Every finding on record at Center on Aging and Health

Based on medical record review and interviews, the facility failed to obtain consent for administration of psychotropic medications for 5 of 5 residents (Resident #21, #33, #8, #42 and #3) reviewed for unnecessary medications.The findings include: 1.Review of the medical record revealed Resident #21 was admitted to the facility on [DATE] with diagnoses including Dementia with Behavioral Disturbance, Delusional Disorder, and Psychotic Disorder. Review of a Physician's Order for Resident #21 dated 6/14/2024, revealed .Memantine [a medication used to treat dementia] .Oral Tablet 1000 mg . Give 1 tablet by mouth two times a day . Review of a Physician's Order for Resident #21 dated 7/24/2024, revealed .Sertraline [a medication used to treat depression] .Oral Tablet 100 mg . Give 1 tablet by mouth one time a day . Review of a Physician's Order for Resident #21 dated 6/11/2025, revealed . Brexpiprazole [antipsychotic medication used to treat agitation] 0.5 milligram [mg] once daily by mouth . Review of a Physician's Order for Resident #21 dated 10/22/2025, revealed .Divalproex Sodium [medication used to treat mood disorders] Capsule .100 mg .Give 3 capsules by mouth in the morning . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #21 scored a 00 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Review of the Medication Administration Record (MAR) dated 2/1/2026- 4/15/2026, revealed Resident #21 received Brexpiprazole, Divalproex Sodium, Memantine, and Sertraline as ordered. Review of the medical record revealed no documentation of an informed consent form for the use of Brexpiprazole, Divalproex Sodium, Memantine, or Sertraline for Resident #21. Review of the medical record revealed no documentation that Resident #21 or Resident #21's representative had been informed in advance of the risks and benefits, options, and alternatives to treatment of the Brexpiprazole, Divalproex Sodium, Memantine, or Sertraline. 2. Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including Dementia, Cognitive Communication Deficit, and Generalized Anxiety Disorder. Review of a Physician's Order for Resident #33 dated 3/30/2023, revealed .trazodone [antidepressant medication used to treat insomnia] .oral tablet 100 mg .give 1 tablet by mouth at bedtime . Review of a Physician's Order for Resident #33 dated 10/19/2023, revealed .Sertraline [antidepressant] .50 mg .give 1 tablet by mouth one time a day . Review of a Physician's Order for Resident #33 dated 6/11/2025, revealed .Memantine [medication used to treat dementia] .Oral Capsule 14 mg .give 1 capsule by mouth one time a day . Review of a Physician's Order for Resident #33 dated 2/18/2026, revealed .Alprazolam Oral Tablet [medication used to treat anxiety] 0.25 mg .give one tablet by mouth at bedtime . Review of a quarterly MDS assessment dated [DATE], revealed Resident #33 scored a 12 on the BIMS assessment, which indicated the resident had moderate cognitive impairment. Review of the MAR for Resident #33 dated 2/1/2026 - 4/15/2026, revealed Resident #33 received Alprazolam, Memantine, Sertraline, and Trazodone as ordered. Review of the medical record for Resident #33 revealed no documentation of an informed consent form for the use of Alprazolam, Memantine, Sertraline, or Trazodone. Review of the medical record revealed no documentation that Resident #33 or Resident #33's representative was informed in advance of the risks and benefits, options, and alternatives to treatment of the Alprazolam, Memantine, Sertraline, or Trazodone. 3. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including Dementia with Psychotic Disturbance, Psychotic Disorder with Delusions, Generalized Anxiety Disorder and Depression. Review of a quarterly MDS assessment dated [DATE], revealed Resident #8 scored a 3 on the BIMS assessment, which indicated the resident had severe cognitive impairment. Review of a Physician's Order for Resident #8 dated 8/17/2024, revealed .Alprazolam Oral Tablet 0.5 mg .Give 1 tablet by mouth in the morning . Review of a Physician's Order for Resident #8 dated 8/21/2024, revealed .Donepezil .Oral Tablet 10 mg .Give 10 mg by mouth at bedtime . and an order for .Memantine .Oral Tablet 10 mg .Give 10 mg by mouth two times a day . Review of a Physician's Order for Resident #8 dated 10/29/2025, revealed .Risperidone [medication used to treat psychosis] Tablet 1 mg .Give 1 tablet by mouth in the afternoon . Review of a Physician's Order for Resident #8 dated 1/3/2026, revealed .Trazodone .tablet 50 mg .Give 1 tablet by mouth in the afternoon . Review of a Physician's Order for Resident #8 dated 2/10/2026, revealed .Sertraline .tablet 100 mg .Give 1 tablet by mouth one time a day . Review of the MAR dated 2/1/2026 - 4/15/2026, revealed Resident #8 received Alprazolam, Donepezil, Memantine, Risperidone, Sertraline, and Trazodone as ordered. Review of the medical record for Resident #8 revealed no informed consent form for the use of Alprazolam, Donepezil, Memantine, Risperidone, Sertraline, or Trazodone prior to administration of the medications. Review of the medical record revealed no documentation that Resident #8 or Resident #8's representative was informed in advance of the risks and benefits, options, and alternatives to treatment of the Alprazolam, Donepezil, Memantine, Risperidone, Sertraline, or Trazodone. 4. Review of the medical record revealed Resident #42 was admitted to the facility on [DATE] with diagnoses to include Dementia, Diabetes, Depression, and Psychotic Disorders. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #42 scored a 5 on the BIMS assessment which indicated the resident had severe cognitive impairment. Review of the physician recapitulation orders dated 3/30/2026, revealed Escitalopram Oxalate (antidepressant medication) Tablet 10 MG give 1 tablet by mouth one time a day, Quetiapine Fumarate Tablet 50 MG give 1 tablet by mouth at bedtime, Xanax Oral Tablet 0.25 MG (Alprazolam) give 1 tablet by mouth every 12 hours as needed for anxiety/agitation. Review of the MAR for Resident #42 dated 4/1/2026 through 4/14/2026 revealed the resident had received the Escitalopram Oxalate, Quetiapine Fumarate daily as ordered, and received the Xanax on 4/2/2026, 4/10/2026, and 4/11/2026. Review of the medical record for Resident #42 revealed no informed consent form for the use of Escitalopram Oxalate, Quetiapine Fumarate, and Xanax prior to administration of the medications. Review of the medical record revealed no documentation that Resident #42 or Resident #42's representative was informed in advance of the risks and benefits, options, and alternatives to treatment of the Xanax, Escitalopram Oxalate, or Quetiapine Fumarate. 5. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including Dementia with Agitation, Post-Traumatic Stress Disorder, and Generalized Anxiety Disorder. Review of the comprehensive MDS assessment dated [DATE], revealed Resident #3 scored a 2 on the BIMS assessment, which indicated the resident had severe cognitive impairment. Review of a Physician's Order for Resident #3 dated 3/17/2026, revealed .Depakote Sprinkles [brand name for divalproex sodium] Oral Capsule .125 mg .Give 125 mg by mouth every 8 hours . Review of a Physician's Order for Resident #3 dated 3/22/2026, revealed .diazepam [medication used to treat anxiety] Oral tablet 10 mg .Give 1 tablet by mouth two times a day . Review of a Physician's Order for Resident #3 dated 3/31/2026, revealed .Mirtazapine [medication used to treat depression] Tablet 15 mg .Give 1 tablet by mouth at bedtime . Review of the MAR dated of 3/17/2026 - 4/15/2026, revealed Resident #3 received Depakote Sprinkles, Diazepam, or Mirtazapine as ordered. Review of the medical record for Resident #3 revealed no informed consent form for the use of Depakote Sprinkles, Diazepam, or Mirtazapine prior to administration of the medications. Review of the medical record revealed no documentation that Resident #3 or Resident #3's representative was informed in advance of the risks and benefits, options, and alternatives to treatment of the Depakote Sprinkles, Diazepam, or Mirtazapine. During an interview on 4/15/2026 at 2:05 PM, the Administrator confirmed the facility did not have a psychotropic medication policy. During an interview on 4/15/2026 at 2:47 PM, the Administrator confirmed the facility did not have psychotropic medication consent forms for any residents.

Based on facility policy review and observations the facility failed to ensure Protected Health Information (PHI) was safeguarded from access and public view for 19 of 19 residents visible on the screen (Residents #15, #2, #69, #9, #13, #68, #30, #29, #14, #49, #24, #7, #41, #60, #23, #1, #11, #31, and #32) on 2 of 3 medication carts observed. The findings include: Review of the facility policy titled, Corporate Compliance and Ethics Manual, dated 7/2024 revealed .Safeguarding Protected Health Information (PHI) .the company shall have in place .appropriate physical and technical safeguards to protect PHI .Staff members shall log off their workstation when leaving the work area .computer monitors shall be positioned so that unauthorized persons cannot easily view information on the screen .Review of the following medical records revealed: Resident #15 was admitted to the facility on [DATE], with diagnoses including Unspecified Fracture of T11-T12 (Thoracic Vertebrae), Muscle Weakness, and Reduced Mobility. Resident #2 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus, Hypertensive Heart Disease, and Cognitive Communication Deficit. Resident #69 was admitted to the facility on [DATE] with diagnoses including Muscle Wasting and Atrophy, Adult Failure to Thrive, and Chronic Obstructive Pulmonary Disease (COPD). Resident #9 was admitted to the facility on [DATE] with diagnoses including Parkinsonism, Unspecified Convulsions, and Cognitive Communication Deficit. Resident #13 was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis (Weakness/Paralysis on 1 side of the body) following Cerebral Infarction (Stroke), Muscle Weakness, and Anorexia. Resident #68 was admitted to the facility on [DATE] with diagnoses including Lack of Coordination, Human Metapneumovirus, and Generalized Anxiety Disorder. Resident #30 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus, COPD, and Atrial Fibrillation. Resident #29 was admitted to the facility on [DATE] with diagnoses including Myocardial Infarction (Heart Attack), Muscle Weakness, and Cardiomyopathy (enlarged heart muscle). Resident #14 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction, Muscle Weakness, and Reduced Mobility.Resident #49 was admitted to the facility on [DATE] with diagnoses including Dementia, Muscle Weakness, Age-Related Cognitive Decline. Resident #24 was admitted to the facility on [DATE] with diagnoses including Senile Degeneration of the Brain, Constipation, and Depression. Resident #7 was admitted to the facility on [DATE] with diagnoses including Lack of Coordination, Gout, and Hypokalemia. Resident #41 was admitted to the facility on [DATE] with diagnoses including Sepsis, Polyneuropathy, and Vitamin D Deficiency.Resident #60 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus, Heart Disease, and Morbid (severe) Obesity.Resident #23 was admitted to the facility on [DATE] with diagnoses including Legal Blindness, Acute Kidney Failure, and Anxiety Disorder. Resident #1 was admitted to the facility on [DATE] with diagnoses including Sepsis, Muscle Weakness, and Dementia. During an observation on 4/13/2026 at 11:41 AM, revealed the 200 South Hall medication cart computer open with 16 resident's identifiers (Picture, name, medical number, wing, and room number) visible on the screen (Residents #1, #2, #7, #9, #13, #14, #15, #23, #24, #29, #30, #41, #49, #60, #68, and #69) in view of the public. Licensed Practical Nurse (LPN) C confirmed she walked away from the medication cart and did not safeguard the PHI. Review of the following medical records revealed:Resident #11 was admitted to the facility on [DATE] with diagnoses including Low Back Pain, End Stage Renal Disease, and Anemia. Resident #31 was admitted to the facility on [DATE] with diagnoses including Encounter for other Orthopedic Aftercare, Muscle Weakness, and Epilepsy. Resident #32 was admitted to the facility on [DATE] with diagnoses including Reduced Mobility, Dysphagia, and Hepatic Encephalopathy. During an observation on 4/14/2026 at 1:44 PM, on the East Hall medication cart computer, revealed resident information (name, medical record number, and room number) visible on the screen and in view of the public. Registered Nurse (RN) D stated she had just walked away and would have normally locked her screen. RN D confirmed she walked away from the medication cart and did not safeguard PHI.

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure nail care had been provided to 1 resident (resident #42) of 3 residents reviewed for nail care. The findings include:Review of the facility policy titled, Activities of Daily Living (ADL), Supporting, dated 3/2018, revealed .Residents will be provided with care, treatment and services as appropriate .residents who are unable to carry out activities of daily living [ADLs] independently will receive the services necessary to maintain .grooming .appropriate care and services will be provided for residents who are unable to carry out ADLs independently . Review of the medical record revealed Resident #42 was admitted to the facility on [DATE] with diagnoses to include Dementia, Diabetes, Depression, and Psychotic Disorders. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 scored a 5 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment and was dependent on staff for personal hygiene and mobility. Review of the comprehensive care plan for Resident #42 revealed .assess fingers and toes for warmth .ADL deficit .evaluate resident's ability to perform ADL's . Review of the facility documents titled Skin Check for Resident #42 dated 3/15/2026 through 4/12/2026, revealed .foot evaluation completed . During an observation and interview on 4/14/2026 at 9:04 AM, revealed Resident #42 laying upright in bed. Continued observation revealed the resident's fingernails were long, untrimmed, and had a brown substance underneath the nails. The resident had bilateral heel protectors in use with toes visible. The residents' toenails were long, curled over the tips of the toes and jagged. The resident stated, .I would feel better if my nails and toes were done [trimmed and cleaned] . During an interview on 4/14/2026 at 9:10 AM, Certified Nursing Assistant (CNA) A stated she provided nail and foot care on bath days and made sure the residents' nails were cleaned. The CNA stated she did not provide foot or nail care to residents with Diabetes. During an observation and interview and on 4/14/2026 at 1:48 PM, Registered Nurse (RN) D observed Resident #42's nails and toenails and confirmed, .those [fingernails and toenails] need to be trimmed .mainly nursing and wound care take care of trimming toes and nails . The nurse was unable to provide an answer as to why Resident #42's nails and toenails had not been cleaned or trimmed. During an interview on 4/14/2026 at 2:00 PM, the Wound Care Nurse (WCN) stated, .nursing is to do weekly skin checks, and it includes feet . the WCN was unable to provide an answer as to why Resident #42's nails and toenails had not been cleaned or trimmed. During an interview on 4/14/2026 at 2:30 PM, the Director of Nursing (DON) stated the expectation was for the skin assessment to be completed and all skin should be dealt with before a weekly skin assessment becomes due. The DON stated Resident #42 is a diabetic and nail and foot care was provided by the RN or WCN. The DON confirmed nail and foot care had not been provided to Resident #42.

Based on facility policy review, medical record review, observations and interviews, the facility failed to ensure foot and nail care had been provided for 1 resident (Resident #25) of 3 residents reviewed. The findings include: Review of the facility policy titled, Activities of Daily Living (ADL), Supporting, dated 3/2018, revealed .Residents will be provided with care, treatment and services as appropriate .residents who are unable to carry out activities of daily living [ADLs] independently will receive the services necessary to maintain .grooming .appropriate care and services will be provided for residents who are unable to carry out ADLs independently .report any changes .in skin .skin between the toes .if nails are too hard or too thick to cut .Documentation .should be recorded in the .medical record .date and time nail care was provided .condition of the .nails .feet . Review of the medical record revealed Resident #25 was admitted to the facility on [DATE] with diagnoses of Malignant Neoplasm of Brain, Palliative Care, and Melanoma of Neck and Scalp. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact and required maximum assistance to total dependence with ADLs. Review of the hospice care plan for Resident #25 dated 3/19/2026 revealed, .adjust ADLs to compensate for resident's changing abilities . Review of the weekly skin assessments for the months of 3/2026 and 4/2026 revealed the foot evaluation assessments had not been completed. During an observation and interview on 4/14/2026 at 8:20 AM, Resident #25 was resting in bed. CNA A was present in the resident's room and stated Resident #25 was .on hospice and they [hospice staff] take care of his baths and care . During an observation and interview on 4/14/2026 at 8:39 AM in Resident #25's room, revealed Licensed Practical Nurse (LPN) C pulled back the sheet and observed Resident #25's feet. The resident's right foot had a thick layer of dried yellow crusted skin over the top of the great toe and in-between all 4 digits. The nails were thick, long, and curled. The nail on the 2nd digit curled approximately 3/4 of an inch to the left and rested against the great toe. The nail on the 3rd digit curled and rested against top of the 2nd digit, and the nail on the 4th digit curled underneath covering the tip of the digit. Observation of the left foot revealed short nails and a thick layer of dried crusted skin on the top of the great toe and in-between all 4 digits. LPN C stated, .hospice does the bathing/showers and foot care .those should have been taken care of .the wound care nurse adds the residents who require foot care above what we can do here to the Podiatry list .I'm not sure if he is on the list for Podiatry . During an interview on 4/14/2026 at 8:47 AM, the Social Service Director (SSD) stated, .if there is an urgent need I send the request [podiatry service request] and the company [podiatry company] adds the resident to the list .currently, I do not have a Podiatry list .I do not have any residents scheduled for any upcoming Podiatry visits as of 4/14/2026 . During an observation and interview and on 4/14/2026 at 1:55 PM, Registered Nurse (RN) D observed Resident #25's feet and toenails and stated the condition of Resident #25's feet and toes were unacceptable (in her professional assessment) and should have been addressed during the full head to toe admission assessment. The RN confirmed foot and nail care had not been provided for the resident. During an interview on 4/14/2026 at 2:02 PM, the Wound care Nurse (WCN) stated, .nursing is to do weekly skin checks, and it includes feet .he is on the list for Podiatry services .he's supposed to be on it .I don't know why he [Resident #25] wasn't added .this is not the first time I've seen his feet like this . During an interview on 4/14/2026 at 2:11 PM, the SSD stated, .a nurse just came in and needed a gentleman added to the Podiatry list, but I can't remember his name [Resident #25] . During an interview on 4/14/2026 at 2:30 PM, the Director of Nursing (DON) stated the expectation on admission was for the skin assessment to be completed and all skin (to include feet) should be dealt with before a weekly skin assessment becomes due. The DON confirmed Resident #25 had not been provided with foot and nail care, had not been seen by the podiatrist and stated, .he should have been taken to Podiatry .

Based on facility policy review, observation, and interview, the facility failed to ensure 1 of 1 wound treatment carts, which contained topical medications and supplies, was locked and secured allowing unauthorized persons including residents, staff, and visitors access to the cart and the contents. The findings include: Review of the facility policy titled, Security of Medication Cart, dated 4/2007, revealed .the nurse must secure .the cart .to prevent unauthorized entry .the cart must be locked before entering a resident's room .carts must be securely locked at all times when out of the nurses view . During an observation on 4/13/2026 at 11:09 AM, in the East hallway, revealed a treatment cart unlocked and unattended against the wall. The cart doors were facing the opposite side of the hall and was accessible to unauthorized staff and visitors. During an interview on 4/13/2026 at 11:11 AM, the Wound Care Nurse (WCN) stated, .I know you just found the treatment cart unlocked. I have not been here since Friday . The WCN confirmed the cart was unlocked and was left unattended. During an observation on 4/15/2026 at 9:03 AM, the treatment cart was observed unlocked and unattended outside of the nurse's station adjacent to the North Hall. The cart doors were facing the nurse's station and was accessible to unauthorized staff and visitors. During an interview on 4/15/2026 at 9:08 AM, Licensed Practical Nurse (LPN) E approached the treatment cart and stated, .the cart is not to be unlocked. We [nursing staff] don't normally leave it open . During an interview on 4/15/2026 at 10:00 AM, the Director of Nursing stated, .the expectation is for all treatment and medication carts to be locked when unattended. The DON confirmed the treatment cart was unlocked and unattended and the contents were accessible to unauthorized staff or visitors.

Based on facility policy review, medical record review, and interview, the facility failed to develop a care plan for falls for 1 resident (Resident #3) of 4 residents reviewed for fall care plans. The findings include: Review of the facility's care plan policy last reviewed 5/2011 revealed .Plans of care will be developed that are .holistic .Care plans will establish goals and objectives specific to each need .Interventions will be listed and evaluated for effectiveness . Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including Repeated Falls, Muscle Weakness, and Difficulty in Walking, the resident discharged home with home health on 11/22/2023. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 scored a 14 on the Brief Interview of Mental Status (BIMS) assessment which indicated the resident was cognitively intact. The resident required assistance of 1 person with activities of daily living (ADL's). Review of a facility document titled, Fall Risk Evaluation, for Resident #3 dated 11/8/2023, revealed .if the total score is 10 or greater the resident should be considered at high risk for potential falls . Resident #3 scored a 10 on the evaluation which indicated the resident was at risk for falls. Review of the facility's fall investigation documentation for Resident #3 dated 11/10/2023 at 2:00 AM, revealed Resident #3 had an unwitnessed fall in his room. The resident had ambulated with a walker, on his own, to the bathroom. Upon return from the bathroom the resident's legs became wobbly, lost his balance, and fell on the walker receiving bruises to the right upper back and upper arm. The fall interventions in place prior to the fall included a yellow dot sticker on the outside of the residents room which alerted staff the resident was a fall risk, non-slip strips at the bedside, and bilateral bedrails. The intervention initiated after the fall was to encourage the resident to use his wheelchair to ambulate. Review of the care plan for Resident #3 dated 11/14/2023, revealed a care plan had not been developed to include the resident's risk for falls, did not include the resident had a fall on 11/10/2023, and the care plan had not been developed with any fall interventions. Review of the facility's fall investigation documentation for Resident #3 dated 11/15/2023 at 12:00 AM, revealed Resident #3 had an unwitnessed fall in his room while attempting to put clothes away. The resident stated he lost his balance and did not like to ask staff for help. Resident #3 received an abrasion the the left elbow. The new fall intervention included a reacher (device used for picking up objects) for the resident to use. Review of the care plan for Resident #3 revealed the care plan was not developed for falls with the fall interventions or risk of falls after the 11/15/2023 fall. During an interview on 6/3/2025 at 11:00 AM, the Administrator stated .no we did not put it on the care plan for falls it's not on there .the interventions were in place it just didn't get put on the care plan . The Administrator confirmed the facility failed to document Resident #3 was at risk for falls on the care plan and failed to develop a fall care plan to include the resident's fall interventions. During an interview on 6/4/2025 at 9:35 AM, the Physical Therapy Assistant Rehabilitation Director stated .I remember [Resident #3] he was a very tall man .I did get him a reacher for assistance with dressing .I got him a wheelchair and he had nonslip strips on the floor .he was alert and oriented and we educated him on the use of the call light and to ask for help .he had a walker and he used it but we told him it would be safter to use the wheelchair if he was doing any ambulation without us .the interventions for falls were in place .

Based on medical record review and interview, the facility failed to make a referral to the State-designated authority for a Level ll Pre-Admission Screening and Resident Review (PASARR) after newly identified serious mental disorders were diagnosed for 1 resident (#6) of 10 residents reviewed for PASARR. The findings include: Resident #6 was admitted to the facility on [DATE] with diagnoses including Dementia, Anxiety Disorder, Type 2 Diabetes Mellitus and History of Asthma. Continued review showed a diagnosis of Psychotic Disorder was added on 4/20/2023. Review of the most recent PASARR Level l Assessment for Resident #6 was completed on 12/16/2021. Continued review revealed a PASARR Level 2 Assessment was not completed for Resident #6, after the new diagnosis of Psychotic Disorder was added. During an interview on 8/1/2023 at 9:22 AM, the Minimum Data Set (MDS) Coordinator #1 and MDS Coordinator #2 confirmed Resident #6 was not referred to the State-designated authority for a PASARR Level 2 screening after the resident was diagnosed with a new serious mental health disorder.

Based on facility policy review, medical record review and interview, the facility failed to develop a care plan addressing Hospice for 1 Resident (#4) of 25 residents reviewed for care plans. The findings include: Review of the facility policy titled Care Plans dated 5/2011, showed, .Care plans will establish goals and objectives specific to each need . Resident #4 was admitted to the facility on [DATE] with diagnoses including Dementia, Chronic Obstructive Pulmonary Disease and Alzheimer's Disease. Continued record review of a Physician order dated 4/4/2023, showed, .Admit to .hospice for end stage senile degeneration of the brain . Review of a comprehensive care plan for Resident #4, initiated on 12/10/2020 and revised on 8/1/2023, showed a care plan had not been developed to address the hospice care and specific needs for Resident #4. During an interview on 8/2/2023 at 10:55 AM, the Minimum Data Set (MDS) Coordinator #1 and MDS Coordinator #2 confirmed a care plan had not been developed to address the hospice care and specific needs for Resident #4.

Based on review of facility policy, medical record review, review of facility investigation, and interview, the facility failed to report allegations of abuse to the State Survey Agency for 1 resident (#3) of 3 residents reviewed for abuse. The findings include: Review of the facility's abuse policy Abuse Investigation and reporting revised 12/2016 showed .All alleged violations involving abuse .will be reported by the facility Administrator, or his/her designee, to .The State Licensing/certification agency responsible for surveying/licensing the facility . Review of the medical record showed Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was discharged to the hospital on 1/6/2022. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] showed Resident #3's Brief Interview of Mental Status (BIMS) score was 99 indicating the resident had severe cognitive impairment. The resident required assistance of one or more persons with activities of daily living (ADL's). Review of facility investigation dated 1/6/2022 - 1/7/2022 showed .on 1/6/22 [Resident #3] had labs drawn which showed a critical sodium level .order was obtained to transfer resident to [hospital] for eval and treatment .while at [hospital] .revealed a left femur Fx (fracture) the IDT (Interdisciplinary Team) met to investigate this finding .it was confirmed that [Resident #3] did not have a fall or other incident while at COAH (Center on Aging and Health) . During a telephone interview on 2/14/2022 at 1:00 PM, [NAME] Administrator stated .we did an investigation but no I didn't report it to the state .

Based on review of facility policy, medical record review, review of fall investigation documentation, observation, and interview, the facility failed to implement the comprehensive care plan for falls for 1 resident (#48) of 3 residents reviewed for falls of 27 residents reviewed. The findings include: Review of the facility policy Interdisciplinary Team Care Plan, reviewed 5/2011, revealed .Interdisciplinary plans of care are developed, implemented, coordinated, and evaluated . Medical record review revealed Resident #48 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of a Fall Investigation dated 5/12/19 revealed Resident #48 had an unwitnessed fall out of bed without injury. Further review revealed the intervention put in place to prevent future falls was an evaluation by Occupational Therapy (OT). Medical record review of Resident #48's Quarterly Minimum (MDS) data set [DATE] revealed the resident was moderately cognitively impaired. Further review revealed the resident required the extensive assistance of 2 persons for transfer, bed mobility, and toileting. Medical record review of Resident #48's fall risk assessment dated [DATE] revealed a total score of 16 indicating the resident was a high risk for falls. Review of a Fall Investigation dated 6/2/19 revealed Resident #48 had an unwitnessed fall in the hallway outside his room without injury. Further review revealed the intervention put in place to prevent future falls was a medication adjustment. Medical record review of Resident #48's Annual Minimum (MDS) data set [DATE] revealed the resident was moderately cognitively impaired. Further review revealed the resident required the extensive assistance of 2 persons for transfer, bed mobility, and toileting. Medical record review of Resident #48's fall risk assessment dated [DATE] revealed a total score of 16, indicating the resident was a high risk for falls. Review of a Fall Investigation, dated 8/17/19, revealed Resident #48 had an unwitnessed fall in the bathroom in front of the toilet which resulted in a minor injury. Further review revealed the intervention put in place to prevent future falls was a .commode extender (a raised toilet seat) . Medial record review of Resident #48's current comprehensive care plan dated 12/1/17 and updated 8/19/19 revealed .(Resident #48) is at risk for falls .Low rider (type of chair) (with) Dysem (nonslip padding to prevent sliding) x 2 (2 pieces) .Add commode extender . Medical record review of Resident #48's Quarterly Minimum (MDS) data set [DATE] revealed the resident was moderately cognitively impaired. Further review revealed the resident required the extensive assistance of 2 persons for transfer, bed mobility, and toileting. Medical record review of Resident #48's fall risk assessment dated [DATE] revealed a total score of 13, indicating the resident was a high risk for falls. Observation of Resident #48's bathroom on 11/6/19 at 8:49 AM, in the resident's room revealed no commode extender on the resident's toilet. Interview with the Director of Nursing (DON) on 11/6/19 at 8:50 AM, in the hallway outside the resident's room, confirmed a commode extender was not in place. Observation of Resident #48 on 11/6/19 at 10:52 AM, near the Alzheimer's Unit activities/dining room, revealed the Dycem (non-slip material) x 2 (2 pieces) was not in place under the chair cushion or on top of the chair cushion in the resident's chair. Interview with the Quality Assurance (QA) nurse on 11/06/19 at 10:54 AM, near the Alzheimer's Unit activities/dining room, confirmed the Dysem x 2 was not in place to prevent the resident from sliding out of his chair. Interview with the DON on 11/06/19 at 11:26 AM, in the conference room, confirmed the facility failed to implement the resident's care planned interventions of commode extender to the resident's toilet and Dysem to the resident's chair.

Based on review of facility policy, medical record review, review of fall investigation documentation, observation, and interview, the facility failed to ensure fall interventions were in place to prevent future falls for 1 resident (#48) of 3 residents reviewed for falls. The findings include: Review of the facility policy Interdisciplinary Team Care Plan, reviewed 5/2011, revealed .Interdisciplinary plans of care are developed, implemented, coordinated, and evaluated . Medical record review revealed Resident #48 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of a Fall Investigation dated 5/12/19 revealed Resident #48 had an unwitnessed fall out of bed without injury. Further review revealed the intervention put in place to prevent future falls was an evaluation by Occupational Therapy (OT). Medical record review of Resident #48's Quarterly Minimum (MDS) data set [DATE] revealed the resident was moderately cognitively impaired. Further review revealed the resident required the extensive assistance of 2 persons for transfer, bed mobility, and toileting. Medical record review of Resident #48's fall risk assessment dated [DATE] revealed a total score of 16 indicating the resident was a high risk for falls. Review of a Fall Investigation dated 6/2/19 revealed Resident #48 had an unwitnessed fall in the hallway outside his room without injury. Further review revealed the intervention put in place to prevent future falls was a medication adjustment. Medical record review of Resident #48's Annual Minimum (MDS) data set [DATE] revealed the resident was moderately cognitively impaired. Further review revealed the resident required the extensive assistance of 2 persons for transfer, bed mobility, and toileting. Medical record review of Resident #48's fall risk assessment dated [DATE] revealed a total score of 16, indicating the resident was a high risk for falls. Review of a Fall Investigation dated 8/17/19 revealed Resident #48 had an unwitnessed fall in the bathroom in front of the toilet which resulted in a minor injury. Further review revealed the intervention put in place to prevent future falls was a .commode extender (a raised toilet seat) . Medial record review of Resident #48's current comprehensive care plan dated 12/1/17 and updated 8/19/19 revealed .(Resident #48) is at risk for falls .Low rider (type of chair) with Dysem (nonslip padding to prevent sliding) x 2 (2 pieces) .Add commode extender . Medical record review of Resident #48's Quarterly Minimum (MDS) data set [DATE] revealed the resident was moderately cognitively impaired. Further review revealed the resident required the extensive assistance of 2 persons for transfer, bed mobility, and toileting. Medical record review of Resident #48's fall risk assessment dated [DATE] revealed a total score of 13, indicating the resident was a high risk for falls. Observation of Resident #48's bathroom on 11/6/19 at 8:49 AM, in the resident's room revealed no commode extender on the resident's toilet. Interview with the Director of Nursing (DON) on 11/6/19 at 8:50 AM, in the hallway outside the resident's room, confirmed a commode extender was not in place. Observation of Resident #48 on 11/6/19 at 10:52 AM, near the Alzheimer's Unit activities/dining room, revealed the Dycem (non-slip material) x 2 (2 pieces) was not in place under the chair cushion or on top of the chair cushion. Interview with the Quality Assurance (QA) nurse on 11/06/19 at 10:54 AM, near the Alzheimer's Unit activities/dining room, confirmed the Dysem x 2 was not in place to prevent the resident from sliding out of his chair. Interview with the DON, on 11/6/19 at 11:26 AM, in the conference room, confirmed Resident #48 had 3 falls in the past 6 months, confirmed Resident #48 was identified as a high risk for future falls, and confirmed the facility failed to ensure the resident's commode extender and Dysem to chair was in place to prevent future falls.

Based on observation and interview, the facility failed to ensure posted staffing was correct for 1 of 1 observations made. The findings included: Observation on 1/27/19 at 10:30 AM, on the main hallway, revealed the posted facility staffing was dated 1/18/19 (10 days earlier). Interview with the Nursing Supervisor on 1/27/19 at 10:45 AM, on the main hallway, confirmed the posted staffing was incorrect for the current date.

Based on medical record review, observation, and interview the facility failed to ensure a resident's care was supervised by a Physician for the delivery of Oxygen for 1 resident (#16) of 37 residents reviewed. The findings include: Medical record review revealed Resident #16 was admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Nurses Note dated 6/13/18 at 6:40 PM, revealed, Resident arrived @ (at) 6:00 PM via EMS (emergency medical service). A&O (alert and oriented) X 3 .Resident is on O2 (Oxygen) 2 LPM (liters per minute) via NC (nasal cannula) .Resp (respiration) even and unlabored . Observation on 9/24/18 at 10:00 AM, in the resident's room, revealed Resident #16 receiving oxygen at 2 LPM via NC Continued observations throughout the survey beginning on 9/24/18 through 9/26/18 revealed Resident #16 resident receiving O2 at 2 LPM via NC. Medical record review of the Physicians Recapitulation orders for (MONTH) (YEAR) revealed no documentation of a physician's orders [REDACTED]. Interview with the Director of Nursing on 9/26/18 at 2:02 PM, at the South Wing nurse's station, confirmed the resident was readmitted to the facility on [DATE] and did not have an order for [REDACTED].>

Based on facility policy review, medical record review, review of facility investigation, and interview, the facility failed to report an allegation of abuse timely to the State Survey Agency for 1 resident (#1) of 3 residents reviewed for abuse of 12 sampled residents. The findings included: Review of facility policy Abuse Investigation and Reporting dated 12/2016, revealed .All reports of resident abuse, neglect, exploitation, and/or misappropriation of resident property shall be promptly reported to local, state and federal agencies .Policy Interpretation and Implementation .Reporting .1. All alleged violations involving abuse, neglect, exploitation, or misappropriation of property will be reported by the facility Administrator .to the following persons or agencies .a. The State licensing/certification agency responsible for surveying/licensing the facility .will be reported within two hours . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the care plan for Resident #1 dated 3/7/16 revealed the resident was care planned for impaired thought processes, delusions, and hallucinations. Further review revealed the resident was socially inappropriate, had disruptive behavior verbalizations, and made statements related to delusions and accusatory statements of sexual aggressive nature toward staff, family, and others. Medical record review of the resident's Minimum Data Set ((MDS) dated [DATE] revealed the resident scored an 8/15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS). Review of a facility investigation dated 5/17/18 revealed the resident reported she had been raped by her brother while in the facility. Continue review revealed the resident stated .I was raped every time I go to the bathroom for the last [AGE] years . Further review revealed the resident was sent to the Emergency Department (ED) for a pelvic exam. Continued review revealed the Social Services Director (SSD) notified the Power of Attorney (POA) of the allegation and the POA stated the resident had been a long history of allegations of abuse toward various family members. Interview with the Administrator on 6/4/18 at 3:40 PM, in the Conference Room, revealed the facility reported the incident to the State Survey Agency on 5/22/18 (5 days later). Further interview confirmed the facility failed to report an allegation of abuse within 2 hours.

Based on facility policy review, facility [MEDICAL TREATMENT] agreement, medical record review, and interview the facility failed to ensure a physicians order was followed for one resident (# 60) and failed to ensure communication with a outside agency occurred for one resident (# 96) of 19 residents reviewed during stage 2 of the survey. The findings included: Medical record review revealed Resident #60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility policy Physician Orders, dated 5/2011, revealed, .ensure .physician's orders .carried out . Medical record review of the Physician's Telephone Order dated 5/30/17, revealed, .(change) daily wts (weights) to wkly (weekly ) wts . Medical record review of Daily Weights for June 2017 revealed, .Freq: (frequency) Weekly . Continued review revealed no documentation of Resident #60's weights for the month of June. Interview with the Director of Nursing, on 9/20/17, at 10:37 AM, in the conference room, confirmed the facility failed to follow their policy on physician orders by not obtaining weekly weights for Resident #60 during the month of June 2017. Medical record review revealed Resident #96 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the .[MEDICAL TREATMENT] Services Agreement . start date 1/21/02 revealed .2. Written Protocol .The Nursing Facility will provide for the interchange of information useful or necessary for the resident . Medical record review of the resident plan of care dated 8/7/17 revealed .Resident is at risk for complications due to End Stage [MEDICAL CONDITION] and [MEDICAL TREATMENT] therapy . Interview with the Director of Nursing (DON) on 9/21/17 at 8:40 AM, at the west wing nurse's station, revealed the DON stated ( .I have tried to get communication (between the [MEDICAL TREATMENT] center and facility) .have talked to 5 different people at the [MEDICAL TREATMENT] center .) Interview with the DON confirmed the facility failed to ensure communication between the [MEDICAL TREATMENT] center and the facility.

Based on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, medical record review and interview, the facility failed to conduct an accurate MDS assessment for 1 resident (#27) of 24 residents reviewed. The findings included: Medical record review of the MDS 3.0 RAI Manual, dated 5/13, revealed .review the medical record, speak with the treatment nurse and direct care staff .examine the resident and determine if any ulcers .present . Medical record review revealed Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed Resident #27 was placed on Hospice care on 12/23/15. Medical record review of the Wound Assessment Report dated 3/1/16 revealed .Date wound identified, 3/1/16 . Medical record review of the Quarterly MDS assessment dated [DATE], of Section M, Skin Conditions revealed 0(zero) no unhealed pressure ulcers. Continued review revealed no documentation of a pressure ulcer on the MDS. Medical record review of the Daily Progress notes dated 7/20/16 revealed .sacral wound stage IV (4) . Medical record review of the Daily Progress notes dated 9/19/16 revealed .nursing following pressure wound . Interview with the MDS Assistant Coordinator on 9/27/16 at 2:15 PM in the MDS office confirmed she was not aware Resident #27 had a stage 4 pressure ulcer to her right buttock. Interview with the Director of Nursing on 9/27/16 at 3:35 PM at the West Nursing Station, confirmed the facility had failed to accurately assess Resident #27 for the presence of pressure ulcers on the 9/18/16 MDS assessment.

Based on observation and interview, the facility failed to maintain an effective pest control program for the prevention of flies for 1 room of 16 rooms on the South hallway, of 4 hallways of the East Wing of the facility. The findings included: Observation and interview in the shared room of Resident #2 and Resident #37 on 9/26/16 at 10:30 AM, revealed flies in the room located on the South hallway of the East wing. During interview with Resident #37 and family members of Resident #37, it was reported the flies were coming in from frequent door openings. Family members reported a problem with flies coming in from the South hallway door located next to the resident's room. Continued observation during the interviews revealed Resident #2 and Resident #37 with fly swatters connected to their wheelchairs. Observation on 9/27/16 from 10:40 AM to 10:50 AM, revealed 4 staff members entering and exiting the South door, located next to the shared room of Resident #2 and Resident #37. Interview with Resident #2 on 9/27/16 at 12:30 PM, in the residents' room, revealed flies are in here all the time. Continued interview revealed the family members of Resident #2 and Resident #37 brought them in the fly swatters. Interview with Resident #37 at the same time revealed I don't ever want to be without it. Observation and interview with Resident #2 and Resident #37 on 9/27/16 at 12:30 PM, in the residents' room, revealed 4 flies in the residents' room. Interview with Resident #2 revealed, employees exit the building to go eat lunch in their picnic areas located outside the South hallway door. Observation on 9/27/16 at 12:37 PM, revealed flies were outside the residents' room next to the South hallway door. Observation on 9/27/16 at 2:30 PM, revealed a staff member transporting a trash can in through the South hall door. Observation on 9/28/16 at 7:45 AM, revealed two flies in Resident #2 and #37's room. Interview with Certified Nursing Assistant (CNA) #1 on 9/27/16 at 12:42 PM, on the South hallway of the East wing, confirmed employees used the South hallway frequently to enter and exit building to take out trash. Continued interview with CNA #1 revealed family members often used the door and the residents used it for smoking breaks. Interview with Licensed Practical Nurse (LPN) #1, on 9/28/16 at 8:28 AM, on the South hallway of the East wing, confirmed previous observation of flies in Resident #2 and #37's room. Interview with CNA #2 on 9/28/16 at 8:49 AM, on the South hallway of the East wing, confirmed there were flies in the residents' room and the South door was frequently used by staff, residents, and visitors. Interview with the Housekeeper #1 on 9/28/16 at 9:34 AM, on the South hallway of the East wing outside of Resident #2 and #37's room, confirmed history of flies in the residents' room. Further interview revealed housekeeping had recently been instructed to strip the beds and disinfect the mattresses. Interview with the Administrator on 9/28/16 at 9:40 AM, in the South hallway, confirmed he was aware of flies in Resident #2 and Resident #37's room.

Based on observation and interview the facility failed to sanitize or wash the hands while serving meals for 1 of 3 dining observations and failed to maintain a sanitary environment during incontinence care before a dressing change for 1 resident (#317) of 4 residents reviewed for pressure ulcers and urinary catheter use. The findings included: Observation in the main dining room on 9/28/15 at 12:30 PM revealed Certified Nursing Assistant (CNA) #1 preparing residents food trays. Further observation revealed the CNA placed two packages of sugar in the resident's coffee cup, threw the packages of sugar in the trash can by lifting the lid off of the garbage can, then stirred the sugar in the resident's coffee cup and served the coffee to the resident. Further observation revealed the CNA failed to wash or sanitize the hands after touching the dirty trash can and lid prior to serving the coffee to the resident. Interview with CNA #1 on 9/28/15 at 12:35 PM, in the dining room, confirmed the CNA failed to wash or sanitize the hands after touching the dirty trash can and prior to serving the coffee to the resident. Interview with the Director of Nursing (DON) on 9/28/15 at 12:45 PM, in the dining room hallway, confirmed the CNA failed to follow hand hygeine practices. Medical record review revealed Resident #317 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Significant Change Minimum Data Set ((MDS) dated [DATE] revealed the resident was cognitively impaired and required extensive assistance with activities of daily living. Observation on 9/30/15 at 10:45 AM, in the resident's room, revealed CNA #2 and CNA #3 providing incontinence care for the resident. Continued observation revealed CNA #2 took the soiled cloth incontinence pad from underneath the resident and placed the soiled incontinence pad in the clean chair on top of a clean pillow. Further observation revealed after the incontinence care was completed, CNA #2 took the soiled incontinence pad off the pillow, placed the pillow underneath the resident's legs where the resident's urinary catheter was located, and placed the soiled incontinence pad in the resident's chair. Interview with CNA #1 on 9/30/15 at 10:55 AM, in the resident's room, confirmed the contaminated incontinence pad was placed on a clean pillow in the resident's chair. Further interview confirmed the CNA used the same contaminated pillow underneath the resident's legs where the urinary catheter was located and then placed the contaminated incontinence pad in the resident's chair. Interview with the DON on 9/30/15 at 11:05 AM, in the conference room, confirmed the CNA failed to follow infection control practices.

Based on medical record review, review of facility investigations, and interview, the facility failed to provide supervision to prevent a fall for one resulting in a left femur fracture and HARM for one resident (#72) of four residents reviewed for accidents, of twenty-eight residents reviewed. The findings included: Resident #72 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set (MDS) dated [DATE], revealed resident #72 had a Brief Interview for Mental Status (BIMS) of 15 (15 over 15 indicated the resident was cognitively intact). Further medical record review revealed the resident had no history of falls prior to admission to the facility. Continued medical record review revealed on surface-to surface transfer (transfer between bed and chair or wheelchair), moving from a seated to standing position, and walking (with an assistive device if used) the resident was not steady and only able to stabilize with human assistance. Further review revealed mobility devices used by the resident were a walker and a wheelchair. Medical record review of the Falls Risk assessment dated [DATE], revealed a falls risk score of 6 (total score of 10 or above represents high risk). Medical record review of the care plan dated February 28, 2014, revealed the resident was care planned for "Potential for fracture" and "Resident is at risk for falls." Medical record review of the Nursing Interdisciplinary Progress Note dated February 10, 2014, at 1:00 p.m., revealed "...uses w/c (wheelchair) for mobility with 1 person assist for transfers and ADL's (activities of daily living). PT (physical therapy) / OT (occupational therapy) continues at time...Res (resident) with weakness et (and) unsteady gait..." Medical record review of the Nursing Interdisciplinary Progress Notes dated February 10, 2014, at 2:30 p.m., revealed "...Res (resident) in therapy this am (morning). Physical therapy stated res was using walker et...(resident) turned to sit et missed the edge of the chair et sat on the floor...(Doctor) aware n/o (new order) received for x ray. Family here et aware..." Medical record review of Telephone Orders dated February 10, 2014, revealed "...Xray bilat (bilateral) knees fall during therapy increased pain bilat knees..." Medical record review of the Final X-ray Report dated February 10, 2014, revealed "...Acute fracture of the distal femoral metaphysis just above the femoral prosthetic knee component..." Medical record review of the Nursing Interdisciplinary Progress Notes dated February 10, 2014, at 5:00 p.m., revealed "...x ray back...(doctor)...aware n.o.(new orders) received to send res to ortho (orthopedic). N.O (new order) for Lortab (pain medication) 5-10 mg (milligrams) PO (by mouth) Q4h (every 4 hours) prn for pain. App (appointment) to ortho to made 2/11/14..." Medical record review of the Nursing Interdisciplinary Progress Notes dated February 10, 2014 at 9:05 p.m., revealed "...res lying in bed at this time. No s/s (signs or symptoms) of distress...n/o to make apt r/t (related to) fracture...able to voice needs as arise..." Medical record review of the Discharge report dated February 14, 2014 revealed "...Resident transported to...(the hospital)...eval (evaluation) and tx (treatment) of L (left) knee fracture. Transported by EMS (emergency medical services) at 12:30pm..." Medical record review of Weekly Progress Note by PT dated February 5, 2014, revealed "...Patient presents with increased fatigue this day. Nursing notified. Increased difficulty with static standing balance. Unable to ambulate pushing wheelchair. Decreased safety with transfers requiring more assistance for proper completion. Ambulate with rw (rolling walker) min (minimum) to mod (moderate) a (assist) secondary to fatigue and difficulty completing task..." Medical record review of a Weekly Progress Note by PT dated February 10, 2014, revealed "...Weekly Summary continues to demonstrate safety deficits with stand to sit transfers. This resulted in fall. Nursing aware. Patient continue to demonstrate ROM (range of motion) within normal limits..." Review of the facility fall investigation dated February 10, 2014, revealed there was no apparent injury to the resident. Further review revealed the Rehabilitation Director was the witness present at the time of the fall. Continued review revealed the resident was in the PT room at time of fall. The resident went to sit in chair and missed the edge of the chair and sat in floor. The Resident was still holding on to walker at the time of fall. Interview with the Rehabilitation Director in the conference room on July 9, 2014 at 2:56 p.m., confirmed the Rehabilitation Director had failed to ensure one person assistance was provided for teh residnet while transferring to a chair resulting in a fracture and Harm. Continued interview with the Rehabilitation Director stated "...I glanced away...and (resident) fell . I wish I hadn't looked away..."

Based on observation, review of facility policy, and interview, the facility failed to follow guidelines to prevent the spread of infection for twenty-five out of ninety-five residents in one of one dining room. The findings included: Observation on July 7, 2014, at 12:20 p.m., in the dining room during lunch service revealed a clear ice bucket filled with ice cubes. Continued observation revealed an ice scoop in the ice. Observation on July 7, 2014, at 12:31 p.m., in the dining room during lunch service revealed an office administrative staffer entered the dining room with a personal water container, and without washing the hands reached for the scoop in the ice, filled the container with ice, replaced the scoop in the ice bucket, and exited the dining room. Continued observation at 12:40 p.m. revealed a volunteer picked up a resident's empty ice tea glass, and without washing the hands reached for the scoop in the ice, filled the glass with ice, replaced the scoop in the bucket, placed the glass on the table for the resident, and sat down with other residents. Further observation at 12:41 p.m. revealed a Certified Nursing Assistant (CNA #1), entered the dining room and without washing the hands, reached into the ice bucket, picked up the scoop out of the ice, filled up the glass with ice, returned the scoop to the ice bucket, and exited the room. Review of facility policy, Handwashing/Hand Hygiene, revised April 2012 revealed, "...washing hands...before and after direct resident contact...handling food...assisting a resident with meals..." Review of Volunteer Guidelines, not dated, revealed "...after each interaction with a resident you must wash hands..." Interview with the Office Administrative Staffer on July 7, 2014, at 12:31 p.m., in the hallway confirmed not washing the hands before using the ice scoop and returning the scoop to the ice filled bucket. Interview with the Volunteer on July 7, 2014, at 12:40 p.m., in the dining room, confirmed not washing the hands before using the ice scoop and returning the scoop to the ice filled bucket. Interview with the CNA #1 on July 7, 2014, at 12:41 p.m., in the hallway, confirmed not washing the hands before using the ice scoop and returning the scoop to the ice filled bucket. Interview with the Director of Nursing on July 7, 2014, at 12:45 p.m., in the dining room, confirmed the Office Staffer, Volunteer, and CNA #1 failed to follow the handwashing policy and confirmed the scoop was not to be left in the ice bucket.

Based on medical record review, review of manufacturer's recommendations, review of the Nursing 2012 Drug Handbook, the facility investigation, review of a pharmacy drug interaction document, review of hospital records, review of facility policy, observation and interview, the facility failed to follow accepted standards of practice to hold [MEDICATION NAME] (a blood thinning medication) and administer Vitamin K (to counteract blood thinning medication) for one (#2); failed to identify likely medication interaction prior to the administration of antibiotics (known to increase the blood clotting time with [MEDICATION NAME]) or obtain more frequent monitoring of blood thinner levels and failed to administer the correct dose of [MEDICATION NAME] and failed to administer [MEDICATION NAME] for one (#13); to obtain blood thinner levels as ordered by the physician for one (#22); and failed to administer [MEDICATION NAME] per physician's orders for twelve (#6, #14, #15, #16, #17, #18, #19, #20, #21, #23, #24 and #25); to train and educate staff of the potential medication interactions between [MEDICATION NAME] and antibiotics; and to ensure a process was in place to assist staff in the identification of potential life-threatening medication interactions with [MEDICATION NAME] of fifteen residents reviewed who were receiving [MEDICATION NAME]. The facility's failure has caused or is likely to cause serious injury, harm, impairment or death to residents #2, #13, #22, #6, #14, #15, #16, #17, #18, #19, #20, #21, #23, #24 and #25. The Administrator and the Director of Nursing were informed of the Immediate Jeopardy in the training room on August 6, 2012 at 11:30 a.m. The Immediate Jeopardy was effective January 18, 2012 and is ongoing. A partial extended survey was conducted on August 6, 2012. The findings included: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the manufacturer's recommendations for the in-house blood thinner monitoring system revealed "...The American College of Chest Physicians makes these recommendations regarding INR (International Normalized Ratio (INR-measures the time it takes for blood to clot and compares it to an average) for patients on anticoagulant therapy:...treatment of [REDACTED]. Review of a hospital consultation dated December 14, 2011 revealed "...history of chronic [MEDICAL CONDITION] Fibrillation...was on aspirin therapy for her [MEDICAL CONDITION] Fibrillation...PAST MEDICAL HISTORY: Includes a recent fall with a recent Subdural Hematoma that was cared for at (hospital) approximately three months prior, Hypertension and chronic [MEDICAL CONDITION] Fibrillation...ASSESSMENT...Left hemispheric...ischemic Stroke, most likely cardioembolic secondary to [MEDICAL CONDITION] Fibrillation, not on anticoagulant (blood thinner), presenting with global [MEDICAL CONDITION] (absence or impairment of speech) and right [MEDICAL CONDITIONS] previously with rapid ventricular rate...was taken off anticoagulation approximately a year ago for uncertain reasons...Recent (approximately two months ago) traumatic [MEDICAL CONDITION], probably a right Subdural Hematoma...Recommend [MEDICATION NAME] with aspirin bridge for now until a better assessment of how (resident) will do can be made..." Review of a second consultation dated December 14, 2011 revealed "...Would be very cautious with long-term anticoagulation..." Medical record review of the physician's progress note dated December 26, 2011 revealed "...embolic (blood clot) [MEDICAL CONDITION]-[MEDICATION NAME] rec (recommended) by Neurology...Cont. (Continue) [MEDICATION NAME] but watch carefully." Medical record review of the facility's admission orders [MEDICATION NAME] 2 mg (milligrams) PO (by mouth) QD (every day)...PT ([MEDICATION NAME] Time-blood test that measures the time it takes blood to clot)/INR 12-27-11." Medical record review of a laboratory result dated December 27, 2012 revealed PT 24.6/INR 2.5 (therapeutic). Medical record review of a physician's order dated December 27, 2012 revealed the same dose of [MEDICATION NAME] was continued (2 mg daily) and PT/INR on December 30, 2012. Medical record review of a laboratory result dated December 30, 2012 revealed PT 27.9/INR 2.8 (therapeutic). Medical record review of a physician's order dated December 30, 2012 revealed the same dose of [MEDICATION NAME] was continued and PT/INR on January 6, 2012. Medical record review of a laboratory result dated January 6, 2012 revealed PT 18.8/INR 1.9 (low). Medical record review revealed a physician's order could not be located on the medical record. Medical record review of a document entitled "Physician Contacts" provided by the Administrator on August 3, 2012 revealed on January 6, 2012 [MEDICATION NAME] was increased to 3 mg daily and PT/INR on January 10, 2012. Medical record review of a laboratory result dated January 10, 2012 revealed PT 12.8/INR 1.3 (low). Medical record review of a physician's order dated January 10, 2012 revealed the [MEDICATION NAME] was increased to 4 mg daily and PT/INR on January 13, 2012. Medical record review of a laboratory result dated January 13, 2012 revealed PT 44.2 (reference range 9.5-11.1) and INR 4.4 (high). Medical record review of the physician's order dated January 13, 2012 revealed "Hold [MEDICATION NAME] until new orders received. Recheck INR on 01-16-12." Medical record review of a laboratory report dated January 16, 2012 revealed INR 3.8 (high). Medical record of the physician's order dated January 16, 2012 revealed "Hold ([MEDICATION NAME]). PT/INR 1/18/12." Medical record review of the Medication Administration Record (MAR) dated January 1-31, 2012 revealed [MEDICATION NAME] was held as ordered on January 16, 17 and 18, 2012. Medical record review revealed no documentation of laboratory results dated [DATE] and no physician's order for [MEDICATION NAME] dated January 18, 2012. Medical record review of the MAR dated January 1-31, 2012 revealed [MEDICATION NAME] 4 mg was resumed on January 19, 2012 without a physician's order and administered January 19, 20, 21, 22, 23 and 24, 2012. Medical record review of a laboratory result dated January 25, 2012 revealed PT-46.3/INR 4.6 (high). Continued review revealed the results of a PT/INR obtained on January 18, 2012 was recorded on the January 25, 2012 results and revealed PT 37.8/INR 3.8 (high) on January 18, 2012. Medical record review of a physician's order dated January 25, 2012 revealed "Hold [MEDICATION NAME]. (Check) PT/INR on 1/26/12." Medical record review of a laboratory result dated January 26, 2012 revealed PT-65/INR 6.2 (high) and repeat the PT/INR on January 27, 2012. Medical record review of the physician's order dated January 26, 2012 revealed "...Hold ([MEDICATION NAME])-was not held as ordered 1-18-2012 (no order). Vitamin K 1 mg PO x (times) 1...1st (first) dose STAT (as soon as possible). PT/INR in AM (a.m.)" Medical record review of the MAR dated January 1-31, 2012 revealed the Vitamin K was not administered until January 27, 2012. Medical record review of a physician's progress note dated January 26, 2012 revealed "...Supratherapeutic (higher than a therapeutic level) INR-INR 6.8...1 mg Vit (Vitamin) [MEDICATION NAME] was ordered to be held since 1-18-2012 but pt...receiving 4 mg [MEDICATION NAME] QD..." Medical record review of a laboratory result dated January 27, 2012 revealed PT-63.0/INR 6.3 (high). Medical record review of the physician's order dated January 27, 2012 revealed "...DC (Discontinue) [MEDICATION NAME]/INR 1/30/12." Medical record review of a laboratory result dated January 30, 2012 revealed PT 19.1/INR 1.9 (low). Medical record review of a physician's progress note dated January 27, 2012 revealed "...hold [MEDICATION NAME]. [MEDICATION NAME] restart next wk (week) vs (versus) [MEDICATION NAME] (blood thinner) if difficult to control INR..." Medical record review of a physician's progress note dated January 31, 2012 revealed "A fib ([MEDICAL CONDITION] Fibrillation) on [MEDICATION NAME], INR labile (rapidly shifting) and having difficulty keeping therapeutic..." Medical record review of a physician's order dated January 31, 2012 revealed "DC [MEDICATION NAME]. Daily PT/INR. When INR falls below 2.0, start [MEDICATION NAME] 110 mg p.o. BID. Medical record review of a laboratory result dated February 1, 2012 revealed INR 1.2 (low). Medical record review of a physician's order dated February 2, 2012 revealed "[MEDICATION NAME] 75 mg po bid." Review of the facility's policy for medication administration revealed "Medication will be given in accordance with physician order...All meds will be given in accordance with facility policy...Follow manufacturer's guidelines for giving medications..." Interview on July 18, 2012 at 9:10 a.m. in the training room with Licensed Practical Nurse (LPN) #1 revealed responsibilities of LPN #1 included the following Monday through Friday: perform wound care for all residents with wounds; obtain PT/INRs using the facility's in-house PT/INR machine for all residents receiving [MEDICATION NAME]-six to eight per day; prepare physicians' orders related to [MEDICATION NAME]; fax new [MEDICATION NAME] orders to the facility's pharmacy; and transcribe orders for [MEDICATION NAME] to the Medication Administration Records for all residents receiving [MEDICATION NAME]. Continued interview with LPN #1 revealed LPN #1 assumed the above responsibilities in March 2012 for residents receiving [MEDICATION NAME] and prior to March 2012 "night shift (nurses) was responsible" to obtain PT/INRs and LPN #1 "addressed them when I came in (day shift)." Telephone interview on July 18, 2012 at 2:45 p.m. with the Nurse Practitioner (NP #2) who was managing the resident's [MEDICATION NAME] dosage based on the PT/INRs confirmed the NP was notified on January 16, 2012 the INR was 3.8. The NP ordered the [MEDICATION NAME] held and the INR rechecked on January 18, 2012. Continued interview confirmed the INR on January 18, 2012 remained elevated at 3.8; however the facility failed to notify the NP or the physician of the elevated INR. Continued interview confirmed the facility administered [MEDICATION NAME] 4 mg daily from January 19-25, 2012 without physician's orders. An INR was done on January 25, 2012 with results reported as 4.6. An order was given to hold the [MEDICATION NAME] and recheck the INR on January 26, 2012. The INR on January 26, 2012 was 6.8. Continued interview revealed "That's when I discovered (resident) had been given [MEDICATION NAME]" daily January 19-25. Continued interview confirmed on January 26, 2012 NP #2 gave an order for [REDACTED]. The NP stated, "I wrote it stat because there had been problems with [MEDICATION NAME] being given." Continued interview confirmed the Vitamin K was not administered until January 27, 2012-eighteen hours after the order was written. The INR returned to a therapeutic range on January 27, 2012 after the Vitamin K was administered. Continued interview confirmed the resident was at "huge risk for head bleed and Stroke" if the resident had fallen and at risk for [MEDICAL CONDITION] with a "high INR like 6.8." Continued interview confirmed the resident was switched to [MEDICATION NAME] "when it happened." Continued interview confirmed the facility "never should have not called me with the high INR;" gave [MEDICATION NAME] after it was ordered to be held; and failed to administer the Vitamin K for eighteen hours. Interview on July 19, 2012 at 10:50 a.m. in the training room with NP #1 confirmed the therapeutic range of the INR for a resident with [MEDICAL CONDITION] Fibrillation was "2 (2.0) to 3 (3.0)." Medical record review and interview on July 19, 2012 at 3:30 p.m. in the training room with the Administrator (Registered Nurse) confirmed the Administrator knew the INR for January 18, 2012 was done because the results were recorded on the laboratory report dated January 25, 2012. Continued interview confirmed on laboratory reports, the facility recorded the previous INR and current [MEDICATION NAME] dosage for the physician's review. Continued interview confirmed the physician was not notified of the elevated INR of 3.8 on January 18, 2012. Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a nurse's note dated January 26, 2012 revealed "...left calf swollen, tight, hot to touch...(no) redness. (Physician) notified." Medical record review of a Doppler scan of the left leg dated January 27, 2012 revealed "...Extensive occlusive [MEDICAL CONDITIONS] is noted within left external iliac vein, left common femoral vein, left greater saphenous vein, left proximal femoral vein, left mid femoral vein, left distal femoral vein, left popliteal vein, left posterior tibial vein, left peroneal vein, and left anterior tibial vein..." Medical record review of a physician's order dated January 27, 2012 revealed, "[MEDICATION NAME] 3 mg daily. Check PT/INR 1/30/12." Medical record review of a laboratory result dated January 30, 2012 revealed PT 10.2/INR 1.0 (low). Medical record review of a laboratory result dated March 9, 2012 revealed PT 24.2/INR 2.4. Medical record review of a physician's order dated March 9, 2012 revealed [MEDICATION NAME] was continued at 4 mg daily (as ordered on March 2, 2012) and "re check PT/INR in 2 weeks." Medical record review of a change in condition form dated March 11, 2012 revealed "Abnormal UA (urinalysis) results." Medical record review of a physician's order dated March 11, 2012 revealed Bactrim DS (antibiotic) q (every) 12 hr (hours) x (times) 10 days." Medical record review of the Medication Administration Record (MAR) dated March 1-31, 2012 revealed Bactrim DS was administered every twelve hours March 11-21, 2012 (20 doses). Review of the Nursing 2012 Drug Handbook revealed Bactrim DS "...May increase anticoagulant effect. Monitor patient for bleeding; monitor PT and INR. Continued review revealed [MEDICATION NAME] ([MEDICATION NAME]) "...can cause major or fatal bleeding...Consider more frequent INR monitoring in those at high risk for bleeding..." Medical record review revealed the PT/INR was not checked from March 9, 2012 until March 23, 2012. Medical record review of the laboratory results dated [DATE] revealed PT 58.3/INR 5.8 (high). Medical record review of a physician's order dated March 23, 2012 revealed "Hold [MEDICATION NAME] til (until) 3/26...PT/INR on 3/27." Medical record review of laboratory results dated [DATE] revealed PT 31.8/INR 3.2 (high). Medical record review of a physician's order dated March 26, 2012 at 5:00 p.m. revealed "Hold [MEDICATION NAME] today (3-26-12. Re-start [MEDICATION NAME] 3 mg on (3-27-12)...PT/INR on Fri. (Friday) (3-30-12)." Medical record review of laboratory results dated [DATE] revealed PT 17.4/INR 1.7 (low). Medical record review of a physician's order dated March 30, 2012 revealed "Cont (Continue) same dose (3 mg daily)...(PT/INR) on 4/27/12." Interview on July 25, 2012 at 8:20 a.m. in the training room with NP #1 confirmed Bactrim DS was started on March 11, 2012 and confirmed a PT/INR was not obtained until March 23, 2012 (twelve days after Bactrim DS was ordered). Continued interview confirmed the INR obtained on March 23, 2012 was "high" and the resident "could bleed" with a high INR. Continued interview confirmed the INR "should be checked every other day when on Bactrim DS and [MEDICATION NAME] and it was not done." Continued interview revealed the facility had a process in place to monitor the INR more frequently when a resident was on [MEDICATION NAME] and started on an antibiotic. Interview (with NP #1 present) on July 25, 2012 at 8:30 a.m. in the training room with LPN #1 confirmed the INR was not checked between March 9 and 23, 2012 while the resident was receiving Bactrim DS. Continued interview confirmed the facility had no process in place to inform or remind the physician a resident was receiving [MEDICATION NAME] when Bactrim DS or other antibiotics which could raise the INR level were ordered. Continued interview confirmed LPN #1 had no knowledge if the pharmacy provided an alert notice of potential interactions when the physician ordered an antibiotic for residents who were receiving [MEDICATION NAME]. Interview on July 25, 2012 at 8:40 a.m. in the training room with NP #1 revealed NP #1 "thought" the facility had a process in place to obtain an INR every two days for a resident on [MEDICATION NAME] who was started on an antibiotic. Continued interview confirmed the therapeutic range of the INR for a resident with a [MEDICAL CONDITION] was 2.0-3.0 and NP #1 "try to keep it around 2.0...never know when an elderly patient may have a bleed. It's easier to deal with a [MEDICAL CONDITION] than a bleed." Telephone interview with the facility's pharmacy provider on July 31, 2012 at 8:20 a.m. revealed when an antibiotic was ordered for a resident receiving [MEDICATION NAME], the pharmacist received a "pop up" in the pharmacy's computer system which noted the potential interaction between [MEDICATION NAME] and the antibiotic; the pharmacist printed the "interaction sheet"; and provided the interaction sheet to the facility when the medication was delivered. Review of a sample document for potential "Drug/Drug Interactions" provided by the pharmacy after the interview revealed the sample alert included the potential for interaction between [MEDICATION NAME] and an antibiotic, onset of the potential interaction, the risk of bleeding and the extent of the potential interactions. Telephone interview on July 31, 2012 at 8:40 a.m. with the physician of resident #13/Medical Director revealed "I think they (facility) have a protocol" if a resident was receiving [MEDICATION NAME] and placed on an antibiotic, an INR was obtained every three days. Continued interview confirmed "try not to exceed 3.0 (INR)...need protocol in place...INR of 5.8 is not good." Continued interview confirmed a high (supra-therapeutic) INR placed the resident at risk for bleeding. Interview on July 31, 2012 at 9:45 a.m. on the South hall with LPN #3 revealed the pharmacy sent a list of "adverse reactions" when a resident was placed on an antibiotic and was receiving [MEDICATION NAME]. Review of the MAR and interview with LPN #3 confirmed the MAR did not include a list of medications that could potentially interact with [MEDICATION NAME] and stated, "It would help" to have a list. Review of the MAR and interview on July 31, 2012 at 10:50 a.m. on the West hall with LPN #10 confirmed the facility did not provide a list of medications that could potentially interact with [MEDICATION NAME]. Interview on July 31, 2012 at 10:55 a.m. on the East wing with LPN #11 confirmed the facility did not provide a list of medications that could potentially interact with [MEDICATION NAME]. Telephone interview on August 2, 2012 at 7:30 a.m. with NP #3 confirmed for a resident with a "new" [MEDICAL CONDITION] or [MEDICAL CONDITION] (PE-blood clot in the lung) the desired INR was 2.5-3.5 and for an "old" [MEDICAL CONDITION] or PE the desired INR was 2.0-3.0. Continued medical record review for resident #13 of the MAR dated April 1-31, 2012 revealed [MEDICATION NAME] 3 mg (daily) was not administered on April 11 or 22, 2012. Interview on July 24, 2012 at 2:10 p.m. in the training room with LPN #1 confirmed no evidence [MEDICATION NAME] was administered on April 11, 2012. Interview on July 24, 2012 at 2:20 p.m. in the training room with LPN #4 who was assigned to administer [MEDICATION NAME] to the resident at 5:00 p.m. on April 22, 2012 confirmed no evidence LPN #4 administered [MEDICATION NAME] on April 22, 2012. Continued medical record review for resident #13 of a physician's order dated April 27, 2012 revealed [MEDICATION NAME] 4 mg was ordered for Tuesday, May 1, 2012 and 3 mg on Wednesday May 2, 2012. Medical record review of the MAR dated May 1-31, 2012 revealed [MEDICATION NAME] 3 mg was administered on May 1 and 4.5 mg was administered on May 2, 2012. Interview on July 24, 2012 at 2:10 p.m. in the training room with LPN #1 confirmed the physician's orders were not followed when [MEDICATION NAME] 3 mg was administered on Tuesday May 1, 2012 and 4.5 mg was administered on Wednesday May 2, 2012. Interview on July 24, 2012 at 2:20 p.m. in the training room with LPN #4 who administered [MEDICATION NAME] on May 1, 2012 and May 2, 2012 confirmed LPN #4 administered an incorrect dose of [MEDICATION NAME] on May 1 and 2, 2012. Resident #22 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a hospital history and physical dated April 25, 2012 revealed "...sent here from (facility) with right popliteal [MEDICAL CONDITION]" Medical record review of physician's orders dated April 27, 2012 revealed [MEDICATION NAME] 2.5 mg daily. Medical record review of laboratory results dated [DATE] revealed PT 75.3/INR 7.5 (high). Medical record review of a physician's order dated May 17, 2012 revealed [MEDICATION NAME] was to be held on May 17 and 18, 2012 and PT/INR on Saturday May 19, 2012. Medical record review of a laboratory report dated May 18, 2012 revealed the PT/INR was still high at PT 56.8/INR 5.7. Medical record review of a physician's order dated May 18, 2012 revealed PT/INR on May 19, 2012. Medical record review revealed no documentation the PT/INR was obtained on May 19, 2012 as ordered by the physician. Medical record review of a laboratory report dated May 21, 2012 revealed PT 19.9/INR 2.0 (therapeutic). Interview on August 1, 2012 at 3:20 p.m. in the training room with LPN #1 confirmed the physician ordered PT/INR for May 19, 2012 and confirmed the PT/INR was not obtained on May 19, 2012 as ordered. Continued interview confirmed the PT/INR was obtained two days later on Monday May 21, 2012 when LPN #1 became aware the PT/INR was not obtained over the weekend (Saturday). Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the facility history and physical dated December 17, 2012 revealed "...history of recurrent [MEDICAL CONDITION] and [MEDICAL CONDITION] venous stasis changes in both lower legs...History of multiple [MEDICAL CONDITION] on chronic [MEDICATION NAME] therapy..." Medical record review of a laboratory result dated April 23, 2012 revealed PT 14.6/INR 1.5 (low). Medical record review of a physician's order dated April 23, 2012 revealed [MEDICATION NAME] 3 mg on April 27 and 29, 2012, 4 mg on April 23 and 26, 2012, and PT/INR on April 30, 2012. Medical record review of the MAR dated April 1-31, 2012 revealed no evidence [MEDICATION NAME] was administered April 27 and 29, 2012. Medical record review of laboratory results dated [DATE] revealed PT 14.5/INR 1.5 (low). Medical record review of a physician's order dated April 30, 2012 revealed [MEDICATION NAME] was increased to 4.5 mg three days a week and 3 mg four days a week. Medical record review of laboratory results dated [DATE] revealed PT 27.7 and INR 2.8 (therapeutic). Medical record review of a physician's order dated May 14, 2012 revealed [MEDICATION NAME] 3 mg daily. Medical record review of the MAR dated May 1-31, 2012 revealed no evidence [MEDICATION NAME] was administered on May 16 or 25, 2012. Medical record review of a laboratory result dated May 25, 2012 revealed PT 21.9/INR 2.2 (therapeutic). Medical record review of a physician's order dated May 25, 2012 revealed [MEDICATION NAME] 3 mg daily was continued and PT/INR on June 22, 2012. Medical record review of the MAR dated June 1-30, 2012 revealed no evidence [MEDICATION NAME] was administered on June 2 or 7, 2012. Medical record review of a laboratory report dated June 22, 2012 revealed PT 21.9/INR 2.9 (therapeutic). Medical record review of a physician's order dated June 22, 2012 revealed [MEDICATION NAME] 3 mg daily was continued. Medical record review and interview on August 1, 2012 at 7:45 a.m. with LPN #1 confirmed no evidence [MEDICATION NAME] was administered on April 27 and 29, May 16 and 25, and June 2 and 7, 2012. Continued medical record review and interview confirmed the PT/INR dated May 30, 2012 revealed a low blood thinner level and the physician increased the [MEDICATION NAME] dose on May 30, 2012. Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a readmission history and physical dated June 2, 2010 revealed "...significant for bilateral [MEDICAL CONDITION] in April 2009 and a [MEDICAL CONDITION] started on [MEDICATION NAME] therapy at that time and continues..." Medical record review of laboratory results dated [DATE] revealed PT 9.3/INR 0.9 (low). Medical record review of a physician's order dated May 14, 2012 revealed [MEDICATION NAME] was increased from 4 mg daily to 5 mg daily and PT/INR on May 17, 2012. Medical record review of the MAR dated May 1-31, 2012 revealed no evidence [MEDICATION NAME] was administered on May 15, 2012. Medical record review of laboratory results dated [DATE] revealed PT 13.3/INR 1.3 (low). Medical record review revealed [MEDICATION NAME] was increased from 5 mg daily to 7.5 mg on May 17 and 19, 2012, 5 mg on May 18 and 20, 2012. Medical record review of laboratory results dated [DATE] revealed PT 19.6/INR 2.0 (therapeutic). Medical record review of a physician's order dated May 24, 2012 revealed [MEDICATION NAME] 5 mg daily. Medical record review of the MAR dated May 1-31, 2012 revealed no evidence [MEDICATION NAME] was administered May 25, 2012. Medical record review of laboratory results dated [DATE] revealed the PT/INR was lower at PT 14.3/INR 1.4 (low). Medical record review of a physician's order revealed [MEDICATION NAME] 5mg daily was continued. Medical record review of the MAR dated May 1-31, 2012 revealed no evidence [MEDICATION NAME] was administered May 30, 2012. Medical record review of laboratory results dated [DATE] revealed PT 45.7/INR 4.6 (high). Medical record review of a physician's order dated June 4, 2012 revealed [MEDICATION NAME] was held on June 4, 2012. Medical record review of laboratory results dated [DATE] revealed PT 19.1/INR 1.9 (low). Medical record review of a physician's order dated June 11, 2012 revealed [MEDICATION NAME] 5 mg to alternate with 2.5 mg every other day. Medical record review of the MAR dated June 1-30, 2012 revealed no evidence [MEDICATION NAME] was administered June 16, 2012. Medical record review of laboratory results dated [DATE] revealed PT 17.4/INR 1.7 (low). Medical record review of a physician's order dated June 18, 2012 revealed [MEDICATION NAME] 5 mg to alternate with 2.5 mg daily. Medical record review of a laboratory result dated June 22, 2012 revealed PT 20.3/INR 2.0 (therapeutic). Medical record review of a physician's order dated June 22, 2012 revealed [MEDICATION NAME] 2.5 mg daily. Medical record review of the MAR dated July 1-31, 2012 revealed no evidence [MEDICATION NAME] was administered July 17, 2012. Medical record review of a laboratory result dated July 24, 2012 revealed PT 13.8/INR 1.4 (low). Medical record review of a physician's order dated July 24, 2012 revealed [MEDICATION NAME] was increased to 4 mg daily. Medical record review and interview on August 1, 2012 at 7:57 a.m. in the training room with Licensed Practical Nurse (LPN) #1 confirmed no evidence [MEDICATION NAME] was administered on May 15, 25 and 30, 2012; no evidence [MEDICATION NAME] was administered on June 16, 2012 and no evidence [MEDICATION NAME] was administered on July 17, 2012. Resident #15 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a facility history and physical dated June 2, 2011 revealed "...Continue [MEDICATION NAME]" Medical record review of a laboratory report dated April 23, 2012 revealed PT 32.8/INR 3.3 (high). Medical record review of a physician's order dated April 23, 2012 revealed "Hold [MEDICATION NAME] x (times) 1 dose then restart 5 mg alternating with 4 mg every other day...PT/INR...4/30/12." Medical record review of the MAR dated April 1-30, 2012 revealed no evidence [MEDICATION NAME] was administered April 29, 2012. Medical record review of a laboratory report dated April 30, 2012 revealed PT 17.4/INR 1.7 (low). Medical record review of a physician's order dated April 30, 2012 revealed [MEDICATION NAME] continued at 5 mg alternating with 4 mg every other day and PT/INR on May 7, 2012. Medical record review of a laboratory report dated May 7, 2012 revealed PT 28.8/INR 2.9 (therapeutic). Medical record review of a physician's order dated May 7, 2012 revealed [MEDICATION NAME] alternating 5mg two days and 4 mg one day in rotation and PT/INR on May 14, 2012. Medical record review of a laboratory report dated May 14, 2012 revealed PT 12.7/INR 1.3 (low). Medical record review of a physician's order dated May 14, 2012 revealed [MEDICATION NAME] was increased to 6.5 mg daily. Medical record review of the MAR dated May 1-31, 2012 revealed no evidence [MEDICATION NAME] was administered May 16, 2012. Medical record review of a laboratory report dated May 21, 2012 revealed PT 14.0/INR 1.4 (low). Medical record review of a physician's order dated May 21, 2012 revealed [MEDICATION NAME] was increased to 6.5 mg two days alternating with 5 mg one day. Observation and interview on August 2, 2012 at 7:05 a.m. revealed LPN #1 performed in-house testing of PT/INR with results PT 37.3/INR 3.7 (high). Medical record review and interview on August 1, 2012 at 7:50 a.m. in the training room with LPN #1 confirmed no evidence [MEDICATION NAME] was administered on April 29, 2012 or May 16, 2012 and the blood thinner levels obtained on April 17 and May 21, 2012 were low. Resident #16 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a hospital history and physical dated August 17, 2011 revealed "...chronic [MEDICAL CONDITION] fib, rate controlled, on chronic [MEDICATION NAME] therapy...supratherapeutic (high level of blood thinner) [MEDICATION NAME]" Medical record review of a physician's order dated July 12, 2012 revealed "Hold [MEDICATION NAME] 7/12/12 then start 2 mg on 7/13 then 3 mg 7/14, 2 mg 7/15 3 mg 7/16...PT/INR on 7/17/12." Medical record review of a laboratory report dated July 17, 2012 revealed PT 21.7/INR 2.2 (therapeutic). Medical record review of a physician's order dated July 17, 2012 revealed the alternating dose of 3 mg and 2 mg every other day was continued. Medical record review of the MAR dated July 1-31, 2012 revealed [MEDICATION NAME] was not administered on July 17, 2012. [MEDICATION NAME] 3 mg was administered on July 18, 20 and 21, 2012 (should have been 2 mg on July 21, 2012 based on physician's orders) and [MEDICATION NAME] 2 mg was administered on July 22, 2012 (should have been 3 mg based on physician's orders). Medical record review of a laboratory report dated July 24, 2012 revealed PT 20.9/INR 2.1 (therapeutic). Medical record review of a physician's order dated July 24, 2012 revealed [MEDICATION NAME] was continued at 3 mg alternating with 2 mg every other day. Medical record review and interview on July 31, 2012 at 4:30 p.m. in the training room with LPN #1 confirmed [MEDICATION NAME] was not administered on July 17, 2012; confirmed the physician's orders were not followed when [MEDICATION NAME] 3 mg was administered on July 21, 2012 and 2 mg was administered on July 22, 2012. Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].

Based on medical record review, review of manufacturer's recommendations, review of the Nursing 2012 Drug Handbook, the facility investigation, review of a pharmacy drug interaction document, review of hospital records, review of facility policy, observation and interview, the facility failed to follow accepted standards of practice to hold [MEDICATION NAME] (a blood thinning medication) and administer Vitamin K (to counteract blood thinning medication) for one (#2); failed to identify likely medication interaction prior to the administration of antibiotics (known to increase the blood clotting time with [MEDICATION NAME]) or obtain more frequent monitoring of blood thinner levels and failed to administer the correct dose of [MEDICATION NAME] and failed to administer [MEDICATION NAME] for one (#13); to obtain blood thinner levels as ordered by the physician for one (#22); and failed to administer [MEDICATION NAME] per physician's orders [REDACTED].#6, #14, #15, #16, #17, #18, #19, #20, #21, #23, #24 and #25); to train and educate staff of the potential medication interactions between [MEDICATION NAME] and antibiotics; and to ensure a process was in place to assist staff in the identification of potential life-threatening medication interactions with [MEDICATION NAME] of fifteen residents reviewed who were receiving [MEDICATION NAME]. The facility provided an acceptable Credible Allegation of Compliance on August 21, 2012. A revisit on August 22 and 23, 2012 and receipt on August 23, 2012 at 7:19 p.m. of verification the Medical Director and the Pharmacist had reviewed and approved all polices revealed the corrective actions, implemented on August 23, 2012 removed the Immediate Jeopardy. Non-compliance for F-281 continues at an "E" level citation. Validation of the Credible Allegation of Compliance was accomplished through medical record review, observation and interview with nurses and administrative staff. The facility provided evidence of new policies and procedures related to identification of and actions to take when residents were receiving [MEDICATION NAME] and orders were given for medications with a likelihood of medication interaction with [MEDICATION NAME]. Inservice and training records including sign-in sheets for all nursing staff related to the new policies and procedures were provided. The sign-in sheets for the training records were compared to a listing of all licensed nurses employed by the facility and confirmed 100% (percent) of the facility's licensed nurses had been trained on the new policies and procedures. The facility provided evidence all residents who were receiving [MEDICATION NAME] had been assessed for [MEDICATION NAME] Time (PT) and International Normalized Ratio (INR) for monitoring anticoagulation therapy. Observation and interview revealed pharmacy alerts were received for residents who were receiving [MEDICATION NAME] and had new orders for medications with a likelihood of interaction with [MEDICATION NAME]. Medical record review, observation and interview confirmed nurses were notifying the physicians of the pharmacy alerts and were following the newly implemented policies and procedures. Observation of the Medication Administration Record [REDACTED]. Continued observation and interview with the medication nurses confirmed the facility had placed an "Anticoagulant Alert Form" printed on red paper in the MAR for each resident receiving [MEDICATION NAME] and had placed a conversion table for Vitamin K 10 mg (milligram) vials on the outside of one of two emergency boxes to assist with a quick calculation of doses ordered by the physician. Observation of the "PT/INR [MEDICATION NAME] ([MEDICATION NAME]) Flowsheet" for each resident receiving [MEDICATION NAME] revealed the flow sheet was being completed after PT/INR results were received and included the following information: Date, Time, INR results, PT results, Current dose of [MEDICATION NAME], if resident receiving antibiotic therapy, dosage change, next PT/INR date, family notification of change and nurses' signature. Continued review of the "PT/INR [MEDICATION NAME] ([MEDICATION NAME]) Flowsheet" for each resident in the facility receiving [MEDICATION NAME] revealed the DON or Designee had not initialed beside the nurses' signature to ensure accuracy of PT/INR results and new orders for [MEDICATION NAME] and the date of the next PT/INR as stated on the Allegation of Compliance. The facility must address this in the Plan of Correction. Based on medical record review, observation and interview, the Immediate Jeopardy was removed on August 23, 2012 at 7:19 p.m. after review of evidence the Medical Director and the Pharmacist had reviewed and approved all new and revised policies and procedures. The facility will remain out of compliance at a Scope and Severity level "E"-a pattern of deficient practice that constitutes no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. The facility remains out of compliance until it provides an acceptable plan of correction and the facility's corrective measures could be reviewed and evaluated by the Quality Assessment/Performance Improvement (QAPI) Committee.

Based on medical record review, review of manufacturer's recommendations, review of the Nursing 2012 Drug Handbook, review of a pharmacy drug interaction document, review of facility policy, review of the facility investigation, observation and interview, the facility failed to hold [MEDICATION NAME] (a blood thinning medication) and administer Vitamin K (to counteract blood thinning medication) for one (#2); failed to identify likely medication interaction prior to the administration of antibiotics (known to increase the blood clotting time with [MEDICATION NAME]) or obtain more frequent monitoring of blood thinner levels and failed to administer the correct dose of [MEDICATION NAME] and failed to administer [MEDICATION NAME] for one (#13); failed to obtain blood thinner levels as ordered by the physician for one (#22); failed to administer [MEDICATION NAME] per physicians' orders for twelve (#6, #14, #15, #16, #17, #18, #19, #20, #21, #23, #24 and #25); failed to train and educate staff of the potential medication interactions between [MEDICATION NAME] and antibiotics; and failed to ensure a process was in place to assist staff in the identification of potential life-threatening medication interactions with [MEDICATION NAME] of fifteen residents reviewed who were receiving [MEDICATION NAME]. The facility also failed to ensure necessary services were provided to promote healing, prevent pain, and prevent extension of a yeast infection ([MEDICAL CONDITION]) for one resident (#9) of twenty-six residents reviewed. The facility's failure has caused or is likely to cause serious injury, harm, impairment or death to residents #2, #13, #22, #6, #14, #15, #16, #17, #18, #19, #20, #21, #23, #24 and #25. The facility's failure resulted in harm to resident #9. The Administrator and the Director of Nursing were informed of the Immediate Jeopardy in the training room on August 6, 2012 at 11:30 a.m. The Immediate Jeopardy was effective January 18, 2012 and is ongoing. A partial extended survey was conducted on August 6, 2012. The deficiency, F309K, represents Substandard Quality of Care. The findings included: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the manufacturer's recommendations for the in-house blood thinner monitoring system revealed "...The American College of Chest Physicians makes these recommendations regarding INR (International Normalized Ratio (INR-blood thinner monitor) for patients on anticoagulant therapy:...treatment of [REDACTED]. Review of a hospital consultation dated December 14, 2011 revealed "...history of chronic [MEDICAL CONDITION] Fibrillation...was on aspirin therapy for her [MEDICAL CONDITION] Fibrillation...PAST MEDICAL HISTORY: Includes a recent fall with a recent Subdural Hematoma that was cared for at (hospital) approximately three months prior, Hypertension and chronic [MEDICAL CONDITION] Fibrillation...ASSESSMENT...Left hemispheric...ischemic Stroke, most likely cardioembolic secondary to [MEDICAL CONDITION] Fibrillation, not on anticoagulant (blood thinner), presenting with global [MEDICAL CONDITION] (absence or impairment of speech) and right [MEDICAL CONDITIONS] previously with rapid ventricular rate...was taken off anticoagulation approximately a year ago for uncertain reasons...Recent (approximately two months ago) traumatic [MEDICAL CONDITION], probably a right Subdural Hematoma...Recommend [MEDICATION NAME] with aspirin bridge for now until a better assessment of how (resident) will do can be made..." Review of a second consultation dated December 14, 2011 revealed "...Would be very cautious with long-term anticoagulation..." Medical record review of the physician's progress note dated December 26, 2011 revealed "...embolic (blood clot) [MEDICAL CONDITION]-[MEDICATION NAME] rec (recommended) by Neurology...Cont. (Continue) [MEDICATION NAME] but watch carefully." Medical record review of the facility's admission orders [REDACTED]." Medical record review of a laboratory result dated December 27, 2012 revealed PT 24.6/INR 2.5 (therapeutic). Medical record review of a physician's order dated December 27, 2012 revealed the same dose of [MEDICATION NAME] was continued (2 mg daily) and PT/INR on December 30, 2012. Medical record review of a laboratory result dated December 30, 2012 revealed PT 27.9/INR 2.8 (therapeutic). Medical record review of a physician's order dated December 30, 2012 revealed the same dose of [MEDICATION NAME] was continued and PT/INR on January 6, 2012. Medical record review of a laboratory result dated January 6, 2012 revealed PT 18.8/INR 1.9 (low). Medical record review revealed a physician's order could not be located on the medical record. Medical record review of a document entitled "Physician Contacts" provided by the Administrator on August 3, 2012 revealed on January 6, 2012 [MEDICATION NAME] was increased to 3 mg daily and PT/INR on January 10, 2012. Medical record review of a laboratory result dated January 10, 2012 revealed PT 12.8/INR 1.3 (low). Medical record review of a physician's order dated January 10, 2012 revealed the [MEDICATION NAME] was increased to 4 mg daily and PT/INR on January 13, 2012. Medical record review of a laboratory result dated January 13, 2012 revealed PT 44.2 (reference range 9.5-11.1) and INR 4.4 (high). Medical record review of the physician's order dated January 13, 2012 revealed "Hold [MEDICATION NAME] until new orders received. Recheck INR on 01-16-12." Medical record review of a laboratory report dated January 16, 2012 revealed INR 3.8 (high). Medical record of the physician's order dated January 16, 2012 revealed "Hold ([MEDICATION NAME]). PT/INR 1/18/12." Medical record review of the Medication Administration Record (MAR) dated January 1-31, 2012 revealed [MEDICATION NAME] was held as ordered on January 16, 17 and 18, 2012. Medical record review revealed no documentation of laboratory results dated [DATE] and no physician's order for [MEDICATION NAME] dated January 18, 2012. Medical record review of the MAR dated January 1-31, 2012 revealed [MEDICATION NAME] 4 mg was resumed without a physician's order and was administered January 19, 20, 21, 22, 23 and 24, 2012. Medical record review of a laboratory result dated January 25, 2012 revealed PT-46.3/INR 4.6 (high). Continued review revealed the results of a PT/INR obtained on January 18, 2012 was recorded on the January 25, 2012 results and revealed PT 37.8/INR 3.8 (high) on January 18, 2012. Medical record review of a physician's order dated January 25, 2012 revealed "Hold [MEDICATION NAME]. (Check) PT/INR on 1/26/12." Medical record review of a laboratory result dated January 26, 2012 revealed PT-65/INR 6.2 (high) and repeat PT/INR on January 27, 2012. Medical record review of the physician's order dated January 26, 2012 revealed "...Hold ([MEDICATION NAME])-was not held as ordered 1-18-2012 (no order). Vitamin K 1 mg PO x (times) 1...1st (first) dose STAT (as soon as possible). PT/INR in AM (a.m.)" Medical record review of the MAR dated January 1-31, 2012 revealed the Vitamin K was not administered until January 27, 2012. Medical record review of a physician's progress note dated January 26, 2012 revealed "...Supratherapeutic (higher than a therapeutic level) INR-INR 6.8...1 mg Vit (Vitamin) [MEDICATION NAME] was ordered to be held since 1-18-2012 but pt...receiving 4 mg [MEDICATION NAME] QD..." Medical record review of a laboratory result dated January 27, 2012 revealed PT-63.0/INR 6.3 (high). Medical record review of the physician's order dated January 27, 2012 revealed "...DC (Discontinue) [MEDICATION NAME]/INR 1/30/12." Medical record review of a physician's progress note dated January 27, 2012 revealed "...hold [MEDICATION NAME]. [MEDICATION NAME] restart next wk (week) vs (versus) [MEDICATION NAME] (blood thinner) if difficult to control INR..." Medical record review of a physician's progress note dated January 31, 2012 revealed "A fib ([MEDICAL CONDITION] Fibrillation) on [MEDICATION NAME], INR labile (rapidly shifting) and having difficulty keeping therapeutic..." Medical record review of a physician's order dated January 31, 2012 revealed "DC [MEDICATION NAME]. Daily PT/INR. When INR falls below 2.0, start [MEDICATION NAME] 110 mg p.o. BID". Medical record review of a laboratory result dated February 1, 2012 revealed INR 1.2 (low). Medical record review of a physician's order dated February 2, 2012 revealed "[MEDICATION NAME] 75 mg po bid." Review of the facility's policy for medication administration revealed "Medication will be given in accordance with physician order...All meds will be given in accordance with facility policy...Follow manufacturer's guidelines for giving medications..." Interview on July 18, 2012 at 9:10 a.m. in the training room with Licensed Practical Nurse (LPN) #1 revealed responsibilities of LPN #1 included the following Monday through Friday: perform wound care for all residents with wounds; obtain PT/INRs using the facility's in-house PT/INR machine for all residents receiving [MEDICATION NAME]-six to eight per day; prepare physicians' orders related to [MEDICATION NAME]; fax new [MEDICATION NAME] orders to the facility's pharmacy; and transcribe orders for [MEDICATION NAME] to the Medication Administration Records for all residents receiving [MEDICATION NAME]. Continued interview with LPN #1 revealed LPN #1 assumed the above responsibilities in March 2012 for residents receiving [MEDICATION NAME] and prior to March 2012 "night shift (nurses) was responsible" to obtain PT/INRs and LPN #1 "addressed them when I came in (day shift)." Telephone interview on July 18, 2012 at 2:45 p.m. with the Nurse Practitioner (NP #2) who was managing the resident's [MEDICATION NAME] dosage based on the PT/INRs confirmed the NP was notified on January 16, 2012 the INR was 3.8. The NP ordered the [MEDICATION NAME] held and the INR rechecked on January 18, 2012. Continued interview confirmed the INR on January 18, 2012 remained elevated at 3.8; however the facility failed to notify the NP or the physician of the elevated INR. Continued interview confirmed the facility administered [MEDICATION NAME] 4 mg daily from January 19-25, 2012 without physician's orders. An INR was done on January 25, 2012 with results reported as 4.6. An order was given to hold the [MEDICATION NAME] and recheck the INR on January 26, 2012. The INR on January 26, 2012 was 6.8. Continued interview revealed "That's when I discovered (resident) had been given [MEDICATION NAME]" daily January 19-25. Continued interview confirmed on January 26, 2012 NP #2 gave an order for [REDACTED]. The NP stated, "I wrote it stat because there had been problems with [MEDICATION NAME] being given." Continued interview confirmed the Vitamin K was not administered until January 27, 2012-eighteen hours after the order was written. The INR returned to a therapeutic range on January 27, 2012 after the Vitamin K was administered. Continued interview confirmed the resident was at "huge risk for head bleed and Stroke" if the resident had fallen and at risk for [MEDICAL CONDITION] with a "high INR like 6.8." Continued interview confirmed the resident was switched to [MEDICATION NAME] "when it happened." Continued interview confirmed the facility "never should have not called me with the high INR;" gave [MEDICATION NAME] after it was ordered to be held; and failed to administer the Vitamin K for eighteen hours. Interview on July 19, 2012 at 10:50 a.m. in the training room with NP #1 confirmed the therapeutic range of the INR for a resident with [MEDICAL CONDITION] Fibrillation was "2 (2.0) to 3 (3.0)." Medical record review and interview on July 19, 2012 at 3:30 p.m. in the training room with the Administrator (Registered Nurse) confirmed the Administrator knew the INR for January 18, 2012 was done because the results were recorded on the laboratory report dated January 25, 2012. Continued interview confirmed on laboratory reports, the facility recorded the previous INR and current [MEDICATION NAME] dosage for the physician's review. Continued interview confirmed the physician was not notified of the elevated INR of 3.8 on January 18, 2012. Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a nurse's note dated January 26, 2012 revealed "...left calf swollen, tight, hot to touch...(no) redness. (Physician) notified." Medical record review of a Doppler scan of the left leg dated January 27, 2012 revealed "...Extensive occlusive [MEDICAL CONDITIONS] is noted within left external iliac vein, left common femoral vein, left greater saphenous vein, left proximal femoral vein, left mid femoral vein, left distal femoral vein, left popliteal vein, left posterior tibial vein, left peroneal vein, and left anterior tibial vein..." Medical record review of a physician's order dated January 27, 2012 revealed, "[MEDICATION NAME] 3 mg daily. Check PT/INR 1/30/12." Medical record review of a laboratory result dated January 30, 2012 revealed PT 19.1/INR 1.9 (low). Medical record review of a laboratory result dated January 30, 2012 revealed PT 10.2/INR 1.0 (low). Medical record review of a laboratory result dated March 9, 2012 revealed PT 24.2/INR 2.4. Medical record review of a physician's order dated March 9, 2012 revealed [MEDICATION NAME] was continued at 4 mg daily (as ordered on March 2, 2012) and "re check PT/INR in 2 weeks." Medical record review of a change in condition form dated March 11, 2012 revealed "Abnormal UA (urinalysis) results." Medical record review of a physician's order dated March 11, 2012 revealed Bactrim DS (antibiotic) q (every) 12 hr (hours) x (times) 10 days." Medical record review of the Medication Administration Record (MAR) dated March 1-31, 2012 revealed Bactrim DS was administered every twelve hours March 11-21, 2012 (20 doses). Review of the Nursing 2012 Drug Handbook revealed Bactrim DS "...May increase anticoagulant effect. Monitor patient for bleeding; monitor PT and INR. Continued review revealed [MEDICATION NAME] ([MEDICATION NAME]) "...can cause major or fatal bleeding...Consider more frequent INR monitoring in those at high risk for bleeding..." Medical record review revealed the PT/INR was not checked from March 9, 2012 until March 23, 2012. Medical record review of the laboratory results dated [DATE] revealed PT 58.3/INR 5.8 (high). Medical record review of a physician's order dated March 23, 2012 revealed "Hold [MEDICATION NAME] til (until) 3/26...PT/INR on 3/27." Medical record review of laboratory results dated [DATE] revealed PT 31.8/INR 3.2 (high). Medical record review of a physician's order dated March 26, 2012 at 5:00 p.m. revealed "Hold [MEDICATION NAME] today (3-26-12. Re-start [MEDICATION NAME] 3 mg on (3-27-12)...PT/INR on Fri. (Friday) (3-30-12)." Medical record review of laboratory results dated [DATE] revealed PT 17.4/INR 1.7 (low). Medical record review of a physician's order dated March 30, 2012 revealed "Cont (Continue) same dose (3 mg daily)...(PT/INR) on 4/27/12." Interview on July 25, 2012 at 8:20 a.m. in the training room with NP #1 confirmed Bactrim DS was started on March 11, 2012 and confirmed a PT/INR was not obtained until March 23, 2012 (twelve days after Bactrim DS was ordered). Continued interview confirmed the INR obtained on March 23, 2012 was "high" and the resident "could bleed" with a high INR. Continued interview confirmed the INR "should be checked every other day when on Bactrim DS and [MEDICATION NAME] and it was not done." Continued interview revealed the facility had a process in place to monitor the INR more frequently when a resident was on [MEDICATION NAME] and started on an antibiotic. Interview (with NP #1 present) on July 25, 2012 at 8:30 a.m. in the training room with LPN #1 confirmed the INR was not checked between March 9 and 23, 2012 while the resident was receiving Bactrim DS. Continued interview confirmed the facility had no process in place to inform or remind the physician a resident was receiving [MEDICATION NAME] when Bactrim DS or other antibiotics which could raise the INR level were ordered. Continued interview confirmed LPN #1 had no knowledge if the pharmacy provided an alert notice of potential interactions when the physician ordered an antibiotic for residents who were receiving [MEDICATION NAME]. Interview on July 25, 2012 at 8:40 a.m. in the training room with NP #1 revealed NP #1 "thought" the facility had a process in place to obtain an INR every two days for a resident on [MEDICATION NAME] who was started on an antibiotic. Continued interview confirmed the therapeutic range of the INR for a resident with a [MEDICAL CONDITION] was 2.0-3.0 and NP #1 "try to keep it around 2.0...never know when an elderly patient may have a bleed. It's easier to deal with a [MEDICAL CONDITION] than a bleed." Telephone interview with the facility's pharmacy provider on July 31, 2012 at 8:20 a.m. revealed when an antibiotic was ordered for a resident receiving [MEDICATION NAME], the pharmacist received a "pop up" in the pharmacy's computer system which noted the potential interaction between [MEDICATION NAME] and the antibiotic; the pharmacist printed the "interaction sheet"; and provided the interaction sheet to the facility when the medication was delivered. Review of a sample document for potential "Drug/Drug Interactions" provided by the pharmacy after the interview revealed the sample alert included the potential for interaction between [MEDICATION NAME] and an antibiotic, onset of the potential interaction, the risk of bleeding and the extent of the potential interactions. Telephone interview on July 31, 2012 at 8:40 a.m. with the physician of resident #13/Medical Director revealed "I think they (facility) have a protocol" if a resident was receiving [MEDICATION NAME] and placed on an antibiotic, an INR was obtained every three days. Continued interview confirmed "try not to exceed 3.0 (INR)...need protocol in place...INR of 5.8 is not good." Continued interview confirmed a high (supra-therapeutic) INR placed the resident at risk for bleeding. Interview on July 31, 2012 at 9:45 a.m. on the South hall with LPN #3 revealed the pharmacy sent a list of "adverse reactions" when a resident was placed on an antibiotic and was receiving [MEDICATION NAME]. Review of the MAR and interview with LPN #3 confirmed the MAR did not include a list of medications that could potentially interact with [MEDICATION NAME] and stated, "It would help" to have a list. Review of the MAR and interview on July 31, 2012 at 10:50 a.m. on the West hall with LPN #10 confirmed the facility did not provide a list of medications that could potentially interact with [MEDICATION NAME]. Interview on July 31, 2012 at 10:55 a.m. on the East wing with LPN #11 confirmed the facility did not provide a list of medications that could potentially interact with [MEDICATION NAME]. Telephone interview on August 2, 2012 at 7:30 a.m. with NP #3 confirmed for a resident with a "new" [MEDICAL CONDITION] or [MEDICAL CONDITIONS] (PE-blood clot in the lung) the desired INR was 2.5-3.5 and for an "old" [MEDICAL CONDITION] or PE the desired INR was 2.0-3.0. Continued medical record review for resident #13 of the MAR dated April 1-31, 2012 revealed [MEDICATION NAME] 3 mg (daily) was not administered on April 11 or 22, 2012. Interview on July 24, 2012 at 2:10 p.m. in the training room with LPN #1 confirmed no evidence [MEDICATION NAME] was administered on April 11, 2012. Interview on July 24, 2012 at 2:20 p.m. in the training room with LPN #4 who was assigned to administer [MEDICATION NAME] to the resident at 5:00 p.m. on April 22, 2012 confirmed no evidence LPN #4 administered [MEDICATION NAME] on April 22, 2012. Continued medical record review for resident #13 of a physician's order dated April 27, 2012 revealed [MEDICATION NAME] 4 mg was ordered for Tuesday, May 1, 2012 and 3 mg on Wednesday May 2, 2012. Medical record review of the MAR dated May 1-31, 2012 revealed [MEDICATION NAME] 3 mg was administered on May 1 and 4.5 mg was administered on May 2, 2012. Interview on July 24, 2012 at 2:10 p.m. in the training room with LPN #1 confirmed the physician's orders were not followed when [MEDICATION NAME] 3 mg was administered on Tuesday May 1, 2012 and 4.5 mg was administered on Wednesday May 2, 2012. Interview on July 24, 2012 at 2:20 p.m. in the training room with LPN #4 who administered [MEDICATION NAME] on May 1, 2012 and May 2, 2012 confirmed LPN #4 administered an incorrect dose of [MEDICATION NAME] on May 1 and 2, 2012. Resident #22 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a hospital history and physical dated April 25, 2012 revealed "...sent here from (facility) with right popliteal [MEDICAL CONDITION]" Medical record review of physician's orders dated April 27, 2012 revealed [MEDICATION NAME] 2.5 mg daily. Medical record review of laboratory results dated [DATE] revealed PT 75.3/INR 7.5 (high). Medical record review of a physician's order dated May 17, 2012 revealed [MEDICATION NAME] was to be held on May 17 and 18, 2012 and PT/INR on Saturday May 19, 2012. Medical record review of a laboratory report dated May 18, 2012 revealed the PT/INR was still high at PT 56.8/INR 5.7. Medical record review of a physician's order dated May 18, 2012 revealed PT/INR on May 19, 2012. Medical record review revealed no documentation the PT/INR was obtained on May 19, 2012 as ordered by the physician. Medical record review of a laboratory report dated May 21, 2012 revealed PT 19.9/INR 2.0 (therapeutic). Interview on August 1, 2012 at 3:20 p.m. in the training room with LPN #1 confirmed the physician ordered PT/INR for May 19, 2012 and confirmed the PT/INR was not obtained on May 19, 2012 as ordered. Continued interview confirmed the PT/INR was obtained two days later on Monday May 21, 2012 when LPN #1 became aware the PT/INR was not obtained over the weekend (Saturday). Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the facility history and physical dated December 17, 2012 revealed "...history of recurrent [MEDICAL CONDITION] and [MEDICAL CONDITIONS] venous stasis changes in both lower legs...History of multiple [MEDICAL CONDITION] on chronic [MEDICATION NAME] therapy..." Medical record review of a laboratory result dated April 23, 2012 revealed PT 14.6/INR 1.5 (low). Medical record review of a physician's order dated April 23, 2012 revealed [MEDICATION NAME] 3 mg on April 27 and 29, 2012, 4 mg on April 23 and 26, 2012, and PT/INR on April 30, 2012. Medical record review of the MAR dated April 1-31, 2012 revealed no evidence [MEDICATION NAME] was administered April 27 and 29, 2012. Medical record review of laboratory results dated [DATE] revealed PT 14.5/INR 1.5 (low). Medical record review of a physician's order dated April 30, 2012 revealed [MEDICATION NAME] was increased to 4.5 mg three days a week and 3 mg four days a week. Medical record review of laboratory results dated [DATE] revealed PT 27.7 and INR 2.8 (therapeutic). Medical record review of a physician's order dated May 14, 2012 revealed [MEDICATION NAME] 3 mg daily. Medical record review of the MAR dated May 1-31, 2012 revealed no evidence [MEDICATION NAME] was administered on May 16 or 25, 2012. Medical record review of a laboratory result dated May 25, 2012 revealed PT 21.9/INR 2.2 (therapeutic). Medical record review of a physician's order dated May 25, 2012 revealed [MEDICATION NAME] 3 mg daily was continued and PT/INR on June 22, 2012. Medical record review of the MAR dated June 1-30, 2012 revealed no evidence [MEDICATION NAME] was administered on June 2 or 7, 2012. Medical record review of a laboratory report dated June 22, 2012 revealed PT 21.9/INR 2.9 (therapeutic). Medical record review of a physician's order dated June 22, 2012 revealed [MEDICATION NAME] 3 mg daily was continued. Medical record review and interview on August 1, 2012 at 7:45 a.m. with LPN #1 confirmed no evidence [MEDICATION NAME] was administered on April 27 and 29, May 16 and 25, and June 2 and 7, 2012. Continued medical record review and interview confirmed the PT/INR dated May 30, 2012 revealed a low blood thinner level and the physician increased the [MEDICATION NAME] dose on May 30, 2012. Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a readmission history and physical dated June 2, 2010 revealed "...significant for bilateral [MEDICAL CONDITIONS] in April 2009 and a [MEDICAL CONDITION] started on [MEDICATION NAME] therapy at that time and continues..." Medical record review of laboratory results dated [DATE] revealed PT 9.3/INR 0.9 (low). Medical record review of a physician's order dated May 14, 2012 revealed [MEDICATION NAME] was increased from 4 mg daily to 5 mg daily and PT/INR on May 17, 2012. Medical record review of the MAR dated May 1-31, 2012 revealed no evidence [MEDICATION NAME] was administered on May 15, 2012. Medical record review of laboratory results dated [DATE] revealed PT 13.3/INR 1.3 (low). Medical record review revealed [MEDICATION NAME] was increased from 5 mg daily to 7.5 mg on May 17 and 19, 2012, 5 mg on May 18 and 20, 2012. Medical record review of laboratory results dated [DATE] revealed PT 19.6/INR 2.0 (therapeutic). Medical record review of a physician's order dated May 24, 2012 revealed [MEDICATION NAME] 5 mg daily. Medical record review of the MAR dated May 1-31, 2012 revealed no evidence [MEDICATION NAME] was administered May 25, 2012. Medical record review of laboratory results dated [DATE] revealed the PT/INR was lower at PT 14.3/INR 1.4 (low). Medical record review of a physician's order revealed [MEDICATION NAME] 5mg daily was continued. Medical record review of the MAR dated May 1-31, 2012 revealed no evidence [MEDICATION NAME] was administered May 30, 2012. Medical record review of laboratory results dated [DATE] revealed PT 45.7/INR 4.6 (high). Medical record review of a physician's order dated June 4, 2012 revealed [MEDICATION NAME] was held on June 4, 2012. Medical record review of laboratory results dated [DATE] revealed PT 19.1/INR 1.9 (low). Medical record review of a physician's order dated June 11, 2012 revealed [MEDICATION NAME] 5 mg to alternate with 2.5 mg every other day. Medical record review of the MAR dated June 1-30, 2012 revealed no evidence [MEDICATION NAME] was administered June 16, 2012. Medical record review of laboratory results dated [DATE] revealed PT 17.4/INR 1.7 (low). Medical record review of a physician's order dated June 18, 2012 revealed [MEDICATION NAME] 5 mg to alternate with 2.5 mg daily. Medical record review of a laboratory result dated June 22, 2012 revealed PT 20.3/INR 2.0 (therapeutic). Medical record review of a physician's order dated June 22, 2012 revealed [MEDICATION NAME] 2.5 mg daily. Medical record review of the MAR dated July 1-31, 2012 revealed no evidence [MEDICATION NAME] was administered July 17, 2012. Medical record review of a laboratory result dated July 24, 2012 revealed PT 13.8/INR 1.4 (low). Medical record review of a physician's order dated July 24, 2012 revealed [MEDICATION NAME] was increased to 4 mg daily. Medical record review and interview on August 1, 2012 at 7:57 a.m. in the training room with Licensed Practical Nurse (LPN) #1 confirmed no evidence [MEDICATION NAME] was administered on May 15, 25 and 30, 2012; no evidence [MEDICATION NAME] was administered on June 16, 2012 and no evidence [MEDICATION NAME] was administered on July 17, 2012. Resident #15 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a facility history and physical dated June 2, 2011 revealed "...Continue [MEDICATION NAME]" Medical record review of a laboratory report dated April 23, 2012 revealed PT 32.8/INR 3.3 (high). Medical record review of a physician's order dated April 23, 2012 revealed "Hold [MEDICATION NAME] x (times) 1 dose then restart 5 mg alternating with 4 mg every other day...PT/INR...4/30/12." Medical record review of the MAR dated April 1-30, 2012 revealed no evidence [MEDICATION NAME] was administered April 29, 2012. Medical record review of a laboratory report dated April 30, 2012 revealed PT 17.4/INR 1.7 (low). Medical record review of a physician's order dated April 30, 2012 revealed [MEDICATION NAME] continued at 5 mg alternating with 4 mg every other day and PT/INR on May 7, 2012. Medical record review of a laboratory report dated May 7, 2012 revealed PT 28.8/INR 2.9 (therapeutic). Medical record review of a physician's order dated May 7, 2012 revealed [MEDICATION NAME] alternating 5mg two days and 4 mg one day in rotation and PT/INR on May 14, 2012. Medical record review of a laboratory report dated May 14, 2012 revealed PT 12.7/INR 1.3 (low). Medical record review of a physician's order dated May 14, 2012 revealed [MEDICATION NAME] was increased to 6.5 mg daily. Medical record review of the MAR dated May 1-31, 2012 revealed no evidence [MEDICATION NAME] was administered May 16, 2012. Medical record review of a laboratory report dated May 21, 2012 revealed PT 14.0/INR 1.4 (low). Medical record review of a physician's order dated May 21, 2012 revealed [MEDICATION NAME] was increased to 6.5 mg two days alternating with 5 mg one day. Observation and interview on August 2, 2012 at 7:05 a.m. revealed LPN #1 performed in-house testing of PT/INR with results PT 37.3/INR 3.7 (high). Medical record review and interview on August 1, 2012 at 7:50 a.m. in the training room with LPN #1 confirmed no evidence [MEDICATION NAME] was administered on April 29, 2012 or May 16, 2012 and the blood thinner levels obtained on April 17 and May 21, 2012 were low. Resident #16 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a hospital history and physical dated August 17, 2011 revealed "...chronic [MEDICAL CONDITION] fib, rate controlled, on chronic [MEDICATION NAME] therapy...supratherapeutic (high level of blood thinner) [MEDICATION NAME]" Medical record review of a physician's order dated July 12, 2012 revealed "Hold [MEDICATION NAME] 7/12/12 then start 2 mg on 7/13 then 3 mg 7/14, 2 mg 7/15 3 mg 7/16...PT/INR on 7/17/12." Medical record review of a laboratory report dated July 17, 2012 revealed PT 21.7/INR 2.2 (therapeutic). Medical record review of a physician's order dated July 17, 2012 revealed the alternating dose of 3 mg and 2 mg every other day was continued. Medical record review of the MAR dated July 1-31, 2012 revealed [MEDICATION NAME] was not administered on July 17, 2012. [MEDICATION NAME] 3 mg was administered on July 18, 20 and 21, 2012 (should have been 2 mg on July 21, 2012 based on physician's orders) and [MEDICATION NAME] 2 mg was administered on July 22, 2012 (should have been 3 mg based on physician's orders). Medical record review of a laboratory report dated July 24, 2012 revealed PT 20.9/INR 2.1 (therapeutic). Medical record review of a physician's order dated July 24, 2012 revealed [MEDICATION NAME] was continued at 3 mg alternating with 2 mg every other day. Medical record review and interview on July 31, 2012 at 4:30 p.m. in the training room with LPN #1 confirmed [MEDICATION NAME] was not administered on July 17, 2012; confirmed the physician's orders were not followed when [MEDICATION NAME] 3 mg was administered on July 21, 2012 and 2 mg was administered on July 22, 2012. Resident #17 was admitted to the facility o

Based on medical record review, review of manufacturer's recommendations, review of the Nursing 2012 Drug Handbook, review of a pharmacy drug interaction document, review of facility policy, review of the facility investigation, observation and interview, the facility failed to hold [MEDICATION NAME] (a blood thinning medication) and administer Vitamin K (to counteract blood thinning medication) for one (#2); failed to identify likely medication interaction prior to the administration of antibiotics (known to increase the blood clotting time with [MEDICATION NAME]) or obtain more frequent monitoring of blood thinner levels and failed to administer the correct dose of [MEDICATION NAME] and failed to administer [MEDICATION NAME] for one (#13); failed to obtain blood thinner levels as ordered by the physician for one (#22); failed to administer [MEDICATION NAME] per physicians' orders for twelve (#6, #14, #15, #16, #17, #18, #19, #20, #21, #23, #24 and #25); failed to train and educate staff of the potential medication interactions between [MEDICATION NAME] and antibiotics; and failed to ensure a process was in place to assist staff in the identification of potential life-threatening medication interactions with [MEDICATION NAME] of fifteen residents reviewed who were receiving [MEDICATION NAME]. The facility also failed to ensure necessary services were provided to promote healing, prevent pain, and prevent extension of a yeast infection ([MEDICAL CONDITION]) for one resident (#9) of twenty-six residents reviewed. The facility provided an acceptable Credible Allegation of Compliance on August 21, 2012. A revisit on August 22 and 23, 2012 and receipt on August 23, 2012 at 7:19 p.m. of verification the Medical Director and the Pharmacist had reviewed and approved all polices revealed the corrective actions, implemented on August 23, 2012 removed the Immediate Jeopardy. Non-compliance for F-309 continues at an "E" level citation. Validation of the Credible Allegation of Compliance was accomplished through medical record review, observation and interview with nurses and administrative staff. The facility provided evidence of new policies and procedures related to identification of and actions to take when residents were receiving [MEDICATION NAME] and orders were given for medications with a likelihood of medication interaction with [MEDICATION NAME]. The facility provided evidence of new policies related to notification of the physician of newly identified reddened areas on the skin in order to secure treatment of [REDACTED]. Inservice and training records including sign-in sheets for all nursing staff related to the new policies and procedures were provided. The sign-in sheets for the training records were compared to a listing of all licensed nurses employed by the facility and confirmed 100% (percent) of the facility's licensed nurses had been trained on the new policies and procedures. The facility provided evidence all residents who were receiving [MEDICATION NAME] had been assessed for [MEDICATION NAME] Time (PT) and International Normalized Ratio (INR) for monitoring anticoagulation therapy. Observation and interview revealed pharmacy alerts were received for residents who were receiving [MEDICATION NAME] and had new orders for medications with a likelihood of interaction with [MEDICATION NAME]. Medical record review, observation and interview confirmed nurses were notifying the physicians of the pharmacy alerts and were following the newly implemented policies and procedures. Observation of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Continued observation and interview with the medication nurses confirmed the facility had placed an "Anticoagulant Alert Form" printed on red paper in the MAR for each resident receiving [MEDICATION NAME] and had placed a conversion table for Vitamin K 10 mg (milligram) vials on the outside of one of two emergency boxes to assist with a quick calculation of doses ordered by the physician. Observation of the "PT/INR [MEDICATION NAME] ([MEDICATION NAME]) Flowsheet" for each resident receiving [MEDICATION NAME] revealed the flow sheet was being completed after PT/INR results were received and included the following information: Date, Time, INR results, PT results, Current dose of [MEDICATION NAME], if resident receiving antibiotic therapy, dosage change, next PT/INR date, family notification of change and nurses' signature. Continued review of the "PT/INR [MEDICATION NAME] ([MEDICATION NAME]) Flowsheet" for each resident in the facility receiving [MEDICATION NAME] revealed the DON or Designee had not initialed beside the nurses' signature to ensure accuracy of PT/INR results and new orders for [MEDICATION NAME] and the date of the next PT/INR as stated on the Allegation of Compliance. The facility must address this in the Plan of Correction. Based on medical record review, observation and interview, the Immediate Jeopardy was removed on August 23, 2012 at 7:19 p.m. after review of evidence the Medical Director and the Pharmacist had reviewed and approved all new and revised policies and procedures. The facility will remain out of compliance at a Scope and Severity level "E"-a pattern of deficient practice that constitutes no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. The facility remains out of compliance until it provides an acceptable plan of correction and the facility's corrective measures could be reviewed and evaluated by the Quality Assessment/Performance Improvement (QAPI) Committee.

Based on medical record review, observation, review of manufacturer's recommendations, review of hospital records, review of facility policy, review of medication publications and interview, the facility failed to be administered in a manner to ensure [MEDICATION NAME] (a blood thinning medication) therapy was provided safely and according to physicians' orders for fifteen (#2, #6, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24 and #25) of fifteen reviewed; to train and educate staff of the potential medication interactions between [MEDICATION NAME] and antibiotics; to ensure a process was in place to assist staff in the identification of potential life-threatening medication interactions with [MEDICATION NAME] of fifteen residents reviewed who were receiving [MEDICATION NAME]. The facility's failure has caused or is likely to cause serious injury, harm, impairment or death to residents #2, #6, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24 and #25. The Administrator and the Director of Nursing were informed of the Immediate Jeopardy in the training room on August 6, 2012 at 11:30 a.m. The Immediate Jeopardy was effective January 18, 2012 and is ongoing. A partial extended survey was conducted on August 6, 2012. The findings included: Interview on July 24, 2012 at 2:55 p.m. in the training room with the Administrator confirmed the facility had no process or system in place to monitor residents receiving [MEDICATION NAME] therapy to determine if the correct dose was being given; if [MEDICATION NAME] was held when ordered by the physician; and if PT ([MEDICATION NAME] Time/INR (International Normalized Ratio) were being done as ordered by the physician and if results were reported to the physician in a timely manner. Interview on August 6, 2012 at 10:00 a.m. in the training room with the Administrator confirmed not all staff that administered [MEDICATION NAME] had been trained on [MEDICATION NAME] therapy, therapeutic levels of [MEDICATION NAME] for [MEDICAL CONDITIONS], PE (Pulmonary [MEDICAL CONDITION]) and [MEDICAL CONDITION] Fibrillation, the risk to residents if [MEDICATION NAME] was not administered or administered in the wrong dosage, to make sure physicians were aware the resident was receiving [MEDICATION NAME] if an antibiotic was ordered and on medications that could potentially interact with [MEDICATION NAME]. Continued interview confirmed no information was available on the content of the "Silver Chair" training some of the staff reviewed in June 2012. Refer to F157, F281 and F309 C/O #

Based on medical record review, observation, review of manufacturer's recommendations, review of hospital records, review of facility policy, review of medication publications and interview, the facility failed to be administered in a manner to ensure [MEDICATION NAME] (a blood thinning medication) therapy was provided safely and according to physicians' orders for fifteen (#2, #6, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24 and #25) of fifteen reviewed; to train and educate staff of the potential medication interactions between [MEDICATION NAME] and antibiotics; to ensure a process was in place to assist staff in the identification of potential life-threatening medication interactions with [MEDICATION NAME] of fifteen residents reviewed who were receiving [MEDICATION NAME]. The facility provided an acceptable Credible Allegation of Compliance on August 21, 2012. A revisit on August 22 and 23, 2012 and receipt on August 23, 2012 at 7:19 p.m. of verification the Medical Director and the Pharmacist had reviewed and approved all polices revealed the corrective actions, implemented on August 23, 2012 removed the Immediate Jeopardy. Non-compliance for F-490 continues at an "E" level citation. Validation of the Credible Allegation of Compliance was accomplished through medical record review, observation and interview with nurses and administrative staff. The facility provided evidence of new policies and procedures related to identification of and actions to take when residents were receiving [MEDICATION NAME] and orders were given for medications with a likelihood of medication interaction with [MEDICATION NAME]. The facility provided evidence of new policies related to notification of the physician of newly identified reddened areas on the skin in order to secure treatment of [REDACTED]. Inservice and training records including sign-in sheets for all nursing staff related to the new policies and procedures were provided. The sign-in sheets for the training records were compared to a listing of all licensed nurses employed by the facility and confirmed 100% (percent) of the facility's licensed nurses had been trained on the new policies and procedures. The facility provided evidence all residents who were receiving [MEDICATION NAME] had been assessed for [MEDICATION NAME] Time (PT) and International Normalized Ratio (INR) for monitoring anticoagulation therapy. Observation and interview revealed pharmacy alerts were received for residents who were receiving [MEDICATION NAME] and had new orders for medications with a likelihood of interaction with [MEDICATION NAME]. Medical record review, observation and interview confirmed nurses were notifying the physicians of the pharmacy alerts and were following the newly implemented policies and procedures. Observation of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Continued observation and interview with the medication nurses confirmed the facility had placed an "Anticoagulant Alert Form" printed on red paper in the MAR for each resident receiving [MEDICATION NAME] and had placed a conversion table for Vitamin K 10 mg (milligram) vials on the outside of one of two emergency boxes to assist with a quick calculation of doses ordered by the physician. Observation of the "PT/INR [MEDICATION NAME] ([MEDICATION NAME]) Flowsheet" for each resident receiving [MEDICATION NAME] revealed the flow sheet was being completed after PT/INR results were received and included the following information: Date, Time, INR results, PT results, Current dose of [MEDICATION NAME], if resident receiving antibiotic therapy, dosage change, next PT/INR date, family notification of change and nurses' signature. Continued review of the "PT/INR [MEDICATION NAME] ([MEDICATION NAME]) Flowsheet" for each resident in the facility receiving [MEDICATION NAME] revealed the DON or Designee had not initialed beside the nurses' signature to ensure accuracy of PT/INR results and new orders for [MEDICATION NAME] and the date of the next PT/INR as stated on the Allegation of Compliance. The facility must address this in the Plan of Correction. Based on medical record review, observation and interview, the Immediate Jeopardy was removed on August 23, 2012 at 7:19 p.m. after review of evidence the Medical Director and the Pharmacist had reviewed and approved all new and revised policies and procedures. The facility will remain out of compliance at a Scope and Severity level "E"-a pattern of deficient practice that constitutes no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. The facility remains out of compliance until it provides an acceptable plan of correction and the facility's corrective measures could be reviewed and evaluated by the Quality Assessment/Performance Improvement (QAPI) Committee.

Based on medical record review, observation, review of manufacturer's recommendations, review of hospital records, review of facility policy, review of medication publications and interview, the facility's Quality Assessment committee failed to maintain an effective quality assessment and assurance program for fifteen (#2, #6, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24 and #25) of fifteen residents reviewed who were receiving [MEDICATION NAME] (blood thinning medication). The facility's failure to identify and implement corrective actions to act upon problems with [MEDICATION NAME] therapy has caused or is likely to cause serious injury, harm, impairment or death to residents #2, #6, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24 and #25. The Administrator and the Director of Nursing were informed of the Immediate Jeopardy in the training room on August 6, 2012 at 11:30 a.m. The Immediate Jeopardy was effective January 18, 2012 and is ongoing. A partial extended survey was conducted on August 6, 2012. The findings included: Interview on July 24, 2012 at 2:45 p.m. in the training room with Licensed Practical Nurse (LPN) #1 who was responsible for obtaining blood thinner levels for PT ([MEDICATION NAME] Time)/INR (International Normalized Ratio) for all residents receiving [MEDICATION NAME] confirmed negative findings with [MEDICATION NAME] therapy were not identified and "Therefore problems with [MEDICATION NAME] therapy are not addressed." Interview on July 25, 2012 at 10:45 a.m. in the training room with the administrator revealed the Administrator was "unaware" of any problems or concerns with [MEDICATION NAME] therapy and confirmed the facility's Quality Assessment Committee had not addressed any concerns with [MEDICATION NAME] therapy since January 2012 when monthly monitoring of the timeliness of PT/INRs was implemented. Telephone interview on July 31, 2012 at 8:40 a.m. with the Medical Director revealed the Medical Director attended the facility's quarterly Quality Assessment Committee meetings. Continued interview confirmed the Medical Director had no recall the Quality Assessment Committee had addressed concerns related to [MEDICATION NAME] therapy. Refer to F157, F281 and F309 C/O #

Based on medical record review, observation, review of manufacturer's recommendations, review of hospital records, review of facility policy, review of medication publications and interview, the facility's Quality Assessment committee failed to maintain an effective quality assessment and assurance program for fifteen (#2, #6, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24 and #25) of fifteen residents reviewed who were receiving [MEDICATION NAME] (blood thinning medication). The facility's failure to identify and implement corrective actions to act upon problems with [MEDICATION NAME] therapy has caused or is likely to cause serious injury, harm, impairment or death to residents #2, #6, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24 and #25. The facility provided an acceptable Credible Allegation of Compliance on August 21, 2012. A revisit on August 22 and 23, 2012 and receipt on August 23, 2012 at 7:19 p.m. of verification the Medical Director and the Pharmacist had reviewed and approved all polices revealed the corrective actions, implemented on August 23, 2012 removed the Immediate Jeopardy. Non-compliance for F-520 continues at an "E" level citation. Validation of the Credible Allegation of Compliance was accomplished through medical record review, observation and interview with nurses and administrative staff. The facility provided evidence of new policies and procedures related to identification of and actions to take when residents were receiving [MEDICATION NAME] and orders were given for medications with a likelihood of medication interaction with [MEDICATION NAME]. The facility provided evidence of new policies related to notification of the physician of newly identified reddened areas on the skin in order to secure treatment of [REDACTED]. Inservice and training records including sign-in sheets for all nursing staff related to the new policies and procedures were provided. The sign-in sheets for the training records were compared to a listing of all licensed nurses employed by the facility and confirmed 100% (percent) of the facility's licensed nurses had been trained on the new policies and procedures. The facility provided evidence all residents who were receiving [MEDICATION NAME] had been assessed for [MEDICATION NAME] Time (PT) and International Normalized Ratio (INR) for monitoring anticoagulation therapy. Observation and interview revealed pharmacy alerts were received for residents who were receiving [MEDICATION NAME] and had new orders for medications with a likelihood of interaction with [MEDICATION NAME]. Medical record review, observation and interview confirmed nurses were notifying the physicians of the pharmacy alerts and were following the newly implemented policies and procedures. Observation of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Continued observation and interview with the medication nurses confirmed the facility had placed an "Anticoagulant Alert Form" printed on red paper in the MAR for each resident receiving [MEDICATION NAME] and had placed a conversion table for Vitamin K 10 mg (milligram) vials on the outside of one of two emergency boxes to assist with a quick calculation of doses ordered by the physician. Observation of the "PT/INR [MEDICATION NAME] ([MEDICATION NAME]) Flowsheet" for each resident receiving [MEDICATION NAME] revealed the flow sheet was being completed after PT/INR results were received and included the following information: Date, Time, INR results, PT results, Current dose of [MEDICATION NAME], if resident receiving antibiotic therapy, dosage change, next PT/INR date, family notification of change and nurses' signature. Continued review of the "PT/INR [MEDICATION NAME] ([MEDICATION NAME]) Flowsheet" for each resident in the facility receiving [MEDICATION NAME] revealed the DON or Designee had not initialed beside the nurses' signature to ensure accuracy of PT/INR results and new orders for [MEDICATION NAME] and the date of the next PT/INR as stated on the Allegation of Compliance. The facility must address this in the Plan of Correction. Based on medical record review, observation and interview, the Immediate Jeopardy was removed on August 23, 2012 at 7:19 p.m. after review of evidence the Medical Director and the Pharmacist had reviewed and approved all new and revised policies and procedures. The facility will remain out of compliance at a Scope and Severity level "E"-a pattern of deficient practice that constitutes no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. The facility remains out of compliance until it provides an acceptable plan of correction and the facility's corrective measures could be reviewed and evaluated by the Quality Assessment/Performance Improvement (QAPI) Committee.

Based on medical record review, review of manufacturer's recommendations, review of the facility investigation, facility policy review, observation and interview, the facility failed to notify the physician of the anticoagulant testing results for two residents (#2 and #21) and failed to notify the physician of the current [MEDICATION NAME] dosage and previous anticoagulant testing results for one (#24) of fifteen residents reviewed who were receiving [MEDICATION NAME] (anticoagulant/blood thinner). The facility's failure has caused or is likely to cause serious injury, harm, impairment or death to residents #2, #21 and #24. The facility failed to notify the physician to ensure assessment and treatment was provided to promote healing and prevent extension of a yeast infection ([MEDICAL CONDITION]) for one resident (#9) of twenty-four residents reviewed. The facility's failure resulted in harm to resident #9. The facility's failure has caused or is likely to cause serious injury, harm, impairment or death to resident #2, #21, #22 and #24. The Administrator and the Director of Nursing were informed of the Immediate Jeopardy in the training room on August 6, 2012 at 11:30 a.m. The Immediate Jeopardy was effective January 18, 2012 and is ongoing. A partial extended survey was conducted on August 6, 2012. The findings included: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the manufacturer's recommendations for the in-house blood thinner monitoring system revealed "...The American College of Chest Physicians makes these recommendations regarding INR (International Normalized Ratio (INR-measures the time it takes for blood to clot and compares it to an average) for patients on anticoagulant therapy:...treatment of [REDACTED]. Medical record review of the physician's orders dated December 26, 2011 revealed "[MEDICATION NAME] (blood thinner) 2 mg (milligrams) PO (by mouth) QD (every day)..." Medical record review of a laboratory result dated January 13, 2012 revealed PT ([MEDICATION NAME] time-blood test that measures how long it takes blood to clot) 44.2 and INR 4.4 (high). Medical record review of a physician's order dated January 13, 2012 revealed "Hold [MEDICATION NAME] until new orders received. Recheck INR 01-16-12 (2012)" Medical record review of a laboratory result dated January 16, 2012 revealed PT 37.8 and INR 3.8 (high). Medical record review of a physician's order dated January 16, 2012 revealed "Hold [MEDICATION NAME]. PT/INR 1/18/12." Medical record review of laboratory results dated [DATE] revealed PT 37.8 (reference range 9.5-11.1 seconds)/INR 3.8 (high). Medical record review of the laboratory results revealed no documentation the physician was notified of the PT/INR results. Review of the facility policy for physician notification revealed "It is the policy of this facility to promptly notify the resident's physician of changes in the resident's condition and/or status...Critical information will be called to the resident's attending physician promptly...In the event (faxes) to physician's offices have not been answered by 2:30 p.m., then the charge nurse should call the office for responses to any outstanding faxes." Telephone interview on July 18, 2012 at 2:25 p.m. with Nurse Practitioner (NP) #1 confirmed the NP and the physician were not notified of the PT/INR results on January 18, 2012 and confirmed the INR was above therapeutic level. Resident #21 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a hospital discharge summary dated March 26, 2012 revealed "...found to have A fib ([MEDICAL CONDITION] Fibrillation) with RVR (rapid ventricular rate)[MEDICATION NAME] level was also increased from 3 to 3.5 mg (milligrams) daily. Current INR is therapeutic. Medical record review of the physician's orders dated March 28, 2012 revealed the [MEDICATION NAME] 3.5 mg was ordered daily. Medical record review of laboratory results dated [DATE] revealed PT 54.8/INR 5.5 (high). Medical record review of a physician's order dated May 4, 2012 revealed [MEDICATION NAME] was placed on hold and PT/INR on May 6, 2012. Medical record review of laboratory results dated [DATE] revealed PT 20.1 and INR 2.0 (therapeutic). Medical record review of the Medication Administration Record [REDACTED]. Medical record review revealed no orders for [MEDICATION NAME] until May 7, 2012. Medical record review of the physician's order dated May 7, 2012 revealed [MEDICATION NAME] 2.5 mg was ordered daily and INR on May 11, 2012. Medical record review of laboratory results dated [DATE] revealed PT 27/INR 1.3 (low). Medical record review of a physician's order dated May 11, 2012 revealed the [MEDICATION NAME] dose was increased to 5 mg on May 11, 2012, 2.5 mg on May 12 and 5 mg on May 13, 2012 and PT/INR on May 14, 2012. Interview on July 23, 2012 at 2:10 p.m. in the training room with Licensed Practical Nurses (LPN) #1 confirmed [MEDICATION NAME] was not administered on May 6, 2012 because the facility failed to notify the physician of the PT/INR results on May 6, 2012. Continued interview revealed LPN #1 "found" on Monday, May 7, 2012 the INR results had not been called to the physician. LPN #1 notified the physician of the results on May 7, 2012 and received orders for [MEDICATION NAME] 2.5 mg daily. Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a hospital history and physical dated May 18, 2012 revealed "...presented to the emergency room after an apparent fall at home...significant fall with significant bruising on the side of...face...history of chronic [MEDICAL CONDITION] Fibrillation on chronic [MEDICATION NAME] therapy...INR supra therapeutic at 3.8...fall with significant hematoma in the periorbital area; with supra therapeutic [MEDICATION NAME]" Medical record review of a facility history and physical revealed "[MEDICAL CONDITION] Fibrillation-watch INR closely and adjust as needed." Medical record review of a baseline laboratory result dated May 22, 2012 revealed PT 9.8/INR 1.0 (low). Medical record review of a physician's order dated May 22, 2012 revealed alternating [MEDICATION NAME] dose of 3 mg two days (May 22 and 23, 2012) and 2 mg one day (May 24, 27, and 30, 2012) in rotation. Medical record review of a laboratory result dated May 29, 2012 revealed PT 19.3/INR 1.9 (low). Medical record review of a physician's order dated May 29, 2012 revealed the alternating [MEDICATION NAME] dose of 3 mg two days (May 29 and 30, and June 1, 2, 4, 5) and 2 mg one day (May 31, June 3) with PT/INR in one week (June 5, 2012). Medical record review of laboratory results dated [DATE] revealed PT 16.5/INR 1.7 (low). Medical record review of a physician's order dated June 5, 2012 revealed [MEDICATION NAME] was increased to 3 mg daily. Medical record review of laboratory results dated [DATE] revealed PT 18.8/INR 1.8 (low). Continued review of the PT/INR revealed the results were faxed to the physician on June 11, 2012. Continued review revealed NP #3 faxed the results back to the facility on [DATE] requesting the current dose of [MEDICATION NAME] and the previous PT/INR results. Medical record review revealed a physician's order for [MEDICATION NAME] was not obtained until June 13, 2012 and revealed [MEDICATION NAME] was increased to alternating 4 mg with 3 mg every other day. Continued medical record review of the MAR indicated [REDACTED]. Review of a facility investigation dated June 19, 2012 revealed the PT/INR results dated June 11, 2012 were faxed to the physician on June 11, 2012; the physician responded on June 12, 2012; and the nurses failed to follow up on the PT/INR which resulted in [MEDICATION NAME] 3 mg being administered every day instead of the alternating dosage of 4 mg and 3 mg. Medical record review of laboratory results dated [DATE] revealed PT 19.4/INR 1.9 (low). Medical record review of a physician's order dated June 20, 2012 revealed the alternating schedule of 4 mg one day and 3 mg one day was continued. Medical record review and interview on July 31, 2012 in the training room with LPN #1 confirmed the PT/INR results dated June 11, 2012 were faxed to the physician on June 11, 2012. Continued interview confirmed NP #3 faxed the results back to the facility on [DATE] requesting the current dose of [MEDICATION NAME] and the previous PT/INR results. Continued interview confirmed a physician's order for [MEDICATION NAME] was not obtained until June 13, 2012 and revealed [MEDICATION NAME] was increased to alternating schedule of 4 mg one day and 3 mg one day. Continued interview confirmed the [MEDICATION NAME] dose of 3 mg alternating with 4 mg in rotation was not transribed to the MAR until LPN #1 returned from vacation on June 18, 2012 and discovered the error in the [MEDICATION NAME] dosage which was being administered. Telephone interview on August 2, 2012 at 7:30 a.m. with NP #3 revealed "The hardest thing for us is residents on antibiotics (medication that often increases the INR to high levels) for UTIs (Urinary Tract Infections). Sometimes they'll (facility staff) fax the results but don't follow up. I'll fax it back and later that day they'll call me and say...didn't get the fax back from you when I had faxed it back with orders." Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE] revealed the resident had short and long-term memory problems and severely impaired decision-making skills; had no pain; and had no ulcers, wounds or skin problems. Medical record review of a weekly skin assessment dated [DATE] revealed the resident's skin was intact and had no open areas. Medical record review of a nurse's note dated July 10, 2012 at 12:30 a.m. revealed the resident's skin was "clammy et (and) sweaty." Continued review revealed "...Temp 102.8 (Fahrenheit)...crackles heard in bil (bilateral) lungs..." Continued review revealed the physician was notified and the resident was transferred to the hospital. Review of the hospital History and Physical dated July 10, 2012 revealed the resident was diagnosed with [REDACTED]. Medical record review of a nurse's note dated July 13, 2012 revealed the resident returned to the facility on [DATE]. Continued review revealed the resident was incontinent of bowel and bladder with "pericare" every two hours and as needed. Medical record review of a "Re-Admit Form" dated July 13, 2012 revealed "...Perineal area red & (and) sl. (slightly) irritated. (No) open areas or skin breakdown." Medical record review of the physician's orders dated July 13, 2012 revealed "[MEDICATION NAME] (antibiotic) 500 mg (milligrams)...daily x (times) 6 [MEDICATION NAME] (antibiotic) 500 mg TID (three times a day) x 6 days." Review of the facility's policy for wound care revealed "It is the policy of this facility that a resident with non-pressure wound(s) will receive necessary...service to prevent infection, promote healing, and if possible protect the wound from further injury...Upon admission and weekly, a skin assessment will be completed. Any identified wounds will be documented. The physician will be supplied with the resident [DIAGNOSES REDACTED]. A protective dressing will be applied to the wound until physician orders are obtained..." Review of the facility's policy for physician notification revealed "It is the policy of this facility to promptly notify the resident's physician of changes in the resident's condition and/or status...The nurse will notify the resident's attending physician when:...There is a significant change in the resident's physical, mental, or psychosocial status...There is a need to alter the resident's treatment significantly..." Observation on July 17, 2012 at 4:15 p.m. revealed the resident sitting in a chair at the bedside with the left pant leg above the knee. Observation revealed the resident continually attempted to raise the pant legs to the thigh saying "They're itching, itching." Observation and interview with Certified Nursing Assistant (CNA) #1 on July 17, 2012 at 4:20 p.m. in the resident's room revealed the CNA transferred the resident from the chair to the bed. Observation revealed the CNA removed the resident's pants. Observation revealed extensive bilateral redness and excoriation of the inner thighs, the entire perineum including the inner and outer labia and vaginal area, the rectal area of the buttocks, the upper buttocks, coccyx and sacrum. Observation revealed CNA #1 gasped when the CNA observed the extent of the yeast (candida) infection. Interview with CNA #1 revealed CNA #1 had taken the resident to the toilet at 3:00 p.m. and had not observed the redness and excoriation because the resident was sitting on the toilet. Continued interview with CNA #1 revealed CNA #1 had knowledge the resident had redness extending from the rectum to the coccyx and had been applying a "cream" (unidentified) to the areas. Continued interview with CNA #1 confirmed the skin was "worse" than what had been observed by the CNA on prior occasions since the resident returned from the hospital on July 13, 2012. The surveyor requested at 4:25 p.m. that the CNA get the charge nurse to assess the resident. Observation and interview on July 17, 2012 at 4:30 p.m. in the resident's room with Licensed Practical Nurse (LPN) #1 (who was also the LPN on duty on July 13, 2012 when the resident returned from the hospital) revealed LPN #1 gasped when the LPN observed the extent of the redness and excoriation of the thighs, perineum and buttocks. Interview with LPN #1 confirmed the yeast infection "did not just happen today but was not like that" on Friday, July 13, 2012 when the resident returned from the hospital (four days earlier). Interview on July 17, 2012 at 4:40 p.m. with LPN #1 revealed the Nurse Practitioner (NP) #1 was notified of the skin condition and the NP was coming to the facility to assess the resident. Observation and interview on July 17, 2012 at 5:00 p.m. in the resident's room with NP #1 confirmed the resident had a yeast infection. Observation revealed LPN #1 and CNA #1 were present in the room. Observation revealed NP #1 instructed the CNA and the LPN to leave the briefs off; cleanse the area gently with tepid water due to pain in the area; and apply [MEDICATION NAME] cream. Interview with the NP confirmed the NP was "in the building twice a day;" was also in the facility on Saturday, July 14, 2012 and had not been notified of the yeast infection. Continued interview confirmed if the NP had been notified of the yeast infection earlier, the NP "would have started treatment." Medical record review of a progress note by NP #1 dated July 17, 2012 at 5:25 p.m. revealed "Patient (with) urogenital [MEDICAL CONDITION](yeast) groin, vulva, rectum, tender...1. [MEDICATION NAME] 100 mg q (every) d (day) x 4 days...2. D/C (Discontinue) [MEDICATION NAME]...3. [MEDICATION NAME] cream apply to red areas urogenital TID x 7 days...4. Yogurt to each tray x 1 wk (week)...5. Continue antibiotics..." Medical record review of a progress note by NP #1 dated July 18, 2012 revealed, "...excoriation/[MEDICAL CONDITION] area from groin, vagina, vulva, & rectal area...it is painful & itchy started [MEDICATION NAME] cream & [MEDICATION NAME] along (with) yogurt to trays yesterday...needs rechecked..." Interview on July 18, 2012 at 9:10 a.m. in the training room with Licensed Practical Nurse (LPN) #1 revealed responsibilities of LPN #1 included the following Monday through Friday: perform wound care for all residents with wounds. Interview on July 18, 2012 at 8:15 a.m. in the training room with LPN #1 confirmed LPN #1 "should have been notified" of the yeast infection on Friday, July 13, 2012 and if LPN #1/Treatment Nurse had been notified, the Treatment Nurse would have notified the NP and obtained orders for treatment. Continued interview with LPN #1/Treatment Nurse confirmed the resident was harmed from the delay of treatment and with treatment; the extensive overgrowth of the yeast infection could have been prevented. C/O #

Based on medical record review, review of manufacturer's recommendations, review of the facility investigation, facility policy review, observation and interview, the facility failed to notify the physician of the anticoagulant testing results for two residents (#2 and #21) and failed to notify the physician of the current [MEDICATION NAME] dosage and previous anticoagulant testing results for one (#24) of fifteen residents reviewed who were receiving [MEDICATION NAME] (anticoagulant/blood thinner). The facility's failure has caused or is likely to cause serious injury, harm, impairment or death to residents #2, #21 and #24. The facility failed to notify the physician to ensure assessment and treatment was provided to promote healing and prevent extension of a yeast infection ([MEDICAL CONDITION]) for one resident (#9) of twenty-four residents reviewed. The facility's failure resulted in harm to resident #9. The facility provided an acceptable Credible Allegation of Compliance on August 21, 2012. A revisit on August 22 and 23, 2012 and receipt on August 23, 2012 at 7:19 p.m. of verification the Medical Director and the Pharmacist had reviewed and approved all polices revealed the corrective actions, implemented on August 23, 2012 removed the Immediate Jeopardy. Non-compliance for F-157 continues at a "D" level. Validation of the Credible Allegation of Compliance was accomplished through medical record review, observation and interview with nurses and administrative staff. The facility provided evidence of new policies related to notification of the physician when residents were receiving [MEDICATION NAME] and orders were given for medications with a likelihood of medication interaction with [MEDICATION NAME]. The facility provided evidence of new policies related to notification of the physician by telephone instead of by fax of critical values as well as all results of laboratory testing for monitoring the blood thinner level. The facility provided evidence of new policies related to notification of the physician of newly identified reddened areas on the skin in order to secure treatment of [REDACTED]. Inservice and training records with sign-in sheets for all nursing staff related to the new policies and procedures were provided and reviewed. The sign-in sheets for the training records were compared to a listing of all licensed nurses employed by the facility and confirmed 100% (percent) of the facility's licensed nurses had been trained on the new policies and procedures. Medical record review and interview confirmed nurses were notifying the physicians by telephone of pharmacy alerts and were following the newly implemented policies and procedures. Based on medical record review, policy review and interview, the Immediate Jeopardy was removed on August 23, 2012. The facility will remain out of compliance at a Scope and Severity level "D"-isolated deficient practice that constitutes no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. The facility remains out of compliance until it provides an acceptable plan of correction and the facility's corrective measures could be reviewed and evaluated by the Quality Assessment/Performance Improvement Committee.

Based on medical record review, review of hospital records, facility policy review, observation and interview, the facility failed to ensure necessary services were provided to promote healing and prevent extension of a yeast infection ([MEDICAL CONDITION]) for one resident (#9) of twenty-six residents reviewed. The facility's neglect resulted in harm to resident #9. The findings included: Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE] revealed the resident had short and long-term memory problems and severely impaired decision-making skills; had difficulty focusing attention, disorganized thinking and altered level of consciousness; required extensive assistance with bed mobility, transfers, dressing, eating, toilet use, personal hygiene and bathing; was only able to move from a seated to standing position, on and off the toilet and surface-to-surface transfers with staff assistance; had an unsuccessful response to a toileting program; was frequently incontinent of bowel and bladder; had no pain; and had no ulcers, wounds or skin problems. Medical record review of a weekly skin assessment dated [DATE] revealed the resident's skin was intact and had no open areas. Medical record review of a nurse's note dated July 10, 2012 at 12:30 a.m. revealed the resident's skin was "clammy et (and) sweaty." Continued review revealed "...Temp 102.8 (Fahrenheit)...crackles heard in bil (bilateral) lungs..." Continued review revealed the physician was notified and the resident was transferred to the hospital. Review of the hospital History and Physical dated July 10, 2012 revealed the resident was diagnosed with [REDACTED]. Medical record review of a nurse's note dated July 13, 2012 revealed the resident returned to the facility on [DATE]. Continued review revealed the resident was incontinent of bowel and bladder with "pericare" every two hours and as needed. Medical record review of a "Re-Admit Form" dated July 13, 2012 revealed "...Perineal area red & (and) sl. (slightly) irritated. (No) open areas or skin breakdown." Medical record review of the physician's orders [REDACTED]." Review of the facility's policy for wound care revealed "It is the policy of this facility that a resident with non-pressure wound(s) will receive necessary...service to prevent infection, promote healing, and if possible protect the wound from further injury...Upon admission and weekly, a skin assessment will be completed. Any identified wounds will be documented. The physician will be supplied with the resident [DIAGNOSES REDACTED]. A protective dressing will be applied to the wound until physician orders [REDACTED]. Observation on July 17, 2012 at 4:15 p.m. revealed the resident sitting in a chair at the bedside with the left pant leg above the knee. Observation revealed the resident continually attempted to raise the pant legs to the thigh saying "They're itching, itching." Observation and interview with Certified Nursing Assistant (CNA) #1 on July 17, 2012 at 4:20 p.m. in the resident's room revealed the CNA transferred the resident from the chair to the bed. Observation revealed the CNA removed the resident's pants. Observation revealed severe and extensive bilateral redness and excoriation of the inner thighs, the entire perineum including the inner and outer labia and vaginal area, the rectal area of the buttocks, the upper buttocks, coccyx and sacrum. Observation revealed CNA #1 gasped when the CNA observed the extent of the major yeast (candida) infection. Interview with CNA #1 revealed CNA #1 had taken the resident to the toilet at 3:00 p.m. and had not observed the redness and excoriation because the resident was sitting on the toilet. Continued interview with CNA #1 revealed CNA #1 had knowledge the resident had redness extending from the rectum to the coccyx and had been applying a "cream" (unidentified) to the areas. Continued interview with CNA #1 confirmed the skin was "worse" than what had been observed by the CNA on prior occasions since the resident returned from the hospital on July 13, 2012. The surveyor requested at 4:25 p.m. that the CNA get the charge nurse to assess the resident. Observation and interview on July 17, 2012 at 4:30 p.m. in the resident's room with Licensed Practical Nurse (LPN) #2 (who was also the LPN on duty on July 13, 2012 when the resident returned from the hospital) revealed LPN #2 gasped when the LPN observed the extent of the redness and excoriation of the thighs, perineum and buttocks. Interview with LPN #2 confirmed the yeast infection "did not just happen today and was not like that" on Friday, July 13, 2012 when the resident returned from the hospital. Continued interview with LPN #2 revealed the "Shower team told me today (July 17, 2012)after the shower (resident) was red but I thought it wasn't any worse than...on Friday." Continued interview with LPN #2 confirmed the LPN did not assess the resident after the shower team reported the redness to the LPN and confirmed LPN #2 had not reassessed the skin condition since Friday, July 13, 2012. Continued interview with LPN #2 revealed LPN #2 observed the shower team also inform the Treatment Nurse (LPN #1) of the yeast infection on July 17, 2012. Interview on July 17, 2012 at 4:40 p.m. with LPN #2 revealed the Nurse Practitioner (NP) #1 was notified of the skin condition and the NP was coming to the facility to assess the resident. Observation and interview on July 17, 2012 at 5:00 p.m. in the resident's room with NP #1 confirmed the resident had a yeast infection. Observation revealed LPN #1 and CNA #1 were present in the room. Observation revealed NP #1 instructed the CNA and the LPN to leave the briefs off; cleanse the area gently with tepid water due to pain in the area; and apply [MEDICATION NAME] cream. Interview with the NP confirmed the NP was "in the building twice a day" and had not been notified of the yeast infection. Continued interview confirmed if the NP had been notified of the yeast infection earlier, the NP "would have started treatment." Medical record review of a progress note by NP #1 dated July 17, 2012 at 5:25 p.m. revealed "Patient (with) urogenital [MEDICAL CONDITION](yeast) groin, vulva, rectum, tender...1. [MEDICATION NAME] 100 mg q (every) d (day) x 4 days...3. [MEDICATION NAME] cream apply to red areas urogenital TID x 7 days...4. Yogurt to each tray x 1 wk (week)...5. Continue antibiotics..." Medical record review of a progress note by NP #1 dated July 18, 2012 revealed, "...excoriation/[MEDICAL CONDITION] area from groin, vagina, vulva, & rectal area...it is painful & itchy started [MEDICATION NAME] cream & [MEDICATION NAME] along (with) yogurt to trays yesterday...needs rechecked..." Interview on July 18, 2012 at 8:15 a.m. in the training room with LPN #1 /Treatment Nurse revealed the resident did not have a shower on Tuesday as reported by LPN #2 and revealed the shower team had not reported the redness to LPN #1/Treatment Nurse on Tuesday, July 17, 2012 as reported by LPN #2. Continued interview with LPN #1/Treatment Nurse confirmed the Treatment Nurse had no knowledge of the yeast infection until notified by LPN #2 "last night" (July 17, 2012). Continued interview with LPN #1/Treatment Nurse confirmed LPN #1 had not been notified by the shower team as reported by LPN #2 and confirmed LPN #1 "should have been notified" of the yeast infection on Friday, July 13, 2012. Continued interview confirmed if LPN #1/Treatment Nurse had been notified, the LPN would have notified the NP and obtained orders for treatment. Continued interview with LPN #1/Treatment Nurse confirmed the resident was harmed from the delay of treatment and with treatment; the extensive overgrowth of the yeast infection could have been prevented. C/O #

Based on medical record review, review of hospital records, facility policy review, observation and interview, the facility failed to ensure necessary services were provided to promote healing and prevent extension of a yeast infection ([MEDICAL CONDITION]) for one resident (#9) of twenty-six residents reviewed. The facility's neglect resulted in harm to resident #9. The findings included: Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE] revealed the resident had short and long-term memory problems and severely impaired decision-making skills; had difficulty focusing attention, disorganized thinking and altered level of consciousness; required extensive assistance with bed mobility, transfers, dressing, eating, toilet use, personal hygiene and bathing; was only able to move from a seated to standing position, on and off the toilet and surface-to-surface transfers with staff assistance; had an unsuccessful response to a toileting program; was frequently incontinent of bowel and bladder; had no pain; and had no ulcers, wounds or skin problems. Medical record review of a weekly skin assessment dated [DATE] revealed the resident's skin was intact and had no open areas. Medical record review of a nurse's note dated July 10, 2012 at 12:30 a.m. revealed the resident's skin was "clammy et (and) sweaty." Continued review revealed "...Temp 102.8 (Fahrenheit)...crackles heard in bil (bilateral) lungs..." Continued review revealed the physician was notified and the resident was transferred to the hospital. Review of the hospital History and Physical dated July 10, 2012 revealed the resident was diagnosed with [REDACTED]. Medical record review of a nurse's note dated July 13, 2012 revealed the resident returned to the facility on [DATE]. Continued review revealed the resident was incontinent of bowel and bladder with "pericare" every two hours and as needed. Medical record review of a "Re-Admit Form" dated July 13, 2012 revealed "...Perineal area red & (and) sl. (slightly) irritated. (No) open areas or skin breakdown." Medical record review of the physician's orders [REDACTED]." Review of the facility's policy for wound care revealed "It is the policy of this facility that a resident with non-pressure wound(s) will receive necessary...service to prevent infection, promote healing, and if possible protect the wound from further injury...Upon admission and weekly, a skin assessment will be completed. Any identified wounds will be documented. The physician will be supplied with the resident [DIAGNOSES REDACTED]. A protective dressing will be applied to the wound until physician orders [REDACTED]. Observation on July 17, 2012 at 4:15 p.m. revealed the resident sitting in a chair at the bedside with the left pant leg above the knee. Observation revealed the resident continually attempted to raise the pant legs to the thigh saying "They're itching, itching." Observation and interview with Certified Nursing Assistant (CNA) #1 on July 17, 2012 at 4:20 p.m. in the resident's room revealed the CNA transferred the resident from the chair to the bed. Observation revealed the CNA removed the resident's pants. Observation revealed severe and extensive bilateral redness and excoriation of the inner thighs, the entire perineum including the inner and outer labia and vaginal area, the rectal area of the buttocks, the upper buttocks, coccyx and sacrum. Observation revealed CNA #1 gasped when the CNA observed the extent of the major yeast (candida) infection. Interview with CNA #1 revealed CNA #1 had taken the resident to the toilet at 3:00 p.m. and had not observed the redness and excoriation because the resident was sitting on the toilet. Continued interview with CNA #1 revealed CNA #1 had knowledge the resident had redness extending from the rectum to the coccyx and had been applying a "cream" (unidentified) to the areas. Continued interview with CNA #1 confirmed the skin was "worse" than what had been observed by the CNA on prior occasions since the resident returned from the hospital on July 13, 2012. The surveyor requested at 4:25 p.m. that the CNA get the charge nurse to assess the resident. Observation and interview on July 17, 2012 at 4:30 p.m. in the resident's room with Licensed Practical Nurse (LPN) #2 (who was also the LPN on duty on July 13, 2012 when the resident returned from the hospital) revealed LPN #2 gasped when the LPN observed the extent of the redness and excoriation of the thighs, perineum and buttocks. Interview with LPN #2 confirmed the yeast infection "did not just happen today and was not like that" on Friday, July 13, 2012 when the resident returned from the hospital. Continued interview with LPN #2 revealed the "Shower team told me today (July 17, 2012)after the shower (resident) was red but I thought it wasn't any worse than...on Friday." Continued interview with LPN #2 confirmed the LPN did not assess the resident after the shower team reported the redness to the LPN and confirmed LPN #2 had not reassessed the skin condition since Friday, July 13, 2012. Continued interview with LPN #2 revealed LPN #2 observed the shower team also inform the Treatment Nurse (LPN #1) of the yeast infection on July 17, 2012. Interview on July 17, 2012 at 4:40 p.m. with LPN #2 revealed the Nurse Practitioner (NP) #1 was notified of the skin condition and the NP was coming to the facility to assess the resident. Observation and interview on July 17, 2012 at 5:00 p.m. in the resident's room with NP #1 confirmed the resident had a yeast infection. Observation revealed LPN #1 and CNA #1 were present in the room. Observation revealed NP #1 instructed the CNA and the LPN to leave the briefs off; cleanse the area gently with tepid water due to pain in the area; and apply [MEDICATION NAME] cream. Interview with the NP confirmed the NP was "in the building twice a day" and had not been notified of the yeast infection. Continued interview confirmed if the NP had been notified of the yeast infection earlier, the NP "would have started treatment." Medical record review of a progress note by NP #1 dated July 17, 2012 at 5:25 p.m. revealed "Patient (with) urogenital [MEDICAL CONDITION](yeast) groin, vulva, rectum, tender...1. [MEDICATION NAME] 100 mg q (every) d (day) x 4 days...3. [MEDICATION NAME] cream apply to red areas urogenital TID x 7 days...4. Yogurt to each tray x 1 wk (week)...5. Continue antibiotics..." Medical record review of a progress note by NP #1 dated July 18, 2012 revealed, "...excoriation/[MEDICAL CONDITION] area from groin, vagina, vulva, & rectal area...it is painful & itchy started [MEDICATION NAME] cream & [MEDICATION NAME] along (with) yogurt to trays yesterday...needs rechecked..." Interview on July 18, 2012 at 8:15 a.m. in the training room with LPN #1 /Treatment Nurse revealed the resident did not have a shower on Tuesday as reported by LPN #2 and revealed the shower team had not reported the redness to LPN #1/Treatment Nurse on Tuesday, July 17, 2012 as reported by LPN #2. Continued interview with LPN #1/Treatment Nurse confirmed the Treatment Nurse had no knowledge of the yeast infection until notified by LPN #2 "last night" (July 17, 2012). Continued interview with LPN #1/Treatment Nurse confirmed LPN #1 had not been notified by the shower team as reported by LPN #2 and confirmed LPN #1 "should have been notified" of the yeast infection on Friday, July 13, 2012. Continued interview confirmed if LPN #1/Treatment Nurse had been notified, the LPN would have notified the NP and obtained orders for treatment. Continued interview with LPN #1/Treatment Nurse confirmed the resident was harmed from the delay of treatment and with treatment; the extensive overgrowth of the yeast infection could have been prevented. C/O #

Based on medical record review, review of hospital records, review of a grievance investigation, review of facility investigations, observation and interview, the facility failed to ensure a safety device was in place for two residents (#12 and #10) who were at high risk for falls of twenty-six residents reviewed. The facility's failure resulted in harm for resident #12 who received a scalp laceration after a fall. The findings included: Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE] revealed the resident had short and long-term memory problems and severely impaired decision-making skills; had disorganized thinking; required extensive assistance with bed mobility, transfers, dressing, eating, hygiene and bathing; required assistance with moving from a seated to a standing position, walking, turning around, moving on and off the toilet and surface-to-surface transfer; used a walker and wheelchair for mobility; and had a fall with injury since admission to the facility. Medical record review of an admission communication note by the Admissions Coordinator dated February 27, 2012 revealed "...fall risk precautions..." Medical record review of the fall risk assessment dated [DATE] revealed the resident was at high risk for falls. Medical record review of a nurse's note dated February 28, 2012 revealed "...observed on the floor in a laying position...had hands behind head & (and) blood was (visible)...C/O (complained of) neck & head. C-spine (Cervical spine) held. MD (Medical Doctor) called...sent to ER (emergency room ) for eval (evaluation)...area on back of head was unable to be determined..." Review of an ER report dated February 28, 2012 revealed a "1-2 cm (centimeter) FT (full thickness) lac (laceration)...mild surrounding Hematoma." Continued review revealed the resident also had a contusion of the scalp and a concussion without loss of consciousness. Continued review revealed staples were used to close the laceration. Review of discharge orders from the ER revealed "...Fall precautions...Staple removal 2-10 days...Daily wound care to scalp wound..." Review of a facility document entitled "Comment/Concern Form (grievance investigation)" dated February 28, 2012 revealed "...was trying to get up out of (wheelchair) and fell and hit...head...POA (Power of Attorney) told me that (resident) was suppose to have a pad alarm. There was no alarm in chair. There was one on the bed. Concern filled out because (POA) ask me to..." Review of a facility investigation dated February 28, 2012 revealed "Resident was observed lying on floor in room bleeding noted to back of head...was returned to...room (prior to being found on floor) after a shower and therapy..." Interview on July 24, 2012 at 4:45 p.m. in the training room with the Administrator revealed the resident was admitted to the facility on [DATE] at 6:30 p.m. and would have been assessed for the risk of falls on February 27, 2012. Continued interview confirmed if the resident was assessed at risk for falls on admission, an alarming pad or clip alarm would have been implemented. Interview on July 25, 2012 at 9:05 a.m. with Licensed Practical Nurse (LPN) #4 revealed LPN #4 was at the nurses' station on February 28, 2012 "getting ready to go in to assisted dining." LPN #4 heard a "thump down West hall" and observed the resident in the floor at the bathroom door in the resident's room. Continued interview revealed the resident's indwelling catheter drainage bag was still attached to the wheelchair. Continued interview revealed LPN #4 observed blood on the floor from the back of the resident's head. LPN #4 had a Certified Nursing Assistant (CNA) hold the C-Spine and LPN #4 "alerted" the resident's assigned nurse and went back to the resident's room. Continued interview revealed LPN #4 "felt the back" of the resident's head and "felt a gash." Continued interview confirmed when the resident fell ; a pressure pad alarm was not in the wheelchair. Continued interview revealed another nurse (no longer works at the facility) entered the room and asked "Where did (resident's) alarm go?" Continued interview revealed the LPN (#5) who was assigned to the resident on February 27, 2012 also reported a pressure pad was in place in the wheelchair before the resident was taken to therapy. Interview on July 25, 2012 at 10:30 a.m. in the training room with LPN #5 revealed LPN #5 was in the assisted dining room at the time of the fall. Continued interview confirmed a pressure pad alarm was in the wheelchair before the resident was taken to therapy. Continued interview revealed "After the fall, I realized therapy brought (resident) back without the alarm. I went around and told the therapists if they move a resident, they have to move the alarm with them and that's the reason (resident) fell ." Interview on July 25, 2012 at 11:00 a.m. in the training room with the Administrator revealed the facility used contracted therapists at the time of the fall and the therapists were not available for interview. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MDS dated [DATE] revealed the resident had short and long-term memory problems and severely impaired decision-making skills; had difficulty focusing attention and disorganized thinking; was totally dependent on staff for all activities of daily living (ADL); had impairment in range of motion for upper and lower extremities; and had two falls without injury since the previous assessment. Medical record review of fall risk assessments dated November 11, 2011 and February 10, 2012 revealed the resident was at high risk for falls. Medical record review of the care plan dated July 19, 2007 revealed the resident had a potential for injury related to Left [DIAGNOSES REDACTED] (Paralysis), CVA, History of Falls, Seizures and Dementia. Continued review revealed interventions related to the risk for falls included a pad alarm in the bed and chair and a low bed with a mat. Review of a facility accident investigation dated February 17, 2012 revealed the resident had a fall from the chair on February 17, 2012 and received a "small abrasion." Review of a facility accident investigation dated May 12, 2012 revealed the resident was observed on the floor mat by the low bed and received no injury. Review of a facility accident investigation dated June 11, 2012 revealed the resident was observed on the floor in front of the geri-chair on June 11, 2012 and received "no visible injury." Observation on July 16, 2012 at 10:20 a.m. revealed the resident lying in bed with the head of the bed in an upright position. Observation revealed a clip alarm lying on the chair at the bedside. Observation revealed a disconnected pressure pad alarm lying in the floor beside the bed. Observation and interview on July 16, 2012 at 10:30 a.m. with CNA #5 confirmed the pressure pad alarm was not connected to the electrical box and was nonfunctional. Observation revealed CNA #5 reconnected the alarm device. C/O #

Based on medical record review, review of hospital records, review of a grievance investigation, review of facility investigations, observation and interview, the facility failed to ensure a safety device was in place for two residents (#12 and #10) who were at high risk for falls of twenty-six residents reviewed. The facility's failure resulted in harm for resident #12 who received a scalp laceration after a fall. The findings included: Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE] revealed the resident had short and long-term memory problems and severely impaired decision-making skills; had disorganized thinking; required extensive assistance with bed mobility, transfers, dressing, eating, hygiene and bathing; required assistance with moving from a seated to a standing position, walking, turning around, moving on and off the toilet and surface-to-surface transfer; used a walker and wheelchair for mobility; and had a fall with injury since admission to the facility. Medical record review of an admission communication note by the Admissions Coordinator dated February 27, 2012 revealed "...fall risk precautions..." Medical record review of the fall risk assessment dated [DATE] revealed the resident was at high risk for falls. Medical record review of a nurse's note dated February 28, 2012 revealed "...observed on the floor in a laying position...had hands behind head & (and) blood was (visible)...C/O (complained of) neck & head. C-spine (Cervical spine) held. MD (Medical Doctor) called...sent to ER (emergency room ) for eval (evaluation)...area on back of head was unable to be determined..." Review of an ER report dated February 28, 2012 revealed a "1-2 cm (centimeter) FT (full thickness) lac (laceration)...mild surrounding Hematoma." Continued review revealed the resident also had a contusion of the scalp and a concussion without loss of consciousness. Continued review revealed staples were used to close the laceration. Review of discharge orders from the ER revealed "...Fall precautions...Staple removal 2-10 days...Daily wound care to scalp wound..." Review of a facility document entitled "Comment/Concern Form (grievance investigation)" dated February 28, 2012 revealed "...was trying to get up out of (wheelchair) and fell and hit...head...POA (Power of Attorney) told me that (resident) was suppose to have a pad alarm. There was no alarm in chair. There was one on the bed. Concern filled out because (POA) ask me to..." Review of a facility investigation dated February 28, 2012 revealed "Resident was observed lying on floor in room bleeding noted to back of head...was returned to...room (prior to being found on floor) after a shower and therapy..." Interview on July 24, 2012 at 4:45 p.m. in the training room with the Administrator revealed the resident was admitted to the facility on [DATE] at 6:30 p.m. and would have been assessed for the risk of falls on February 27, 2012. Continued interview confirmed if the resident was assessed at risk for falls on admission, an alarming pad or clip alarm would have been implemented. Interview on July 25, 2012 at 9:05 a.m. with Licensed Practical Nurse (LPN) #4 revealed LPN #4 was at the nurses' station on February 28, 2012 "getting ready to go in to assisted dining." LPN #4 heard a "thump down West hall" and observed the resident in the floor at the bathroom door in the resident's room. Continued interview revealed the resident's indwelling catheter drainage bag was still attached to the wheelchair. Continued interview revealed LPN #4 observed blood on the floor from the back of the resident's head. LPN #4 had a Certified Nursing Assistant (CNA) hold the C-Spine and LPN #4 "alerted" the resident's assigned nurse and went back to the resident's room. Continued interview revealed LPN #4 "felt the back" of the resident's head and "felt a gash." Continued interview confirmed when the resident fell ; a pressure pad alarm was not in the wheelchair. Continued interview revealed another nurse (no longer works at the facility) entered the room and asked "Where did (resident's) alarm go?" Continued interview revealed the LPN (#5) who was assigned to the resident on February 27, 2012 also reported a pressure pad was in place in the wheelchair before the resident was taken to therapy. Interview on July 25, 2012 at 10:30 a.m. in the training room with LPN #5 revealed LPN #5 was in the assisted dining room at the time of the fall. Continued interview confirmed a pressure pad alarm was in the wheelchair before the resident was taken to therapy. Continued interview revealed "After the fall, I realized therapy brought (resident) back without the alarm. I went around and told the therapists if they move a resident, they have to move the alarm with them and that's the reason (resident) fell ." Interview on July 25, 2012 at 11:00 a.m. in the training room with the Administrator revealed the facility used contracted therapists at the time of the fall and the therapists were not available for interview. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MDS dated [DATE] revealed the resident had short and long-term memory problems and severely impaired decision-making skills; had difficulty focusing attention and disorganized thinking; was totally dependent on staff for all activities of daily living (ADL); had impairment in range of motion for upper and lower extremities; and had two falls without injury since the previous assessment. Medical record review of fall risk assessments dated November 11, 2011 and February 10, 2012 revealed the resident was at high risk for falls. Medical record review of the care plan dated July 19, 2007 revealed the resident had a potential for injury related to Left [DIAGNOSES REDACTED] (Paralysis), CVA, History of Falls, Seizures and Dementia. Continued review revealed interventions related to the risk for falls included a pad alarm in the bed and chair and a low bed with a mat. Review of a facility accident investigation dated February 17, 2012 revealed the resident had a fall from the chair on February 17, 2012 and received a "small abrasion." Review of a facility accident investigation dated May 12, 2012 revealed the resident was observed on the floor mat by the low bed and received no injury. Review of a facility accident investigation dated June 11, 2012 revealed the resident was observed on the floor in front of the geri-chair on June 11, 2012 and received "no visible injury." Observation on July 16, 2012 at 10:20 a.m. revealed the resident lying in bed with the head of the bed in an upright position. Observation revealed a clip alarm lying on the chair at the bedside. Observation revealed a disconnected pressure pad alarm lying in the floor beside the bed. Observation and interview on July 16, 2012 at 10:30 a.m. with CNA #5 confirmed the pressure pad alarm was not connected to the electrical box and was nonfunctional. Observation revealed CNA #5 reconnected the alarm device. C/O #