Every finding on record at Country Care Manor

Based on interview and record review, the facility failed to ensure the residents' clinical record was complete and accurate for 2 (Resident #3, Resident #50) in that: 1. Resident #3's facesheet, care plan, and physician orders did not match. 2. Resident #50's diet order was missing from the clinical record for one month. This deficient practice could result in delayed or improper care due to inaccurate clinical records.The findings were: 1. Record review of Resident #3's facesheet, dated 12/14/2025, revealed the resident was admitted to the facility on [DATE] with diagnoses including Cerebral infarction, Type 2 diabetes mellitus without complications, and Chronic obstructive pulmonary disease. Record review of Resident #3's Quarterly MDS, dated [DATE], revealed a BIMS score of 11 which indicated moderate cognitive impairment. Record review of Resident #3's care plan, dated 09/11/2025, revealed, [Resident #3] require[s] anti-depressant medication [related to diagnosis:] Depression. Record review of Resident #3's physician order, dated 07/28/2025, revealed, Medication: Mirtazapine Tablet 7.5 MG, Medication Class: Antidepressants, Order Summary: Mirtazapine Tablet 7.5 MG Give 1 tablet by mouth at bedtime for Appetite Stimulant. Record review of Resident #3's clinical record, as of 12/17/2025, revealed Depression was not among the listed diagnoses. During an interview with the DON on 12/17/2025 at 10:55 a.m., the DON confirmed that Resident #3 had not been diagnosed with depression, was prescribed an antidepressant class medication for appetite stimulation, and stated that the care plan erroneously noted a diagnoses of depression. The DON stated the error was likely due to the medication classification. The DON confirmed that the resident's diagnoses list, care plan, and physician orders should be uniform, and stated it was important for providers and clinicians to have an accurate understanding of the residents' health status. 2. Record review of Resident #50's facesheet, dated 12/14/2025, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Aftercare following explantation of hip joint prosthesis, Unspecified fall subsequent encounter, and Acute kidney failure. Record review of Resident #50's Quarterly MDS, dated [DATE], revealed a BIMS score of 3 which indicated severe cognitive impairment. Record review of Resident #50's care plan, revised 09/12/2025, revealed, I [Resident #50] am at risk for nutritional deficits and/or dehydration risks [related to] Chronic comorbidity medical diagnosis, therapeutically restricted diet (No animal meat). Record review of Resident #50's order summary, dated 12/14/2025, revealed no diet order was present. Record review of Resident #50's diet order history as of 12/14/2025, revealed the resident's most recent diet order had a start date 10/16/2025 and an end date 11/15/2025. During an interview with [NAME] A on 12/16/2025 at 4:40 p.m., [NAME] A stated the Dietary Manager was unavailable for interview and stated that the kitchen staff was informed of the residents' diet order via the electronic medical record. [NAME] A further stated that kitchen staff would utilize the last recorded order if there was not a current diet order in the residents' record. [NAME] A also confirmed that Resident #50 had been receiving the diet approved by his physician and the Registered Dietician. During an interview with the Registered Dietician on 12/16/2025 at 4:45 p.m., the Registered Dietician stated the facility nursing communicates order changes to dietary department and that she has never encountered a communication error regarding a resident's diet order. The Registered Dietician also confirmed that Resident #50 has been receiving the correct diet.Observation on 12/16/2025 at 12:36 p.m. revealed Resident #50 received a meal in accordance with the physician and Registered Dietician orders. During an attempted interview with Resident #50 12/16/2025 at 12:36 p.m., Resident #50 was unable to participate in the interview but nodded and smiled when asked if he enjoyed his meal. Additional record review of Resident #50's order summary, dated 12/15/2025, revealed a diet order dated 12/14/2025 was present. During an interview with the DON on 12/16/2025 at 4:55 p.m., the DON confirmed that Resident #50's diet order had been missing for one month, stated the order should have been present, and stated the oversight was an error. Record review of the facility policy, Medical Records, revised January 2023, revealed, A medical record is maintained for every person admitted to a community in accordance with accepted professional standards and practices.

Based on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public on 5 of 12 resident rooms (rooms 101, 105, 107, 108, and 110) and 3 of 3 areas (hallway 100 shower room A, laundry room, and the maintenance office) reviewed for environmental concerns: The facility failed to repair bathroom ceiling vents in rooms #'s 101, 105, 107, 108 and 110, a non-functioning light in room # 110, a ceiling vent in the # 100 resident hallway shower room, a ceiling light in the laundry room, and a ceiling vent in the Maintenance office. These failures could place residents and staff at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe. The findings included: Observation on 12/16/25 from 1210-1230pm with the Administrator and Maintenance Director revealed the following:a-There was a bathroom ceiling vent that had rust on the vents in room # 101.b-There was a bathroom ceiling vent that had rust on the vents in room # 105.c-There was a bathroom ceiling vent that had rust on the vents in room # 107.d-There was a bathroom ceiling vent that had rust on the vents in room # 108.e-There was a bathroom ceiling vent that had rust on the vents in room # 110 and 1 of 2 bathrooms lights did not come on when engaged.f-There was a shower room in the Resident hallway #100 that had a bathroom ceiling vent with rust on the vents.g-There was a overhead light fixture with two 4 ft florescent lights that did not have a cover and 10 cracked 1x1 ft floor tiles in the laundry room.h-There was a 6x12 inch ceiling vent in the Maintenance office that had dirt and rust on the ceiling vents During an interview on 12/16/25 at 12:35pm with the Administrator and Maintenance Director the Maintenance Director stated he was aware of the resident room ceiling vents which needed repaired, and the repairs had been noted on the TELS work order list. The Maintenance Director stated that a cover for the ceiling lights in the laundry room would be beneficial for employee safety. The Administrator stated that making all of the facility repairs would promote a better facility building appearance. Record review of the facility work order log from 6/16/25 through 12/16/25 revealed that bathroom air vents were repaired as needed. Record review of the facility policy titled Preventative Maintenance from the Environment of Care Policy and Procedure Manual that was undated revealed preventative maintenance will be completed routinely and according to protocol by the Maintenance Supervisor or qualified designee.

Number of residents sampled: Number of residents cited: Based on observation, interview, and record review, the facility failed to ensure that residents received appropriate treatment and services to prevent urinary tract infections for 1 of 8 residents (Resident #25) who were reviewed for indwelling urinary catheter care, in that: Resident #25's indwelling urinary catheter bag was on the floor. These failures could affect residents with indwelling urinary catheters, placing them at risk of urinary tract infections. The findings were: Record review of Resident #25's face sheet, 12.14.25, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnosis that included: retention of urine [the inability to empty your bladder], heart failure[condition where the heart is too weak to pump blood and oxygen to meet the needs of body], and diabetes type 2 [ condition where body does not produce enough insulin or can't use insulin effectively]. Record review of Resident #25's Quarterly MDS, dated [DATE], revealed the resident had a BIMS of 12, which indicated moderate cognitive impairment. Record review of the quarterly MDS for Resident #25 revealed that, under the Bowel and Bladder section, option A was selected, indicating an Indwelling Foley catheter. Record review of Resident #25's care plan, dated 11/20/2025, revealed I require a catheter; check for kinks each shift. Observation on 12/14/2025 at 10:45 AM revealed Resident #25 was in bed sleeping. Further observation revealed that Resident # 25's indwelling urinary catheter bag was on the floor. Interview with Resident #25 on 12/14/2025 at 10:50 AM; stated his Foley catheter bag should not be on the floor, as this could cause urine to travel back up his urinary system and cause an infection. He was unaware that the bag was on the floor and did not know how long it had been there. During an interview with CNA (A) on 12/14/2025 at 10:55 AM, CNA (A) , stated she was the assigned to Resident #25's and his indwelling urinary catheter bag was on the floor not attached to movable part of bed, she stated that she forgot to attach catheter bag to the movable part of the bed this morning as she provided perineal care. During an interview with LVN (B) on 12/14/2025 at 11:05 AM, LVN (B) stated she was the assigned nurse for Resident #25 and that his catheter bag was on the floor. She noted that catheter bags should not be on the floor, as this was not good nursing practice and could lead to urinary infections. During an interview with the DON on 12/17/2023 at 9:35 AM, the DON stated that Resident #25's indwelling urinary catheter bag should not have been on the floor. She noted that all staff had been in-service on not allowing catheter tubing/bags to touch the floor to prevent urinary infections. The DON stated she did not know this deficient practice occurred, but would in-service all staff again. The DON noted that the risk to the resident of the catheter bag being on the floor was that urine bacteria could travel through the tubing and reach the kidneys, causing a urinary infection. She also stated that her ADON currently monitors whether the catheter bags are on or off the floor during rounds, and she oversees this task. Record review of facility policy Incontinence and Catheterization, dated 2017, revised January 2023, revealed, The community employs standard infection control practices in managing catheters and associated with the drainage system.

Based on interview and record review, the facility failed to permit a resident to return to the facility after hospitalization for 1 of 3 residents (Resident #1) reviewed for discharge rights. The facility failed to allow Resident #1 to return to the facility after hospitalization on 10/17/2025. This failure could lead to psychosocial harm and decreased quality of life. Findings included:Record review of Resident #1's face sheet dated 11/20/2025 reflected an [AGE] year-old-male admitted to the facility on [DATE] and discharged on 10/16/2025 to an acute care hospital. Relevant diagnoses included malignant neoplasm (cancer) of left bronchus or lung. Record review of Resident #1's quarterly MDS reflected a BIMS score of 13, which indicated intact cognition. Record review of Resident #1's EMR did not reveal a discharge summary signed by the resident's physician. Record review of Resident #1's physician orders active as of 10/16, 2025, the date of discharge, did not reveal and order to discharge Resident #1. Record review of Resident #1's hospital records dated 10/19/2025 revealed the following:In fact patient was feeling much better was ready to go home and clinically stable we placed the discharge orders andeven did the discharge summary. Later on I was notified by the nursing that doctors at the facility where the patient isresiding are not willing to accept him due to some dispute with the patient's [family member].As such patient will stay in the hospital until this is figured out. Will place a consultation with case management [sic]Record review of an e-mail dated 10/20/2025 from the Admin. to the facility's ombudsman indicated the facility would not allow Resident #1 to return to the facility after discharge from the acute care hospital due to concerns about his chosen facility. The Admin. said the resident's chosen physician was not responsive to the urgent messages communicated by the facility regarding Resident #1, and thus the facility felt the physician could not meet the needs of Resident #1. Therefore, they would not readmit Resident #1. Record review of an e-mail dated 10/21/2025 from the ombudsman to the facility reflected information from the TAC 554.1204 and 554.1201 sent to the facility advising them that it was the facility's responsibility to provide physician services 24-hours a day in the event of an emergency, as well as the responsibility to have a back-up physician available in the event that the primary physician was unavailable. The ombudsman asked in the e-mail if this clarifying information would be sufficient to allow readmission of Resident #1, but no response message was included in the file. Record review of Resident #1's hospital discharge records dated 10/24/2025 revealed Resident #1 was discharged from the acute care hospital on [DATE] to a skilled nursing facility. In an interview with Resident #1's family member on 11/20/2025 at 12:08 PM, she said she acted as Resident #1's POA and coordinated his medical care. She said she was not notified by the facility during Resident #1's hospitalization beginning on 10/17/2025, that Resident #1 would not be readmitted to the facility. She said she was not contacted by the Admin. at any time during the hospitalization, and she was notified by the hospital's case manager that the facility was refusing readmission. She said she did not receive any documentation, including e-mails or letters, notifying her of Resident #1's discharge. She said Resident #1 had not severed the patient-doctor relationship with MD B at the facility, and he intended to resume care from MD B upon return to the facility. She said Resident #1 remained under the care of MD B as of the date of the interview. She said she notified the ombudsman that they wanted to appeal the discharge, but Resident #1 was still refused readmission. Due to the unexpected difficulty with finding new placement, Resident #1's family member said the discharge from the acute care hospital was delayed, and Resident #1 experienced anxiety and sadness about remaining in the hospital without a place to discharge. In an interview with the ombudsman on 11/20/2025 at 2:50 PM, he said that when he became aware of the refusal of the facility to readmit Resident #1 during the hospitalization beginning on 10/17/2025, he notified the Admin. that Resident #1 had a right to return to the facility, and that the actions of the facility constituted dumping. He said the Admin. told him that the facility Resident #1 did not have a physician overseeing his care properly, so he could not return. He said he also told the facility that Resident #1 should be issued a notice of discharge, but the facility refused. He notified the facility that Resident #1 was formally appealing the discharge, but the facility informed him that Resident #1 could not return despite the appeal. He felt the facility was refusing to readmit Resident #1 due to conflicts with Resident #1's family member, not the issue regarding Resident #1's physician. In an interview with the Admin. on 11/20/2025 at 2:35 PM, he stated Resident #1 was initially terminated as a patient by the facility's MD, MD A, in August 2025, and the facility's second physician was not accepting new patients. Resident #1 then selected his outpatient physician, MD B, to be his physician at the facility, but he said MD B did not meet their expectations of responsiveness when the facility staff attempted to contact him after hours. He said that because of the lack of responsiveness from MD B, he felt readmitting Resident #1 under MD B's care would be a disservice. Since MD A had previously terminated Resident #1 and would not be accepted as a patient, he felt Resident #1's needs could not be met at the facility. He said he did not notify Resident #1 or his family member about the discharge by conversation or letter, and he was communicating only with the ombudsman. He said he was aware Resident #1 had appealed the discharge, but he was not permitted to return while the appeal was pending because the facility felt like there was not a physician available to oversee his care during the appeal period. He was unsure if Resident #1 had been given an opportunity to select a different physician prior to the refusal to readmit. He said the facility requested a discharge summary from MD B at the end of October, but the document had not been returned. In an interview with MD B's office on 11/21/2025 at 2:16 PM, MD B's medical assistant stated MD B was the physician overseeing Resident #1's care at the facility. She said the last communication made by the facility to MD B's office was on 10/16/2025 to the after hours on-call service regarding a change in condition. She said MD B had not been notified by the facility that Resident #1 had been discharged from the facility.Record review of the facility policy titled Admission, Transfer, and discharge date d September 2022, revealed the following:The notice of transfer or discharge must be given at least 30 days before the resident is transferred or discharged . The community permits residents to return to the community after they are hospitalized or placed on therapeutic leave . If the community determines that a resident who was transferred with an expectation of returning to the community, the community will comply with the transfer and discharge requirements as they apply .

Based on interview and record review, the facility failed to inform the resident if the facility determines that the physician chosen by the resident is unable or unwilling to meet requirements for 1 of 3 residents (Resident #1) reviewed for physician services. The facility failed to inform Resident #1 that his chosen physician did not meet the facility requirements and allow the resident to select a new physician while he was hospitalized beginning on 10/17/2025, leading to the facility refusing readmission of Resident #1. This failure could result in inappropriate discharges or decreased quality of life. Findings included:Record review of Resident #1's face sheet dated 11/20/2025 reflected an [AGE] year-old-male admitted to the facility on [DATE] and discharged on 10/16/2025 to an acute care hospital. Relevant diagnoses included malignant neoplasm (cancer) of left bronchus or lung. The face sheet indicated Resident #1's attending physician was MD B. Record review of Resident #1's quarterly MDS reflected a BIMS score of 13, which indicated intact cognition. Record review of a letter dated 8/05/2025 to Resident #1 from MD A (also the facility's Medical Director) revealed MD A terminated the physician-relationship with Resident #1 effective 9/07/2025 due to conflict with Resident #1's family. Record review of a letter dated 8/28/2025 to Resident #1 from the facility revealed a notice of discharge from the facility effective 9/07/2025 due to the termination of the physician-patient relationship by MD A. The letter instructed Resident #1 to identify a physician prior to 9/07/2025 who is able/willing to serve as Resident #1's attending physician, or he will be discharged to his family member's residence. The letter also included information about residents' rights to appeal discharges. Record review of Resident #1's hospital records dated 10/19/2025 revealed the following:In fact patient was feeling much better was ready to go home and clinically stable we placed the discharge orders andeven did the discharge summary. Later on I was notified by the nursing that doctors at the facility where the patient isresiding are not willing to accept him due to some dispute with the patient's [family member].As such patient will stay in the hospital until this is figured out. Will place a consultation with case management [sic]Record review of Resident #1's hospital discharge records dated 10/24/2025 revealed Resident #1 was discharged from the acute care hospital on [DATE] to a skilled nursing facility. Record review of an e-mail dated 10/20/2025 from the Admin. to the facility's ombudsman indicated the facility would not allow Resident #1 to return to the facility after discharge from the acute care hospital due to concerns about his chosen physician, MD B. The Admin. said MD B was not responsive to the urgent messages communicated by the facility regarding Resident #1, and thus the facility felt MD B could not meet the needs of Resident #1. Therefore, they would not readmit Resident #1. Record review of an e-mail dated 10/21/2025 from the ombudsman to the facility reflected information from the TAC 554.1204 and 554.1201 sent to the facility advising them that it was the facility's responsibility to provide physician services 24-hours a day in the event of an emergency, as well as the responsibility to have a back-up physician available in the event that the primary physician was unavailable. The ombudsman asked in the e-mail if this clarifying information would be sufficient to allow readmission of Resident #1, but no response message was included in the file. In an interview with Resident #1's family member on 11/20/2025 at 12:08 PM, she said she acted as Resident #1's POA and coordinated his medical care. She said she was not notified by the facility during Resident #1's hospitalization beginning on 10/17/2025, that Resident #1 would not be readmitted to the facility. She said she was not contacted by the Admin. at any time during the hospitalization, and she was notified by the hospital's case manager that the facility was refusing readmission. She said she did not receive any documentation, including e-mails or letters, notifying her of Resident #1's discharge. She said Resident #1 had not severed the patient-doctor relationship with MD B at the facility, and he intended to resume care from MD B upon return to the facility. She said she was satisfied with the care provided by MD B, and Resident #1 remained under the care of MD B as of the date of the interview. She said she notified the ombudsman that they wanted to appeal the discharge, but Resident #1 was still refused readmission. Due to the unexpected difficulty with finding new placement, Resident #1's family member said the discharge from the acute care hospital was delayed, and Resident #1 experienced anxiety and sadness about remaining in the hospital without a place to discharge. In an interview with the ombudsman on 11/20/2025 at 2:50 PM, he said that when he became aware of the refusal of the facility to readmit Resident #1 during the hospitalization beginning on 10/17/2025, he notified the Admin. that Resident #1 had a right to return to the facility, and that the actions of the facility constituted dumping. He said the Admin. told him that the facility Resident #1 did not have a physician overseeing his care properly, so he could not return. He notified the facility that Resident #1 was formally appealing the discharge, but the facility informed him that Resident #1 could not return despite the appeal. He felt the facility was refusing to readmit Resident #1 due to conflicts with Resident #1's family member, not the issue regarding Resident #1's physician because Resident #1 had an attending physician willing to oversee his care when the facility refused his readmission. In an interview with the Admin. on 11/20/2025 at 2:35 PM, he stated Resident #1 was initially terminated as a patient by the facility's MD, MD A, in August 2025, and the facility's second physician was not accepting new patients. Resident #1 then selected his outpatient physician, MD B, to be his physician at the facility, but he said MD B did not meet their expectations of responsiveness when the facility staff attempted to contact him after hours. Because of the lack of responsiveness from MD B, the Admin. said he felt readmitting Resident #1 under MD B's care would be a disservice. Since MD A had previously terminated Resident #1 and would not be accepted as a patient, he felt Resident #1's needs could not be met at the facility. He said he did not notify Resident #1 or his family member about the discharge by conversation or letter, and he was communicating only with the ombudsman. He said he was aware Resident #1 had appealed the discharge, but he was not permitted to return while the appeal was pending because the facility felt like there was not a physician available to oversee his care during the appeal period. He was unsure if Resident #1 had been given an opportunity to select a different physician prior to the refusal to readmit. He said the facility requested a discharge summary from MD B at the end of October, but the document had not been returned. In an interview with MD B's office on 11/21/2025 at 2:16 PM, MD B's medical assistant stated MD B was the physician overseeing Resident #1's care at the facility effective 9/4/2025. She said the last communication made by the facility to MD B's office was on 10/16/2025 to the after hours on-call service regarding a change in condition. She said MD B had not been notified by the facility that Resident #1 had been discharged from the facility.Record review of the facility policy titled Physician Responsibility: Documentation, Coverage and Rounding dated 2025 (no month) reflected the following:The Community is committed to ensuring that each resident is under the care of a licensed physician who assumes responsibility for medical care while the resident/patient resides in the community. In cases where a resident's primary care physician does not round, does not hold privileges, or refuses to provide direct oversight or 24 hour on-call, the community will assign or offer access to an attending physician approved and/or credentialed privileges at the community to ensure continuity of care.

Based on interviews and record reviews the facility failed to record in residents' medical records sufficient information to identify the Resident and services provided, for 4 of 8 residents (Residents #12, #24, #40 and #46) reviewed for services provided with activities of everyday life hygiene. 1. CNA B had no log in ID number to document care services provided to residents for 2 weeks. 2. CNAs had not documented oral care that was offered, preformed, and or refused for Resident #46 during the review period of September 2024. 3. CNAs had nowhere to document oral care that was offered, preformed, and or refused for Resident #40. 4. CNAs had nowhere to document oral care that was offered, preformed, and or refused for Resident #12. 5. CNAs had nowhere to document oral care that was offered, preformed, and or refused for Resident #24. These failures could place residents at risk for of having incomplete or inaccurate records and inadequate care. The findings included: Resident #46 A record review of Resident #46's admission record dated 09/18/2024, revealed an admitted [DATE] with diagnoses which included polyarthritis (five or more of your joints have arthritis at the same time) and contracted left and right hands, contracted left and right knees. A record review of Resident #46's quarterly MDS assessment dated [DATE] revealed Resident #46 was a [AGE] year-old female admitted for long term care and assessed with a BIMS score of 09 out of a possible 15 which indicated moderate impaired cognition. Further review revealed Resident #46 had no difficulty hearing, had clear speech, could understand others and could make herself understood, Resident #46 had adequate vision with the use of glasses. Further review revealed Resident #46 was totally dependent on staff and needed total assistance with oral care, personal hygiene, and transfers. A record review of Resident #46's care plan dated 09/18/2024 revealed, I am at risk for oral care issues: . provide and set up oral care supplies as indicated A record review of Resident #46's physician's orders dated 09/18/2024 revealed Resident #40's physician on 11/22/2020, ordered for Resident #40 to receive oral care as needed. A record review of Resident #46's medical record for the month of September 2024, revealed CNAs had not documented oral care that was offered, preformed, and or refused. Resident #40 A record review of Resident #40's admission record dated 09/18/2024, revealed an admitted [DATE] with diagnoses which included aphasia (impairment of language, speech, comprehension, and the ability to read and write), multiple sclerosis (a disease where a person's own immune system deteriorates muscle nerves), and myasthenia gravis (results from a problem in signaling between nerves and muscles.) A record review of Resident #40's quarterly MDS assessment dated [DATE] revealed Resident #40 was a [AGE] year-old female admitted for long term care and assessed with a BIMS score of 06 out of a possible 15 which indicated severe impaired cognition. Further review revealed Resident #40 had minimal difficulty hearing, clear speech, could usually understand and could usually make herself understood, Resident #40 had impaired vision, did not use glasses, and could see large print. Further review revealed Resident #40 needed assistance with oral care, personal hygiene, and transfers. Resident #40 was totally dependent on staff for activities of daily life to include personal hygiene and transfers (bed to chair) and Resident needed, substantial maximal assistance helper does more than half the effort with oral care. A record review of Resident #40's care plan dated 09/18/2024 revealed, I am at risk for oral care issues: own teeth, some loss or carious teeth. provide and set up oral care supplies as indicated A record review of Resident #40's physician's orders dated 09/18/2024 revealed Resident #40's physician on 05/30/2023, ordered for Resident #40 to receive oral care as needed. A record review of Resident #40's medical record revealed CNAs had nowhere to document oral care that was offered, preformed, and or refused. Resident #12 A record review of Resident #12's admission record dated 09/18/2024, revealed an admitted [DATE] with diagnoses which included dementia (a group of symptoms affecting memory, thinking and social abilities. In people who have dementia, the symptoms interfere with their daily lives), and end stage COPD (chronic obstructive pulmonary disease). A record review of Resident #12's annual MDS assessment dated [DATE] revealed Resident #12 was an [AGE] year-old female admitted for long term care and diagnosed with a life expectancy of less than 6 months. Resident #12 was assessed with a BIMS score of 05 out of a possible 15 which indicated severe cognitive impairment. Resident #12 was assessed and needed substantial maximal assistance helper does more than half the effort with transfers to and from a bed to a chair or wheelchair. A record review of Resident #12's physician's orders dated 09/18/2024 revealed Resident #12's physician on 11/07/2022, ordered for Resident #12 to receive oral care as needed. A record review of Resident #12's medical record revealed CNAs had nowhere to document oral care that was offered, preformed, and or refused. Resident #24 A record review of Resident #24's admission record dated 09/18/2024 revealed an admitted [DATE] with diagnoses which included Alzheimer's disease (a disabling degenerative disease of the nervous system occurring in middle-aged or older persons and characterized by dementia and failure of memory for recent events, followed by total incapacitation and death), muscle wasting, and heart failure. A record review of Resident #24's quarterly MDS assessment dated [DATE] revealed Resident #24 was a [AGE] year-old female admitted for long term care and assessed with a BIMS score of 08 out of a possible 15 which indicated moderately impaired cognition. Further review revealed Resident #24 needed assistance with personal hygiene and transfers, substantial maximal assistance helper does more than half the effort with transfers to and from a bed to a chair or wheelchair and partial / moderate - helper does less than half the effort. A record review of Resident #24's physician's orders dated 09/18/2024 revealed Resident #24's physician on 04/07/2024, ordered for Resident #24 to receive oral care as needed. A record review of Resident #24's medical record revealed CNAs had nowhere to document oral care that was offered, preformed, and or refused. During an interview on 09/18/2024 at 01:30 PM CNA B stated she was the CNA usually assigned to the facility's 100-hall and usually worked from 02:00-10:00 PM and has also worked some 06:00 AM to 02:00 PM shift on 100-hall. CNA B stated she had provided care, oral, personal hygiene, and incontinence care for Residents #12, #24, #40, #46. CNA B stated she had no log-in ID number to access the electronic medical record to document care provided to residents. CNA B stated she had access prior to September 2024 and as of September 2024 she had lost access. CNA B stated she had not been able to document any care offered and or refused. CNA B stated she had reported the loss of access to the ADON E. During an interview on 09/17/2024 at 09:40 AM ADON E stated she had just today learned CNA B had no access to document in residents' electronic medical record. ADON E stated CNA B should have access to document in the electronic medical record. ADON E stated the risk for harm to residents would be neglect and CNA B had the responsibility to report loss of access to document immediately. During a joint interview on 09/18/2024 at 03:00 PM with the Administrator and the DON, the administrator and the DON stated the expectation was for all CNA's to document the care provide immediately and to immediately report the inability to access the electronic record. A record review of the facilities Medical records policy dated February 2017, revealed, . Compliance Guidelines: A medical record is maintained for every person admitted to a community in accordance with accepted professional standards and practices. The administrator has ultimate responsibility for the maintenance of medical records but may delegate this responsibility to another team member. The medical record consists of but not limited to the following: ? information to identify the Resident . ? the plan of care and services provided

47611 Based on observations, interviews, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for Residents for two (Hall 100 and 200) of six shower rooms observed for environment and 1 laundry room reviewed for a safe, functional, sanitary, and comfortable environment. 1. The facility failed to ensure Residents' shower rooms on Halls 100 and 200 were clean, safe, and in good repair. 2. The facility failed to ensure the laundry washroom was clean, safe, and in good repair. 3. The ceiling vent in the bathroom of Resident room [ROOM NUMBER] had dirt and rust on the vent slats and parameter surface. 4. The bathroom door of Resident room [ROOM NUMBER] had a large indention on the bottom of wood surface of the door. This failure could place residents at risk for diminished quality of life due to the lack of a well-kept environment. Findings included: 1. Observation on 9/17/2024 at 10:57 am of the resident shower room on the 100-hall revealed black mildew and rust on the doorframe of the shower room, black mildew along the bottom of the shower room, and orange sediment on the shower chair. Observation on 9/17/2024 at 11:00 am of the resident shower room on the 200-hall revealed black mildew along the bottom of the shower room and orange sediment on the shower chair and black mildew on the shower chair wheels. Interview with the Maintenance Director on 9/17/2024 at 11:55 am, the Maintenance Director verified the black mildew and orange sediment on the shower chairs and the black mildew and rust on the 100-hall shower room door. He did verify that the bottom of the doorframe was rusted and needed to be repaired or replaced. He stated, the black stuff could be poop. He stated, the orange stuff looks to be sediment. He also explained that deep cleaning the shower rooms were housekeeping's responsibility. During an interview with the Administrator on 9/17/2024 at 1:22 pm, the Administrator stated the shower rooms should be sprayed down after every resident by the CNA's. He stated that housekeeping should be preforming a deep clean as needed. During an interview with the Housekeeping Manager on 9/18/2024 at 11:57 am, the Housekeeping Manager stated that housekeeping performs a deep cleaning on the resident showers once a week or sooner if needed. 2. During an observation and interview on 09/18/2024 at 12:04 PM revealed the facility's laundry washroom without drywall around 4 inches from the floor due to previous flooding and a significant gap under the exit door. The Maintenance Director stated the facility bought and installed a new commercial washer around 2 months ago (July 2024) because the old washer failed and leaked water and flooded the laundry washroom. The Maintenance Director stated the flood damaged the drywall about 3-4 above the floor, had missing pieces of drywall, and needed to be replaced. The Maintenance Director stated the threshold at the exit door had to be removed to allow the old washer and new washer to be removed and installed and thus revealed a 5/8 gap at the bottom of the door and could potentially allow insects and pest to enter the facility. Record review of the facility policy review titled, Physical Environment, revision date January 2023, showed under section titled Environmental Issues, The community is designed, constructed, equipped, and maintained to protect the health and safety of residents, personnel, and the public. Under the section titled, Preventative Maintenance, it showed The community has a preventive maintenance program that ensures that all essential mechanical, electrical, and patient-care equipment is in safe operating condition. 3. Observation on 09/17/24 at 12:00 p.m. with the Maintenance Director, revealed Resident room [ROOM NUMBER] had a bathroom ceiling vent which measured approximately one foot in diameter that had dirt and rust on the vent slats and parameter surface. 4. Observation on 09/17/24 at 12:05 p.m. with the Maintenance Director, revealed Resident room [ROOM NUMBER] had a bathroom door that had an indention on the bottom of wood surface of the door which measured approximately 1.5 ft x 13 inches. During an interview with the Maintenance Director on 09/17/24 at 12:10 p.m., Maintenance Director stated he had not been made aware by staff of the noted areas to be repaired. The Maintenance Director stated that completing the repairs would promote a homelike environment for the residents. During a tour with the Administrator on 9/17/24 at 12:15 to 12:20p.m., he observed Resident rooms #407 and #413 and stated that completing the repairs would promote a homelike environment for the residents. Record review of the facility's policy on Physical Environment dated 01/2023 stated that the community environment is safe, functional, sanitary, and comfortable for residents, team members, and the public.

Based on observations, interviews, and record reviews the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 4 of 8 residents (Residents #12, #24, #40, and #46) reviewed for oral care. 1. Resident #46 was not assisted with brushing her teeth on 09/17/2024. 2. Resident #40 was not assisted with brushing her teeth on 09/17/2024. 3. Resident #12 was not assisted with brushing her teeth on 09/17/2024. 4. Resident #24 was not assisted with brushing her teeth on 09/17/2024. These failures could place residents at risk for a decline in health status with dental caries and oral infections. The findings included: Resident #46 A record review of Resident #46's admission record dated 09/18/2024, revealed an admitted [DATE] with diagnoses which included polyarthritis (five or more of your joints have arthritis at the same time) and contracted left and right hands, contracted left and right knees. A record review of Resident #46's quarterly MDS assessment dated [DATE] revealed Resident #46 was a [AGE] year-old female admitted for long term care and assessed with a BIMS score of 09 out of a possible 15 which indicated moderate impaired cognition. Further review revealed Resident #46 had no difficulty hearing, had clear speech, could understand others and could make herself understood, Resident #46 had adequate vision with the use of glasses. Further review revealed Resident #46 was totally dependent on staff and needed total assistance with oral care, personal hygiene, and transfers. A record review of Resident #46's care plan dated 09/18/2024 revealed, I am at risk for oral care issues: . provide and set up oral care supplies as indicated A record review of Resident #46's physician's orders dated 09/18/2024 revealed Resident #40's physician on 11/22/2020, ordered for Resident #40 to receive oral care as needed. A record review of Resident #46's medical record for the month of September 2024, revealed CNAs had not documented oral care that was offered, preformed, and or refused. During an observation and interview on 09/15/24 at 10:50 AM revealed Resident #46 in her bed with the head of the bed up where she was positioned in a way so she could access her call light and her water drink with her left and right contracted hands. Further observation revealed Resident #46 had toothpaste and toothbrushes on a cubbyhole shelf by her bed. Resident #46 stated the supplies were brought to her by family member however they remained unused. Continued observations revealed LVN KT attended to Resident #46 at her bedside. Resident #46 stated she had complaints that she was not assisted with activities of daily life especially in the morning, on Fridays when church people come in, I would like my face washed and teeth brushed . I cannot do it myself I have bad arthritis. It's been weeks since I had help. LVN KT stated she worked part time on the weekends and stated Resident #46 should be assisted with her oral care due to her arthritis. LVN KT stated she was not aware if Resident #46 had her teeth brushed today and commented Resident #46 often refuses care. During an interview and observation on 09/17/24 at 08:30 AM revealed Resident #46's toothbrush and toothpaste in the same position and conditions as observed on 09/15/2024. Resident #46 stated no one has brushed her teeth today, yesterday and the day before. Further observation revealed Resident #46 in her bed receiving assistance eating her breakfast from CNA transport. Resident #46 stated she had not received assistance with oral care and CNA stated she had brushed her teeth this morning to which Resident #46 strongly denied and stated she had not had her teeth brushed this week. During an interview on 09/18/2024 at 02:44 PM Resident #46's representative and MPOA stated she believed Resident #46 had rarely received oral care. Resident #46's representative and MPOA stated she visited Resident #46 2-3 times a month and has recognized the unused toothbrushes and toothpaste. Resident #46's representative and MPOA stated Resident #46 was vulnerable and relies on staff for all care. Resident #46's representative and MPOA stated she believed the staff CNAs were caring but were short staffed and would not offer oral care like teeth brushing. Resident #46's representative and MPOA stated she had recognized a decline in Resident #46's oral health to include bad breath and dirty teeth. Resident #40 A record review of Resident #40's admission record dated 09/18/2024, revealed an admitted [DATE] with diagnoses which included aphasia (impairment of language, speech, comprehension, and the ability to read and write), multiple sclerosis (a disease where a person's own immune system deteriorates muscle nerves), and myasthenia gravis (results from a problem in signaling between nerves and muscles.) A record review of Resident #40's quarterly MDS assessment dated [DATE] revealed Resident #40 was a [AGE] year-old female admitted for long term care and assessed with a BIMS score of 06 out of a possible 15 which indicated severe impaired cognition. Further review revealed Resident #40 had minimal difficulty hearing, clear speech, could usually understand and could usually make herself understood, Resident #40 had impaired vision, did not use glasses, and could see large print. Further review revealed Resident #40 needed assistance with oral care, personal hygiene, and transfers. Resident #40 was totally dependent on staff for activities of daily life to include personal hygiene and transfers (bed to chair) and Resident needed, substantial maximal assistance helper does more than half the effort with oral care. A record review of Resident #40's care plan dated 09/18/2024 revealed, I am at risk for oral care issues: own teeth, some loss or carious teeth. provide and set up oral care supplies as indicated A record review of Resident #40's physician's orders dated 09/18/2024 revealed Resident #40's physician on 05/30/2023, ordered for Resident #40 to receive oral care as needed. A record review of Resident #40's medical record revealed CNAs had nowhere to document oral care that was offered, preformed, and or refused. During an interview on 09/15/2024 at 10:48 AM Resident #40 stated she could not recall when staff had offered assistance with brushing her teeth. Resident #40 stated she had not had her teeth brushed today. During an interview on 09/17/2024 at 08:48 AM Resident #40 stated she could not recall when staff had offered assistance with brushing her teeth. Resident #40 stated she had not had her teeth brushed today. Resident #12 A record review of Resident #12's admission record dated 09/18/2024, revealed an admitted [DATE] with diagnoses which included dementia (a group of symptoms affecting memory, thinking and social abilities. In people who have dementia, the symptoms interfere with their daily lives), and end stage COPD (chronic obstructive pulmonary disease). A record review of Resident #12's annual MDS assessment dated [DATE] revealed Resident #12 was an [AGE] year-old female admitted for long term care and diagnosed with a life expectancy of less than 6 months. Resident #12 was assessed with a BIMS score of 05 out of a possible 15 which indicated severe cognitive impairment. Resident #12 was assessed and needed substantial maximal assistance helper does more than half the effort with transfers to and from a bed to a chair or wheelchair. A record review of Resident #12's physician's orders dated 09/18/2024 revealed Resident #12's physician on 11/07/2022, ordered for Resident #12 to receive oral care as needed. A record review of Resident #12's medical record revealed CNAs had nowhere to document oral care that was offered, preformed, and or refused. During an observation and interview on 09/15/2024 at 12:20 PM Resident #12 and her family member were observed in Resident #12's bedroom. Resident #12 was seated in her wheelchair and appeared sleepy. Resident #12's family member was concerned Resident #12 was not receiving assistance from staff to eat and daily hygiene, specifically teeth brushing. Resident #12's family member stated they had been visiting 1-2 times a month for the last 6-7 months and had never seen any evidence Resident #12 was receiving dental care as evidenced by the same toothpaste tube and new toothbrushes stored in Resident #12's dresser. Observation of Resident #12's dresser drawer revealed new toothbrushes and a tube of tooth paste in good condition. During an observation and interview on 09/16/2024 at 8:30 AM revealed Resident #12 and her family member #2 were in Resident #12's bedroom while Resident #12 ate her breakfast. Resident #12's family member #2 stated she visited 3 times a week and had never seen Resident #12 receive assistance with brushing her teeth as evidenced by unused toothpaste and brushes. Resident #12's family member #2 stated their expectation would be that Resident #12 would receive oral care daily prior to breakfast. Resident #24 A record review of Resident #24's admission record dated 09/18/2024 revealed an admitted [DATE] with diagnoses which included Alzheimer's disease (a disabling degenerative disease of the nervous system occurring in middle-aged or older persons and characterized by dementia and failure of memory for recent events, followed by total incapacitation and death), muscle wasting, and heart failure. A record review of Resident #24's quarterly MDS assessment dated [DATE] revealed Resident #24 was a [AGE] year-old female admitted for long term care and assessed with a BIMS score of 08 out of a possible 15 which indicated moderately impaired cognition. Further review revealed Resident #24 needed assistance with personal hygiene and transfers, substantial maximal assistance helper does more than half the effort with transfers to and from a bed to a chair or wheelchair and partial / moderate - helper does less than half the effort. A record review of Resident #24's physician's orders dated 09/18/2024 revealed Resident #24's physician on 04/07/2024, ordered for Resident #24 to receive oral care as needed. A record review of Resident #24's medical record revealed CNAs had nowhere to document oral care that was offered, preformed, and or refused. During an observation and interview on 09/15/2024 at 10:44 AM revealed Resident #24 in her bedroom lying in bed. Resident #24 stated she had lived in the facility since spring and has not been offered to brush her teeth since. Resident #24 stated she would like to be offered a mouthwash if she could be assisted to the bathroom. Resident #24 stated she may not brush her teeth daily but would like to be offered assistance daily. During an observation and interview on 09/16/2024 at 1:44 PM revealed Resident #24 in her bedroom lying in bed while her representative visited. Resident #24's representative and Resident #24 stated the facility had treated her fine, but the facility had not offered to assist with brushing her teeth over the weeks she had been admitted . During an interview on 09/17/2024 at 8:50 AM Resident #24 stated she was not offered assistance with brushing her teeth. During an interview on 09/17/2024 at 8:28 AM CNA D stated she was the CNA for Residents #12, #24, #40, and #46 as well as other residents on 100-hall. CNA D stated she had not had time to provide residents on 100-hall oral care. During a joint interview on 09/17/2024 at 09:40 AM with ADON E and ADON F stated residents should be assisted and or offered assistance with oral care, teeth brushing, denture cleaning, and mouth washing at a minimum once a day in the mornings and preferably 2x a day morning and evening. The ADONs stated lack of oral care could lead to a health status decline with poor oral health. During a joint interview on 09/18/2024 at 03:00 PM with the Administrator and the DON, the administrator stated residents should receive oral care daily and staff should document the care. The DON stated the expectation was for residents to receive assistance with oral care daily and for staff to document the care. The DON and the administrator stated lack of oral care could lead to dental caries. A record review of the facility's Activities of Daily Living policy dated February 2017, revealed, . Activities of daily living include: personal hygiene . Residents who refuse care and treatment will be offered alternative treatment options and be advised of the negative impact of continued refusal to accept treatment and care.

Based on interview, and record review, the facility failed to ensure Quality Assurance Performance Improvement (QAPI) Training that outlines and informs staff of the elements and goals of the facility's QAPI program for 3 of 22 staff (CNAs G &H and LVN I) reviewed for training, in that: The facility failed to ensure that 3 of 22 staff (CNAs G&H and LVN I) had completed their mandatory QAPI annual training. This failure could place residents at risk for care by C.N.A. and L.V.N staff who had been insufficiently trained while working in the facility. The findings included: Record review of the annual CNA, and LVN training information revealed that: CNA G (hired-7/7/23), CNA H (hired-7/7/23), and LVN I (hired 8/16/16) had not completed their mandatory QAPI annual training requirement. During an interview with the Human Resources (HR) Director on 9/17/24 at 2:30p.m., she stated that there was not a record of completed annual QAPI training for C.N.A.-G, C.N.A.-H, and L.V.N-I. The HR Director stated that she had responsibility for coordinating the employee's training program and that it was the staff member's responsibility to have completed their training assignments. The HR Director stated that the staff member's completion of the training would have assisted them with providing improved resident care services. During an interview with the Regional HR Director on 9/17/24 at 2:40pm she stated that staff completion of their training requirements would have helped improve their resident care services. During an interview with the Administrator on 9/17/24 at 3:30p.m., he stated that staff's completion of their QAPI training would have made them aware of the process for improving resident care services. Record review of the facility's Team Member Handbook dated 9/2022 stated that All personnel are required to attend regularly scheduled in-service training classes and may also be asked to complete certain training programs using online modules.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for 1 of 4 halls (Hall 100) observed for environment, in that: The facility failed to ensure potential hazards were locked up in Hall 100 This deficient practice could place residents at risk of a diminished quality of life due to an unsafe environment. The findings were: Observation on 07/30/23 at 12:27 p.m. on Hall 100 revealed a container of Sani-Cloth, purple top (a germicidal wipe) in an open alcove. The container had physical and chemical hazard and precautionary statements., such as causes substantial but temporary eye damage. Call poison center or doctor for treatment advice. Further observation revealed several unnamed residents were seen in the hall. During an interview on 07/30/2023 at 12:33 p.m. with RN A, she confirmed the container of Sani-Cloth was in the open and it contained wipes. She also confirmed there were multiple residents with dementia able to transfer, ambulate or propel themselves on hall 100. She confirmed the wipes could be a hazard if handled improperly. She revealed the containers were usually kept in the carts and under lock. RN A did not know who had placed the Sani-Cloth container in the open alcove or when the wipes were left there. During an interview on 08/02/2023 at 12:41 p.m. with the DON, she revealed the Sani-Cloth constrainers are supposed to be kept out of reach of the residents. She confirmed that for a resident with dementia they could constitute a hazard and place them at risk for injury. She confirmed the staff was trained in the handling of hazardous products. She revealed the staff, including managerial staff, did rounds to ensure safety. Review of facility policy, titled Handling of needles, sharps containers, supplies and equipment, dated 5/30/2023, revealed All hazardous or dangerous supplies should be stored in supply closet, cabinet or in other designated area that is not within reach of our residents, patients, or other visitors.

Based on observation, interview, and record review, the facility failed to maintain a safe, clean, comfortable, and homelike environment for three (3) of twenty-two (22) residents (Resident #11, Resident #23, and Resident #39) reviewed in that: 1. There was a 1.5 inch by 18-inch scrape on the bathroom wall in room [ROOM NUMBER] in which Resident #11 and Resident #39 resided. 2. There was a hole in the wall and approximately one half of the baseboard along the same wall was loose in the bathroom of Resident #23's room. These failures could result in residents living in an environment that is not safe, clean, comfortable, and homelike in nature. The findings were: 1. Record review of Resident #11's face sheet, dated 08/02/2023, revealed the [AGE] year-old female resident was admitted to the facility on [DATE] with diagnoses including: right femur fracture (fracture of the thigh bone), chronic obstructive pulmonary disease (a type of progressive lung disease), and asthma (a long-term inflammatory disease of the lungs). Record review of Resident #39's face sheet, dated 8/2/23, revealed the [AGE] year-old female resident was admitted to the facility on [DATE] with diagnoses of cerebral infarction (a type of stroke that occurs when a blood vessel in the brain is blocked)., sick sinus syndrome (a group of abnormal heart rhythms), and COPD (a type of progressive lung disease). Record review of Resident #11's quarterly MDS assessment, completed on 6/23/23 revealed the resident had a BIMS score of 14 (a mental status test which showed an intact cognitive response). Record review of Resident # 39s annual MDS assessment, completed on 6/16/23 revealed the resident had a BIMS score of 15 (a mental status test which showed an intact cognitive response). Record review of Resident #1's most recent comprehensive MDS assessment, dated 06/01/2022, revealed Section I Active Diagnoses, Sub-section Psychiatric/Mood Disorder was left blank. During an observation in the room of Resident # 11 and Resident #39 on 7/31/23 at 9: 25am revealed a 1.5 inch by 18-inch scrape on the bathroom wall. During an interview with the Resident #11 and Resident #39 in room [ROOM NUMBER] on 7/31/23 at 9:30am, both residents stated that the scrape on the bathroom wall had been present for over one year. During an interview with the RN A on 7/31/23 at 9:30am in room [ROOM NUMBER] stated she had not been aware of the scrape on the bathroom wall. She stated that a work order to the Maintenance Director to repair the scrape was not made but she would complete this request. During an interview with the Maintenance Director on 7/31/23 at 9:40 a.m., in room [ROOM NUMBER] stated that he had not received a work order request to fix the bathroom wall scrape but would do so. During an interview with the Administrator on 7/1/23 at 4:40 pm stated the facility did not have a policy on the TELS (a work order notification system). 2. Record review of Resident #23's face sheet, dated 08/02/2023, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Difficulty in Walking, Unsteadiness on Feet, and Anxiety Disorder. Record review of Resident #23's Quarterly MDS, dated [DATE], revealed a BIMS score of 9 which indicated moderate cognitive impairment. Observation on 08/02/2023 at 9:42 a.m. of the Resident #23's bathroom revealed the wall behind the sink and toilet had a hole approximately ten inches square and approximately one half of the baseboard along the same wall was loose, with part of it lying in the floor. During an interview with Resident #23 on 08/02/2023 at 10:18 a.m., Resident #23 stated she disliked the disrepair in the bathroom connected to her room and that she wished the hole and baseboard would be repaired. Resident #23 stated she was concerned she might trip or slip on the loose baseboard and injure herself by falling. During an interview with the Maintenance Director on 08/02/2023 at 11:32 a.m., the Maintenance Director verbally confirmed the presence of a hole in the wall and loose baseboard in the bathroom connected to Resident #23's room, stated the hole had been cut to facilitate an ongoing repair, and that the baseboard had been loose for approximately two weeks. Record review of the facility policy on preventative maintenance dated 02/2017 on page 80 stated that the Maintenance Director is responsible for all preventative maintenance. Record review of the facility policy, Maintenance, dated February 2017, revealed, Nonoperating equipment is fixed or replaced in a timely manner. 41651

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one (1) of 1 kitchen, in that: The facility failed to ensure that dietary staff were wearing hair restraints and that the ceiling light covers were kept clean. This deficient practice could place residents who received meals and snacks from the kitchen at risk for food borne illness. The findings included: Observation on 07/30/23 at 9:40 a.m., revealed that two ceiling covers measuring four (4) foot by two (2) foot for the light fixtures in the main kitchen area had a accumulation of dust particles with several dead insects noted inside each cover. Observation on 07/30/2023 at 9:45 a.m. revealed Dietary Aide (DA) #1 and DA#2 were not wearing hair restraints. Interview with DA-b on 7/30/23 at 9:46 stated that he was not aware that he had to wear a hair restraint since he shaved his head every other week. He stated that he understood wearing hair restraints would prevent hair particles from falling onto a food surface. Interview with DA-C on 7/30/23 at 9:47 a.m., stated he was not aware that he had to wear a hair restraint since he wore a baseball cap. He stated that he understood wearing a hair restraint would prevent hair particles from falling onto a food surface. Interview with the Dietary Manager on 7/30/23 at 12:30 p.m., stated the two dietary aides who were not wearing hair restraints should have known it was necessary to prevent hair particles from falling onto the food. The Dietary Manager stated that she was responsible for notifying the Maintenance Director to clean the ceiling light covers. She stated she understood having dirty ceiling light covers could affect the kitchen's overall sanitation. Interview with the Maintenance Director on 7/31/23 at 9:45 a.m., stated that he had not received a work order request to clean the ceiling covers in the kitchen but they were now cleaned. Record review of the facility policy on employee sanitation in the Nutrition and Food Service Policy and Procedure manual dated 2018 Section 4-1 stated that hair restraints must be worn to keep hair from food and food-contact surfaces. Record review of the facility's policy on general kitchen sanitation in the Nutrition and Food Service Policy and Procedure Manual dated 2018 Section 4-5 stated that non-food-contact surfaces should be cleaned to keep them free of dust, dirt, and food particles in a clean and sanitary condition. Record review of the Dietician's Quality Assurance Monitor reports dated 4/21/23 and 7/11/23 stated that the general appearance of the kitchen's ceiling and light fixtures was not a clean appearance.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: 1. The DM and Dietary Aide D were wearing jewelry while preparing food in the kitchen. 2. Cook E's bare hands made contact with the blade of the blender used to process for modified diets and with ready-to-eat food. 3. Cook F did not sanitize the food thermometer when taking temperatures of food on the steam table prior to serving the lunch meal. These deficient practices could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. 1. An observation on 06/22/2022 at 10:30 a.m. revealed Dietary Aide A was standing in the kitchen in front of the ice machine. Dietary Aide D scooped ice from the machine into individual drinking glasses. At 10:43 a.m., Dietary Aide D went to the iced tea maker and poured mix into the machine. Dietary Aide D then poured tea into drinking cups and covered the cups with plastic wrap. Dietary Aide D was wearing a watch on her left wrist. An observation on 06/22/2022 at 11:16 a.m. revealed revealed the Dietary manager (DM) was standing over a pot on the stove, pouring a powder from a packet into boiling water. Further observation revealed the DM had on her left hand a watch, a ring on her middle finger, and a wedding ring set (engagement ring and wedding band) on her ring finger; on her right hand she had a ring on her index finger and one on her ring finger. During an interview with the DM on 06/22/2022 at 11:17 a.m., when asked what the DM was doing, the DM responded, I'm making some mashed potatoes. During a later interview with Dietary Aide D and the DM on 06/22/2022 at 12:50 p.m., Dietary Aide D confirmed that she was wearing a wristwatch in the kitchen while engaged in food preparation and the DM confirmed that she was wearing jewelry and a wristwatch in the kitchen while engaged in food preparation. When asked who was responsible for training the employees, the DM stated that she was responsible for training. 2. An observation on 06/22/2022 at 11:12 a.m. revealed Cook E poured a pot containing brown chunks and gravy into the blender in the kitchen. When asked what the food was, Cook E responded, Salisbury steak. Cook E pressed the start button on the blender; however, the blender did not begin operating. Using bare hands, Cook E removed the lid to the blender, reached inside the blender, removed the blade shaft that was approximately 7' in length, and then poured the food back into the pot. Cook E ran the blender blade shaft and lid under running water, and then, still using bare hands that had not been washed or sanitized, began to inspect the blade shaft by running her fingers along the surface of the three individual circular metal blades on the shaft several times. After this inspection, Cook E reinserted the blade shaft inside the blender, poured the food back into the blender, covered the blender with the lid, and pushed the start button. The blender operated properly and processed the meat for the modified diets. Observation on 06/22/2022 at 11:34 a.m. revealed that Cook E processed cooked chicken in the blender for modified diets. After stopping the blender, Cook E used bare hands to remove the lid to the blender, reached inside the blender, removed the blade shaft that was in direct contact with the chicken, poured the chicken into a pan and placed the pan on the steam table. During an interview with Cook E and the DM on 06/22/2022 at 12:50 p.m., Cook E confirmed that she touched the blade to the blender with her bare hands multiple times before the blade made direct contact with food, that she had not washed or sanitized her hands prior to handling the blade, and that by doing so, it was [NAME] to her putting her bare, unwashed hand directly inside the pan of food. Cook E further stated she understood that touching equipment with bare hands that came in direct contact with ready-to-eat food could potentially transmit harmful bacteria to the food and place residents at risk for food borne illness. Cook E could not state why she failed to wear gloves prior to handling the blade. 3. An observation on 6/22/2022 at 12:40 p.m. of the steam table in the kitchen where the food for the lunch meal was placed revealed Cook F standing in front of the table ready to take food temperatures. The DM was present as Cook F prepared to take food temperatures but then stepped away from the area of the steam table. Cook E was present and standing to the right of the steam table. There were individual disposable alcohol wipes on the ledge attached to the steam table. Cook F inserted the probe of a digital food thermometer with her right hand into a pan of pureed spinach. Cook F removed the thermometer from the spinach and wiped the probe with a paper towel that was in her left hand. Cook F inserted the same thermometer probe into a pan of pureed meat, removed the thermometer, and wiped the probe using the same paper towel that was still in her left hand. Cook F inserted the same thermometer into a pan of ground meat with her right hand, removed the thermometer, and wiped the probe of the thermometer with the same paper towel that was in her left hand. Cook F inserted the thermometer into a pan of gravy with her right hand, removed the thermometer, and wiped the probe with the same paper towel that was in her left hand. The DM returned to the steam table, observed Cook F taking food temperatures, and told Cook F, You need to sanitize it. Cook F then reached for an individual alcohol swab, opened the packet, inserted the thermometer probe into the packet, and then inserted the thermometer probe into a pan of meat and gravy on the steam table. During an interview with the DM on 6/22/2022 at 12:50 p.m., the DM confirmed that Cook F did not properly sanitize the thermometer when taking food temperatures by using a paper towel instead of an alcohol swab in between inserting the thermometer into different pans of food. When asked how long Cook F had worked in the kitchen, the DM stated, Two days. When asked if Cook F had been properly trained, the DM stated, No. When asked who was responsible for training new employees, the DM stated that she was responsible, and fell ow staff members also provided on-the-job training. Record review revealed that Cook F had a valid Food Handler certificate. Record review of facility policy 03.009 Sanitizing and Calibrating Thermometers, 2018, revealed, The facility will use a properly calibrated and sanitized thermometer to check the temperatures of potentially hazardous foods. 1. The thermometer must be sanitized prior to taking temperatures to avoid contaminating the food being tested . To sanitize the thermometer: a. Wipe off any food. b. Wash the entire thermometer stem in hot detergent water and rinse steam in clean water. C. Place stem in a sanitizing solution for one minute. Let solution drain from stem before placing in food items. d. Between food items, wipe off any food and place the stem or probe in a sanitizing solution for at least five seconds, then air dry. Record review of facility policy 03.004 Food Preparation and Handling, 2018, revealed, b. Wash hands properly before beginning food preparation. C. Prepare food with the least manual contact possible. Do not allow bare hands to touch raw food directly. Record review of facility policy 0.004 Employee Sanitation, 2018, revealed, No jewelry can be worn on the arms and hands while preparing food, except for a plain ring such as a wedding band. Record review of Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed, 2-303.11 Jewelry Prohibition. Except for a plain ring such as a wedding band, while preparing food, food employees may not wear jewelry including medical information jewelry on their arms and hands.

Based on record review and interview, the facility failed to ensure all Preadmission Screening and Resident Review (PASRR) Level I residents with mental illness were provided with a PASRR Level II assessment for 1 of 3 residents (Resident #18) reviewed for a mental illness, intellectual disability or developmental disability, in that: Resident #18 did not have a level II PASRR assessment. This deficient practice could affect residents who had been identified as requiring a level II PASRR assessment and place them at risk for not receiving needed care and services to meet their needs. The findings were: Record review of Resident #18's face sheet, dated 06/23/2022, revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed the [CONDITION(S)] was dated 10/12/2021. Record review of a physician note dated 05/03/2021 and, faced to the facility on [DATE] revealed He presented with [CONDITION(S)]. The symptoms started during childhood. Symptoms are made worse by no known associated factors. Record review of Resident #18's Admission MDS, dated [DATE] revealed the resident had an active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #18's PASRR Level 1 screen, dated 10/11/2021 revealed the resident was not indicated to have a developmental disability. Record review of Resident #18's PASRR Level 1 screen, dated 06/23/2022 revealed the resident was not indicated to have a developmental disability. The PASRR screening was obtained after the surveyor inquired about Resident #18's PASRR evaluation. During an interview on 06/23/2922 at 2:40 p.m. with MDS Nurse A confirmed Resident #18's PASRR Level I screen dated 10/11/2021 did not reflect developmental disability, and therefore a PASRR Level II evaluation had not been completed. The PASRR level 1 screen revealing the resident was positive for a developmental disability was dated 06/23/2022. Further interview revealed that Resident #18 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Texas Department of Aging and Disability Information Letter on Pre-Admission Screening and Resident Review- Reviewing and requesting changes to PASRR Level 1 (PL 1) screening forms, dated 12/31/2015, revealed: when a PL 1 screening form is received from a referring entity, the nursing facility should review section C, PASRR Screen, of the form before the form is entered to the portal. If any questions is answered no and the facility has information from medical records or information from family members that would make the answer to Section C yes the facility should contact the referring entity and request a revised PL 1. If the nursing facility is unable to get a revised PL 1 , the nursing facility should complete Form 1013, Request to Change a Negative PL 1

Based on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 7 residents (Resident #79) reviewed for infection control, in that: CNA B did not wash or sanitize her hands between change of gloves and cleaned Resident #79's catheter after placing a clean on the resident. This deficient practice could place residents at-risk for infection due to improper care practices. The findings include: Record review of Resident #79's face sheet, dated 06/22/2022, revealed an admitted [DATE], and a readmitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #79's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 12 which indicated moderate cognitive impairment. Resident #79 required extensive assistance, had an indwelling catheter and was frequently incontinent of bowel. Record review of Resident #79's care plan revealed a care plan, created on 02/24/2022, with a problem of I require a catheter Indwelling Catheter, related to a diagnostic of [CONDITION(S)] Bladder , related to a diagnostic of Urinary Retention and a goal of I will not experience any complications associated with my catheter to include trauma, infection or pain, dignity concerns through my next review date. Observation on 06/22/2022 at 11:40 a.m. revealed CNA B , while providing catheter and perineal care for Resident #79, cleaned Resident #79's buttocks, changed her gloves but did not wash or sanitize her hands. CNA B applied perineal cream on the resident's buttocks, changed her gloves but did not wash or sanitized her hands. CNA B placed new brief under Resident #79 and, with the assistance of CNA C, rolled the resident on her back. CNA B, then clean the resident's catheter after the clean brief were placed under Resident #79. During an interview with CNA B on 06/22/2022 at 11:53 a.m., CNA B verbally confirmed she did not wash her hands between change of gloves and clean the catheter after placing clean brief under Resident #79 . CNA confirmed she should have sanitized or washed her hands between change of gloves to avoid the risk of cross contamination. CNA B verbally confirmed she should have cleaned the catheter prior to changing the resident's brief. She added she was still a new CNA and was still learning. During an interview with the DON on 06/23/2022 at 9:55 a.m., the ADON confirmed the CNA should have washed or sanitized her hands between change of gloves. The DON confirmed the CNA should have clean the catheter prior to changing the brief of the resident. The DON confirmed there was a risk of cross contamination and infection for the resident. The DON confirmed infection control training was provided to the staff and she revealed the CNA had just passed her certification and was new. Record review of CNA B's, CNA skills checklist, checklist, dated 4/02/2022, revealed CNA B met requirement for handwashing and infection control skills. Record review of the facility's policy titled, Hand washing/Hand hygiene, dated 08/2025, revealed, Use an alcohol-based hand rub [ .] for the following situations [ .] After contact with blood or bodily fluid [ .]After removing gloves

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and time frames to meet residents' physical, mental, and psychosocial needs that are identified in the comprehensive assessment and to ensure that the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including the right to refuse treatment for 2 of 20 residents (Resident #21 and #55) reviewed for care plans, in that: 1. The facility failed to implement a comprehensive person-centered care plan to address Resident #21's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 2. The facility failed to implement a comprehensive person-centered care plan to address Resident #55's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures could affect residents who have care areas not addressed by the care plan by not having their needs met and putting them at risk of not receiving appropriate care. The findings were: 1. Record review of Resident #21's face sheet, dated 06/23/2022, revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #21's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 10, which indicated the resident had moderate cognitive impairment. Further review revealed the resident had a PHQ-9 score of 11 which indicated the resident had moderate depression, and in Section I, Active Diagnoses, under the category Psychiatric/Mood Disorder that . Depression (other than [CONDITION(S)]) was checked. Record review of Resident #21's Care Plan, last revision date 06/01/2022, revealed no focus area related to depression, monitoring for signs or symptoms of depression, goals or interventions related to the management of depression. During an interview with the MDS nurse on 06/23/2022 at 10:29 a.m., the MDS nurse stated, I don't see anything about depression in his [Resident #21's] care plan. We try to do care plans as a team. I am responsible for the nursing part. I have no idea why the MDS information did not trigger it - it should have so we could address it. During an interview with the ADON on 06/23/2022 at 10:32 a.m., the ADON confirmed that the focus area of Depression was a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] #21's care plan and should have been. The ADON noted that during Resident #21's baseline plan of care upon admission he was offered psychiatric care and refused services at that time; however, the ADON acknowledged that depression should have been listed as a focus area in Resident #21's care plan. 2. Record review of Resident #55's face sheet, dated 06/23/2022, revealed an initial admitted [DATE], and current admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #55's Admission MDS, dated [DATE], revealed the resident had a BIMS score of 10, which indicated the resident had moderate cognitive impairment. Further review revealed the resident had a PHQ-9 score of 6 which indicated the resident had mild depression, and in Section I, Active Diagnoses, under the category Psychiatric/Mood Disorder that . Depression (other than [CONDITION(S)]) was checked. Record review of Resident #55's active orders, dated 06/23/2022, revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #55's electronic clinical record, revealed a consent for psychoactive medication therapy, dated 05/21/2022, for [MEDICATION(S)]. The consent indicated the specific condition(s) to be treated includes: Depression. Record review of Resident #55's active orders, dated 06/23/2022, revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #55's Care Plan, last revision date 05/26/2022, revealed no focus area related to depression, anti-depressant medication use or monitoring of side effects. During an interview with the MDS nurse on 06/23/2022 at 3:53 p.m., the MDS nurse confirmed Resident #55's care plan did not address the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS nurse stated her understanding in the past was depression would trigger a care area from the MDS assessment. The MDS nurse further stated she was confused because she has had it explained two ways to her and will need to obtain clarification as to what is to be included. Record review of the facility's policy titled, Care Plans, implemented February 2017, revealed, The community develops a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. The care plan will describe: the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Record review of the facility's policy titled, Comprehensive Assessments, implemented February 2017, revealed, Comprehensive resident assessment: The community uses the Resident Assessment Instrument (RAI) to develop the comprehensive resident assessment. It identifies the care, services, and treatments that each resident needs to attain or maintain his or her highest practicable mental and physical functional status. Components of a Comprehensive Resident Assessment: The comprehensive assessment allows for the development of plan of care that addresses all of the resident's care needs. It also identifies the interventions that may be required to overcome barriers to the provision of resident care. The comprehensive assessment consists of a variety of data and information elements, including .mood and behavior patterns. Record review of, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, October 2019, revealed, Chapter 2.7 The Care Area Assessment (CAA) Process and Care Plan Completion: Federal statute and regulations require nursing homes to conduct initial and periodic assessments for all their residents. The assessment information is used to develop, review, and revise the resident's plans of care that will be used to provide services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The RAI process, which includes the Federally mandated MDS, is the basis for an accurate assessment of nursing home residents. The MDS information and the CAA process provide the foundation upon which the care plan is formulated. There are 20 problem-oriented CAAs, each of which includes MDS-based trigger conditions that signal the need for additional assessment and review of the triggered care area. Further review of the RAI User's Manual, revealed, Chapter 4 Care Area Assessment (CAA) Process and Care Planning: Table 1. Care Area Assessments in the RAI, Version 3.0 reveals, 8. Mood State and 17. [CONDITION(S)] Medication Use.

Based on interviews and record reviews, the facility failed to ensure residents' right to formulate an advance directive for 1 of 4 residents (Resident #23) reviewed for advanced directives, in that: The facility failed to ensure Resident #23's Out-of-Hospital Do Not Resuscitate (OOHDNR) was completed correctly by the attending physician. This failure could place residents at-risk of having their end of life wishes dishonored, and of having CPR performed against their wishes. The findings were: Record review of Resident #23's face sheet dated [DATE] revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . It leads to changes in awareness, movement and behaviors). Record review of Resident #23's Admission MDS, dated [DATE], revealed a BIMS score of 8, which indicated moderate cognitive impairment. Record review of Resident #23's Care Plan, last review date [DATE], revealed a focus area, date initiated [DATE], I/Family/RP has completed documentation for DNR status. I wish to be designated as DNR. Record review of Resident #23's active orders, dated [DATE], revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #23's electronic clinical record revealed an OOH-DNR for Resident #23, signed on [DATE] by the resident's family member and two witnesses. Further review revealed a signature on the line where Resident #23's attending physician would sign; however, the physician's printed name and license number were not included to identify which physician had signed the document. The physician had also not dated the document when it was signed. In an interview and record review with the SW on [DATE] at 3:15 p.m., the SW was asked if the OOH-DNR in Resident #23's electronic clinical record was correct. The SW stated the OOH-DNR was missing the physician's printed name and license number and was not dated. The SW was asked if she knew who had signed the OOH-DNR. She stated the signature was Resident #23's attending physician however confirmed not everyone would be able to determine that without the physician's printed name and license number. The SW further revealed herself to be the one responsible to discuss advance directives with residents and families and ensure correct completion of the documents. She stated she would speak with the family and physician to ensure the OOH-DNR is corrected right away. Record review of the Texas Health and Safety Code Title 2 Health, Subtitle H Public Health Provisions, Chapter 166 Advance Directives, Section 166.083 Form of Out-Of-Hospital DNR order, effective [DATE], revealed, (a) A written out-of-hospital DNR order shall be in the standard form specified by department rule as recommended by the department. (b) The standard form of an out-of-hospital DNR order specified by department rule must, at a minimum, contain the following: . (6) places for the printed names and signatures of the witnesses or the notary public's acknowledgment and for the printed name and signature of the attending physician of the person and the medical license number of the attending physician. Record review of the Texas Health and Human Services webpage titled, Out of Hospital Do Not Resuscitate Program, updated [DATE], revealed, Frequently Asked Questions for DNR: Filling out the Out-of-Hospital Do-Not-Resuscitate Form. Physician's Statement: The patient's attending physician must sign and date the form, print or type his/her name and give his/her license number. Record review of the facility's policy titled, Advanced Directives, dated February 2017, revealed, Every resident has the right to formulate an advance directive and to refuse treatment. The community will determine the existence of an advance directive at the time of admission. The community will inform the resident prior to admission whether its policies contain any limitations that are inconsistent with state law implementing a resident's advance directive.

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for 1 of 1 kitchen reviewed for food service safety, in that: 1. There was an opened bag of raw bacon in the walk-in cooler that was past its use-by date. 2. There were two open 8 oz. bags of potato chips in the dry storage room without a label indicating the date opened. These deficient practices could place residents who ate food from the kitchen at risk for foodborne illness. The findings were: 1. Observation on 03/07/2021 at 10:45 a.m. in the walk-in cooler in the kitchen revealed there was an opened commercial bag of raw bacon inside of a zip-locked bag. Further observation revealed the dates on the zip-locked bag were: Received 2/21, use by 2/27. The date printed on the bag of bacon was, Best before 2/10/21. During an interview with the Assistant Dietary Manager (ADM) on 03/07/2021 at 10:46 a.m., the ADM confirmed that the bacon was beyond its use-by date and should have been discarded. The ADM stated that it was the responsibility of any staff member who returns open food items to the cooler to ensure the item is properly labeled and dated with an opened and use-by date. 2. Observation on 03/07/2021 at 10: 57 a.m. in the dry storage room revealed two individual 8 oz. bags of potato chips, each rolled down and in a separate sealed zip locked bag. Further observation revealed there were no labels on the bags indicating the dates the bags of chips were opened. During an interview with the ADM on 03/07/2021 at 10:58 a.m., the ADM confirmed the bags of chips were opened and there were no labels indicating the dates they were opened. The ADM stated it was the responsibility of any staff member who returns open food items to the dry storage room to ensure the item is properly labeled and dated with an, opened, and, use-by, date. Record review of the Texas Food Establishment Rules (TFER), October 2015, §228.75(f)(1)(a) revealed, refrigerated, ready-to-eat, time/temperature controlled for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and held at a temperature of 41 degrees Fahrenheit or less if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises A) the day the original container is opened in the food establishment shall be counted as Day 1 (I) A food specified in subsection (g) (1) or (2) of this section shall be discarded if it (B) is in a container or package that does not bear a date or day, or (C) is appropriately marked with a date or day that exceeds a temperature and time combination as specified in subsection (g) (1) of this subsection.

Based on interview and record review, the facility failed to ensure that residents had the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, to formulate an advance directive, and also to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive for 3 of 18 residents, (Residents #218, #31, and #3) reviewed for advance directives in that: 1. Neither Resident #218 or his responsible party were informed of or provided written information of Resident #218's right to formulate an advance directive, resulting in being assigned a code status that was not his preference. 2. Resident #31 was a competent adult who did not sign her own OOH-DNR and did not know it had been executed on her behalf. 3. Resident #3 was a competent adult who did not sign her own OOH-DNR and did not know it had been executed on her behalf. These deficient practices could place residents at risk of having their personal medical decisions not honored. The findings were: 1. Record review of Resident #218's face sheet, dated [DATE], revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Further review revealed the face sheet indicated an Advance Directive of Full Code. Record review of Resident #218's Admission MDS, dated [DATE], revealed the resident had a BIMS of 12, which indicated mild cognitive impairment. Record review of Resident #218's care plan, dated [DATE], revealed: Focus - Resident/Family/RP does not have advance directives and elects Full Code Status, designating that the resident is a FULL CODE (CPR) status. Goal: Community will follow full code status through review date. Intervention: Review code status at least annually and as indicated. Review of Resident #218's Electronic Health Record (EHR) on [DATE] revealed the IDT (Inter-Disciplinary Tool): Admission/Readmission Tool V-2, Section W., remained uncompleted 4 days after Resident #218's date of admission. This section includes questions pertaining to Code Status, provides the resident and/or RP an opportunity to request a status and to complete documentation for DNR status, and to inform the facility of the resident's desire. During an interview with Resident #218 on [DATE] at 12:15 p.m., Resident #218 stated he was not asked his code preference status, provided the opportunity to formulate an advance directive, provided any written documentation from the facility concerning the right to formulate an advance directive, or the opportunity to provide documentation of an existing advance directive. Resident #218 further stated his admitted was [DATE], his family member was his responsible party (RP), his preferred code status was Do Not Resuscitate, and his RP had all the necessary paperwork. Resident #218 stated, I do have heart problems. No one asked me anything when I was admitted . My family member brought me here, he has all the paperwork. I think that paperwork is important. During an interview with Resident #218's RP on [DATE] at 1:08 PM, the RP stated that he was not asked about Resident #218's code preference upon admission and during his initial assessment. The RP further stated that he was in possession of Resident #218's advance directive paperwork and would be happy to provide it to the facility. 2. Record review of Resident #31's facesheet, dated [DATE], revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #31's clinical record revealed a physician's order, dated [DATE], which read, DNR. Further review of Resident #31's clinical record revealed an OOH-DNR, dated [DATE], and signed by the resident's family member. Record review of Resident #31's Admission MDS, dated [DATE], revealed a BIMS score of 15, which indicated intact cognition. Record review of Resident #31's Quarterly MDS, dated [DATE], revealed a BIMS score of 14, which indicated intact cognition. Record review of Resident #31's Quarterly MDS, dated [DATE], revealed a BIMS score of 15, which indicated intact cognition. Record review of Resident #31's care plan, revised [DATE], revealed a focus, I/Family/RP has completed documentation for DNR status. I wish to be designated as DNR, a goal, community will follow DNR status request, and interventions, a physician's order for DNR is to be placed in my clinical record, keep a copy of the OOHDNR form in my clinical record, review code status quarterly and as needed, send a copy of the OOHDNR with me in the event of transfer to the hospital or other facility. During an interview with Resident #31 on [DATE] at 10:35 a.m., Resident #31 confirmed she had not signed an OOH-DNR form and was unaware it had been executed on her behalf. 3. Record review off Resident #3's facesheet, dated [DATE], revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #3's clinical record revealed a physician's order, dated [DATE], which read, DNR. Further review of Resident #3's clinical record revealed an OOH-DNR, dated [DATE], and signed by the resident's family member. Record review of Resident #3's admission MDS, dated [DATE], revealed a BIMS score of 15 which indicated intact cognition. Record review of Resident #3's annual MDS, dated [DATE], revealed a BIMS score of 15 which indicated intact cognition. Record review of Resident #3's annual MDS, dated [DATE], revealed a BIMS score of 15 which indicated intact cognition. Record review of Resident #3's care plan, revised [DATE], revealed a focus, I/Family/RP has completed documentation for DNR status. I wish to be designated as DNR, a goal, community will follow DNR status request, and interventions, DNR will be placed in resident's clinical records, review code status quarterly and PRN. During an interview with Resident #3 on [DATE] at 10:40 a.m., Resident #3 confirmed she had not signed an OOH-DNR form and was unaware it had been executed on her behalf. During an interview on [DATE] at 5:34 p.m. with the DON, she stated that the resident's advance directive preference is obtained upon admission, and if the resident is unable to provide that information, it is requested from the resident's RP. Further interview revealed the nursing staff are responsible for completing advance directives, including OOH-DNR, upon admission. Record review of the Texas Department of State Health Services website (https://www.dshs.texas.gov/emstraumasystems/dnr.shtm) Out of Hospital Do Not Resuscitate Program, updated [DATE], revealed, Filling out the Out-of-Hospital Do-Not-Resuscitate Form .Declaration . A. This box is for patients who are competent. The patient should sign his/her name, date the document, and print or type his/her name . Record review of the facility policy, Statement of Resident Rights, dated February 2017, revealed, Residents do not give up any rights when entering a nursing home the resident has a right: .to participate in developing a plan of care, to refuse treatment . Record review of the facility policy, Resident Participation in Care Planning, dated February 2017, revealed, The resident has the right to participate in planning care and treatment or changes in care and treatment. 'Participates in planning care and treatment' means that the resident is afforded the opportunity to select alternative treatments .the community will assist resident participation in the care planning process .the resident has the right to refuse specific treatment and to select among treatment options before a care plan is instituted.

Based on interview and record review, the facility failed to purchase a surety bond, or otherwise provide assurance satisfactory to the Secretary, to assure the security of all personal funds of residents deposited with the facility for 1 of 1 surety bond reviewed for financial solvency, in that: The facility's $25,000.00 surety bond was not enough to match the $29,092.78 total residents' trust fund account balance. This deficient practice could place residents who deposit personal funds with the facility at-risk of their personal funds not being assured. The findings were: Record review of the facility's surety bond revealed the bond, dated 02/28/2015 and renewed 02/28/2021, was insured for $25,000.00, and was in effect from 02/28/2021 until 02/28/2022. Record review of the facility's current balance report, dated 03/10/2021, revealed the total balance of the residents' trust fund accounts was a total of $29,092.78, which exceeded the amount of the facility's surety bond. Further review revealed 20 of the facility's 65 residents had funds on deposit with the resident trust bank account. During an interview with the Business Office Manager on 03/10/2021 at 11:08 a.m., the Business Office Manager confirmed the total balance of the residents' trust fund accounts was $29,092.78, and confirmed that total balance exceeded the facility's $25,000.00 surety bond. During an interview with the Administrator on 03/10/2021 at 11:10 a.m., the Administrator confirmed the total balance of the residents' trust fund accounts was $29,092.78, confirmed that total balance exceeded the facility's $25,000.00 surety bond, and confirmed the residents' trust fund account should not have exceeded the surety bond. Record review of the facility's policy titled, Assurance of Financial Security, dated February 2017, revealed, The community has purchased a surety bond to ensure the security of all residents' personal funds deposited with the community.

Based on interviews and record reviews, the facility failed to develop and implement written policies and procedures that prohibit neglect for 2 of 6 residents (resident #1 and resident # 2) whose care was reviewed in that: Resident #1's [MEDICATION NAME] (a blood thinner) was given for almost 3 months without any monitoring of her INR. Resident # 1 was admitted to the hospital with [REDACTED]. Resident #2's [MEDICATION NAME] was given for about 7 months and without PT/INR monitoring for about 6 months. An immediate jeopardy was identified on [DATE]. The immediate jeopardy was removed on [DATE]. The facility remained out of compliance at a scope of pattern with actual harm, because the facility had not had time to monitor and evaluate the effectiveness of the Plan of Removal. This failure could affect 2 residents at the facility with prescribed [MEDICATION NAME] by contributing to inappropriate [MEDICATION NAME] administration resulting in harm or death based on missing orders or missing labs. The findings were: Review of resident #1's facesheet (dated [DATE]) revealed that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of resident #1's Admission MDS, dated [DATE] and Quarterly MDS, dated [DATE] revealed the resident was on anticoagulant therapy. Review of resident #1's Consolidated Physician Orders (dated [DATE]) revealed [MEDICATION NAME] Sodium ([MEDICATION NAME]) 3 mg give one tablet by mouth one time a day for treating/preventing blood clots. Order start date [DATE]. Review of resident #1's Consolidated Physician Orders (dated [DATE]) revealed no Physician order for [REDACTED]. With PT/INR levels out of range, [MEDICATION NAME] can cause bleeding which can be serious and may lead to death). Review of resident #1's August, September and October of 2016 MAR's revealed that [MEDICATION NAME] Sodium ([MEDICATION NAME]) was initialed as being given at 8:00 p.m. daily. Review of resident #1's Care Plan initiated on [DATE] and reviewed on [DATE] revealed there was no Care Plan for anticoagulant therapy. Review of resident #1's Consultant Pharmacist's Medication Regimen Review dated, [DATE] and [DATE], [DATE] and [DATE] revealed no notes or recommendation regarding anticoagulant therapy. Review of resident #1's Physician's Progress Notes from [DATE] through [DATE] revealed the resident was taking [MEDICATION NAME] 3 mg oral tablet, 1 PO daily since admission. These notes also revealed there was no evidence to support PT/INR monitoring ever occurred. Review of resident #1's Physician's Progress Notes dated [DATE] and signed [DATE] revealed the resident was taking [MEDICATION NAME] 3 mg oral tablet, 1 PO daily since admission. This note also revealed an Assessment of long term current use of anticoagulant (situation). Plan: Long-term current use of anticoagulant (situation) to continue [MEDICATION NAME] therapy for chronic A-fib, change schedule to give [MEDICATION NAME] at 5:00 p.m. versus at bedtime otherwise follow-up with INR per protocol. Review of resident #1's Nursing Progress Note dated [DATE] at 7:40 a.m. by ADON revealed that resident #1 was transferred from the facility to the hospital after resident was found unresponsive to verbal and tactile stimulation. EMS was notified and resident was transported to the hospital. Review of resident #1's Provider Investigation Report signed on [DATE] for the incident which occurred on [DATE] revealed an elevated INR which was reported from the hospital. The hospital requested the last INR lab values from the facility which prompted their lab audit. The resident did not recover from her unresponsiveness and she passed away. Findings inconclusive (waiting on hospital medical records) Review of resident #1's hospital Emergency Department Initial Order Set dated [DATE] at 9:30 a.m. revealed Diagnoses: [REDACTED]. Review of resident #1's hospital Emergency Department Physician Record dated [DATE] revealed the resident was given Vitamin K (used to increase blood clotting factors in the blood) 10 mg via IV. Review of resident #1's hospital History and Physical dated [DATE] revealed in the History of Present Illness: history of spontaneous fracture of her leg, left-sided subdural hematoma. Also noted was a marked coaguolpathy with INR of greater than 11. Past Medical history: a-fibrillation, [MEDICAL CONDITION], pacemaker, recent fracture. Review of resident #1's hospital PT/INR lab report dated [DATE] revealed a PT level of 85.1 with reference values (29.4 - 34.6) and an INR of 11.957 with reference values of (0.680 - 1.170), Review of resident #1's hospital Death Summary dated [DATE] revealed resident #1 was admitted from the emergency room after finding a large subdural hematoma and pending uncal herniation (downward displacement of medial brain structures which exerts pressure on the underlying structure including the [DIAGNOSES REDACTED]. The resulting injury to brainstem function rapidly leads to coma, nerve palcies and death.) Resident #1 was admitted for comfort measures. Hospital Recourse: over-anticoagulation with an INR of greater than 11. Final Diagnoses: [REDACTED]. [MEDICAL CONDITION], 3. Anticoagulation with coagulopathy, 11. Recent fracture of leg. Review of the Facility's Anticoagulant Therapy Procedure dated ,[DATE] revealed: 1. Identify resident on anticoagulant therapy and obtain medical [DIAGNOSES REDACTED]. 2. Review the resident's medication regimen for potential drug-drug interactions and notify the physician of any potential drug-drug-interactions. 3. Confirm with the physician the desired INR and/or PT testing schedule and therapeutic range at the time of the anticoagulant therapy order. 4. Initiate and order anticoagulant therapy labs per physician ' s order. 5. Upon receipt of lab results, review INR and/or lab results for abnormal values. 6. If lab results exceed therapeutic range, Hold anticoagulant medications until physician had been notified and new order is received. 7. Report lab results and current medication order to physician. 9. If acute or gross bleeding is noted, transfer resident to an acute care setting and notify physician. 10. Review the monthly pharmacist drug regimen review to include anticoagulant therapy for recommendation and follow. Interview on [DATE] at 4:00 p.m. with the DON, revealed resident #1 had no orders for PT/INR. She confirmed resident #1 was on [MEDICATION NAME]. She further stated there was no order, so the lab for PT/INR was never drawn. Interview on [DATE] at 9:40 a.m. with the ADON, revealed a nurse from the hospital called requesting resident #1's last PT/INR level. The hospital informed us on [DATE] that her PT/INR was 11.6. ADON became aware that no PT/INR had been ordered since resident #1's admit in July. Resident #1 died on [DATE]. The facility began their lab audits on [DATE]. ADON stated, We all dropped the ball, I really think we failed her. Interview on [DATE] at 12:20 p.m. with the Medical Director/ Primary Care Physician revealed resident #1 was there for rehabilitation for a fracture and was on an anticoagulant and doing well. He went on to state, we ordered standard labs, but never added the PT/INR. He stated, that the last DON discontinued the use of standing orders and used protocols. The Medical Director/ Primary Care Physician stated, he felt it was missed by everyone involved (in regards to the PT/INR labs). He also stated, Since her admit, PT/INR was never done, not ordered, not in her chart. We missed it. Interview on [DATE] at 3:00 p.m. with the DON, revealed resident #1 went to the hospital on [DATE]. On [DATE], the hospital called the facility and requested the last PT/INR. She further stated, When I requested lab results, I found out none were done. At that point she ran a report on all residents on [MEDICATION NAME]. She also found out there were no standing orders and notified the Medical Director. 2. Review of resident #2 's facesheet (dated [DATE]) revealed that she was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of resident #2's Consolidated Physician Orders (dated [DATE]) revealed [MEDICATION NAME] Sodium ([MEDICATION NAME]) 5 mg give one tablet by mouth one time a day at bedtime for treating/preventing blood clots. Order start date [DATE]. Review of resident #2's August, September and October of 2016 MAR's revealed that [MEDICATION NAME] Sodium ([MEDICATION NAME]) was initialed as being given at 8:00 p.m. daily. Review of resident #2's Laboratory Results printed on [DATE] revealed the last PT/INR was last drawn on [DATE] with PT level of 13.0 with reference values (10.4 - 13.8) and an INR of 1.15 with reference values of (0.80 - 1.20), Review of resident #2's Medication Incident Report (dated [DATE]) revealed scheduled PT/INR were not ordered or completed on this resident from her last PT/INR on [DATE] till it was discovered on [DATE] during a lab audit for [MEDICATION NAME]. Review of resident #2's Nurse Progress Note dated [DATE] revealed PT/INR was drawn at 7:00 p.m. on [DATE]. Review of resident #2's medical chart on [DATE] revealed a new order was written on [DATE] for PT/INR to be drawn every Monday. The Administrator and DON were notified on [DATE] at 8:25 a.m. that and Immediate Jeopardy was identified. The facility's plan of removal was provided by the Administrator on [DATE]. Plan of Removal was accepted by Surveyor on [DATE] at 3:05 p.m. Plan of Removal: I. Anticoagulant Therapy Labs Action(s): Audit all residents receiving anticoagulant therapy for the following: a. PT/INR orders - If PT/INR orders not in place, orders will be secured from physician. b. Audit lab results on residents receiving anticoagulant therapy for the past 30 days and notification of physician for abnormal finding. c. Care Plans for residents receiving anticoagulant therapy have been reviewed and updated as needed, Responsible: DON/designee Retraining: Nursing team members will be retrained by [DATE] on: a. Securing anticoagulant lab orders on admission/readmission/ change in orders. b. Normal lab values PT/INR c. Care planing for residents receiving anticoagulant therapy d. Physician notification of abnormal values e. Monitoring for side-effects anticoagulant therapy Completion Date: [DATE] Monitoring: DON/designee will review orders for anticoagulant therapy on Readmission/Admission/order change during morning meeting. DON/designee will randomly review 2 charts at least weekly of residents receiving anticoagulant. Findings will be brought to QAPI for at least 3 months. On [DATE], Surveyor reviewed the plan of removal which included the review of medical records, care plans, in-services, protocols and new orders put in place to be in compliance. Surveyor interviewed the staff and DON to verify implementation of changes had been made, for the plan of removal and that those changes were in place. At this point, the surveyor confirmed plan of removal was complete. Verification of the plan of removal included interviews with nursing staff. The nursing staff confirmed they had been in-serviced and had acquired sufficient education regarding the policies and procedures for anticoagulant therapy. In-services were held on [DATE] and completed on [DATE]. Seventeen LVN's/RN's were in-serviced on Lab Results by the DON on [DATE]. Twenty-three LVN's/RN's were in-serviced from [DATE] to [DATE], on Standing Orders for Blood Thinners. Twenty LVN's/RN' were in-serviced form [DATE] to [DATE] on Medications and Therapeutic Labs. DON provided a handwritten audit of all residents on [MEDICATION NAME] dated [DATE]. A review of resident #2's chart confirmed PT/INR orders were in place and included in the care plans. The Administrator and Corporate Manager were notified on [DATE] that the immediate jeopardy was removed, however the facility remained out of compliance at a scope of pattern with actual harm because the facility had not had time to monitor and evaluate the effectiveness of the Plan of Removal. Information was provided by the facility dated [DATE] revealed there were two residents on [MEDICATION NAME].

Based on interviews and record reviews, the facility failed to develop and implement written policies and procedures that prohibit neglect for 2 of 6 residents (resident #1 and resident # 2) whose care was reviewed in that: Resident #1's [MEDICATION NAME] (a blood thinner) was given for almost 3 months without any monitoring of her INR. Resident # 1 was admitted to the hospital with [REDACTED]. Resident #2's [MEDICATION NAME] was given for about 7 months and without PT/INR monitoring for about 6 months. An immediate jeopardy was identified on [DATE]. The immediate jeopardy was removed on [DATE]. The facility remained out of compliance at a scope of pattern with actual harm, because the facility had not had time to monitor and evaluate the effectiveness of the Plan of Removal. This failure could affect 2 residents at the facility with prescribed [MEDICATION NAME] by contributing to inappropriate [MEDICATION NAME] administration resulting in harm or death based on missing orders or missing labs. The findings were: Review of resident #1's facesheet (dated [DATE]) revealed that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of resident #1's Admission MDS, dated [DATE] and Quarterly MDS, dated [DATE] revealed the resident was on anticoagulant therapy. Review of resident #1's Consolidated Physician Orders (dated [DATE]) revealed [MEDICATION NAME] Sodium ([MEDICATION NAME]) 3 mg give one tablet by mouth one time a day for treating/preventing blood clots. Order start date [DATE]. Review of resident #1's Consolidated Physician Orders (dated [DATE]) revealed no Physician order for [REDACTED]. With PT/INR levels out of range, [MEDICATION NAME] can cause bleeding which can be serious and may lead to death). Review of resident #1's August, September and October of 2016 MAR's revealed that [MEDICATION NAME] Sodium ([MEDICATION NAME]) was initialed as being given at 8:00 p.m. daily. Review of resident #1's Care Plan initiated on [DATE] and reviewed on [DATE] revealed there was no Care Plan for anticoagulant therapy. Review of resident #1's Consultant Pharmacist's Medication Regimen Review dated, [DATE] and [DATE], [DATE] and [DATE] revealed no notes or recommendation regarding anticoagulant therapy. Review of resident #1's Physician's Progress Notes from [DATE] through [DATE] revealed the resident was taking [MEDICATION NAME] 3 mg oral tablet, 1 PO daily since admission. These notes also revealed there was no evidence to support PT/INR monitoring ever occurred. Review of resident #1's Physician's Progress Notes dated [DATE] and signed [DATE] revealed the resident was taking [MEDICATION NAME] 3 mg oral tablet, 1 PO daily since admission. This note also revealed an Assessment of long term current use of anticoagulant (situation). Plan: Long-term current use of anticoagulant (situation) to continue [MEDICATION NAME] therapy for chronic A-fib, change schedule to give [MEDICATION NAME] at 5:00 p.m. versus at bedtime otherwise follow-up with INR per protocol. Review of resident #1's Nursing Progress Note dated [DATE] at 7:40 a.m. by ADON revealed that resident #1 was transferred from the facility to the hospital after resident was found unresponsive to verbal and tactile stimulation. EMS was notified and resident was transported to the hospital. Review of resident #1's Provider Investigation Report signed on [DATE] for the incident which occurred on [DATE] revealed an elevated INR which was reported from the hospital. The hospital requested the last INR lab values from the facility which prompted their lab audit. The resident did not recover from her unresponsiveness and she passed away. Findings inconclusive (waiting on hospital medical records) Review of resident #1's hospital Emergency Department Initial Order Set dated [DATE] at 9:30 a.m. revealed Diagnoses: [REDACTED]. Review of resident #1's hospital Emergency Department Physician Record dated [DATE] revealed the resident was given Vitamin K (used to increase blood clotting factors in the blood) 10 mg via IV. Review of resident #1's hospital History and Physical dated [DATE] revealed in the History of Present Illness: history of spontaneous fracture of her leg, left-sided subdural hematoma. Also noted was a marked coaguolpathy with INR of greater than 11. Past Medical history: a-fibrillation, [MEDICAL CONDITION], pacemaker, recent fracture. Review of resident #1's hospital PT/INR lab report dated [DATE] revealed a PT level of 85.1 with reference values (29.4 - 34.6) and an INR of 11.957 with reference values of (0.680 - 1.170), Review of resident #1's hospital Death Summary dated [DATE] revealed resident #1 was admitted from the emergency room after finding a large subdural hematoma and pending uncal herniation (downward displacement of medial brain structures which exerts pressure on the underlying structure including the [DIAGNOSES REDACTED]. The resulting injury to brainstem function rapidly leads to coma, nerve palcies and death.) Resident #1 was admitted for comfort measures. Hospital Recourse: over-anticoagulation with an INR of greater than 11. Final Diagnoses: [REDACTED]. [MEDICAL CONDITION], 3. Anticoagulation with coagulopathy, 11. Recent fracture of leg. Review of the Facility's Anticoagulant Therapy Procedure dated ,[DATE] revealed: 1. Identify resident on anticoagulant therapy and obtain medical [DIAGNOSES REDACTED]. 2. Review the resident's medication regimen for potential drug-drug interactions and notify the physician of any potential drug-drug-interactions. 3. Confirm with the physician the desired INR and/or PT testing schedule and therapeutic range at the time of the anticoagulant therapy order. 4. Initiate and order anticoagulant therapy labs per physician ' s order. 5. Upon receipt of lab results, review INR and/or lab results for abnormal values. 6. If lab results exceed therapeutic range, Hold anticoagulant medications until physician had been notified and new order is received. 7. Report lab results and current medication order to physician. 9. If acute or gross bleeding is noted, transfer resident to an acute care setting and notify physician. 10. Review the monthly pharmacist drug regimen review to include anticoagulant therapy for recommendation and follow. Interview on [DATE] at 4:00 p.m. with the DON, revealed resident #1 had no orders for PT/INR. She confirmed resident #1 was on [MEDICATION NAME]. She further stated there was no order, so the lab for PT/INR was never drawn. Interview on [DATE] at 9:40 a.m. with the ADON, revealed a nurse from the hospital called requesting resident #1's last PT/INR level. The hospital informed us on [DATE] that her PT/INR was 11.6. ADON became aware that no PT/INR had been ordered since resident #1's admit in July. Resident #1 died on [DATE]. The facility began their lab audits on [DATE]. ADON stated, We all dropped the ball, I really think we failed her. Interview on [DATE] at 12:20 p.m. with the Medical Director/ Primary Care Physician revealed resident #1 was there for rehabilitation for a fracture and was on an anticoagulant and doing well. He went on to state, we ordered standard labs, but never added the PT/INR. He stated, that the last DON discontinued the use of standing orders and used protocols. The Medical Director/ Primary Care Physician stated, he felt it was missed by everyone involved (in regards to the PT/INR labs). He also stated, Since her admit, PT/INR was never done, not ordered, not in her chart. We missed it. Interview on [DATE] at 3:00 p.m. with the DON, revealed resident #1 went to the hospital on [DATE]. On [DATE], the hospital called the facility and requested the last PT/INR. She further stated, When I requested lab results, I found out none were done. At that point she ran a report on all residents on [MEDICATION NAME]. She also found out there were no standing orders and notified the Medical Director. 2. Review of resident #2 's facesheet (dated [DATE]) revealed that she was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of resident #2's Consolidated Physician Orders (dated [DATE]) revealed [MEDICATION NAME] Sodium ([MEDICATION NAME]) 5 mg give one tablet by mouth one time a day at bedtime for treating/preventing blood clots. Order start date [DATE]. Review of resident #2's August, September and October of 2016 MAR's revealed that [MEDICATION NAME] Sodium ([MEDICATION NAME]) was initialed as being given at 8:00 p.m. daily. Review of resident #2's Laboratory Results printed on [DATE] revealed the last PT/INR was last drawn on [DATE] with PT level of 13.0 with reference values (10.4 - 13.8) and an INR of 1.15 with reference values of (0.80 - 1.20), Review of resident #2's Medication Incident Report (dated [DATE]) revealed scheduled PT/INR were not ordered or completed on this resident from her last PT/INR on [DATE] till it was discovered on [DATE] during a lab audit for [MEDICATION NAME]. Review of resident #2's Nurse Progress Note dated [DATE] revealed PT/INR was drawn at 7:00 p.m. on [DATE]. Review of resident #2's medical chart on [DATE] revealed a new order was written on [DATE] for PT/INR to be drawn every Monday. The Administrator and DON were notified on [DATE] at 8:25 a.m. that and Immediate Jeopardy was identified. The facility's plan of removal was provided by the Administrator on [DATE]. Plan of Removal was accepted by Surveyor on [DATE] at 3:05 p.m. Plan of Removal: I. Anticoagulant Therapy Labs Action(s): Audit all residents receiving anticoagulant therapy for the following: a. PT/INR orders - If PT/INR orders not in place, orders will be secured from physician. b. Audit lab results on residents receiving anticoagulant therapy for the past 30 days and notification of physician for abnormal finding. c. Care Plans for residents receiving anticoagulant therapy have been reviewed and updated as needed, Responsible: DON/designee Retraining: Nursing team members will be retrained by [DATE] on: a. Securing anticoagulant lab orders on admission/readmission/ change in orders. b. Normal lab values PT/INR c. Care planing for residents receiving anticoagulant therapy d. Physician notification of abnormal values e. Monitoring for side-effects anticoagulant therapy Completion Date: [DATE] Monitoring: DON/designee will review orders for anticoagulant therapy on Readmission/Admission/order change during morning meeting. DON/designee will randomly review 2 charts at least weekly of residents receiving anticoagulant. Findings will be brought to QAPI for at least 3 months. On [DATE], Surveyor reviewed the plan of removal which included the review of medical records, care plans, in-services, protocols and new orders put in place to be in compliance. Surveyor interviewed the staff and DON to verify implementation of changes had been made, for the plan of removal and that those changes were in place. At this point, the surveyor confirmed plan of removal was complete. Verification of the plan of removal included interviews with nursing staff. The nursing staff confirmed they had been in-serviced and had acquired sufficient education regarding the policies and procedures for anticoagulant therapy. In-services were held on [DATE] and completed on [DATE]. Seventeen LVN's/RN's were in-serviced on Lab Results by the DON on [DATE]. Twenty-three LVN's/RN's were in-serviced from [DATE] to [DATE], on Standing Orders for Blood Thinners. Twenty LVN's/RN' were in-serviced form [DATE] to [DATE] on Medications and Therapeutic Labs. DON provided a handwritten audit of all residents on [MEDICATION NAME] dated [DATE]. A review of resident #2's chart confirmed PT/INR orders were in place and included in the care plans. The Administrator and Corporate Manager were notified on [DATE] that the immediate jeopardy was removed, however the facility remained out of compliance at a scope of pattern with actual harm because the facility had not had time to monitor and evaluate the effectiveness of the Plan of Removal. Information was provided by the facility dated [DATE] revealed there were two residents on [MEDICATION NAME].

Based on interviews and record reviews, the facility failed to develop and implement written policies and procedures that prohibit neglect for 2 of 6 residents (resident #1 and resident # 2) whose care was reviewed in that: Resident #1's [MEDICATION NAME] (a blood thinner) was given for almost 3 months without any monitoring of her INR. Resident # 1 was admitted to the hospital with [REDACTED]. Resident #2's [MEDICATION NAME] was given for about 7 months and without PT/INR monitoring for about 6 months. An immediate jeopardy was identified on [DATE]. The immediate jeopardy was removed on [DATE]. The facility remained out of compliance at a scope of pattern with actual harm, because the facility had not had time to monitor and evaluate the effectiveness of the Plan of Removal. This failure could affect 2 residents at the facility with prescribed [MEDICATION NAME] by contributing to inappropriate [MEDICATION NAME] administration resulting in harm or death based on missing orders or missing labs. The findings were: Review of Abuse and Neglect Policy: Defining Neglect (not dated) Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Review of Abuse and Neglect Policy: Signs of Neglect (not dated) -Improper use/administration of medications Review of the Facility's Anticoagulant Therapy Procedure dated ,[DATE] revealed: 1. Identify resident on anticoagulant therapy and obtain medical [DIAGNOSES REDACTED]. 2. Review the resident's medication regimen for potential drug-drug interactions and notify the physician of any potential drug-drug-interactions. 3. Confirm with the physician the desired INR and/or PT testing schedule and therapeutic range at the time of the anticoagulant therapy order. 4. Initiate and order anticoagulant therapy labs per physician ' s order. 5. Upon receipt of lab results, review INR and/or lab results for abnormal values. 6. If lab results exceed therapeutic range, Hold anticoagulant medications until physician had been notified and new order is received. 7. Report lab results and current medication order to physician. 9. If acute or gross bleeding is noted, transfer resident to an acute care setting and notify physician. 10. Review the monthly pharmacist drug regimen review to include anticoagulant therapy for recommendation and follow. Review of resident #1's facesheet (dated [DATE]) revealed that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of resident #1's Admission MDS, dated [DATE] and Quarterly MDS, dated [DATE] revealed the resident was on anticoagulant therapy. Review of resident #1's Consolidated Physician Orders (dated [DATE]) revealed [MEDICATION NAME] Sodium ([MEDICATION NAME]) 3 mg give one tablet by mouth one time a day for treating/preventing blood clots. Order start date [DATE]. Review of resident #1's Consolidated Physician Orders (dated [DATE]) revealed no Physician order for [REDACTED]. With PT/INR levels out of range, [MEDICATION NAME] can cause bleeding which can be serious and may lead to death). Review of resident #1's August, September and October of 2016 MAR's revealed that [MEDICATION NAME] Sodium ([MEDICATION NAME]) was initialed as being given at 8:00 p.m. daily. Review of resident #1's Care Plan initiated on [DATE] and reviewed on [DATE] revealed there was no Care Plan for anticoagulant therapy. Review of resident #1's Consultant Pharmacist's Medication Regimen Review dated, [DATE] and [DATE], [DATE] and [DATE] revealed no notes or recommendation regarding anticoagulant therapy. Review of resident #1's Physician's Progress Notes from [DATE] through [DATE] revealed the resident was taking [MEDICATION NAME] 3 mg oral tablet, 1 PO daily since admission. These notes also revealed there was no evidence to support PT/INR monitoring ever occurred. Review of resident #1's Physician's Progress Notes dated [DATE] and signed [DATE] revealed the resident was taking [MEDICATION NAME] 3 mg oral tablet, 1 PO daily since admission. This note also revealed an Assessment of long term current use of anticoagulant (situation). Plan: Long-term current use of anticoagulant (situation) to continue [MEDICATION NAME] therapy for chronic A-fib, change schedule to give [MEDICATION NAME] at 5:00 p.m. versus at bedtime otherwise follow-up with INR per protocol. Review of resident #1's Nursing Progress Note dated [DATE] at 7:40 a.m. by ADON revealed that resident #1 was transferred from the facility to the hospital after resident was found unresponsive to verbal and tactile stimulation. EMS was notified and resident was transported to the hospital. Review of resident #1's Provider Investigation Report signed on [DATE] for the incident which occurred on [DATE] revealed an elevated INR which was reported from the hospital. The hospital requested the last INR lab values from the facility which prompted their lab audit. The resident did not recover from her unresponsiveness and she passed away. Findings inconclusive (waiting on hospital medical records) Review of resident #1's hospital Emergency Department Initial Order Set dated [DATE] at 9:30 a.m. revealed Diagnoses: [REDACTED]. Review of resident #1's hospital Emergency Department Physician Record dated [DATE] revealed the resident was given Vitamin K (used to increase blood clotting factors in the blood) 10 mg via IV. Review of resident #1's hospital History and Physical dated [DATE] revealed in the History of Present Illness: history of spontaneous fracture of her leg, left-sided subdural hematoma. Also noted was a marked coaguolpathy with INR of greater than 11. Past Medical history: a-fibrillation, [MEDICAL CONDITION], pacemaker, recent fracture. Review of resident #1's hospital PT/INR lab report dated [DATE] revealed a PT level of 85.1 with reference values (29.4 - 34.6) and an INR of 11.957 with reference values of (0.680 - 1.170), Review of resident #1's hospital Death Summary dated [DATE] revealed resident #1 was admitted from the emergency room after finding a large subdural hematoma and pending uncal herniation (downward displacement of medial brain structures which exerts pressure on the underlying structure including the [DIAGNOSES REDACTED]. The resulting injury to brainstem function rapidly leads to coma, nerve palcies and death.) Resident #1 was admitted for comfort measures. Hospital Recourse: over-anticoagulation with an INR of greater than 11. Final Diagnoses: [REDACTED]. [MEDICAL CONDITION], 3. Anticoagulation with coagulopathy, 11. Recent fracture of leg. Interview on [DATE] at 4:00 p.m. with the DON, revealed resident #1 had no orders for PT/INR. She confirmed resident #1 was on [MEDICATION NAME]. She further stated there was no order, so the lab for PT/INR was never drawn. Interview on [DATE] at 9:40 a.m. with the ADON, revealed a nurse from the hospital called requesting resident #1's last PT/INR level. The hospital informed us on [DATE] that her PT/INR was 11.6. ADON became aware that no PT/INR had been ordered since resident #1's admit in July. Resident #1 died on [DATE]. The facility began their lab audits on [DATE]. ADON stated, We all dropped the ball, I really think we failed her. Interview on [DATE] at 12:20 p.m. with the Medical Director/ Primary Care Physician revealed resident #1 was there for rehabilitation for a fracture and was on an anticoagulant and doing well. He went on to state, we ordered standard labs, but never added the PT/INR. He stated, that the last DON discontinued the use of standing orders and used protocols. The Medical Director/ Primary Care Physician stated, he felt it was missed by everyone involved (in regards to the PT/INR labs). He also stated, Since her admit, PT/INR was never done, not ordered, not in her chart. We missed it. Interview on [DATE] at 3:00 p.m. with the DON, revealed resident #1 went to the hospital on [DATE]. On [DATE], the hospital called the facility and requested the last PT/INR. She further stated, When I requested lab results, I found out none were done. At that point she ran a report on all residents on [MEDICATION NAME]. She also found out there were no standing orders and notified the Medical Director. 2. Review of resident #2 's facesheet (dated [DATE]) revealed that she was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of resident #2's Consolidated Physician Orders (dated [DATE]) revealed [MEDICATION NAME] Sodium ([MEDICATION NAME]) 5 mg give one tablet by mouth one time a day at bedtime for treating/preventing blood clots. Order start date [DATE]. Review of resident #2's August, September and October of 2016 MAR's revealed that [MEDICATION NAME] Sodium ([MEDICATION NAME]) was initialed as being given at 8:00 p.m. daily. Review of resident #2's Laboratory Results printed on [DATE] revealed the last PT/INR was last drawn on [DATE] with PT level of 13.0 with reference values (10.4 - 13.8) and an INR of 1.15 with reference values of (0.80 - 1.20), Review of resident #2's Medication Incident Report (dated [DATE]) revealed scheduled PT/INR were not ordered or completed on this resident from her last PT/INR on [DATE] till it was discovered on [DATE] during a lab audit for [MEDICATION NAME]. Review of resident #2's Nurse Progress Note dated [DATE] revealed PT/INR was drawn at 7:00 p.m. on [DATE]. Review of resident #2's medical chart on [DATE] revealed a new order was written on [DATE] for PT/INR to be drawn every Monday. Review of Abuse and Neglect Policy: Defining Neglect (not dated) Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Review of Abuse and Neglect Policy: Signs of Neglect (not dated) -Improper use/administration of medications The Administrator and DON were notified on [DATE] at 8:25 a.m. that and Immediate Jeopardy was identified. The facility's plan of removal was provided by the Administrator on [DATE]. Plan of Removal was accepted by Surveyor on [DATE] at 3:05 p.m. Plan of Removal: I. Anticoagulant Therapy Labs Action(s): Audit all residents receiving anticoagulant therapy for the following: a. PT/INR orders - If PT/INR orders not in place, orders will be secured from physician. b. Audit lab results on residents receiving anticoagulant therapy for the past 30 days and notification of physician for abnormal finding. c. Care Plans for residents receiving anticoagulant therapy have been reviewed and updated as needed, Responsible: DON/designee Retraining: Nursing team members will be retrained by [DATE] on: a. Securing anticoagulant lab orders on admission/readmission/ change in orders. b. Normal lab values PT/INR c. Care planing for residents receiving anticoagulant therapy d. Physician notification of abnormal values e. Monitoring for side-effects anticoagulant therapy Completion Date: [DATE] Monitoring: DON/designee will review orders for anticoagulant therapy on Readmission/Admission/order change during morning meeting. DON/designee will randomly review 2 charts at least weekly of residents receiving anticoagulant. Findings will be brought to QAPI for at least 3 months. On [DATE], Surveyor reviewed the plan of removal which included the review of medical records, care plans, in-services, protocols and new orders put in place to be in compliance. Surveyor interviewed the staff and DON to verify implementation of changes had been made, for the plan of removal and that those changes were in place. At this point, the surveyor confirmed plan of removal was complete. Verification of the plan of removal included interviews with nursing staff. The nursing staff confirmed they had been in-serviced and had acquired sufficient education regarding the policies and procedures for anticoagulant therapy. In-services were held on [DATE] and completed on [DATE]. Seventeen LVN's/RN's were in-serviced on Lab Results by the DON on [DATE]. Twenty-three LVN's/RN's were in-serviced from [DATE] to [DATE], on Standing Orders for Blood Thinners. Twenty LVN's/RN' were in-serviced form [DATE] to [DATE] on Medications and Therapeutic Labs. DON provided a handwritten audit of all residents on [MEDICATION NAME] dated [DATE]. A review of resident #2's chart confirmed PT/INR orders were in place and included in the care plans. The Administrator and Corporate Manager were notified on [DATE] that the immediate jeopardy was removed, however the facility remained out of compliance at a scope of pattern with actual harm because the facility had not had time to monitor and evaluate the effectiveness of the Plan of Removal. Information was provided by the facility dated [DATE] revealed there were two residents on [MEDICATION NAME].

Based on interviews and record reviews, the facility failed to develop and implement written policies and procedures that prohibit neglect for 2 of 6 residents (resident #1 and resident # 2) whose care was reviewed in that: Resident #1's [MEDICATION NAME] (a blood thinner) was given for almost 3 months without any monitoring of her INR. Resident # 1 was admitted to the hospital with [REDACTED]. Resident #2's [MEDICATION NAME] was given for about 7 months and without PT/INR monitoring for about 6 months. An immediate jeopardy was identified on [DATE]. The immediate jeopardy was removed on [DATE]. The facility remained out of compliance at a scope of pattern with actual harm, because the facility had not had time to monitor and evaluate the effectiveness of the Plan of Removal. This failure could affect 2 residents at the facility with prescribed [MEDICATION NAME] by contributing to inappropriate [MEDICATION NAME] administration resulting in harm or death based on missing orders or missing labs. The findings were: Review of resident #1's facesheet (dated [DATE]) revealed that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of resident #1's Admission MDS, dated [DATE] and Quarterly MDS, dated [DATE] revealed the resident was on anticoagulant therapy. Review of resident #1's Consolidated Physician Orders (dated [DATE]) revealed [MEDICATION NAME] Sodium ([MEDICATION NAME]) 3 mg give one tablet by mouth one time a day for treating/preventing blood clots. Order start date [DATE]. Review of resident #1's Consolidated Physician Orders (dated [DATE]) revealed no Physician order for [REDACTED]. With PT/INR levels out of range, [MEDICATION NAME] can cause bleeding which can be serious and may lead to death). Review of resident #1's August, September and October of 2016 MAR's revealed that [MEDICATION NAME] Sodium ([MEDICATION NAME]) was initialed as being given at 8:00 p.m. daily. Review of resident #1's Care Plan initiated on [DATE] and reviewed on [DATE] revealed there was no Care Plan for anticoagulant therapy. Review of resident #1's Consultant Pharmacist's Medication Regimen Review dated, [DATE] and [DATE], [DATE] and [DATE] revealed no notes or recommendation regarding anticoagulant therapy. Review of resident #1's Physician's Progress Notes from [DATE] through [DATE] revealed the resident was taking [MEDICATION NAME] 3 mg oral tablet, 1 PO daily since admission. These notes also revealed there was no evidence to support PT/INR monitoring ever occurred. Review of resident #1's Physician's Progress Notes dated [DATE] and signed [DATE] revealed the resident was taking [MEDICATION NAME] 3 mg oral tablet, 1 PO daily since admission. This note also revealed an Assessment of long term current use of anticoagulant (situation). Plan: Long-term current use of anticoagulant (situation) to continue [MEDICATION NAME] therapy for chronic A-fib, change schedule to give [MEDICATION NAME] at 5:00 p.m. versus at bedtime otherwise follow-up with INR per protocol. Review of resident #1's Nursing Progress Note dated [DATE] at 7:40 a.m. by ADON revealed that resident #1 was transferred from the facility to the hospital after resident was found unresponsive to verbal and tactile stimulation. EMS was notified and resident was transported to the hospital. Review of resident #1's Provider Investigation Report signed on [DATE] for the incident which occurred on [DATE] revealed an elevated INR which was reported from the hospital. The hospital requested the last INR lab values from the facility which prompted their lab audit. The resident did not recover from her unresponsiveness and she passed away. Findings inconclusive (waiting on hospital medical records) Review of resident #1's hospital Emergency Department Initial Order Set dated [DATE] at 9:30 a.m. revealed Diagnoses: [REDACTED]. Review of resident #1's hospital Emergency Department Physician Record dated [DATE] revealed the resident was given Vitamin K (used to increase blood clotting factors in the blood) 10 mg via IV. Review of resident #1's hospital History and Physical dated [DATE] revealed in the History of Present Illness: history of spontaneous fracture of her leg, left-sided subdural hematoma. Also noted was a marked coaguolpathy with INR of greater than 11. Past Medical history: a-fibrillation, [MEDICAL CONDITION], pacemaker, recent fracture. Review of resident #1's hospital PT/INR lab report dated [DATE] revealed a PT level of 85.1 with reference values (29.4 - 34.6) and an INR of 11.957 with reference values of (0.680 - 1.170), Review of resident #1's hospital Death Summary dated [DATE] revealed resident #1 was admitted from the emergency room after finding a large subdural hematoma and pending uncal herniation (downward displacement of medial brain structures which exerts pressure on the underlying structure including the [DIAGNOSES REDACTED]. The resulting injury to brainstem function rapidly leads to coma, nerve palcies and death.) Resident #1 was admitted for comfort measures. Hospital Recourse: over-anticoagulation with an INR of greater than 11. Final Diagnoses: [REDACTED]. [MEDICAL CONDITION], 3. Anticoagulation with coagulopathy, 11. Recent fracture of leg. Review of the Facility's Anticoagulant Therapy Procedure dated ,[DATE] revealed: 1. Identify resident on anticoagulant therapy and obtain medical [DIAGNOSES REDACTED]. 2. Review the resident's medication regimen for potential drug-drug interactions and notify the physician of any potential drug-drug-interactions. 3. Confirm with the physician the desired INR and/or PT testing schedule and therapeutic range at the time of the anticoagulant therapy order. 4. Initiate and order anticoagulant therapy labs per physician ' s order. 5. Upon receipt of lab results, review INR and/or lab results for abnormal values. 6. If lab results exceed therapeutic range, Hold anticoagulant medications until physician had been notified and new order is received. 7. Report lab results and current medication order to physician. 9. If acute or gross bleeding is noted, transfer resident to an acute care setting and notify physician. 10. Review the monthly pharmacist drug regimen review to include anticoagulant therapy for recommendation and follow. Interview on [DATE] at 4:00 p.m. with the DON, revealed resident #1 had no orders for PT/INR. She confirmed resident #1 was on [MEDICATION NAME]. She further stated there was no order, so the lab for PT/INR was never drawn. Interview on [DATE] at 9:40 a.m. with the ADON, revealed a nurse from the hospital called requesting resident #1's last PT/INR level. The hospital informed us on [DATE] that her PT/INR was 11.6. ADON became aware that no PT/INR had been ordered since resident #1's admit in July. Resident #1 died on [DATE]. The facility began their lab audits on [DATE]. ADON stated, We all dropped the ball, I really think we failed her. Interview on [DATE] at 12:20 p.m. with the Medical Director/ Primary Care Physician revealed resident #1 was there for rehabilitation for a fracture and was on an anticoagulant and doing well. He went on to state, we ordered standard labs, but never added the PT/INR. He stated, that the last DON discontinued the use of standing orders and used protocols. The Medical Director/ Primary Care Physician stated, he felt it was missed by everyone involved (in regards to the PT/INR labs). He also stated, Since her admit, PT/INR was never done, not ordered, not in her chart. We missed it. Interview on [DATE] at 3:00 p.m. with the DON, revealed resident #1 went to the hospital on [DATE]. On [DATE], the hospital called the facility and requested the last PT/INR. She further stated, When I requested lab results, I found out none were done. At that point she ran a report on all residents on [MEDICATION NAME]. She also found out there were no standing orders and notified the Medical Director. 2. Review of resident #2 's facesheet (dated [DATE]) revealed that she was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of resident #2's Consolidated Physician Orders (dated [DATE]) revealed [MEDICATION NAME] Sodium ([MEDICATION NAME]) 5 mg give one tablet by mouth one time a day at bedtime for treating/preventing blood clots. Order start date [DATE]. Review of resident #2's August, September and October of 2016 MAR's revealed that [MEDICATION NAME] Sodium ([MEDICATION NAME]) was initialed as being given at 8:00 p.m. daily. Review of resident #2's Laboratory Results printed on [DATE] revealed the last PT/INR was last drawn on [DATE] with PT level of 13.0 with reference values (10.4 - 13.8) and an INR of 1.15 with reference values of (0.80 - 1.20), Review of resident #2's Medication Incident Report (dated [DATE]) revealed scheduled PT/INR were not ordered or completed on this resident from her last PT/INR on [DATE] till it was discovered on [DATE] during a lab audit for [MEDICATION NAME]. Review of resident #2's Nurse Progress Note dated [DATE] revealed PT/INR was drawn at 7:00 p.m. on [DATE]. Review of resident #2's medical chart on [DATE] revealed a new order was written on [DATE] for PT/INR to be drawn every Monday. Review of Abuse and Neglect Policy: Defining Neglect (not dated) Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Review of Abuse and Neglect Policy: Signs of Neglect (not dated) -Improper use/administration of medications The Administrator and DON were notified on [DATE] at 8:25 a.m. that and Immediate Jeopardy was identified. The facility's plan of removal was provided by the Administrator on [DATE]. Plan of Removal was accepted by Surveyor on [DATE] at 3:05 p.m. Plan of Removal: I. Anticoagulant Therapy Labs Action(s): Audit all residents receiving anticoagulant therapy for the following: a. PT/INR orders - If PT/INR orders not in place, orders will be secured from physician. b. Audit lab results on residents receiving anticoagulant therapy for the past 30 days and notification of physician for abnormal finding. c. Care Plans for residents receiving anticoagulant therapy have been reviewed and updated as needed, Responsible: DON/designee Retraining: Nursing team members will be retrained by [DATE] on: a. Securing anticoagulant lab orders on admission/readmission/ change in orders. b. Normal lab values PT/INR c. Care planing for residents receiving anticoagulant therapy d. Physician notification of abnormal values e. Monitoring for side-effects anticoagulant therapy Completion Date: [DATE] Monitoring: DON/designee will review orders for anticoagulant therapy on Readmission/Admission/order change during morning meeting. DON/designee will randomly review 2 charts at least weekly of residents receiving anticoagulant. Findings will be brought to QAPI for at least 3 months. On [DATE], Surveyor reviewed the plan of removal which included the review of medical records, care plans, in-services, protocols and new orders put in place to be in compliance. Surveyor interviewed the staff and DON to verify implementation of changes had been made, for the plan of removal and that those changes were in place. At this point, the surveyor confirmed plan of removal was complete. Verification of the plan of removal included interviews with nursing staff. The nursing staff confirmed they had been in-serviced and had acquired sufficient education regarding the policies and procedures for anticoagulant therapy. In-services were held on [DATE] and completed on [DATE]. Seventeen LVN's/RN's were in-serviced on Lab Results by the DON on [DATE]. Twenty-three LVN's/RN's were in-serviced from [DATE] to [DATE], on Standing Orders for Blood Thinners. Twenty LVN's/RN' were in-serviced form [DATE] to [DATE] on Medications and Therapeutic Labs. DON provided a handwritten audit of all residents on [MEDICATION NAME] dated [DATE]. A review of resident #2's chart confirmed PT/INR orders were in place and included in the care plans. The Administrator and Corporate Manager were notified on [DATE] that the immediate jeopardy was removed, however the facility remained out of compliance at a scope of pattern with actual harm because the facility had not had time to monitor and evaluate the effectiveness of the Plan of Removal. Information was provided by the facility dated [DATE] revealed there were two residents on [MEDICATION NAME].