated 2/27/17 at 6:43 p.m., documented, Lab called with PT INR results which the lab states are too high to read on their machine. (Nurse Practitioner) called and she gave an order to give 5 Mg Vit (vitamin) K (used to reverse the effects of blood thinning medications when too much is given (10)) IM stat (5 milligrams of Vitamin K, via intramuscularly injection immediately). Order written, noted and faxed to the pharmacy. Resident vomited coffee ground material (vomit having the appearance and consistency of coffee grounds because of blood mixed with gastric contents*) at 17:25 (5:25 p.m.). (Nurse Practitioner) notified. She gave an order to give 40 mg of [MEDICATION NAME] (used to treat reflux and ulcers (10)) stat (immediately) and then cont. (continue) the order BID (twice daily). [MEDICATION NAME] given as ordered. her daughter (name) was notified. Resident was instructed that if she had more emesis then she would need to go to the hospital. She stated that she didn't want to go to hospital as she didn't want to loose (sic) her bed. A nurse's note dated 2/27/17 at 11:30 p.m., documented, Staff notified writer that resident was not feeling well and acting differently. Writer assessed resident, found resident to be confused, disoriented, skin tone appeared light yellow all over, large purple bruises noted to Rt (right) upper arm, a large raised hematoma to Rt forearm. Resident c/o (complained of) Rt arm being weak, more than normal. Writer had received in report, resident had vomited x1 dark brown, coffee ground looking emesis earlier in the evening. CNA (certified nursing assistant) reported to writer that resident had vomited again, just before writer entered room, x2. CNA described emesis as dark brown coffee grounds. Resident said she was unable to eat any food, vomited from drinking a sip of water. Resident said she wanted to go to ER (emergency room ). POA (Power of Attorney) notified of change, and agreed that she wanted her mom to be sent to the ER. Placed call to 911, resident sent via squad to (hospital). A nurse's note dated 2/28/17 at 2:42 a.m., documented, SBAR: Situation: Change in condition, symptoms or signs I am calling about is/are: Altered mental status Functional decline (worsening function and/or mobility) Nausea/Vomiting. This started on 02/27/2017 and the time of day Afternoon. Background: Resident is in the nursing home for long term care .(resident [DIAGNOSES REDACTED]. Assessment/Appearance: Vitals: BP (blood pressure) 107/54 - 2/27/17 00:48 (12:48 a.m.) Position: Lying r/arm. P (pulse) 85 - 2/27/2017 00:49 (12:49 a.m.) Pulse Type: Regular. R (respirations) 17 - 2/27/17 00:50 (12:50 a.m.). T (temperature) 99.4 - 2/27/2017 19:19 (7:19 p.m.) Route: Oral. W (weight) 210.8 lb (pounds) - 2/15/2017 13:18 (1:18 p.m.) Scale: Lift Scale. O2 (oxygen) 94% - 2/27/2017 19:20 (7:20 p.m.) Method: Room air, BS (blood sugar) 271 - 2/27/2017 00:51 (12:51 a.m.) Pain: 0. Resident has increased confusion (e.g. disorientation). Resident has general weakness, no behavioral changes observed. no (sic) respiratory changes observed. Resident noted to be Jaundice Blood (sic) noted in stool or vomitus c/o (sic) of nausea. Vomiting noted. appetite (sic) diminished No (sic) Urinary changes observed. Other neurological symptoms observed. Skin Changes: Discoloration. Disoriented, confused, c/o (complained of) weakness. Resident c/o not feeling well, asked to go to ER Request: Reported to primary care clinician. No, d/t (due to) time of night, on. (sic) Orders obtained: (none listed). Name of Family/healthcare agent notified: (name) residents (sic) daughter. on 02/27/2017 11:30 PM. A nurse's note dated 3/1/17, documented as a Late entry for 2-23-17 documented, NP (nurse practitioner) notified of resident not receiving PT/INR since 2-8-17 NP with order for PT/INR next day 2-24-17. Resident transferred to Unit 1 Lab slip taken down to south unit manager. Resident aware of lab orders for next day. A review of the resident's care plan revealed one for Anticoagulant use which was initiated on 1/31/17. The interventions included one for Monitor labs per orders and notify MD of abnormalities. This intervention was dated 1/31/17. A review of the facility policy for Anticoagulation Protocol documented, b. The nurse will obtain an order from the physician for any pertinent labs for monitoring of the anticoagulant therapy Additional interviews conducted with staff as follows: In an interview conducted on 3/22/17 at 1:18 with LPN (licensed practical nurse) #2, she stated that at the time of this resident (Resident #1), she was the unit manager for the skilled unit. LPN #2 stated that the nurses were responsible to ensure that labs were received and reported to the physician. She could not provide further explanation as to how it fell through the cracks that this resident's PT/INR that was drawn on 2/10/17 was never followed up on for the results. In a follow up interview that was conducted with LPN #2 on 3/23/17 at 10:24 a.m., she stated that as the unit manager she should have ensured that the lab results were received. In addition LPN #2 stated that the care plan for monitoring the labs as ordered was not followed. LPN #2 stated that as the unit manager, she would bring to the morning meetings, any information regarding abnormal labs, but that whether or not a lab result was actually received was not part of the process at the time. LPN #2 stated that aside from the nurses, the physician/nurse practitioner should also have followed up; asking about lab results that he/she had ordered was expecting to receive. In an interview conducted 3/22/17 at 2:02 p.m., with LPN #1 (Licensed Practical Nurse) she stated that she received the resident from the other unit on 2/21/17 and that everything was going ok with the resident. LPN #1 stated that a couple days later, the unit manager from the other unit brought over the PT/INR flow sheet (which had not been initiated until 1/20/17) and that the unit manager told her she just realized that the resident had not had a PT/INR drawn since about 2/8/17. LPN #1 stated the nurse practitioner was notified and orders were obtained to get a PT/INR on Friday (which was 2/24/17). She stated that during the approximately 1 week the resident was on her unit, there were no noted issues with the resident until the events of 2/27/17. On 3/22/17 at 5:00 an interview was conducted with OSM (Other Staff Member) #1, the pharmacist. She stated that until a resident is stable, that labs should be monitored frequently, at least weekly. She stated that if a resident has [MEDICATION NAME] toxicity, that the effects of that could be significant bleeding related issues (i.e., brain bleed, [MEDICAL CONDITION], etc.) On 3/23/17 at 11:20 a.m., in an interview with the Director of Nursing (DON) (Administrative Staff Member #2 - ASM #2) she stated that ever since this situation occurred, she has been in contact with the lab and that results from Resident #1's PT/INR draw on 2/10/17 could not be located by the lab company either. She stated that the lab company followed up with the hospital laboratory facility that they utilize and that it would appear the hospital lab did not perform the testing. In addition, ASM #2 stated a similar scenario occurred with the stat testing that was done on 2/24/17 wherein the lab collected was for a D-Dimer and a PT/INR but the hospital laboratory failed to perform the PT/INR. Therefore, the lab company only had results for the D-Dimer to return to the facility. The facility had failed to follow up with the lab company regarding the results for the PT/INR for either of these dates Resident #1's levels went unchecked and Resident #1 continued to receive 8 mg of [MEDICATION NAME] without monitoring and was sent to the emergency roiagnom on [DATE] and was hospitalized for [REDACTED]. On 3/23/17 at approximately 8:30 a.m., the Administrator stated that the nurse practitioner had been out sick but was expecting my call; and that the physician was expecting my call specifically at 10:00 a.m. On 3/23/17 at 9:58 a.m., and 10:05 a.m., attempts were made to contact the physician, without success. Attempts to contact the nurse practitioner were made on 3/23/17 at 10:11 a.m. and 10:20 a.m. The nurse practitioner did not answer the call. A review of the hospital discharge summary dated 3/14/17 documented in part the following: Acute blood loss [MEDICAL CONDITION] (source unknown), in setting of [MEDICATION NAME] toxicity/fluctuation (resolved) On 3/22/17 at approximately 3:00 p.m., the Administrator and Director of Nursing were notified of the concern for harm. The following plan of correction was presented: 1. Incident: 2/27/17 - resident with a high PT/INR (with a result of) - (unable to read); bruising noted; emesis x1 coffee ground in color - (inconsistency of labs)): resident evaluated by NP, labs ordered, PT/INR elevated; Vit K given; resident to hospital and admitted . 2. 100% audit of residents receiving [MEDICATION NAME] (12), [MEDICATION NAME], Eliquis (13), Xarelto (14) audited for pertinent labs and bruising/bleeding and relating care plans. 3. Education to nursing staff on anticoagulant policy to include signs and symptoms; education to licensed nurses on anticoagulant policy and lab process by DON/designee 4. Audits of labs and audits of resident on [MEDICATION NAME], Eliquis, Xarelto audited 5 times a week for 12 weeks for lab orders/completion/ MD/RP notification by DON/designee. Results of audits will be taken to QAPI monthly x 3 months for review and revision as needed. 5. Date of compliance: March 6, 2017. A review of the plan of correction revealed that 100% of the nursing staff was educated. Audits to date were reviewed. All current residents on [MEDICATION NAME] or [MEDICATION NAME] who were also in the facility at the time the resident was in the facility were reviewed by the surveyor. There were no discrepancies identified with these residents' labs and [MEDICATION NAME] dosing at the time Resident #1 was in the facility or since then up to the date of survey. No further information was provided by the end of the survey. Complaint Deficiency past noncompliance. References: (1) [MEDICATION NAME] is a medication that helps keep your blood from clotting. Information obtained from https://medlineplus.gov/ency/patientinstructions/ 5.htm (2) [MEDICATION NAME] is another name for [MEDICATION NAME] (see 1 above) (3) INR (International Normalized Ratio) a blood test used to monitor the effectiveness of [MEDICATION NAME] ([MEDICATION NAME]). Information obtained from https://labtestsonline.org/understanding/analytes/pt/tab/test (4) Bactrim is an antibiotic. Information obtained from https://medlineplus.gov/druginfo/meds/a 6.html (5) PT ([MEDICATION NAME]) is a blood test used in conjunction with the INR test to monitor the effectiveness of [MEDICATION NAME] (see 3 above) (6) While accuracy of laboratory testing has significantly evolved over the past few decades, some lab-to-lab variability can occur due to differences in testing equipment, chemical reagents used, and analysis techniques. Consequently, for most lab tests, there is no universally applicable reference value. Information obtained from https://labtestsonline.org/understanding/features/ref-ranges/ (7) [MEDICATION NAME] is used to prevent blood clots. Information obtained from https://medlineplus.gov/druginfo/meds/a 6.html (8) D-Dimer is a lab test used to check for blood clotting problems. Information obtained from https://medlineplus.gov/ency/article/ 0.htm (9) Tylenol is used to relieve mild to moderate pain. Information obtained from https://medlineplus.gov/druginfo/meds/a 4.html (10) Vitamin K is used to reverse the effects of blood thinning medications when too much is given. Information obtained from https://medlineplus.gov/druginfo/natural/983.html (11) [MEDICATION NAME] is. Information obtained from https://medlineplus.gov/druginfo/meds/a 0.html (12) [MEDICATION NAME] is used to prevent blood clots in the legs of patients who are on bedrest, or who are having hip replacement, knee replacement, or stomach surgery. Information obtained from https://medlineplus.gov/druginfo/meds/a 0.html (13) Eliquis is used to prevent [MEDICAL CONDITION] and blood clots in people who have [MEDICAL CONDITION]. Information obtained from https://medlineplus.gov/druginfo/meds/a 2.html (14) Xarelto is used to treat [MEDICAL CONDITION] or [MEDICAL CONDITION] embolism. Information obtained from https://medlineplus.gov/druginfo/meds/a 9.html (15) According to Mosby's Medical Dictionary, sixth edition, 2002. St. Louis, MO: Mosby, Inc. Page 405, a CBC (complete blood count) is a blood test used to determine the number of red and white blood cells per cubic millimeter of blood; and is one of the most valuable screening and diagnostic techniques. (16) A BMP (Basic metabolic panel) is a group of blood tests that provides information about your body's metabolism This test can be used to evaluate kidney function, blood acid/base balance, and your levels of blood sugar, and electrolytes. Depending on which lab you use, a basic metabolic panel may also check your levels of calcium and a protein called [MEDICATION NAME]. Information obtained from http://www.nlm.nih.gov/medlineplus/ency/article/ 2.htm (17) According to Mosby's Medical Dictionary, sixth edition, 2002. St. Louis, MO: Mosby, Inc. Page 1042, an MG level (Magnesium) is a blood test used to determine the level of magnesium, an electrolyte that is critical in nearly all metabolic processes. Abnormal levels may indicate [MEDICAL CONDITION], chronic [MEDICAL CONDITION], uncontrolled diabetes, diabetic acidosis, [DIAGNOSES REDACTED], [MEDICAL CONDITION], malnutrition, malabsorption, [MEDICAL CONDITION], and alcoholism. (18) Phosphorus tests are most often ordered along with other tests .to help diagnose and/or monitor treatment of [REDACTED].org/understanding/analytes/phosphorus/tab/test *This information was obtained from the website: <a href=http://medical-dictionary.thefreedictionary.com/coffee-ground+vomit>coffee-ground vomit</a>

Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide timely lab services to meet the resident's needs for 1 of 4 residents in the survey sample; Resident #1. For Resident #1, the facility staff failed to ensure timely results of a laboratory test for PT / INR levels, for which an anticoagulant medication dosing was dependent on. When the laboratory results were not received, the facility staff failed to follow up with the lab regarding the results, and therefore, the medication dose was not readjusted accordingly, resulting in toxic levels of the medication for the resident, that required hospitalization . The findings include: Resident #1 was admitted to the facility on [DATE] and discharged on [DATE]. The resident was admitted with the [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) was a 5-day assessment post readmission (1/11/17 after brief re-hospitalization ) with an ARD (Assessment Reference Date) of 1/18/17. The resident was coded as being cognitively intact in ability to make daily life decisions, scoring a 15 out of a possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #1 was coded as requiring total assistance for transfers; extensive assistance for hygiene, toileting, and dressing; supervision for eating; and as incontinent of bowel and bladder. Review of the hospital record for the hospitalization leading to the resident's initial admission of 12/31/16 revealed the following: A review of the hospital record dated 12/31/16 revealed a discharge summary which documented, Principle Discharge Diagnosis: [REDACTED].o. (year old) female with a history of poorly controlled DM (diabetes) c/b (complicated by) [MEDICAL CONDITION] and right BKA (below knee amputation), hypertension (high blood pressure), [MEDICAL CONDITIONS] s/p (status [REDACTED].No history of stroke. Reports compliance with [MEDICATION NAME]. Takes 4 mg (milligrams) nightly (at 6 pm) but had been off all medications, including [MEDICATION NAME], for a year due to insurance issues Continue full anticoagulation for history of recurrent PEs with [MEDICATION NAME] (also known as [MEDICATION NAME] (2)). Check INR (International Normalized Ratio (3)) in 1-2 days after discharge. Restart [MEDICATION NAME] at 1 mg (milligram) daily once INR is between 2-3. Continue [MEDICATION NAME] 1 mg daily for the duration of antibiotic therapy with Bactrim (an antibiotic (4)). After Bactrim is completed, would recommend close INR monitoring and readjustment of her [MEDICATION NAME] to higher doses. In addition, the above dated hospital record documented that on 12/29/16, the resident's INR was 2.9 (normal range was identified as 0.9 to 1.2). The [MEDICATION NAME] (PT) level was high at 32.9. Documented normal range was 9.8 to 12.6 A review of the facility physician's orders dated 12/31/16 and 1/1/17 revealed that, per the discharge summary above, Resident #1 was not yet started on the [MEDICATION NAME] at the time of admission to the facility on [DATE]. On 1/3/17, the resident was sent from the facility to the hospital for suspected [MEDICAL CONDITION] related to complaints of chest pain. The hospital record for this visit contained an INR result of 1.4, which was still elevated above the normal range. The PT was documented as 15.6, which was also still above the normal range. The resident was released back to the facility the same day. The discharge paperwork documented, [MEDICATION NAME] 1 mg please wait till INR is between 2 - 3 to resume. On 1/4/17 the facility obtained an INR level, which the results were 1.5. The facility's laboratory ranges for this documented normal range as being 0.80 to 3.50. A PT result was documented as 12.1. The facility's laboratory documented normal range as being 10.5 to 12.0. (NOTE: variances in normal ranges and results vary by laboratory, based on equipment used, procedures used, laboratory policy, and standard deviation. (6)). The nurse practitioner notated the lab results on 1/5/17. There were no further labs or medication changes until 1/9/17. Up to this date, the facility had not ordered any [MEDICATION NAME] / [MEDICATION NAME] for the resident. In the approximately 10 days the resident was in the facility, the PT and INR had been checked twice (1/3/17 at the hospital and 1/4/17 at the facility). Review of the clinical record revealed that on 1/9/17, Resident #1 was again sent to the hospital, for altered mental status related to [DIAGNOSES REDACTED]. Resident #1 was admitted , and was discharged back to the facility on [DATE]. The hospital record documented the following: PT normal ranges 9.6 to 11.0. INR normal ranges (not provided). On 1/8/17 the resident's PT was 11.5 and INR was 1.12. On 1/10/17 the PT was 12.7 and the INR was 1.22. On 1/11/17 the PT was 13.9 and the INR was 1.34. The hospital record further documented, Discussion: 5. [MEDICAL CONDITION]/PE ([MEDICAL CONDITION]/pulmonary [MEDICAL CONDITION]) history. Patient not currently on anticoagulation despite being continued at discharge recently; will start a [MEDICATION NAME] (7) bridge to [MEDICATION NAME]. The resident was readmitted to the facility on [DATE]. A physician's order dated 1/12/17 documented [MEDICATION NAME] 4 mg in the evening. A review of the MAR (Medication Administration Record) for the month of January 2017 revealed that Resident #1 received [MEDICATION NAME], 4 mg every evening through 1/19/17. There were no further labs for PT / INR obtained until 1/19/17. On 1/19/17, a PT / INR were drawn. The results were: PT 13.5 (normal ranges 10.0 - 12.0) and INR 1.28 (normal ranges 0.80 - 3.5). Review of the clinical record revealed that on 1/20/17 a PT / INR were drawn. The results were PT 12.8 and INR 1.22. The nurse practitioner documented on the lab results to check (labs) on Monday (1/23/17) and to increase the [MEDICATION NAME] to 6 mg every evening. A review of the physician's orders revealed one dated 1/20/17 for [MEDICATION NAME] 6 mg in the evening. A review of the MAR for January 2017 revealed the resident received this medication as prescribed each evening from 1/20/17 through 1/26/17. On 1/23/17 a PT / INR were drawn. The results were: PT 14.0 and INR 1.33. The nurse practitioner documented on the results on 1/25/17 to check (labs) on Friday (1/27/17) and to increase the [MEDICATION NAME] to 8 mg. A review of the physician's orders revealed no new orders at this time. The medication dose did not change. Review of the MARs revealed the resident remained on the previous dose of 6 mg every evening through 1/26/17. On 1/25/17 a PT / INR were drawn. The results were: PT 16.9 and INR 1.59. It was unclear as to why the results were drawn on this date as there was not an order to do so. However, the nurse practitioner initialed the results on 1/26/17 and hand written on the results was a notation to increase the [MEDICATION NAME] to 8 mg and recheck the INR on 2/1/17. A review of the physician's orders revealed one dated 1/27/17 for [MEDICATION NAME] 4 mg tabs, give 2 tabs (8 mg) every morning. A review of Resident #1's January MAR indicated [REDACTED]. Up to this point, the medication was being administered at night. On 1/27/17, when the above order was written for 4 mg [MEDICATION NAME], give 2 tabs (8 mg) in the morning, it was before the resident's evening dose was due, thus an order for [REDACTED]. On 2/1/17 a PT / INR were drawn. The results were PT 13.4 and INR 1.28. The nurse practitioner initialed the results on 2/2/17 and handwritten on the results was the notation for 12 mg tonight (2/1/17), 10 mg Thurs (Thursday, 2/2/17) and recheck the labs on Monday (2/6/17). A review of the physician's orders revealed one dated 2/1/17 for [MEDICATION NAME] 12 mg one time only and an order also dated 2/1/17 for [MEDICATION NAME] 10 mg in the evening. A review of Resident #1's February MAR indicated [REDACTED]. It was noted that this order was, once again, scheduling the medication for an evening administration. On 2/6/17 a PT and INR were drawn. The results were: PT 24.1 and INR 2.24. Hand written on the results was Now 10 mg [MEDICATION NAME] and check Wednesday (2/8/17). The nurse practitioner initialed the results on 2/8/17. There was no evidence of an order written [REDACTED]. It was unclear if that was the intent of the notation, as the resident was already on 10 mg every evening at that time. On 2/8/17 a PT / INR were drawn. The results were: PT 41.1 and INR 3.74. The nurse practitioner wrote on the results to decrease ([MEDICATION NAME]) to 8 mg and hold x 2dy (it was unclear if this meant today or for 2 days.) A review of Resident #1's physician's orders revealed one dated 2/8/17 that documented, [MEDICATION NAME] 8 mg in the evening, start 2/10/17. A review of Resident #1's February 2017 MAR indicated [REDACTED]. The physician's orders did not specify to hold any doses even though the notation on the lab results documented to hold x 2 days. Further review of the MAR indicated [REDACTED]. Review of the clinical record failed to reveal the results of the PT / INR that were to be drawn on 2/10/17. A review of the facility lab order sheet revealed that a PT / INR were ordered to be drawn on 2/10/17 and the lab tech (technician) initialed that the labs were drawn. However, to date of the survey (3/23/17), the results were never provided to the facility from the lab company. There was no evidence the facility attempted to follow up with the lab regarding this lab test results until after Resident #1 was discharged to the hospital for [MEDICATION NAME] toxicity on 2/27/17. On 2/15/17 (a Wednesday) the nurse practitioner saw the resident. The NP note dated 2/15/17 did not document anything regarding the missing PT/INR results that were drawn on 2/10/17. A notation was made that documented INR on Wednesdays indicating that the lab was performed on Wednesdays. There were no orders written dated 2/15/17 for a PT/INR to be drawn, or for a dose change in the medication. On 2/21/17 Resident #1 was transferred to a different unit in the facility. Review of the February 2017 MAR indicated [REDACTED]. There were no further PT / INR orders obtained until 2/24/17. On 2/23/17 the NP saw the resident. The note documented, (illegible) INR still (illegible). Review of the physician's orders revealed one dated 2/23/17 for CBC (complete blood count (15)), BMP (basic metabolic panel (16)), Mag (magnesium (17)) level, Phos (phosphorous (18)) level and d-dimer (test used to check for blood clotting problems (8)) in A.M. Also dated 2/23/17 was an order for [REDACTED]. In an interview conducted with LPN #2 (Licensed Practical Nurse #2) on 3/23/17 at 10:24 a.m., she stated that on 2/23/17 she realized the results were never obtained from the 2/10/17 PT/INR lab draw and notified the nurse practitioner. LPN #2 stated the nurse practitioner saw the resident and ordered Labs for PT / INR and a D-Dimer (8). A review of the labs dated 2/24/17 revealed that the d-dimer could not be performed due to a problem with the sample and was going to be redrawn. There was no evidence the PT/INR was drawn with the other labs drawn the morning of 2/24/17. A review of the lab order slips revealed one dated 2/24/17 that documented PT/INR, d-dimer, re-collect. On 2/24/17 the NP saw the resident again. The note documented, INR (illegible) .INR still not in (illegible) .INR results (illegible) 2-3 . On 3/22/17 at 3:28 p.m., in an interview with LPN #3, she stated that the lab called her on 2/24/17 regarding labs drawn that morning and reported that there was something wrong with the sample for the d-dimer and PT/INR and that they would be back later that day to redraw these labs. On 3/22/17 at 4:57 p.m., an interview was conducted with LPN #4. She stated that she worked evening shift on 2/24/17 and saw the lab tech in the building and going into Resident #1's room to redraw the labs. LPN #4 stated that she inquired of the lab tech about the labs she was drawing because she was not made aware from day shift, to be expecting any labs to be drawn that evening. She stated the lab tech was drawing a PT/INR and d-dimer. A review of the labs drawn 2/24/17 revealed the d-dimer was 738. The normal range documented on the lab results was 0-243. Further review of the clinical record failed to reveal any evidence that the facility followed up with the lab regarding the results of the PT / INR that were drawn. Review of the nurses' notes documented the following entries: - 2/25/17 at 11:00 a.m., documented the resident's skin tone was normal, and warm and dry, and that stool was soft and formed. - 2/26/17 at 10:30 a.m., documented the resident's skin tone was normal and skin was warm and dry. - 2/26/17 at 5:15 p.m., Resident c/o pain dramatically crying out into hall. She c/o pain in ribs, neck, and arms. When I took the resident some Tylenol (9) down she refused it stating, I am not going to even take it anymore, it doesn't help. She stopped crying out as soon as I left the room. Note left for MD (medical doctor) to evaluate her pain. Will continue to monitor - 2/27/17 at 3:30 a.m., documented, .Resident skin tone is normal. Skin is warm and dry .Last BM (bowel movement) 02/26/17. Stool appearance is soft and formed - 2/27/17 at 10:34 a.m., documented, Resident c/o chest pain at 08:40 A.M. Crying out during the episode. V/S (vital signs) are 97.6 (temperature), 75 (pulse), 17 (respirations), 159/85 (blood pressure) with an 02 sat (oxygen saturation) of 95% on RA (room air). Took her meds and is calmer at this time. A note by the nurse practitioner on 2/27/17 at 11:26 a.m., documented, f/u (follow up) CP (complaints of pain), with elevated dimer, no inc (sic - INR) as of yet, getting stat today as not returned prior per report to me, pt (patient) declining ED (emergency department) visit as I stated multiple times that she should be evaluated, is oriented and able to make decisions, ekg (electrocardiogram) looked ok, no nausea, no bleeding, no sob (shortness of breath) Physical Exam: Skin: no rash, turgor normal, warm, dry A/P: (assessment/plan) 1. CP improved, pt awake and alert, could suspect PE (pulmonary [MEDICAL CONDITION]), need INR returned asap (as soon as possible), nurse to call me, pt (patient) declines ED visit and understands risks. 2. [MEDICAL CONDITION]/debility, cont LTC (continue long term care). 3. URI (upper respiratory infection), on antibiotic. A nurse's note dated 2/27/17 at 6:15 p.m., documented the resident was given Tylenol 2 tabs for pain, and a follow up note documented that the medication was ineffective. A routine weekly skin assessment completed on 2/27/17 at 4:14 p.m., documented no changes in skin condition or areas of concern. A nurse's note dated 2/27/17 at 6:43 p.m., documented, Lab called with PT INR results which the lab states are too high to read on their machine. (Nurse Practitioner) called and she gave an order to give 5 Mg Vit (vitamin) K (used to reverse the effects of blood thinning medications when too much is given (10)) IM stat (5 milligrams of Vitamin K, via intramuscularly injection immediately). Order written, noted and faxed to the pharmacy. Resident vomited coffee ground material (vomit having the appearance and consistency of coffee grounds because of blood mixed with gastric contents*) at 17:25 (5:25 p.m.). (Nurse Practitioner) notified. She gave an order to give 40 mg of [MEDICATION NAME] (used to treat reflux and ulcers (10)) stat (immediately) and then cont. (continue) the order BID (twice daily). [MEDICATION NAME] given as ordered. her daughter (name) was notified. Resident was instructed that if she had more emesis then she would need to go to the hospital. She stated that she didn't want to go to hospital as she didn't want to loose (sic) her bed. A nurse's note dated 2/27/17 at 11:30 p.m., documented, Staff notified writer that resident was not feeling well and acting differently. Writer assessed resident, found resident to be confused, disoriented, skin tone appeared light yellow all over, large purple bruises noted to Rt (right) upper arm, a large raised hematoma to Rt forearm. Resident c/o (complained of) Rt arm being weak, more than normal. Writer had received in report, resident had vomited x1 dark brown, coffee ground looking emesis earlier in the evening. CNA (certified nursing assistant) reported to writer that resident had vomited again, just before writer entered room, x2. CNA described emesis as dark brown coffee grounds. Resident said she was unable to eat any food, vomited from drinking a sip of water. Resident said she wanted to go to ER (emergency room ). POA (Power of Attorney) notified of change, and agreed that she wanted her mom to be sent to the ER. Placed call to 911, resident sent via squad to (hospital). A nurse's note dated 2/28/17 at 2:42 a.m., documented, SBAR: Situation: Change in condition, symptoms or signs I am calling about is/are: Altered mental status Functional decline (worsening function and/or mobility) Nausea/Vomiting. This started on 02/27/2017 and the time of day Afternoon. Background: Resident is in the nursing home for long term care .(resident [DIAGNOSES REDACTED]. Assessment/Appearance: Vitals: BP (blood pressure) 107/54 - 2/27/17 00:48 (12:48 a.m.) Position: Lying r/arm. P (pulse) 85 - 2/27/2017 00:49 (12:49 a.m.) Pulse Type: Regular. R (respirations) 17 - 2/27/17 00:50 (12:50 a.m.). T (temperature) 99.4 - 2/27/2017 19:19 (7:19 p.m.) Route: Oral. W (weight) 210.8 lb (pounds) - 2/15/2017 13:18 (1:18 p.m.) Scale: Lift Scale. O2 (oxygen) 94% - 2/27/2017 19:20 (7:20 p.m.) Method: Room air, BS (blood sugar) 271 - 2/27/2017 00:51 (12:51 a.m.) Pain: 0. Resident has increased confusion (e.g. disorientation). Resident has general weakness, no behavioral changes observed. no (sic) respiratory changes observed. Resident noted to be Jaundice Blood (sic) noted in stool or vomitus c/o (sic) of nausea. Vomiting noted. appetite (sic) diminished No (sic) Urinary changes observed. Other neurological symptoms observed. Skin Changes: Discoloration. Disoriented, confused, c/o (complained of) weakness. Resident c/o not feeling well, asked to go to ER Request: Reported to primary care clinician. No, d/t (due to) time of night, on. (sic) Orders obtained: (none listed). Name of Family/healthcare agent notified: (name) residents (sic) daughter. on 02/27/2017 11:30 PM. A nurse's note dated 3/1/17, documented as a Late entry for 2-23-17 documented, NP (nurse practitioner) notified of resident not receiving PT/INR since 2-8-17 NP with order for PT/INR next day 2-24-17. Resident transferred to Unit 1 Lab slip taken down to south unit manager. Resident aware of lab orders for next day. A review of the resident's care plan revealed one for Anticoagulant use which was initiated on 1/31/17. The interventions included one for Monitor labs per orders and notify MD of abnormalities. This intervention was dated 1/31/17. A review of the facility policy for Anticoagulation Protocol documented, b. The nurse will obtain an order from the physician for any pertinent labs for monitoring of the anticoagulant therapy Additional interviews conducted with staff as follows: In an interview conducted on 3/22/17 at 1:18 with LPN (licensed practical nurse) #2, she stated that at the time of this resident (Resident #1), she was the unit manager for the skilled unit. LPN #2 stated that the nurses were responsible to ensure that labs were received and reported to the physician. She could not provide further explanation as to how it fell through the cracks that this resident's PT/INR that was drawn on 2/10/17 was never followed up on for the results. In a follow up interview that was conducted with LPN #2 on 3/23/17 at 10:24 a.m., she stated that as the unit manager she should have ensured that the lab results were received. In addition LPN #2 stated that the care plan for monitoring the labs as ordered was not followed. LPN #2 stated that as the unit manager, she would bring to the morning meetings, any information regarding abnormal labs, but that whether or not a lab result was actually received was not part of the process at the time. LPN #2 stated that aside from the nurses, the physician/nurse practitioner should also have followed up; asking about lab results that he/she had ordered was expecting to receive. In an interview conducted 3/22/17 at 2:02 p.m., with LPN #1 (Licensed Practical Nurse) she stated that she received the resident from the other unit on 2/21/17 and that everything was going ok with the resident. LPN #1 stated that a couple days later, the unit manager from the other unit brought over the PT/INR flow sheet (which had not been initiated until 1/20/17) and that the unit manager told her she just realized that the resident had not had a PT/INR drawn since about 2/8/17. LPN #1 stated the nurse practitioner was notified and orders were obtained to get a PT/INR on Friday (which was 2/24/17). She stated that during the approximately 1 week the resident was on her unit, there were no noted issues with the resident until the events of 2/27/17. On 3/22/17 at 5:00 an interview was conducted with OSM (Other Staff Member) #1, the pharmacist. She stated that until a resident is stable, that labs should be monitored frequently, at least weekly. She stated that if a resident has [MEDICATION NAME] toxicity, that the effects of that could be significant bleeding related issues (i.e., brain bleed, [MEDICAL CONDITION], etc.) On 3/23/17 at 11:20 a.m., in an interview with the Director of Nursing (DON) (Administrative Staff Member #2 - ASM #2) she stated that ever since this situation occurred, she has been in contact with the lab and that results from Resident #1's PT/INR draw on 2/10/17 could not be located by the lab company either. She stated that the lab company followed up with the hospital laboratory facility that they utilize and that it would appear the hospital lab did not perform the testing. In addition, ASM #2 stated a similar scenario occurred with the stat testing that was done on 2/24/17 wherein the lab collected was for a D-Dimer and a PT/INR but the hospital laboratory failed to perform the PT/INR. Therefore, the lab company only had results for the D-Dimer to return to the facility. The facility had failed to follow up with the lab company regarding the results for the PT/INR for either of these dates Resident #1's levels went unchecked and Resident #1 continued to receive 8 mg of [MEDICATION NAME] without monitoring and was sent to the emergency roiagnom on [DATE] and was hospitalized for [REDACTED]. On 3/23/17 at approximately 8:30 a.m., the Administrator stated that the nurse practitioner had been out sick but was expecting my call; and that the physician was expecting my call specifically at 10:00 a.m. On 3/23/17 at 9:58 a.m., and 10:05 a.m., attempts were made to contact the physician, without success. Attempts to contact the nurse practitioner were made on 3/23/17 at 10:11 a.m. and 10:20 a.m. The nurse practitioner did not answer the call. A review of the hospital discharge summary dated 3/14/17 documented in part the following: Acute blood loss [MEDICAL CONDITION] (source unknown), in setting of [MEDICATION NAME] toxicity/fluctuation (resolved) On 3/22/17 at approximately 3:00 p.m., the Administrator and Director of Nursing were notified of the concern for harm. The following plan of correction was presented: 1. Incident: 2/27/17 - resident with a high PT/INR (with a result of) - (unable to read); bruising noted; emesis x1 coffee ground in color - (inconsistency of labs)): resident evaluated by NP, labs ordered, PT/INR elevated; Vit K given; resident to hospital and admitted . 2. 100% audit of residents receiving [MEDICATION NAME] (12), [MEDICATION NAME], Eliquis (13), Xarelto (14) audited for pertinent labs and bruising/bleeding and relating care plans. 3. Education to nursing staff on anticoagulant policy to include signs and symptoms; education to licensed nurses on anticoagulant policy and lab process by DON/designee 4. Audits of labs and audits of resident on [MEDICATION NAME], Eliquis, Xarelto audited 5 times a week for 12 weeks for lab orders/completion/ MD/RP notification by DON/designee. Results of audits will be taken to QAPI monthly x 3 months for review and revision as needed. 5. Date of compliance: March 6, 2017. A review of the plan of correction revealed that 100% of the nursing staff was educated. Audits to date were reviewed. All current residents on [MEDICATION NAME] or [MEDICATION NAME] who were also in the facility at the time the resident was in the facility were reviewed by the surveyor. There were no discrepancies identified with these residents' labs and [MEDICATION NAME] dosing at the time Resident #1 was in the facility or since then up to the date of survey. No further information was provided by the end of the survey. Complaint Deficiency past noncompliance. References: (1) [MEDICATION NAME] is a medication that helps keep your blood from clotting. Information obtained from https://medlineplus.gov/ency/patientinstructions/ 5.htm (2) [MEDICATION NAME] is another name for [MEDICATION NAME] (see 1 above) (3) INR (International Normalized Ratio) a blood test used to monitor the effectiveness of [MEDICATION NAME] ([MEDICATION NAME]). Information obtained from https://labtestsonline.org/understanding/analytes/pt/tab/test (4) Bactrim is an antibiotic. Information obtained from https://medlineplus.gov/druginfo/meds/a 6.html (5) PT ([MEDICATION NAME]) is a blood test used in conjunction with the INR test to monitor the effectiveness of [MEDICATION NAME] (see 3 above) (6) While accuracy of laboratory testing has significantly evolved over the past few decades, some lab-to-lab variability can occur due to differences in testing equipment, chemical reagents used, and analysis techniques. Consequently, for most lab tests, there is no universally applicable reference value. Information obtained from https://labtestsonline.org/understanding/features/ref-ranges/ (7) [MEDICATION NAME] is used to prevent blood clots. Information obtained from https://medlineplus.gov/druginfo/meds/a 6.html (8) D-Dimer is a lab test used to check for blood clotting problems. Information obtained from https://medlineplus.gov/ency/article/ 0.htm (9) Tylenol is used to relieve mild to moderate pain. Information obtained from https://medlineplus.gov/druginfo/meds/a 4.html (10) Vitamin K is used to reverse the effects of blood thinning medications when too much is given. Information obtained from https://medlineplus.gov/druginfo/natural/983.html (11) [MEDICATION NAME] is. Information obtained from https://medlineplus.gov/druginfo/meds/a 0.html (12) [MEDICATION NAME] is used to prevent blood clots in the legs of patients who are on bedrest, or who are having hip replacement, knee replacement, or stomach surgery. Information obtained from https://medlineplus.gov/druginfo/meds/a 0.html (13) Eliquis is used to prevent [MEDICAL CONDITION] and blood clots in people who have [MEDICAL CONDITION]. Information obtained from https://medlineplus.gov/druginfo/meds/a 2.html (14) Xarelto is used to treat [MEDICAL CONDITION] or [MEDICAL CONDITION] embolism. Information obtained from https://medlineplus.gov/druginfo/meds/a 9.html (15) According to Mosby's Medical Dictionary, sixth edition, 2002. St. Louis, MO: Mosby, Inc. Page 405, a CBC (complete blood count) is a blood test used to determine the number of red and white blood cells per cubic millimeter of blood; and is one of the most valuable screening and diagnostic techniques. (16) A BMP (Basic metabolic panel) is a group of blood tests that provides information about your body's metabolism This test can be used to evaluate kidney function, blood acid/base balance, and your levels of blood sugar, and electrolytes. Depending on which lab you use, a basic metabolic panel may also check your levels of calcium and a protein called [MEDICATION NAME]. Information obtained from http://www.nlm.nih.gov/medlineplus/ency/article/ 2.htm (17) According to Mosby's Medical Dictionary, sixth edition, 2002. St. Louis, MO: Mosby, Inc. Page 1042, an MG level (Magnesium) is a blood test used to determine the level of magnesium, an electrolyte that is critical in nearly all metabolic processes. Abnormal levels may indicate [MEDICAL CONDITION], chronic [MEDICAL CONDITION], uncontrolled diabetes, diabetic acidosis, [DIAGNOSES REDACTED], [MEDICAL CONDITION], malnutrition, malabsorption, [MEDICAL CONDITION], and alcoholism. (18) Phosphorus tests are most often ordered along with other tests .to help diagnose and/or monitor treatment of [REDACTED].org/understanding/analytes/phosphorus/tab/test *This information was obtained from the website: <a href=http://medical-dictionary.thefreedictionary.com/coffee-ground+vomit>coffee-ground vomit</a>