Every finding on record at Crockett County Care Center

Based on interview and record review, the facility failed to designate a registered nurse to serve as the director of nursing on a full-time basis for 1 of 1 facility (identifier) reviewed for nursing services. The facility failed to have a full-time DON as of September of 2025 through 8/13/2026 at 4:30pm. This failure could place residents at risk of lack or nursing oversight and a higher level of care.Findings included: In an interview on 08/13/26 at 11:14am with the Administrator, she stated the previous DON resigned in September of 2025. The Administrator stated the job was not posted because the plan was for the ADON to assume the position when she completed the RN program. The Administrator stated she was unsure when the ADON would complete the RN program, but she knew that she started it. The Administrator stated there was some DON oversight from a management company, but they were not on-site for 40 hours a week. She stated the management company's consultant met with the ADON to review clinical information and was in the facility quarterly to do inspections. The Administrator stated she applied for a DON waiver, but it was denied. She stated there was an RN that completed the RN coverage requirement. The Administrator stated those were the steps the facility took to prevent any negative outcome. The Administrator stated the DON position had significant oversite duties and without any systems in place this could result in a negative outcome, but no negative outcomes occurred due to not having a DON. In an interview on 08/13/26 at 3:33 PM with the ADON, she stated they did not have a DON. The ADON stated the DON resigned in September of 2025. The ADON stated the last day the DON worked at the facility was in September of 2025. The ADON stated since then they had been without a DON. The ADON stated she completed the prerequisite requirements for the RN program and would apply to start the transition from LVN to RN program in January 2027, and that program was approximately 9-12 months in duration. She stated she performed DON duties and 2 RNs helped her. Record review of the facility's policy titled, Director of Nursing Services, dated 2006, reflected:The Nursing Services department is under the direct supervision of a Registered Nurse.Policy Interpretation and Implementation1. The nursing services department is managed by the Director of Nursing Services. The Director is a Registered Nurse (RN), licensed by this state, and has experience in nursing service administration, rehabilitative and geriatric nursing.2. The director is employed full-time (40 hours per week) and is responsible for, but is not necessarily limited to:a. developing and periodically updating the nursing service objectives and statements of philosophy;b. developing standards of nursing practice;c. developing and maintaining nursing policy and procedure manuals;d. developing and maintaining written job descriptions for each level oof nursing personnel;e. scheduling of daily rounds to visit residents;f. Developing methods for coordination of nursing services with other resident services;g. Recruiting and retaining the number and levels of nursing personnel necessary to meet the nursing care needs of each resident;h. Developing staff training programs for nursing service personnel;i. Participating in the planning and budgeting for nursing services;j. Ensuring that all health services notes are informative and descriptive of the supervision and care rendered including the resident's response to his or her care;k. Assessing the nursing requirements for each resident admitted and assisting the Attending Physician in planning for the resident's care;l. Participating in the development and implementation of the resident assessment (MDS) and comprehensive care plan.m. Establishing resident selection criteria for determining which residents may be fed by paid feeding assistants; andn. Assuring the nursing care personnel are administering care and services in accordance with the resident's assessment and care plan.

Based on observation, interview, and record review, the facility failed to ensure controlled drugs were securely stored for 1 of 1 treatment carts reviewed for drug storage. The facility failed to keep controlled medications in the treatment cart behind 2 separate locks at all times. This failure could place residents at risk of drug diversion and access to medications or accidental ingestion.Findings included: Observation and interview on 08/11/2026 at 9:45 AM, the treatment cart was inspected with the treatment nurse. Observation reflected the bottom drawer of the cart contained approximately 8 blister packs of controlled medications and locked with a latch and padlock. The treatment nurse said the push lock on the cart did not lock the bottom drawer and the reason for the padlock. The treatment nurse said the cart had been like that since she started working there. The treatment nurse said that she was not sure if it was reported. Interview on 08/13/2026 at 3:52 PM, the ADON said it was expected for the controlled medications to be stored behind 2 locks. The ADON said the treatment cart where the controlled medications were stored had some issues with the bottom drawer not working as effectively. The ADON said they had already moved the controlled medications into another cart that had 2 working locks. Interview on 08/13/2026 at 4:28 PM, the Administrator said it was expected for the controlled medications to be kept behind 2 locks. The Administrator said that if the medications were not locked properly it could lead to possible drug diversions. Review of the facility's policy titled, Controlled Substances, dated 2001, indicated in part: The facility complies with all laws, regulations and other requirements related to handling, storage, disposal and documentation of controlled medications. Only authorized licensed nursing and/or pharmacy personnel have access to schedule II controlled substances maintained on premises. Controlled substances are separately locked in permanently affixed compartments.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. 1.The facility failed to ensure stored foods were properly stored, labeled, and dated.2. The facility failed to check temperatures of food items prior to serving food. 3.The facility failed to ensure staff wore hairnets appropriately while in the kitchen.4.The facility failed to ensure clean dishes/utensils were stored in a way to prevent them from being exposed to dust and/or splatter.5.The facility failed to ensure stock was rotated on a first-in, first-out basis. 6.The facility failed to ensure expired items were discarded.These failures could place residents who received prepared meals from the kitchen at risk of food-borne illnesses and cross-contamination.The findings included:During the initial tour of the kitchen on 08/11/2026 between 9:40 AM - 11:00 AM, the following was observed: 1.Cook A wore a hairnet that did not cover the sides of her hair.2.Dietary Aide B wore a hairnet that did not cover the sides of her hair.3.The DM wore a hairnet that did not cover the sides and back of her hair.Walk-In Refrigerator1.1 repackaged bag of [NAME]-jack cheese cubes did not have any dates.2.1 repackaged bag of cheddar cheese cubes did not have any dates.3.2 repackaged bags of grated cheddar cheese had a date of 7/26/26 that was not specified as the received, opened or Use-By-Date (UBD).4.1 repackaged bag of grated American cheese had a date of 6/29/26 that was not specified as the received, opened or UBD.5.1 repackaged bag of sliced white cheese had a date of 2/2/26 that was not specified as the received, opened or UBD.6.1 repackaged bag of sliced American cheese had a date of 7/20/26 that was not specified as the received, opened or UBD.7.1 roll of hamburger meat on a tray did not have any dates.8.1 bowl of chicken pieces did not have any dates.Dry Storage1.2 opened bags of tortilla chips did not have any dates.2.1 opened bag of potato chips did not have any dates.3.1 opened bag of pumpkin spice cheesecake had a date of 12/18/24 that was not specified as the received or opened date and a Best-By-Date (BBD) of 10/25.4.1 opened bag of vanilla frosting mix was in a zip bag, not sealed, had a date of 10/8/24 that was not specified as the received or opened date and a BBD of 02/26.5.1 opened bag of vanilla frosting mix had a date of 10/8/24 that was not specified as the received or opened date and a BBD of 02/26.6.1 opened bag of diet chocolate frosting mix had a date of 8/8/25 that was not specified as the received or opened date and a BBD of 09/25.7.1 opened bag of pecan pieces had a date of 3/7/25 that was not specified as the received or opened date and a BBD of 1/3/26.8.1 opened package of chocolate candy coating had a date of 10/30/24 that was not specified as the received or opened date and a BBD of 1/30/26.9.1 opened jar of nut topping had a date of 8/24/24 that was not specified as the received or opened date and a BBD of 5/15/25.10.1 opened jar of black sugar sprinkles had a date of 10/31/22 that was not specified as the received or opened date and no BBD.11.1 opened jar of red and white heart shaped items was not labeled and was not dated.12.1 opened tube of green frosting did not have any dates.13.1 opened tube of red frosting did not have any dates.14.1 opened tube of black frosting did not have any dates.15.1 tube of crackers was not labeled or dated.16.1 package of melting chocolate for hot chocolate had only 1 date, BBD 1/31/26.17.1 opened package of cherry gelatin mix had a date of 6/11/25 that was not specified as the received, opened date, or BBD.Plastic Bins1.1 plastic bin of elbow macaroni had a date of 4/22/26 that was not specified as the received, opened date, or BBD.2.1 plastic bin of egg noodles had a date of 1/14/26 that was not specified as the received, opened date, or BBD.3.1 plastic bin of rotini pasta had a date of 6/11/25 that was not specified as the received, opened date, or BBD.4.1 plastic bin of corn meal had a date of 6/17/26 that was not specified as the received, opened date, or BBD.5.1 plastic bin of panko had a date of 1/13/25 that was not specified as the received, opened date, or BBD.6.1 plastic bin of pinto beans had a date of 7/29/26 that was not specified as the received, opened date, or BBD.7.1 plastic bin of gravy mix had a date of 11/3/25 that was not specified as the received, opened date, or BBD.8.1 plastic bin of crushed saltine crackers had a date of 11/12/25 that was not specified as the received, opened date, or BBD.9.1 plastic bin of instant rice had a date of 7/1/26 that was not specified as the received, opened date, or BBD.Stand Alone Freezer1.2 bowls with white substance was not labeled or dated.3 Door Refrigerator1.1 opened jar of picante sauce had a date of 7/1/26 that was not specified as the received, opened date, or BBD.2.1 metal bin of orange slices had a date of 8/8/26 that was not specified as the received, opened date, or BBD.3.1 plastic bin of orange pieces had a date of 7/1/26 that was not specified as the received, opened date, or BBD.4.1 opened bag of whipped topping was not dated.5.1 zip bag of chopped onions had a date of 8/9/26 that was not specified as the received, opened date, or BBD.6.1 zip bag of 1/2 of an onion had a date of 8/9/26 that was not specified as the received, opened date, or BBD.7.1 zip bag of sliced lemons had a date of 8/7/26 that was not specified as the received, opened date, or BBD.8.1 repackaged bag of sliced cheese had a date of 7/29/26 that was not specified as the received, opened date, or BBD.9.1 opened bag of classic bologna had a date of 7/20/26 that was not specified as the received, opened date, or BBD.10.1 opened bag of thick cut bologna had a date of 8/2/26 that was not specified as the received, opened date, or BBD.11.1 repackaged bag of sliced American cheese had a date of 7/20/26 that was not specified as the received, opened or UBD.12.1 bowl of lemon pudding was dated 8/7/26-8/9/26.13.1 bowl of watermelon had a date of 8/7/26 that was not specified as the received, opened date, or BBD.14.1 container of yogurt had a date of 7/9/26 that was not specified as the received or opened date, and a BBD of 7/29/26.15.1 opened bottle of orange juice that was not dated.16.1 can of whipped topping spray had a date of 3/17 that was not specified as the received or opened date, and a BBD of 5/10/26.Storage Under Prep Table1.1 opened bag of lime gelatin powder was not dated.2.1 opened bag of vanilla candy coating was not dated.3.1 opened bag of strawberry gelatin powder was not dated.4.1 bag of white powder was not labeled or dated.5.1 opened bag of powdered sugar was not dated.Above the Prep Table1.1 hanging rack holding measuring cups, strainers, graters, cooking and serving utensils was not covered and exposed to splashes, dust, and insects.Spices1.1 opened bottle of cinnamon was not dated.2.1 opened bottle of tajin was not dated.3.1 opened bottle of thickener had 2 dates of 7/28/26 and 7/31 that were not specified as the received, opened date, or BBD.4.1 plastic bin of sugar had a date of 7/21/26 that was not specified as the received, opened date, or BBD.5.1 plastic bin of flour had a date of 7/21/26 that was not specified as the received, opened date, or BBD.6.1 opened bottle of pure lemon extract a date of 8/10/23 that was not specified as the received or opened date, and a BBD of 1/3/26.7.1 opened bottle of toasted sesame oil had a date of 7/8/25 that was not specified as the received or opened date, and a BBD of 7/2026.8.1 repackaged bottle of red coloring had a date of 1/26/26 that was not specified as the received, opened date, or BBD.9.1 repackaged bottle of yellow coloring had a date of 1/26/26 that was not specified as the received, opened date, or BBD.10.1 repackaged bottle of parsley flakes had a date of 12/10/24 that was not specified as the received, opened date, or BBD.11.1 opened bottle of parsley flakes had a date of 10/10/25 that was not specified as the received, opened date, or BBD.12.1 plastic tub of rice was not dated.13.1 opened jar of beef flavor soup base had a date of 10/1/25 that was not specified as the received, opened date, or BBD.14.1 repackaged bottle of vanilla had a date of 6/1/26 that was not specified as the received, opened date, or BBD.15.1 opened bottle of sage had a date of 11/19/24 that was not specified as the received, opened date, or BBD.16.1 repackaged bottle of pumpkin spice had a date of 11/13/25 that was not specified as the received, opened date, or BBD.17.1 opened jar of green sugar sprinkles was not dated.18.1 opened bottle of anise seed had a date of 10/28/24 that was not specified as the received, opened date, or BBD.19.1 opened bottle of ground mustard had a date of 1/11/24 that was not specified as the received or opened date, and a BBD of 1/27/2026.20.1 opened bottle of green coloring had a BBD of 3/16/25.21.1 opened bottle of ground cloves had a date of 11/19/24 that was not specified as the received, opened date, or BBD.22.1 opened bottle of beef cubes had a BBD of 3/5/26.23.1 bottle of white powder was not labeled or dated.24.1 opened bottle of all spice had a date of 10/30/23 that was not specified as the received, opened date, or BBD.25.1 opened bottle of nutmeg had a date of 2/17/24 that was not specified as the received, opened date, or BBD.26.1 opened bottle of lemon pepper had a date of 4/30/25 that was not specified as the received, opened date, or BBD.During the follow-up tour of the kitchen on 08/12/2026 between 11:30 AM - 12:20 PM, the following was observed: 1.Food temperatures were not taken before serving the cooked carrots, mechanical soft chicken, gravy, and the steak fingers.2.The steak fingers and fried chicken were held in the same metal bin on the steam table. 3.The gravy was not placed on the steam table while serving.During an interview with the DM on 08/13/2026 at 3:00 PM, the DM said leftovers were discarded after 3 days. She said the only labeling requirement they have was a received date. She said open dates were not required and all items should have a manufacturer's BBD. She said that stock was rotated and used in its entirety every 2-3 months, so nothing had time to expire. She said she was not aware that items removed from their original package needed to have the BBD transferred to the new package. The DM said all staff were responsible for checking food storage areas for BBD's and discarding expired items. The DM said hairnets were required to cover all the staff's hair on their head, but it was impossible to do that. She said the hairnets provided did not cover everything, especially the sides and the back. The DM said she worked in the kitchen at this facility for 27 years and was the DM for 3 years and was never aware of the need to have opened dates and BBD's on items. She said the residents were not at risk due to these failures because she did the same thing for 27 years and had not been corrected.Cook #A and Dietary Aide #B were not available for interview.Record review of the facility's policy, Food Preparation and Service, dated 2001, revealed: 1. Proper hot and cold temperatures are maintained during food distribution and service.2. The temperatures of foods held in steam tables are monitored throughout the meal service by food and nutrition services staff.3. Food and nutrition services staff wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food.Record review of the facility's policy, Food Receiving and Storage, dated 2001, revealed: 1. Foods shall be received and stored in a manner that complies with safe food handling practices.2. Dry foods and goods are handled and stored in a manner that maintains the integrity of the packaging until they are ready to use.3. Dry foods that are stored in bins are removed from original packaging, labeled and dated (use by date). Such foods are rotated using a first in - first out system.4. All foods stored in the refrigerator or freezer are covered, labeled, and dated (use by date).5. Refrigerated foods are labeled, dated and monitored so they used by their use-by date, frozen, or discarded.Record review of the facility's policy, Refrigerators and Freezers, dated 2001, revealed: 1. This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines.2. All food is appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) are marked on cases and on individual items removed from cases for storage. Use by dates are completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food are observed and use by dates are indicated once food is opened.3. Supervisors are responsible for ensuring food items in pantry, refrigerators, and freezers are not past use by or expiration dates. Supervisors should contact vendors or manufacturers when expiration dates are in question or to decipher codes on packaging.Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 2-402 Hair Restraints, 2-402.11, Effectiveness., (A) Except as provided in paragraph (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES.Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) - (G) of this section, refrigerated, ready-to-eat, time/temperature control 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 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, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety.

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 diseases and infections for 1 of 4 (Residents #29) reviewed for infection control. The facility failed to ensure Residents #29's oxygen nasal cannula tube was bagged when not in use and CNA A did not touch the nasal cannula with her bare hands to place it on the resident's nose. This failure could place the residents at risk of infection. Findings included: Record review of Resident #29's admission record, dated 08/17/2026, indicated she was admitted to the facility on [DATE] with diagnosis of chronic respiratory failure with hypoxia (low blood oxygen). She was [AGE] years of age. Record review of Resident #29's care plan, dated 03/03/2026, indicated in part: Resident has altered respiratory status/difficulty breathing R/T Respiratory failure with Hypoxemia. The resident will have nocomplications related to SOB though the review date. Oxygen settings: O2 via nasal canula, Continuous O2 @ 4/LPM. (Continuous oxygen at 4 liters per minute) Record review of Resident #29's quarterly MDS assessment, dated 06/14/2026, indicated in part: BIMS of 3 indicating the resident had severe cognitive impairment. Respiratory treatments - Oxygen therapy. Record review of Resident #29's order summary report, dated 08/17/2026, indicated in part: May use O2 at 2-4 LPM via nasal cannula PRN with a start date of 11/12/2024. Observation and interview on 08/11/2026 at 10:32 AM, CNA C transferred Resident #29 from the wheelchair to the recliner. Resident #29 was seen wearing an oxygen nasal cannula which was attached to the oxygen tank. After CNA C removed the resident's nasal cannula, she wrapped it around with bare hands and placed it around the wheelchair's handle. CNA C said she now understood how that could possibly lead to cross contamination by using her bare hands to wrap it around her hand and then placing the cannula on the wheelchair handle. Record review of the facility's policy titled, Respiratory Therapy Prevention of Infection, dated 2001, indicated in part: Change the oxygen cannula and tubing every seven (7) days or as needed. Keep the oxygen cannula and tubing used PRN in a plastic bag when not in use. Record review of the facility's policy titled, Infection Prevention and Control Program, dated 12/2025, indicated in part: An infection prevention and control (IPC) program is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The IPC program is developed to address the facility-specific infection prevention and control needs and requirements identified in the facility assessment and the infection control risk assessment.

Based on interview and record review the facility failed to designate a registered nurse to serve as the director of nursing on a full-time basis for 1 of 1 DON (DON) reviewed for DON coverage. The facility failed to have a full-time DON as of September of 2024 through 6/11/2025. This failure could place residents at risk of lack or nursing oversight and a higher level of care. Findings include: Record review of the DON's Letter of Resignation, dated 08/14/24, revealed the DON submitted her letter of resignation on 08/14/24 for resignation effective on 9/30/24. In an interview on 06/11/25 at 3:14 PM with the Administrator, she stated the previous DON resigned due to family matters in September of 2024. The Administrator stated the job has been posted since in the local newspaper, social media like Facebook and Indeed. The Administrator stated there was no applicants for this position. The Administrator stated the current ADON was going to be trained by a contract agency for a nurse leadership role. The Administrator stated this was the steps the facility was taking to prevent any negative outcome. The Administrator stated the DON position had significant oversite duties and without any systems in place this could result in a negative outcome. In an interview on 06/11/25 at 3:33 PM with the ADON, she stated they did not have a DON. The ADON stated the DON resigned due to a personal matter. The ADON stated the last day the DON worked at the facility was in September of 2024. The ADON stated since then they had been without a DON. Record review of the facility's policy titled Director of Nursing Services, dated 2006, reflected: The Nursing Services department is under the direct supervision of a Registered Nurse. Policy Interpretation and Implementation 1. The nursing services department is managed by the Director of Nursing Services. The Director is a Registered Nurse (RN), licensed by this state, and has experienced ini nurse service administration, rehabilitative and geriatric nursing. 2. The director is employed full-time (40-hours per week) and is responsible for, but is not necessarily limited to: a. developing and periodically updating the nursing service objectives and statements of philosophy; b. developing standards of nursing practice; c. developing and maintaining nursing policy and procedure manuals; d. developing and maintaining weitten job descriptions for each level oof nursing personnel; e. scheduling of daily rounds to visit residents; f. Developing methods for coordination of nursing services with other resident services; g. Recruiting and retaining the number and levels of nursing personnel necessary to meet the nursing care needs of each resident; h. Developing staff training programs for nursing service personnel; i. Participating in the planning and budgeting for nursing services; j. Ensuring that all health services notes are informative and descriptive of the supervision and care rendered including the residents response to his or her care; k. Assessing the nursing requirements for each resident admitted and assisting the Attending Physician in planning for the residents care; l. Participating in the development and implementation of the resident assessment (MDS) and comprehensive care plan. m. Establishing resident selection criteria for determining which residents may ne fed by paid feeding assistants; and n. Assuring the nursing care personnel are administering care and services in accordance with the residents assessment and care plan.

Based on observations, interviews, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, which included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 3 medication carts (Nurse Cart) and 1 of 1 medication storage room reviewed for medication storage. 1. The facility failed to ensure 2 of 2 insulin pens were labeled with an open date in the Nurse Medication Cart. 2. The facility failed to ensure the medication room was free of expired medications. These failures could place residents at risk of not receiving the therapeutic benefit of medications or adverse reactions to medications. Findings included: Observation of the medication room on 06/11/2025 at 10:30 AM revealed the following: - Four unopened 8-ounce jars of protein powder in cabinet with expiration date of 05/24/2025. - One opened box of 0.9% sodium chloride inhalation solution 5ml/vial with a total of 56 vials with an expiration date of 04/2025 - Four boxes of 3% sodium chloride inhalation solution 15ml/vial with a total of 160 vials with an expiration date of 05/31/2025 - One unopened box Dulcolax suppositories (8 total) in refrigerator with expiration date of 04/2025 Observation of Nurse Cart on 06/11/2025 at 2:40 PM revealed the following: - One Lantus Solostar 100 units/ml injector pen with approximately 160 units remaining with no label to indicate open date. - One Tresiba FlexTouch 100 units/ml injector pen with approximately 220 units remaining with no label to indicate open date. In an interview on 06/11/2025 at 2:50 PM with LVN A, she stated that the night shift nurse went through the medication room each month (on the 15th) to ensure that all expired medications were removed and disposed of. She stated that there were no residents currently using the protein powder or the sodium chloride. She stated that any resident needing a protein supplement received one from the dietary department and was unsure why the protein powder was in the medication room at all. She stated that the sodium chloride was on hand for a resident no longer in the facility and should have been disposed of during the last medication room clean out. She stated that the Dulcolax suppositories were floor stock and should have been disposed of during the last medication storage room clean out. She stated that insulin pens should be labeled with the date they were opened and disposed of after 28 days. She stated that she did not know when the two insulin pens were opened. She stated that if insulin pens were not dated when opened it could put the residents at risk of receiving expired and possibly ineffective insulin. In an interview on 06/12/2025 at 1:08 PM, the ADON stated that all expired meds should be removed from the medication room and medication carts. She stated that any time a container was opened it should be dated with that date. She stated each nurse, or med aide was responsible for checking the dates on the meds they would be giving to ensure the medication was not expired. She stated that the CNA Supervisor was responsible for ordering and restocking the floor stock and she goes went through the med room once a month to clean out the expired items in the med room. She stated that all insulin pens are were to be labeled with the resident's name and the date the pen was opened. Insulin pens were to be disposed of after 28 days or 30 days depending on the manufacturer suggestions. She stated that she believed the reason the expired items were in the med room is was due to the CNA Supervisor being on extended leave and the job not being delegated to another staff member. She stated there was no excuse for the insulin pens to be without open dates. She stated that medications that were expired would not be as effective if given to residents. In an interview on 06/12/2025 at 1:32 PM, the Administrator stated she had no additional information or comments about medication labeling and storage. Record review of the facility's policy titled Storage of Medication, revision date April 2019, revealed, in part: Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Record review of the facility's policy titled Labeling of Medication Containers, revision date of April 2019, revealed, in part: Labels for individual resident medications include all necessary information, such as .The date the medication was dispensed .The expiration date when applicable.

Based on observation, interview, and record review the facility failed to establish and 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 diseases and infections for 2 (Resident #5 and Resident #20) of 3 residents reviewed for infection control. 1. CNA D failed to change her gloves when going from dirty to clean and failed to perform hand hygiene when she provided incontinent care to Resident #20. 2. CNA C failed to change her gloves when going from dirty to clean and failed to perform hand hygiene when she provided incontinent care to Resident #5. These failures could place residents at risk for cross contamination and the spread of infection. Findings include: 1. Record review of Resident #20's admission record, dated 06/12/2025, indicated an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #20 had diagnoses which included Alzheimer's Disease (a progressive disease that destroys memory and other mental functions) and Chronic Kidney Disease (a gradual loss of kidney function). Record review of Resident #20's care plan, dated 02/12/2025, indicated in part: Focus: Resident has a history of bladder incontinence related to Alzheimer's Disease. Goal: Resident will remain free from skin breakdown due to incontinence and brief use through the review date. Interventions/Tasks: Clean peri-area with each incontinence episode. Resident is offered toileting on rounds and prefers to wear protective undergarments. Record review of Resident #20's MDS, dated [DATE], indicated in part: Cognitive Skills for Daily Decision Making was a 3, which indicated the resident was severely impaired and never/rarely made decisions. Urinary and Bowel Continence documented Resident #20 was always incontinent. During an observation on 06/11/2025 at 03:27 PM revealed CNA D and CNA F performed incontinent care for Resident #20. Both CNAs washed their hands and donned gloves. CNA D wiped the front part of the perineum. Both CNAs turned Resident #20 on her left side and CNA D wiped the resident's rectal area. While still wearing the same gloves, CNA D placed a clean brief on Resident #20. CNA D then changed gloves, without washing or sanitizing hands between glove change. Both CNAs dressed Resident #20 in clean pants. CNA D doffed her gloves and exited the room without washing or sanitizing hands. CNA D returned with the mechanical lift to transfer Resident #20 to her wheelchair. During an interview on 06/11/2025 at 04:20 PM, CNA D said she should have changed her gloves after she wiped Resident #20's rectal area before putting the clean brief on the resident. CNA D said she knew about changing her gloves when going from dirty to clean and washing her hands when doffing gloves but had forgotten. 2. Record review of Resident #5's admission record, dated 06/12/2025, indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #5 had a diagnosis which included Alzheimer's Disease. Record review of Resident #5's care plan, dated 04/03/2025, indicated in part: Focus: Resident #20 had bladder and bowel incontinence related to Alzheimer's/Dementia. Goal: Resident will remain free from skin breakdown due to incontinence and brief use through the review date. Interventions/Tasks: Check every 2 hours and as required for incontinence. Wash, rinse and dry perineum. Record review of Resident #5's MDS, dated [DATE], indicated in part: resident had a Brief Interview for Mental Status (BIMS) score of 4, which indicated severe cognitive impairment. Urinary and Bowel continence documented Resident #5 was always incontinent. During an observation on 06/11/2025 at 03:50 PM, revealed CNA C and CNA E performed incontinent care for Resident #5. Both CNAs washed their hands and donned gloves. CNA C wiped the front part of the perineum. Both CNAs turned Resident #5 on her left side and CNA C wiped the resident's rectal area. While still wearing the same gloves, CNA C placed a clean brief on Resident #5. CNA C changed gloves, without washing or sanitizing hands between glove change. Both CNAs placed a hoyer lift sling underneath Resident #5. CNA C doffed her gloves and exited the room without washing or sanitizing hands. CNA C returned with the hoyer lift and Resident #5's wheelchair. During an interview on 06/12/2025 at 01:40 PM, CNA C said she did not change gloves between going from dirty to clean and did not wash hands between glove changes and after removing gloves to exit. CNA C said the lapses could cause infections. During an interview on 06/11/2025 at 04:12 PM, the ADON regarding incontinent care said it was her expectation for staff to wash their hands before starting incontinent care, change gloves when going from dirty to clean, and wash or sanitize hands between glove changes. The ADON said each step was a vital part of infection prevention. During an interview on 06/12/2025 at 03:00 PM, the Administrator was made aware of the observations of incontinent care. The Administrator stated lapses in infection control could lead to serious complications to the residents, staff, and facility. Record review of the facility's policy titled Perineal Care, dated 02/2018, indicated in part: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. The following equipment and supplies will be necessary when performing this procedure: Personal protective equipment (e.g., gloves, mask etc., as needed). Avoid unnecessary exposure of the resident's body. Put on gloves. Wash the perineal area, wiping from front to back, rinse and dry thoroughly. Wash the rectal area, rinse and dry thoroughly. Discard disposable items into designated containers, remove gloves and discard into designated container, wash and dry your hands thoroughly. Record review of the facility's policy titled [The facility] Hand Hygiene, dated 03/08/2023, indicated in part: Hand Hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. Hand Hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. The hand hygiene table indicated in part the following conditions require hand hygiene: 1. After handling contaminated objects, 2. Before applying and after removing personal protective equipment (PPE), including gloves, 3. Before and after handling clean or soiled dressings, linens, etc., 4. After handling items potentially contaminated with blood, body fluids, secretions, or excretions, 5. When moving from a contaminated body site to a clean body site. Additional considerations: the use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves and immediately after removing gloves.

Based on observation, interview and record review the facility failed to ensure that residents had the right to examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility; and were posted in a place readily accessible to residents, and family members and legal representatives of residents for 7 of 7 residents interviewed in a confidential group meeting. The facility failed to have the survey results book readily accessible for the residents to review. This failure could place residents at risk of not being able to fully exercise their rights to be informed of the facility's survey history. Findings included: During a confidential group meeting on 5/8/24 at 11:00 am, seven out of seven residents in attendance stated they did not know where or how to access the survey results in the facility, or that it was an option for them to do so. Four of the seven residents in attendance stated that they would like to read the results from previous surveys to know what issues were found by the surveyors and what the facility had planned to do to fix the problems that had been identified. Observation on 5/8/24 at 2:25 PM revealed that the survey results binder was in a clear plastic wall mounted file holder on Hall 400. The location of the binder was accessible by walking down Hall 400 towards resident rooms located on that hall; all other resident rooms were located on the opposite side of the building. The binder was labeled Plan of Correction Health Survey and was behind another binder labeled Plan of Correction Life Safety Survey. In an interview with Administrator on 5/8/24 at 4:41 PM, he stated that the survey results binder was not located in an easily accessible location for all residents and that the binder should be relocated to somewhere more central for all the residents. He stated the issue with moving the binders was finding a safe place to hang the file holder since most of the residents were in wheelchairs and he did not want any of them to hit their head on it. He stated that the binders had been in the same spot since before he started working in the facility. He stated that the labeling on the binder would be confusing for the residents because they would not understand what Plan of Correction meant. He stated that the binder should have been labeled State Survey Results and said that he would make sure it was changed immediately. In an interview on 5/9/24 at 2:39 PM with the Activity Director she stated that she had talked to the residents about the survey results binder during Resident Council meetings in the past, but she did not bring it up at every meeting. She stated she had explained where the binders were located and had taken residents individually to the binders when they had asked where they were. She stated that she only spoke about the survey results binders during Resident Council meetings so only the residents that attended the meetings would have heard about them. She stated that since it had been several months since she had discussed the survey results binders at a meeting, some of the newer residents would not have heard about them even during Resident Council. She stated she did not like where the binders were located because the residents who lived on Hall 100, Hall 200, and Hall 300 rarely, if ever, came down that hall and would not see the binders. She stated that the binders should be hung in the dining room/living room area where all the residents like to congregate because all the residents would be able to see them. Review of facility policy titled Examination of Survey Results, revised April 2017, revealed, in part: Survey reports and plans of correction are readily accessible to the resident, family members, resident representative and to the public. Residents may examine the results of the most recent survey of the facility conducted by federal or state surveyors, as well as any plans of correction in effect. A copy of the most recent survey report and any plans of correction are kept in a binder in the residents' day room. Survey reports, certifications, complaint investigations and plans of correction for the preceding three years are available for any individual to review upon request.

Based on interview and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 14 residents (Resident #5 and Resident #31) reviewed for care plans. 1.The facility failed to ensure that Resident #5 had a care plan in place for her use of diuretic medication related to her diagnosis of edema. 2.The facility failed to ensure that Resident #31 had care plans in place for her diagnosis of diabetes mellitus and her use of insulin. These failures could affect residents by placing them at risk of not receiving individualized care and services to meet their needs. The findings included: Resident #5 Review of Resident #5's Admission Record dated 5/9/24 revealed she was an [AGE] year-old female originally admitted to the facility on [DATE], with a most recent admitted [DATE]. She had diagnoses which included congestive heart failure, chronic kidney disease - stage three, and edema. Review of Resident #5's Annual MDS assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 5 indicating severe cognitive impairment. She was dependent on staff for all ADLs except eating for which she only required setup assistance. She was always incontinent of bowel and bladder, and she was taking a diuretic medication. Review of Resident #5's care plan, most recent revision date 3/6/24, revealed no care plan in place for her use of a diuretic medication related to her diagnosis of edema. Review of Resident #5's Order Summary Report dated 5/9/24 revealed the following order: - Lasix Oral Tablet 80 mg (Furosemide) Give 1 tablet by mouth one time a day for edema (Order Date: 6/21/23, Start Date: 6/22/23) Resident #31 Review of Resident #31's Admission Record dated 5/9/23 revealed she was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses which included Type 2 Diabetes Mellitus with unspecified complications and Type 2 Diabetes Mellitus with diabetic retinopathy (damage caused to blood vessels at the back of the eye caused by poorly controlled blood sugar) and macular edema (swelling in the area of the retina responsible for central vision). Review of Resident #31's Quarterly MDS assessment dated [DATE] revealed she had sort and long-term memory problems with severely impaired cognitive skills for daily decision making. She was dependent on staff for all ADLs. She received insulin injections daily and a hypoglycemic medication. Review of Resident #31's care plan, most recent revision date 4/24/24, revealed no care plan in place for her diagnosis of diabetes and no care plan in place for her insulin use. Review of Resident #31's Order Summary Report dated 5/9/24 revealed the following orders: - NCS (No Concentrated Sweets) Diet (Order Date: 9/7/22, Start Date: 9/7/22) - A1C (blood test to measure average blood sugar levels over a 3 month period) in the morning every 6 months starting on the 15th related to Type 2 Diabetes Mellitus - Every 6 months May/November (Order Date: 11/14/23, Start Date: 11/15/23) - Lantus SoloStar Solution Pen-injector 100 Unit/ml (Insulin Glargine) - Inject 14 unit subcutaneously at bedtime related to Type 2 Diabetes Mellitus (Order Date: 10/26/22, Start Date: 10/26/22) - Metformin Hcl Tablet 500 mg give 1 tablet by mouth two times a day related to Type 2 Diabetes Mellitus (Order Date: 9/7/22, Start Date: 9/7/22) - Novolog FlexPen Solution Pen-Injector 100 units/ml (Insulin Aspart) - Inject as per sliding scale (if 71-150 = 0; 150-180 = 2 units; 181-220 = 4 units; 221-260 = 6 units; 261 - 300 = 10 units; 351-400 = 12 units; >400 12 units and call physician) subcutaneously before meals and at bedtime related to Type 2 Diabetes Mellitus (Order Date: 9/7/22, Start Date: 9/7/22) In an interview on 5/9/24 at 2:12 PM with the Care Plan Nurse, she explained the MDS Coordinator was responsible for completing the baseline care plan and starting the comprehensive care plan based on the triggered items from the initial MDS assessment. She stated a resident's care plan already had the MDS triggered items on it when she it came to her. She stated she added focus areas to the care plan based on new orders received, incident reports, and new information from staff regarding the residents. She stated that she did the quarterly renewal/revisions to the care plans and the MDS Coordinator did the annual revisions to the care plans. She stated that initially the MDS Coordinator would be responsible for creating a care plan for a specific diagnosis or medication based on the MDS assessment, but if an additional medication was added then she (Care Plan Nurse) would be responsible for adding it to the care plan. She stated that Resident #5 should have had a care plan in place for her use of a diuretic medication related to her diagnosis of edema based on the MDS assessment and that Resident #31 should have had a care plan in place for her diagnosis of diabetes and a separate care plan in place for her insulin use based on the MDS assessment. In an interview on 5/9/24 at 3:26 PM with the DON, she stated that a care plan should contain information regarding care to be provided to a resident, anything medically/psychologically/physically unique to the resident, and individualized instructions for the care of the resident. The DON reviewed Resident #31's care plan and stated that she was admitted with the diagnosis of diabetes and there should have been a care plan for both her diabetes diagnosis and her use of insulin dating back to her admission in 2022. She stated she was surprised to see that those care plans were missing. She stated that Resident #5 should have had a care plan for her use of a diuretic medication due to her edema diagnosis. She stated she had not done care plan audits in quite a while but she would add it to her list of audits for the future. Review of facility policy titled Comprehensive Care Plans dated February 2023, revealed, in part, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timelines to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record. The comprehensive care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, interview, and record review the facility failed to ensure residents received services in the facility with reasonable accommodation of each resident's needs for 1 (residents who were in their rooms during observation) of 29 residents reviewed for call lights: Resident #12's call light was out of reach. This deficient practice could affect residents who need assistance with activities of daily living of not having needs met. Findings Include: Review of Resident #12's Admission Record dated, 3/16/23, revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis (paralysis) following a stroke affecting the right side. Review of Resident #12's quarterly MDS Assessment, dated 2/22/23, revealed: He had a mental status exam of 13 of 15 (indicating he was cognitively intact). He needed extensive assistance of one person for most ADLs. Review of Resident #12's Care Plan, revised 12/1/22, revealed: Focus: Resident had an ADL self-care performance related to stroke, right sided weakness. Goal: Resident will maintain current level of ADL function through the review dated Interventions: ensure /provide a safe environment. Call light in reach. Observation on 03/14/23 at 9:56 AM revealed Resident #12 was in his room up in his wheelchair. Resident #12's call light on the A side of the room was clipped to the privacy curtain above his head. The other call light (B side) was draped on the over bed light out of reach of the resident. Resident #12 reached for the call light (clipped to the curtain) with his right arm, but was unable to reach above his shoulder. He asked the surveyor to give him the call light. Interview 03/16/23 at 2:32 PM the DON stated her expectation was that call lights be answered within two minutes. She revealed she expected the residents be able to use the light for whenever they needed. The DON stated if the call light was higher than the resident's range of motion would allow then it was out of reach. She stated all staff were responsible for monitoring that the call light was within reach. The DON stated the definition of within reach was if the resident could grab it. The DON stated Resident #12's range of motion was completely intact on the left side, but she did not know about the right side. She said Resident #12 was not a resident who played helpless and liked to be as independent as he could. The DON stated she did not know why the call light was clipped to the curtain. She said Resident #12 told her yesterday that he liked for the call light to be on a cabinet on his right side so he would not knock it over. She said she did an in-service about it. Review of the in-service material and call light policy (undated), completed with staff 3/15/23, revealed: Call lights: accessibility and timely response: The purpose of this policy is to assure the facility is adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. Policy Explanation: Staff will ensure the call light is within reach of resident and secured, as needed. Practice Guidelines - Accessible Call lights Why you do it: To assure appropriate placement of call lights for resident accessibility. How you do it - Determine if the call light is easily accessible. Identify resident function in the environment: limitations, strengths, adaptation needs, preferences. Assist the resident in arranging the environment for as much independent function as possible.

Based on observation, interview and record review, the facility failed to store and label medications according to professional standards in 1 of 1 medication room and for 1 of 6 residents (Resident #6) reviewed for medication storage and labeling. The facility failed to ensure: a) cleaners and insect killer were stored separately from resident medication in the medication room; and b) Resident #6's multidose insulin vial was dated and timed with the expiration date when opened. These failures could result in contamination of medications to be administered to residents potentially causing serious adverse reactions, and insulin being administered after the expiration date causing residents receiving insulin at risk of not receiving the intended therapeutic benefit of their prescribed insulin. The findings were as follows: An observation of the medication room on [DATE] at 10:00 AM revealed the following: - 1 gallon bottle of liquid laundry detergent on med room counter - 1 gallon bottle of germicidal ultra bleach on med room counter - 1 bottle of urine remover spray on med room counter - 6 bottles of disinfectant spray stored in cabinet with nebulizer medication - 1 bottle of absorbent powder stored in cabinet with nebulizer medication - 3 bottles of absorbent powder stored in cabinet with enema supplies - 1 bottle of clinging disinfectant cleaner stored in cabinet with enema supplies - 1 can of ant and roach killer stored in cabinet with enema supplies In an interview with the DON on [DATE] at 10:40 AM she explained that the laundry detergent and bleach are stored in the med room so the night shift staff can do laundry if needed. She stated that the 2 bottles are kept separate from the laundry room storage, so the staff only have access to the chemicals for washing clothes and not all the laundry chemicals. She explained that all other chemical storage areas are locked at night with no access. In an interview with LVN C on [DATE] at 11:03 AM, she explained that only the nurses and medication aides have the code for the med room door so at night, if staff needs to access the chemicals being stored in the med room, the have to get a nurse to let them in. In an interview with the facility administrator on [DATE] at 11:34 AM, he explained that the initial reason for storing the laundry detergent and bleach in the med room was to keep it out of reach of residents. He stated that about 2 years ago he noticed that the bottles were being left out on the counter at the nurse's station at night and he was concerned that a resident might try to take the bottle. He stated that at that time he asked the staff to keep those chemicals locked up, though he did not specify where they should be stored. He stated that he was not aware that disinfectants and bug spray were being stored in the med room. In an interview with the facility's consultant pharmacist on [DATE] at 1:25 PM, he explained that he does med room and med cart audits monthly and he had seen bleach and laundry detergent on the counter in the med room in the past. He stated he had never seen other chemicals being stored in the med room. Review of facility policy titled Storage of Medications dated [DATE] revealed, in part, Antiseptics, disinfectants, and germicide used in any aspect of resident care have legible, distinctive labels that identify the contents and the directions for use and are stored separately from regular medications. Review of Resident #6's Admission Record dated [DATE] indicated she was [AGE] years old and admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #6's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] = 6 units. Observed RN D on [DATE] at 11:15 AM check Resident # 6's blood glucose with result of 242. RN C removed Resident #6's Novolog Insulin from the med cart. The box was labeled opened [DATE] . No time was on label. The insulin bottle was not labeled. RN D said they normally just label the box. RN D drew up 6 units and administered to Resident #6. Review of facility policy, Insulin Administration, revised [DATE], under Steps in the Procedure #4 included: Check expiration date if drawing from a multi-dose vial . In an interview with the DON on [DATE] at 3:00 PM she said insulin vials should be labeled with the date and time opened. She said just labeling the box is not appropriate as the box may get discarded or lost. She said unlike most insulin which expires 30 days after opening, Novolog Insulin expires 28 days after opening. She said Resident #6's vial should have been discarded on [DATE]. In an interview with RN D on [DATE] at 9:40 AM she said the DON told her about the dating and expiration of the insulin. She agreed that insulin vials should be labeled with date and time opened because the box could get lost. She said she just assumed Novolog expired 30 days after opening like most insulins. In an interview with the DON on [DATE] at 3:00 PM she said the facility policy is when opening a new vial of insulin to record the expiration date and time of opening on the vial. She said they follow the manufacturer's recommendation as to when a vial of insulin should be discarded after opening. She said Novolog's expiration is 28 days after opening. Review of the Novolog insulin [MEDICATION(S)] injection 100 units/ml package insert dated ,d+[DATE], provided by the DON, included Table 9. Storage conditions for 10 ml multidose vial: In-use (opened) 28 days stored refrigerated/room temperature.

Based on observation, interview and record review the facility failed to maintain an infection control program designed to prevent the development and transmission of infections for 2 of 3 (Residents #8 and #13) reviewed for infection control. The facility failed to ensure: CNAs A and B washed their hands before providing resident care for Resident #8. Residents #13's oxygen nasal cannula and SVN mask was bagged when not in use. This failure placed residents at risk for infection. Findings included: RESIDENT #8 Record review of Resident #8's admission record dated 12/27/2021 indicated she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was [AGE] years of age. Record review of Resident #8's MDS dated [DATE] indicated in part: BIMS = 04 indicating resident had severe impairment. Bladder and bowel: Urinary continence = Always incontinent (no episodes of continent voiding). Bowel continence = Always incontinent (no episodes of continent bowel movements). Record review of Resident #8's care plan dated 12/08/2021 indicated in part: Focus: Resident has bladder and bowel incontinence r/t Alzheimer's Dementia. Goal: The resident will remain free from skin breakdown due to incontinence and brief use through the review date. Interventions/Tasks: INCONTINENT: Check every 2 hours and as required for incontinence. Wash, rinse and dry perineum. Apply lotion after cleansing to increase pliability PRN. Change clothing as needed after incontinence episodes. During an observation on 12/27/21 at 01:08 PM CNAs A and B transferred Resident #8 to the bed with the use of a mechanical lift. Both CNAs entered the resident's room and donned gloves without first using hand sanitizer or washing their hands. CNA A left the resident's room to retrieve some supplies and when she re-entered the resident's room, she washed her hands. CNA A washed her hands with soap then proceeded to close the faucet with her bare hands. CNA A performed the incontinent care while CNA B assisted with repositioning the resident. CNA B then took her gloves off and washed her hands. CNA B turned the faucet on, washed her hands and then closed the faucet with her bare hands. During an interview on 12/28/21 at 04:48 PM CNA A said after she washed her hands, she remembered she had closed the faucet with her bare hands. CNA A said she could have re-contaminated her hands when closing the faucet with her bare hands. CNA A said she had made a mistake and said she should have used a paper towel to close the faucet. CNA A said she should have washed her hands prior to donning gloves when she first entered Resident #8's room. CNA A said if she did not wash her hands prior to performing resident care she could possibly cause cross contamination. During an interview on 12/28/21 at 04:55 PM CNA B said she had not washed her hands or used hand sanitizer prior to donning gloves when she assisted Resident #8. CNA B said if she did not wash her hands prior to assisting the resident she could possibly cause cross contamination. CNA B said that when she washed her hands after they were done assisting Resident #8 that she had closed the faucet with her bare hands instead of using a paper towel. CNA B said she could have re-contaminated her hands when closing the faucet with her bare hands. During an interview on 12/29/21 at 10:54 AM the DON was made aware of the observation regarding the resident care provided to Resident #8 by CNAs A and B. The DON said the aides were supposed to have washed their hands or used hand sanitizer prior to performing the resident care. The DON said the staff were supposed to have used a paper towel to close the faucet once they were done washing their hands. The DON said the infection control preventionist was responsible for training the CNAs on hand hygiene and glove use. The DON said she would monitor the aides by her assisting with resident care and also observing the staff doing their job correctly. The DON said she believed the failures occurred because the staff got nervous and required more training. During an interview on 12/29/21 at 11:34 AM the infection control preventionist was made aware of the observation regarding the resident care provided to Resident #8 by CNAs A and B. The infection control preventionist said she was in charge of doing the training and would have the staff view CDC videos on handwashing, PPE donning and such. She said she would go and observe the staff wash their hands and use gloves. She said she would observe them on a monthly basis. The infection control preventionist said the staff were expected to use alcohol hand sanitizer or wash their hands prior to performing resident care. She said the staff were supposed to use a paper towel to turn off the faucet. The infection control preventionist said she believed the failure occurred due to the staff being nervous. During an interview on 12/29/21 at 12:55 PM the Administrator was made aware of the observation regarding the resident care provided to Resident #8 by CNAs A and B. The Administrator said he was not a nurse but would agree with what the DON and the infection control preventionist said. The Administrator said the infection control preventionist was responsible for doing the training. The Administrator said this failure could possibly cause the spread of germs throughout the facility. RESIDENT #13 Record review of Resident #13's admission record dated 12/28/2021 indicated she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was [AGE] years of age. Record review of Resident 13's December 2021 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 02@ 3Liters/NC continuous when in the bed, r/t low 02 sat readings while in the bed. Order date 12/02/2021. Record review of Resident #13's care plan dated 12/14/2021 indicated in part: Focus: The resident has a terminal prognosis r/t subarachnoid hemorrhage with [CONDITION(S)]. On Hospice services. GOAL: The resident's comfort will be maintained through the review date. Interventions/Tasks: New order for O2 at 3L per NC continuous when in bed. During an observation on 12/27/21 at 01:12 PM Resident #13's nasal cannula was wrapped around the oxygen concentrator and the SVN mask was lying on top of the dresser. During an interview on 12/29/21 at 10:54 AM the DON was made aware of an observation of Resident #13's nasal cannula wrapped around the oxygen concentrator and the SVN mask lying on top of the dresser. The DON said the cannula and SVN mask were supposed to be stored in a bag when not in use. The DON said the nurses were responsible for making sure the items were kept in a bag and ultimately it was also her responsibility to monitor them. The DON said all nurses were supposed to monitor that items were bagged when not in use and they were supposed to do it daily. The DON said this failure could result in an infection control issue by introducing bacteria into the resident's nose and respiratory system. The DON said the failure occurred because the staff failed to place the items in the bags. During an interview on 12/29/21 at 12:55 PM the Administrator was made aware of an observation of Resident #13's nasal cannula wrapped around the oxygen concentrator and the SVN mask lying on top of the dresser. The Administrator said staff were supposed to monitor that and help keep items from becoming contaminated. The Administrator said if the items were left out it could possibly cause the resident to become contaminated with the particles to could get on the cannula and mask. Record review of the facility's policy titled hand hygiene dated 07/18/2019 indicated in part: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors. This applies to all staff working in all locations within the facility. Staff will perform hand hygiene when indicated using proper technique consistent with accepted standards of practice. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to the attached hand hygiene table - Between resident contacts, after handling contaminated objects, before applying and after removing personal protective equipment (PPE) including gloves, before performing resident care procedures. Hand hygiene technique when using soap and water: wet hands with water, avoid using hot water to prevent drying of skin. Apply to hands the amount of soap recommended by the manufacturer. Rub hands together vigorously for at least 15 seconds covering all surfaces of the hands and fingers. Rinse hands with water. Dry thoroughly with a single use towel. Use towel to turn off the faucet. Additional considerations -The [NAME] of gloves does not replace hand hygiene. If your task requires gloves perform hand hygiene prior to donning gloves and immediately after removing gloves. Record review of the facility's policy titled Oxygen concentrator dated 2021 indicated in part: The purpose of this policy is to establish responsibilities for the care and use of oxygen concentrators. Use of concentrator - keep delivery devices in bag when not in use. Nurse responsibilities - Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. Record review of the facility's policy titled Nebulizer therapy dated 2021 indicated in part: It is the policy of this facility for nebulizer treatments once ordered to be administered by nursing staff as directed using proper technique and standard precautions. Care of equipment - clean after each use, Once completely dry store the nebulizer cup and the mouthpiece in bag.

Based on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 6 residents (Resident #6) reviewed for medication administration. The facility failed to ensure Novolog Insulin was not administered after the expiration date. This failure could result in residents receiving insulin after the expiration date at risk of not receiving the therapeutic benefit of their prescribed insulin. Review of Resident #6's Admission Record dated [DATE] indicated she was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included dementia, diabetes and hypertension. Review of Resident #6's physician orders dated [DATE] included Novolog Solution 100 units/ml (Insulin [MEDICATION(S)]) Inject as per sliding scale .201 - 400 = 6 units. Observed RN D on [DATE] at 11:15 AM check Resident # 6's blood glucose with result of 242. RN C removed Resident #6's Novolog Insulin from the med cart. The box was labeled opened 11/ ,d+[DATE]. No time was on label. The insulin bottle was not labeled. RN D said they normally just label the box. RN D drew up 6 units and administered to Resident #6. In an interview with the DON on [DATE] at 3:00 PM she said insulin vials should be labeled with the date and time opened. She said just labeling the box is not appropriate as the box may get discarded or lost. She said unlike most insulin which expires 30 days after opening, Novolog Insulin expires 28 days after opening. She said Resident #6's vial should have been discarded on [DATE]. In an interview with RN D on [DATE] at 9:40 AM she said the DON told her about the dating and expiration of the insulin. She agreed that insulin vials should be labeled with date and time opened because the box could get lost. She said she just assumed Novolog expired 30 days after opening like most insulins. In an interview with the DON on [DATE] at 3:00 PM she said the facility policy is when opening a new vial of insulin to record the expiration date and time of opening on the vial. She said they follow the manufacturer's recommendation as to when a vial of insulin should be discarded after opening. She said Novolog's expiration is 28 days after opening. Review of the Novolog insulin [MEDICATION(S)] injection 100 units/ml package insert dated ,d+[DATE], provided by the DON, included Table 9. Storage conditions for 10 ml multidose vial: In-use (opened) 28 days stored refrigerated/room temperature.

Based on interview and record review the facility failed to designate a registered nurse to serve as the Director of Nursing (DON) on a full time basis. The facility has not had a Director of Nurses (DON) since 04/19/2019. This failure could place residents at risk for not receiving necessary care and services. The Findings were: Interview on 09/09/2020 at 09:30 AM with the Administrator revealed he has not had a full time Director of Nursing (DON) since 04/19/2019, only hired a part time interim Director of Nursing (DON) on 01/01/2020. Interim DON went full time in March after the Covid19 shut down and has returned to part-time in August. Record review of nursing schedule from June 1, 2020 to September 10, 2020 revealed that there are three full time Registered Nurses, one is the MDS nurse she works Monday-Friday and the other two full time Registered Nurses rotate weekends. During interview with the Administrator on 09/10/2020 at 2:30 PM he revealed he has been running ads in the surrounding cities newspapers since January 2019 before his Director of Nurses (DON) left in April, 2019, he had a sign on bonus of ten thousand dollars. On October 23, 2019 the Administrator hired a recruitment resource agency to find a Director of Nurses, then the recruitment agency broke the contract during the Covid19 outbreak. During record review on 09/10/2020 at 3:09 PM of Time Clock Plus report dated 06/01/2019 -09/10/2020 revealed the interim DON had gone back to her full time school nurse position and only working weekends since the beginning of August.

Based on observation and interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment in 5 of 8 resident rooms on Hall 100. The facility failed to: * maintain the tile flooring in the bathrooms of rooms 101, 102, 103, 107, and 108; * ensure the toilet was flushing in room [ROOM NUMBER]; and * ensure the vinyl toilet seat in room [ROOM NUMBER] was free of splits. These failures could place residents at risk for injury, infection, and decreased quality of life. Findings include: During observations from 04/15/19 at 11:40 AM to 04/17/19 at 3:00 PM loose tiles were noted around the toilets in rooms 101, 103, 107, and 108. The vinyl toilet seat in room [ROOM NUMBER] had a split approximately 1 1/2'' long along the top right side. The toilet in room [ROOM NUMBER] did not flush. In an interview with the Administrator on 04/17/19 at 3:20 PM he acknowledged the loose tiles around the toilets could be slip/trip hazards, and pose infection control risks. In an interview with the Administrator on 04/17/19 at 4:05 PM he acknowledged the tear in the toilet seat could pose the risk of causing skin tears. The facility did not have a policy specifically addressing floor tiles or toilets.

Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections for one (Resident #12) of one resident reviewed contact isolation. Resident #12 was in contact isolation due [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus). Staff were not following facility policy and procedure in regards to contact isolation precautions by not wearing gowns when providing care for Resident #12. These failures could place all residents in the facility at risk for developing infections due to cross contamination. Findings included: Review of Resident #12's undated Face Sheet revealed she was a [AGE] year-old female admitted on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #12's quarterly MDS (minimum data set) dated 03/25/19 revealed her BIMS (brief interview memory status) revealed a score of 15 indicating she was not cognitively impaired. Her functional status revealed she required extensive assistance with transfers, toilet use, and 1 person for hygiene assistance. Record review of undated Care Plan revealed: Resident #12 is in contact isolation for infection to right heel and left great toe. Goal: Wound will be cleared of infection and nobody else will be infected with it within 2 weeks' time. Approach: Gloves to be worn with any contact care with resident and if touching infected material. Gowns to be worn by caregivers if soiling is likely and shoe covers as needed. Review of Resident #12's wound culture dated 03/26/19 revealed the following: Wound culture: Heavy growth [MEDICAL CONDITION]-resistant staphylococcus aureus. Review of Physician orders [REDACTED]. During an observation and interview on 04/15/19 at 3:20 PM with CNA B and CNA C revealed upon entering Resident #12's room they put on shoe covers and said they were told by the wound care clinic they just had to put on shoe covers in case blood or other body fluids fell on the floor; they would not track it through the facility. The Aides said the wound care center told them it was not necessary to wear gowns when providing care to Resident #12 and were not specific who told them about the gowns and shoe covers. During incontinence care observation on 04/15/19 at 3:30 PM CNA B and CNA C washed hands, gloved, removed Resident #12's brief, cleaned perianal area, touching sheets, bed rails and other environmental surfaces with their clothing and exposed areas of wrists, and arms. During an interview on 04/15/19 at 2:30 PM with Treatment Nurse LVN C she said they (the staff) were only supposed to put on shoe covers in case blood or other infectious material fell on the floor and would not be tracked through the facility. In regards to possibly touching other environmental surfaces she said she was going by what the wound care clinic tells them and that if the wound was covered there is no reason to wear gowns. During an interview with LVN C on 04/16/19 at 9:00 AM she said Resident #12 was in contact isolation because she [MEDICAL CONDITION] or the great toe. During an interview on 04/16/19 at 10:45 AM with the DON she said they have been following what they were told by the wound care center, (when Resident #12 began going to the clinic when she was positive [MEDICAL CONDITION] on 3/26/19) , and realized they were not following their facility's policy and procedure regarding Contact Isolation procedures. Review of the facility's policy and procedure dated (YEAR) revealed the following: Definition: Contact Precautions are measures that are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the resident or the resident's environment. Recommendations for Personal Protective Equipment (PPE) Contact: Gowns - Whenever anticipating that clothing will have direct contact with the patient or potentially contaminated environment surfaces or equipment in close proximity to the patient. Don gown upon entry into the room or cubicle.

Based on observation, interview and record review, the facility failed to ensure that it was free of a medication error rate of 5 percent (5%) or greater. Twenty-five opportunities were observed with a total of two errors, resulting in an 8 percent (8%) medication error rate. One (MA A) of three staff observed administering medication made errors. One (Resident #24) of five residents observed during the medication pass were affected. MA A failed to follow physician's orders [REDACTED].#24 medications Lactobacillus 1 capsule in the morning, and Pantoprazole 40 mg (milligrams) during medication pass observation. These failures could affect residents by placing them risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders. Findings included: Review of Resident #24's undated Face Sheet revealed he was a [AGE] year-old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #24's quarterly MDS (minimal data set) dated 04/05/19 revealed Resident #24 had a BIMS (brief interview for mental status) of 8 indicating Resident #24 was moderately cognitively impaired and able to make his needs known. Resident #24's functional status revealed he required extensive assistance of two staff members for transfers and supervision during meals. Review of Resident #24's undated Care Plan revealed the following: non-compliance with medication administration needs and meals at times related to knowledge deficit, denial of risk factors and mostly cognitive impairment. Goal: Resident will verbalize understanding of consequences of non-compliance when non-compliance happens for next 90 days. Approach: Inform resident risks of non-compliance. Review of Resident #25's Physician order [REDACTED]. NAME] 40 mg Oral Tablet delayed release give 1 tablet by mouth start date 01/18/18 before breakfast daily Review of the website https://www.pfizermedicalinformation.com/en-us/patient/[MEDICATION NAME] revealed the following: You should take Pantoprozole ([MEDICATION NAME]) exactly as prescribed . During an observation on 04/16/19 at 9:00 AM revealed MA A preparing Resident #24's medications. She placed [MEDICATION NAME] 160 mg 1 tablet, [MEDICATION NAME] 20 mg (milligram) 1 tablet, [MEDICATION NAME] 125 mg (3) capsules, [MEDICATION NAME] 100 mg 1 tablet, Senna 8.6 mg 1 tablet, and [MEDICATION NAME] HCL 1000 mg 1 tablet and placed them in a medicine cup. Total of 8 tablets and capsules were verified with MA A. She said these are the medications that are due now then gave Resident #24 his medication. During the MAR (medication administration record) record review on 04/17/19 at 11:00 AM revealed the following: Lactobacillus 1 capsule ordered twice daily was documented as given at 9:04 AM by MA A (medication pass observation at 9:00 AM was not observed given Lactobacillus 1 capsule to Resident #24) and Pantoprazole 40 mg ordered QAM (every morning) documented as given at 8:59 AM by MA A (medication pass observation at 9:00 AM was not observed given Pantoprazole 40 mg 1 tablet medication to Resident #24). Total 10 tablets and capsules of medications would have been expected if Lactobacillus and Pantoprazole 40 mg were given. During an observation on 04/17/19 at 11:05 AM Resident #24 took the medication provided by MA A which contained all the medication counted and reconcilled by the physician orders [REDACTED]. During an interview on 04/17/19 at 2:15 PM with MA A she said she gave Resident #24 the Lactobacillus but it was in the refrigerator and had to take it out. She said she went to get the medication after the observation was made during medication pass. MA A also said she knew she gave the Pantoprazole 40 mg because it was the last medication on the card. During the interview MA A was reminded by the surveyor prior to the Medication Pass observation she was instructed three times to give Resident #24 all his medications that were due and failure to give the medication at that time could possibly initiate a medication error. She said she understood the instructions. During an interview with the Administrator on 04/17/19 at 3:40 PM revealed the potential medication error. During this interview with the Administrator, MA A was told on three occasions the observation procedure and what was expected and failed to follow the instructions. Administrator said he would expect MA A to follow directions and failing to do so would cause a potential medication error. The facility's Medication Administration policy was requested on 04/17/19; however, no policy was provided prior to exit on 04/17/19.

Based on interview and record review, the facility failed to ensure each resident's drug regimen was free of significant medication errors for 2 of 6 residents reviewed for medications. (Resident # 1 and Resident # 3) a) The facility did not adequately monitor Resident #1's and Resident #3's PT/INR levels properly with the Coagucheck SX Machine and continued to administer [MEDICATION NAME] (anticoagulant medication) to the resident after orders indicated the medication had been discontinued/held. Resident #1's INR was 23.64 on [DATE]. The resident had rectal bleeding, and expired on [DATE]. b) The facility failed to ensure Resident #3's hospital discharge medication orders were followed and resumed a previous order for [MEDICATION NAME]. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm not IJ with a scope of pattern because the facility had not had time to monitor their plan of removal for effectiveness. This failure placed 4 residents on anticoagulant medications, at risk of major or fatal bleeding. Findings included: Resident #1 Closed record review of Resident #1's Face Sheet dated [DATE] indicated a [AGE] year old female admitted on [DATE] [DIAGNOSES REDACTED]. Record review of Resident #1's two most recent quarterly MDSs dated [DATE] and [DATE] indicated no significant declines in cognition or ADLs. The most recent Quarterly MDS Indicated a BIMS of 7 indicating extensive cognitive impairment and extensive to total dependence for ADLs of ,[DATE] people and on anticoagulant therapy. The MDS indicated Resident #1 was receiving hospice services and had a prognosis of less than 6 months to live. Record review of Resident #1's care plan last revised [DATE] indicated the following: Goal: Resident will be free of bruising, bleeding or injury Approach: Administer medications as ordered. Closed record review of the Physicians Visit Form for Resident #1 with a printed date of [DATE] provided by the DON indicated a [MEDICATION NAME] order that was started on [DATE] and discontinued on [DATE] that read as follows: [MEDICATION NAME] 2mg every Monday, Wednesday, Friday, Saturday, and Sunday. [MEDICATION NAME] 1mg every Tuesday and Thursday. Record review of Resident #1's INR results in (MONTH) (YEAR) indicated no results above 3.1. Record review of INR Results Sheets for Resident #1 indicated the following: [DATE]= 1.8 [DATE]= 2.2 [DATE]= 2.2 [DATE] 3.6 [DATE]= 8.0 and documented the dose was held [DATE], [DATE], and [DATE] [DATE]= 8.0 and documented held [MEDICATION NAME] on [DATE], [DATE], and [DATE]. PT/INR taken by vein on [DATE] read PT 63.4 and INR 21.75. Record review of the Coagucheck SX machine manual indicated the following: Out of range values The Coagucheck XS PT test strips provide test results if the INR value is 0.8 and 8.0 if the result falls outside of this range, the meter displays < (less than) 0.8 or > (greater than) 8.0 if the meter indicates an out-of-range value, refer to the test strip package insert and repeat test . If this error message appears again when the test is repeated, the result must be checked using another method. (PT/INR is a blood test that measures the time it takes for the liquid portion (plasma) of blood to clot. Per the U.S. National Library of Medicine: [MEDICATION NAME] time (PT). [DATE]; https://medlineplus.gov/ency/article/ 2.htm accessed on [DATE]. For people taking [MEDICATION NAME], most laboratories report PT results that have been adjusted to the INR. These people should have an INR of 2.0 to 3.0 for basic blood-thinning needs. For some who have a high risk of a blood clot, the INR needs to be higher - about 2.5 to 3.5. (https://labtestsonline.org/tests/[MEDICATION NAME]-time-and-international-normalized-ratio-ptinr accessed [DATE]) Record review of the nurse's notes for Resident #1 for (MONTH) (YEAR) indicated the following: [DATE] [MEDICATION NAME] order changed to 1mg Tuesday and Thursday and [MEDICATION NAME] 2mg given Monday, Wednesday, Friday, Saturday, and Sunday. [DATE] [MEDICATION NAME] and [MEDICATION NAME] ordered for fever/URI [DATE] Resident #1 coughed up blood, the doctor was notified and a duo neb breathing treatment was ordered. [DATE] after the PT/INR machine was used, an INR value was identified of 3.6 which was an abnormal high value. An order to hold the [MEDICATION NAME] for the next 3 days was ordered by the doctor. [DATE] an INR value of 8.0 was identified, the doctor again ordered to hold the [MEDICATION NAME] for an additional 3 days and recheck PT/ INR on [DATE]. [DATE] the machine again read 8.0 and a lab draw was ordered that identified the following values: PT 66.6 and INR 23.64 per vein collection. The doctor ordered [MEDICATION NAME] (medicine used to treat vitamin K deficiency or bleeding problems caused by various disorders) 5mg PO qd and retest INR post 48 hours. [DATE] At 3:49 pm note stating a large amount of blood was in resident's brief and the nurse notified doctor. [DATE] Resident #1 expired at 3:30 am. Using [MEDICATION NAME] together with [MEDICATION NAME] may cause you to bleed more easily. You may need a dose adjustment based on your [MEDICATION NAME] time or International Normalized Ratio (INR). (https://www.drugs.com/drug-interactions/[MEDICATION NAME]-with-[MEDICATION NAME]-[DATE]-0.html?consumer=1 accessed [DATE]) During an interview with CNA K on [DATE] at 11:59 am she said that on [DATE] Resident #1 had coughed up blood and she reported it to LVN M. Record review of the 24 hour report for the following days indicated a note to hold Resident #1's [MEDICATION NAME] on [DATE], [DATE], and [DATE]. Record review of the MAR for Resident #1 provided by the DON on [DATE] for (MONTH) (YEAR) indicated the [MEDICATION NAME] was given [DATE]-[DATE] the days the medication was ordered to be held originally after the reading of 3.6 (high value) was identified. During an interview with the DON on [DATE] at 12:35 pm she said that [MEDICATION NAME] should have been held for Resident #1 on [DATE], [DATE], and [DATE] as ordered by the physician. She said the [MEDICATION NAME] was given on those days. During an interview with LVN B on [DATE] at 2:02 pm she said that she received an order from the doctor's LVN at the clinic on [DATE] to hold Resident #1's [MEDICATION NAME] but it had been already given the day of the call so she said she tried to call back and clarify the order but the doctor did not answer after 5:00 pm that day so she passed it on in report to the oncoming nurse and she said she should have followed up on the order. She said she never wrote the order or put it in the system. During an interview with RN E on [DATE] at 3:49 pm she said that she had received the order clarification phone call for the 3 day hold for the [MEDICATION NAME] of Resident #1 taken by LVN B on [DATE]. She said she passed on the order clarification to LVN B. She said she did not input orders. She said she had seen that LVN B had wrote it on the 24 hour report and had assumed it had been input into the system. During an interview with CMA A on [DATE] at 1:46 pm she said she gave Resident #1 [MEDICATION NAME] on [DATE] and [DATE] she said she was not aware that there was a hold on the order. She said she went by what the MAR indicated [REDACTED]. She said the Nurses check the PT/INR and she said the CMAs gave the medication unless told not to. She said she had not observed or known Resident #1 had bleeding episodes prior to her administering the medication. During an interview with LVN B on [DATE] at 11:15 am she said that she passed on the order to be clarified to the night nurse that she had not put in the order because the [MEDICATION NAME] had been given on [DATE] and wanted to see if the doctor wanted to hold the [MEDICATION NAME] for the following 3 days. She said the documentation on [DATE] of the PT/INR check stating the [MEDICATION NAME] being held on [DATE], [DATE] and [DATE] that she had wrote on the INR Result Sheet was an error. She said the [MEDICATION NAME] was not held on those days. She said she had only received a ,[DATE] minute training video on how to use the PT/INR Machine. She said the machine was supposedly taken out of use but she had read a note for Resident #3 that said it had been used within the last week. She said she had never received a clarification order from any other staff member and assumed the order had been put in the system and the [MEDICATION NAME] had been held for the 3 days mentioned. LVN B also said that she was not aware that the machine had a greater than 8 marker and that the video she watched did not contain information on the machines max value reading. Record review of the Coagucheck SX machine video on [DATE], indicated no mention of a greater than 8 value. The video said to refer to the manual for any further questions. During an interview with Physician C on [DATE] at 3:08 pm, the physician of Resident #1, said that he was aware that the [MEDICATION NAME] was not held as ordered on [DATE], [DATE], and [DATE]. He said that treatment ([MEDICATION NAME], medicine used to treat vitamin K deficiency or bleeding problems caused by various disorders, 5mg PO qd and retest INR post 48 hours) was given to Resident #1 to try to reverse the abnormal PT/INR results following the orders not being followed. During an interview with CNA H on [DATE] at 3:52 pm she said that she saw blood in the residents brief on [DATE]. She said it was a lot of what appeared to be blood. She said it wasn't bright red and it wasn't the color of stool. She said it was somewhere in the middle. She said it was hard to describe. She said that Resident #1 died sometime in the morning the following day on [DATE]. During an interview with LVN L on [DATE] at 3:53 pm, she said she was called into the room after a CNA report of blood in Resident #1's brief on [DATE]. She said the brief was completely covered in bright red blood. She said she then reported her findings to the doctor. During an interview with the DON on [DATE] at 2:16 pm she said that she believed that the order not being held did not contribute to the resident expiring. She said that she disciplined LVN B, had in-services, and put LVN B on orientation for another month. She said she also took away the PT/INR machine from staff use because LVN B did not see the greater than sign that would come after the machines max value of 8. She said when the lab was drawn by vein on [DATE] the results were far more elevated than the 8 value LVN B documented from the PT/INR machine. The DON said that once LVN B had the reading of greater than 8, a sample should have been obtained through Resident #1's vein using a needle and tube. During an interview with the DON on [DATE] at 10:49 am, she said that the nurses had only watched the video for the Coagucheck SX machine and had not read the manual for the Coagucheck SX machine. Record review of an undated in-service provided by the DON on [DATE] that she said was for an in-service regarding [MEDICATION NAME], PT/INR, and the Coagucheck Sx Machine for [DATE] which indicated education for the topics and included that the facility would not be using the Coagucheck SX machine any longer as a means of checking INR values. Record review of the nurses notes dated [DATE] indicated the Anticoag Sx machine was used to check Resident #3's INR on [DATE]. The nurse checking was LVN F. Record review of the in-service for [MEDICATION NAME], PT/INR, and the Coagucheck SX machine provided by the DON which she said was for in-servicing on [DATE] indicated 5 missing nursing staff signatures. During an interview with LVN I on [DATE] at 11:29 am she said if she would have received an order to stop the [MEDICATION NAME] for 3 days and the day of the order the [MEDICATION NAME] had been given she would have at least stopped the order for the remaining days and got clarification from the doctor after stopping the order for the remaining days. During an interview with LVN B on [DATE] at 11:48 am, she said that there had been no way of monitoring for bleeding other than nurses notes until yesterday [DATE]. She said the nurses follow the physician orders [REDACTED]. During an interview with LVN J on [DATE] at 11:50 am she said if she had received an order to stop [MEDICATION NAME] for 3 days and the [MEDICATION NAME] had already been given that day, she would have held the order in the system for the remaining days at least until the order could be clarified further for the day that had been missed. During an interview with the Administrator on [DATE] at 1:41 pm he said that the incident happened due to a miss identification of a value by the machine. He said that the DON had told him that RN E had told LVN B about the order clarification and the order mistake had happened with confusion in the transfer of the order from nurse to nurse. He said that the machine was used one time on [DATE] with the approval of the DON and ADON because Resident #3 had an emergency and since the last one time use the machine had been destroyed and taken out of service. During an interview with the DON on [DATE] at 1:50 pm she said that she believed it was an accident due to LVN B being fairly new. She said the situation happened due to confusion and failure to input the order into the system after receiving the order from the physician by LVN B. She said LVN B failed to follow up on the order. She said that she did believe the situation was an IJ but did not believe the [MEDICATION NAME] caused Resident #1's death on [DATE]. She said Resident #1 was declining before the error with the [MEDICATION NAME]. She said she educated, disciplined, and trained LVN B appropriately after the incident so it wouldn't happen again. During an interview with the DON on [DATE] at 4:18 pm she said the staff members that were not in-serviced on [DATE] for [MEDICATION NAME], PT/INR, and the Coagucheck SX machine had not been in-serviced yet. During an interview with LVN F on [DATE] at 4:28 pm she said she only watched the video for the Coagucheck SX machine on [DATE] and was not aware of the greater than 8 value the machine would identify for readings over 8.0. Resident #3 Review of Resident #3's undated Face Sheet indicated he was [AGE] years old and was originally admitted to the facility on [DATE]. He returned from a hospitalization on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #3's MDS assessment dated [DATE] indicated he had moderate cognitive impairment (BIMS score of 10 out of 15). He required total to extensive assistance of two or more people for bed mobility, transfers, dressing and bathing. He was able to feed himself with setup and supervision. He had not received anticoagulant medication during the 7-day look-back period. Review of Resident #3's Hospital Discharge Summary dated [DATE] indicated he was hospitalized from [DATE] to [DATE]. [DIAGNOSES REDACTED]. He was kept on empiric IV antibiotic. On [DATE] he was taken to surgery for [REDACTED]. The Eliquis was changed to [MEDICATION NAME] (another anticoagulant also known as [MEDICATION NAME]) at discharge. Review of Resident #3's Hospital Discharge Summary dated [DATE] indicated he was hospitalized from [DATE] to [DATE]. [DIAGNOSES REDACTED]. Description of the hospital course included: His [MEDICATION NAME] was held given his coagulopathy and eventually discontinued given his recent [MEDICAL CONDITION] 3 months ago and after 1 month of [MEDICATION NAME]. Further review of the discharge summary included the discharge medication list, which included the following changes: START taking these medications [MEDICATION NAME] ,[DATE] mg 1 tablet twice daily for 7 days [MEDICATION NAME] 500 mg 1 tablet once daily for 7 days STOP taking these medications Apixaban 5 mg tablet Commonly known as: Eliquis [MEDICATION NAME] 2.5 mg tablet Commonly known as: [MEDICATION NAME] [MEDICATION NAME] 5 mg tablet Commonly known as: [MEDICATION NAME] Review of Resident #3's Nursing Progress Notes dated [DATE] by RN D included the following: (3:43 PM) NOTE: Resident return to facility from (the hospital) in stable condition via facility van with facility staff. New orders as follows: 1. [MEDICATION NAME] 500 mg po BID till all taken 2. [MEDICATION NAME] 500 mg po daily till all taken (4:56 PM) NOTE: 16:30 Unsuccessful attempts at drawing PT/INR here in facility. Res. transported to lab at clinic for blood draw . 17:00 Res return to facility in stable condition. Will await new [MEDICATION NAME] orders. Will continue with 3 mg q day and re-draw PT/INR on [DATE]. Review of laboratory results dated [DATE] indicated the [MEDICATION NAME] (PT) was 12.3 (Reference Range 10.0 - 14.0) and the INR was 1.25 (Reference Range < = 5.00). Further review of Resident #3's facility record did not reveal a physician order [REDACTED]. Review of Resident #3's (MONTH) (YEAR) MAR indicated [REDACTED]. The MAR indicated [REDACTED]. In an interview with RN D on [DATE] at 12:35 PM confirmed that the discharge summary from the hospital was what she went by when Resident #3 returned from the hospital on [DATE]. She said she looked at the medication list from the hospital and said, My thinking was that his PT/INR was high prior to him going to the hospital and there was an order to hold the [MEDICATION NAME] for three days and recheck the PT/INR. He had been without [MEDICATION NAME] for more than three days so I got a PT/INR and resumed the [MEDICATION NAME] at 3 mg daily, which was the dose he was on before going to the hospital. The Surveyor asked RN D if it was her normal practice to get lab work done and order medications to be given without a physician's orders [REDACTED]. Review of the facility's Policy and Procedure, Anticoagulation - Clinical Protocol, dated (MONTH) 2012 including the following, in part: Treatment/Management 1. The physician will prescribe anticoagulation therapy . Monitoring and Follow-up 1. The physician will order appropriate lab testing to monitor anticoagulant therapy and potential complications . An Immediate Jeopardy (IJ) was identified on [DATE] at 3 PM, the Administrator and Director of Nursing were informed. The facility's plan of removal of immediate Jeopardy was accepted on [DATE] at 10:20 AM and included the following: * In-service on [MEDICATION NAME] orders, PT/INR, and Coagucheck SX machine ([DATE]). * Nurses and Medication Aides to listen to 24 hour report ([DATE]) * Residents identified for high risk for side effects of anticoagulants were assessed ([DATE]) * Eliminated the Coagucheck SX INR machine [DATE]. * Traditional Lab draws for PT/INR ([DATE]) * LVN B placed on orientation [DATE] - [DATE] * DON and/or designee to review for compliance randomly for at least a month's time ([DATE]) * Continued education for medication aides, nurses, and new hires related to anticoagulants. ([DATE]) * Discussion of medication errors for morning stand up meetings at least weekly ([DATE]). * 2 Nurses will check admission orders [REDACTED]. ([DATE]) Observation of 4 residents on anticoagulant medication on [DATE] indicated no signs of bleeding, bruising, or injuries. Resident #2 was currently on [MEDICATION NAME]. Review of 4 residents currently on anticoagulant medication indicated orders to monitor signs and symptoms of bleeding that read as follows: Bleeding assessments added to residents with ordered anticoagulants ([DATE]) Nurse to monitor for bleeding, hematoma, petechiae, nosebleed, fever, nausea, vomiting, hematuria, skin rash, bleeding gums, or dark tarry stools every shift and report to physician if found. Interviews with 5 LVNs and 2RNs facility staff covering all shifts on [DATE] indicated staff had been in serviced on [MEDICATION NAME], orders, PT/INR, signs and symptoms of bleeding, new bleeding assessment, and 2 nurses for admissions/readmissions and not using the Coagucheck SX for monitoring PT/INR. On [DATE] at 1:33 PM the administrator was informed that the IJ was removed. The facility remained out of compliance at a severity level of actual harm that is not IJ with a scope of pattern because the facility had not had time to monitor their plan of removal for effectiveness. According to the DON on [DATE], there was currently one resident receiving [MEDICATION NAME] in the facility, and three others on other anticoagulants.

Based on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for 2 of 6 residents reviewed for medications. (Resident # 1 and Resident # 3) a) The facility did not adequately monitor Resident #1's and Resident #3's PT/INR levels properly with the Coagucheck SX Machine and continued to administer [MEDICATION NAME] (anticoagulant medication) to the resident after orders indicated the medication had been discontinued/held. Resident #1's INR was 23.64 on [DATE]. The resident had rectal bleeding, and expired on [DATE]. b) The facility failed to ensure Resident #3's hospital discharge medication orders were followed and resumed a previous order for [MEDICATION NAME]. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm not IJ with a scope of pattern because the facility had not had time to monitor their plan of removal for effectiveness. This failure placed 4 residents on anticoagulant medications, at risk of major or fatal bleeding. Findings included: Resident #1 Closed record review of Resident #1's Face Sheet dated [DATE] indicated a [AGE] year old female admitted on [DATE] [DIAGNOSES REDACTED]. Record review of Resident #1's two most recent quarterly MDSs dated [DATE] and [DATE] indicated no significant declines in cognition or ADLs. The most recent Quarterly MDS Indicated a BIMS of 7 indicating extensive cognitive impairment and extensive to total dependence for ADLs of ,[DATE] people and on anticoagulant therapy. The MDS indicated Resident #1 was receiving hospice services and had a prognosis of less than 6 months to live. Record review of Resident #1's care plan last revised [DATE] indicated the following: Goal: Resident will be free of bruising, bleeding or injury Approach: Administer medications as ordered. Closed record review of the Physicians Visit Form for Resident #1 with a printed date of [DATE] provided by the DON indicated a [MEDICATION NAME] order that was started on [DATE] and discontinued on [DATE] that read as follows: [MEDICATION NAME] 2mg every Monday, Wednesday, Friday, Saturday, and Sunday. [MEDICATION NAME] 1mg every Tuesday and Thursday. Record review of Resident #1's INR results in (MONTH) (YEAR) indicated no results above 3.1. Record review of INR Results Sheets for Resident #1 indicated the following: [DATE]= 1.8 [DATE]= 2.2 [DATE]= 2.2 [DATE] 3.6 [DATE]= 8.0 and documented the dose was held [DATE], [DATE], and [DATE] [DATE]= 8.0 and documented held [MEDICATION NAME] on [DATE], [DATE], and [DATE]. PT/INR taken by vein on [DATE] read PT 63.4 and INR 21.75. Record review of the Coagucheck SX machine manual indicated the following: Out of range values The Coagucheck XS PT test strips provide test results if the INR value is 0.8 and 8.0 if the result falls outside of this range, the meter displays < (less than) 0.8 or > (greater than) 8.0 if the meter indicates an out-of-range value, refer to the test strip package insert and repeat test . If this error message appears again when the test is repeated, the result must be checked using another method. PT/INR is a blood test that measures the time it takes for the liquid portion (plasma) of blood to clot. Per the U.S. National Library of Medicine: [MEDICATION NAME] time (PT). [DATE]; (https://medlineplus.gov/ency/article/ 2.htm accessed on [DATE]) For people taking [MEDICATION NAME], most laboratories report PT results that have been adjusted to the INR. These people should have an INR of 2.0 to 3.0 for basic blood-thinning needs. For some who have a high risk of a blood clot, the INR needs to be higher - about 2.5 to 3.5. (https://labtestsonline.org/tests/[MEDICATION NAME]-time-and-international-normalized-ratio-ptinr accessed [DATE]) Record review of the nurse's notes for Resident #1 for (MONTH) (YEAR) indicated the following: [DATE] [MEDICATION NAME] order changed to 1mg Tuesday and Thursday and [MEDICATION NAME] 2mg given Monday, Wednesday, Friday, Saturday, and Sunday. [DATE] [MEDICATION NAME] and [MEDICATION NAME] ordered for fever/URI [DATE] Resident #1 coughed up blood, the doctor was notified and a duo neb breathing treatment was ordered. [DATE] after the PT/INR machine was used, an INR value was identified of 3.6 which was an abnormal high value. An order to hold the [MEDICATION NAME] for the next 3 days was ordered by the doctor. [DATE] an INR value of 8.0 was identified, the doctor again ordered to hold the [MEDICATION NAME] for an additional 3 days and recheck PT/ INR on [DATE]. [DATE] the machine again read 8.0 and a lab draw was ordered that identified the following values: PT 66.6 and INR 23.64 per vein collection. The doctor ordered [MEDICATION NAME] (medicine used to treat vitamin K deficiency or bleeding problems caused by various disorders) 5mg PO qd and retest INR post 48 hours. [DATE] At 3:49 pm note stating a large amount of blood was in resident's brief and the nurse notified doctor. [DATE] Resident #1 expired at 3:30 am. Using [MEDICATION NAME] together with [MEDICATION NAME] may cause you to bleed more easily. You may need a dose adjustment based on your [MEDICATION NAME] time or International Normalized Ratio (INR). (https://www.drugs.com/drug-interactions/[MEDICATION NAME]-with-[MEDICATION NAME]-[DATE]-0.html?consumer=1 accessed [DATE]) During an interview with CNA K on [DATE] at 11:59 am she said that on [DATE] Resident #1 had coughed up blood and she reported it to LVN M. Record review of the 24 hour report for the following days indicated a note to hold Resident #1's [MEDICATION NAME] on [DATE], [DATE], and [DATE]. Record review of the MAR for Resident #1 provided by the DON on [DATE] for (MONTH) (YEAR) indicated the [MEDICATION NAME] was given [DATE]-[DATE] the days the medication was ordered to be held originally after the reading of 3.6 (high value) was identified. During an interview with the DON on [DATE] at 12:35 pm she said that [MEDICATION NAME] should have been held for Resident #1 on [DATE], [DATE], and [DATE] as ordered by the physician. She said the [MEDICATION NAME] was given on those days. During an interview with LVN B on [DATE] at 2:02 pm she said that she received an order from the doctor's LVN at the clinic on [DATE] to hold Resident #1's [MEDICATION NAME] but it had been already given the day of the call so she said she tried to call back and clarify the order but the doctor did not answer after 5:00 pm that day so she passed it on in report to the oncoming nurse and she said she should have followed up on the order. She said she never wrote the order or put it in the system. During an interview with RN E on [DATE] at 3:49 pm she said that she had received the order clarification phone call for the 3 day hold for the [MEDICATION NAME] of Resident #1 taken by LVN B on [DATE]. She said she passed on the order clarification to LVN B. She said she did not input orders. She said she had seen that LVN B had wrote it on the 24 hour report and had assumed it had been input into the system. During an interview with CMA A on [DATE] at 1:46 pm she said she gave Resident #1 [MEDICATION NAME] on [DATE] and [DATE] she said she was not aware that there was a hold on the order. She said she went by what the MAR indicated [REDACTED]. She said the Nurses check the PT/INR and she said the CMAs gave the medication unless told not to. She said she had not observed or known Resident #1 had bleeding episodes prior to her administering the medication. During an interview with LVN B on [DATE] at 11:15 am she said that she passed on the order to be clarified to the night nurse that she had not put in the order because the [MEDICATION NAME] had been given on [DATE] and wanted to see if the doctor wanted to hold the [MEDICATION NAME] for the following 3 days. She said the documentation on [DATE] of the PT/INR check stating the [MEDICATION NAME] being held on [DATE], [DATE] and [DATE] that she had wrote on the INR Result Sheet was an error. She said the [MEDICATION NAME] was not held on those days. She said she had only received a ,[DATE] minute training video on how to use the PT/INR Machine. She said the machine was supposedly taken out of use but she had read a note for Resident #3 that said it had been used within the last week. She said she had never received a clarification order from any other staff member and assumed the order had been put in the system and the [MEDICATION NAME] had been held for the 3 days mentioned. LVN B also said that she was not aware that the machine had a greater than 8 marker and that the video she watched did not contain information on the machines max value reading. Record review of the Coagucheck SX machine video on [DATE], indicated no mention of a greater than 8 value. The video said to refer to the manual for any further questions. During an interview with Physician C on [DATE] at 3:08 pm, the physician of Resident #1, said that he was aware that the [MEDICATION NAME] was not held as ordered on [DATE], [DATE], and [DATE]. He said that treatment ([MEDICATION NAME], medicine used to treat vitamin K deficiency or bleeding problems caused by various disorders, 5mg PO qd and retest INR post 48 hours) was given to Resident #1 to try to reverse the abnormal PT/INR results following the orders not being followed. During an interview with CNA H on [DATE] at 3:52 pm she said that she saw blood in the residents brief on [DATE]. She said it was a lot of what appeared to be blood. She said it wasn't bright red and it wasn't the color of stool. She said it was somewhere in the middle. She said it was hard to describe. She said that Resident #1 died sometime in the morning the following day on [DATE]. During an interview with LVN L on [DATE] at 3:53 pm, she said she was called into the room after a CNA report of blood in Resident #1's brief on [DATE]. She said the brief was completely covered in bright red blood. She said she then reported her findings to the doctor. During an interview with the DON on [DATE] at 2:16 pm she said that she believed that the order not being held did not contribute to the resident expiring. She said that she disciplined LVN B, had in-services, and put LVN B on orientation for another month. She said she also took away the PT/INR machine from staff use because LVN B did not see the greater than sign that would come after the machines max value of 8. She said when the lab was drawn by vein on [DATE] the results were far more elevated than the 8 value LVN B documented from the PT/INR machine. The DON said that once LVN B had the reading of greater than 8, a sample should have been obtained through Resident #1's vein using a needle and tube. During an interview with the DON on [DATE] at 10:49 am, she said that the nurses had only watched the video for the Coagucheck SX machine and had not read the manual for the Coagucheck SX machine. Record review of an undated in-service provided by the DON on [DATE] that she said was for an in-service regarding [MEDICATION NAME], PT/INR, and the Coagucheck Sx Machine for [DATE] which indicated education for the topics and included that the facility would not be using the Coagucheck SX machine any longer as a means of checking INR values. Record review of the nurses notes dated [DATE] indicated the Anticoag Sx machine was used to check Resident #3's INR on [DATE]. The nurse checking was LVN F. Record review of the in-service for [MEDICATION NAME], PT/INR, and the Coagucheck SX machine provided by the DON which she said was for in-servicing on [DATE] indicated 5 missing nursing staff signatures. During an interview with LVN I on [DATE] at 11:29 am she said if she would have received an order to stop the [MEDICATION NAME] for 3 days and the day of the order the [MEDICATION NAME] had been given she would have at least stopped the order for the remaining days and got clarification from the doctor after stopping the order for the remaining days. During an interview with LVN B on [DATE] at 11:48 am, she said that there had been no way of monitoring for bleeding other than nurses notes until yesterday [DATE]. She said the nurses follow the physician orders [REDACTED]. During an interview with LVN J on [DATE] at 11:50 am she said if she had received an order to stop [MEDICATION NAME] for 3 days and the [MEDICATION NAME] had already been given that day, she would have held the order in the system for the remaining days at least until the order could be clarified further for the day that had been missed. During an interview with the Administrator on [DATE] at 1:41 pm he said that the incident happened due to a miss identification of a value by the machine. He said that the DON had told him that RN E had told LVN B about the order clarification and the order mistake had happened with confusion in the transfer of the order from nurse to nurse. He said that the machine was used one time on [DATE] with the approval of the DON and ADON because Resident #3 had an emergency and since the last one time use the machine had been destroyed and taken out of service. During an interview with the DON on [DATE] at 1:50 pm she said that she believed it was an accident due to LVN B being fairly new. She said the situation happened due to confusion and failure to input the order into the system after receiving the order from the physician by LVN B. She said LVN B failed to follow up on the order. She said that she did believe the situation was an IJ but did not believe the [MEDICATION NAME] caused Resident #1's death on [DATE]. She said Resident #1 was declining before the error with the [MEDICATION NAME]. She said she educated, disciplined, and trained LVN B appropriately after the incident so it wouldn't happen again. During an interview with the DON on [DATE] at 4:18 pm she said the staff members that were not in-serviced on [DATE] for [MEDICATION NAME], PT/INR, and the Coagucheck SX machine had not been in-serviced yet. During an interview with LVN F on [DATE] at 4:28 pm she said she only watched the video for the Coagucheck SX machine on [DATE] and was not aware of the greater than 8 value the machine would identify for readings over 8.0. Resident #3 Review of Resident #3's undated Face Sheet indicated he was [AGE] years old and was originally admitted to the facility on [DATE]. He returned from a hospitalization on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #3's MDS assessment dated [DATE] indicated he had moderate cognitive impairment (BIMS score of 10 out of 15). He required total to extensive assistance of two or more people for bed mobility, transfers, dressing and bathing. He was able to feed himself with setup and supervision. He had not received anticoagulant medication during the 7-day look-back period. Review of Resident #3's Hospital Discharge Summary dated [DATE] indicated he was hospitalized from [DATE] to [DATE]. [DIAGNOSES REDACTED]. He was kept on empiric IV antibiotic. On [DATE] he was taken to surgery for [REDACTED]. The Eliquis was changed to [MEDICATION NAME] (another anticoagulant also known as [MEDICATION NAME]) at discharge. Review of Resident #3's Hospital Discharge Summary dated [DATE] indicated he was hospitalized from [DATE] to [DATE]. [DIAGNOSES REDACTED]. Description of the hospital course included: His [MEDICATION NAME] was held given his coagulopathy and eventually discontinued given his recent [MEDICAL CONDITION] 3 months ago and after 1 month of [MEDICATION NAME]. Further review of the discharge summary included the discharge medication list, which included the following changes: START taking these medications [MEDICATION NAME] ,[DATE] mg 1 tablet twice daily for 7 days [MEDICATION NAME] 500 mg 1 tablet once daily for 7 days STOP taking these medications Apixaban 5 mg tablet Commonly known as: Eliquis [MEDICATION NAME] 2.5 mg tablet Commonly known as: [MEDICATION NAME] [MEDICATION NAME] 5 mg tablet Commonly known as: [MEDICATION NAME] Review of Resident #3's Nursing Progress Notes dated [DATE] by RN D included the following: (3:43 PM) NOTE: Resident return to facility from (the hospital) in stable condition via facility van with facility staff. New orders as follows: 1. [MEDICATION NAME] 500 mg po BID till all taken 2. [MEDICATION NAME] 500 mg po daily till all taken (4:56 PM) NOTE: 16:30 Unsuccessful attempts at drawing PT/INR here in facility. Res. transported to lab at clinic for blood draw . 17:00 Res return to facility in stable condition. Will await new [MEDICATION NAME] orders. Will continue with 3 mg q day and re-draw PT/INR on [DATE]. Review of laboratory results dated [DATE] indicated the [MEDICATION NAME] (PT) was 12.3 (Reference Range 10.0 - 14.0) and the INR was 1.25 (Reference Range < = 5.00). Further review of Resident #3's facility record did not reveal a physician order [REDACTED]. Review of Resident #3's (MONTH) (YEAR) MAR indicated [REDACTED]. The MAR indicated [REDACTED]. In an interview with RN D on [DATE] at 12:35 PM confirmed that the discharge summary from the hospital was what she went by when Resident #3 returned from the hospital on [DATE]. She said she looked at the medication list from the hospital and said, My thinking was that his PT/INR was high prior to him going to the hospital and there was an order to hold the [MEDICATION NAME] for three days and recheck the PT/INR. He had been without [MEDICATION NAME] for more than three days so I got a PT/INR and resumed the [MEDICATION NAME] at 3 mg daily, which was the dose he was on before going to the hospital. The Surveyor asked RN D if it was her normal practice to get lab work done and order medications to be given without a physician's orders [REDACTED]. Review of the facility's Policy and Procedure, Anticoagulation - Clinical Protocol, dated (MONTH) 2012 including the following, in part: Treatment/Management 1. The physician will prescribe anticoagulation therapy . Monitoring and Follow-up 1. The physician will order appropriate lab testing to monitor anticoagulant therapy and potential complications . An Immediate Jeopardy (IJ) was identified on [DATE] at 3 PM, the Administrator and Director of Nursing were informed. The facility's plan of removal of immediate Jeopardy was accepted on [DATE] at 10:20 AM and included the following: * In-service on [MEDICATION NAME] orders, PT/INR, and Coagucheck SX machine ([DATE]). * Nurses and Medication Aides to listen to 24 hour report ([DATE]) * Residents identified for high risk for side effects of anticoagulants were assessed ([DATE]) * Eliminated the Coagucheck SX INR machine [DATE]. * Traditional Lab draws for PT/INR ([DATE]) * LVN B placed on orientation [DATE] - [DATE] * DON and/or designee to review for compliance randomly for at least a month's time ([DATE]) * Continued education for medication aides, nurses, and new hires related to anticoagulants. ([DATE]) * Discussion of medication errors for morning stand up meetings at least weekly ([DATE]). * 2 Nurses will check admission orders [REDACTED]. ([DATE]) Observation of 4 residents on anticoagulant medication on [DATE] indicated no signs of bleeding, bruising, or injuries. Resident #2 was currently on [MEDICATION NAME]. Review of 4 residents currently on anticoagulant medication indicated orders to monitor signs and symptoms of bleeding that read as follows: Bleeding assessments added to residents with ordered anticoagulants ([DATE]) Nurse to monitor for bleeding, hematoma, petechiae, nosebleed, fever, nausea, vomiting, hematuria, skin rash, bleeding gums, or dark tarry stools every shift and report to physician if found. Interviews with 5 LVNs and 2RNs facility staff covering all shifts on [DATE] indicated staff had been in serviced on [MEDICATION NAME], orders, PT/INR, signs and symptoms of bleeding, new bleeding assessment, and 2 nurses for admissions/readmissions and not using the Coagucheck SX for monitoring PT/INR. On [DATE] at 1:33 PM the administrator was informed that the IJ was removed. The facility remained out of compliance at a severity level of actual harm that is not IJ with a scope of pattern because the facility had not had time to monitor their plan of removal for effectiveness. According to the DON on [DATE], there was currently one resident receiving [MEDICATION NAME] in the facility, and three others on other anticoagulants.

Based on observation, interview, and record review, it was determined the facility failed to maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment, and to help prevent the development and transmission of disease and infection for three (Residents #2, #4, and #5, ) of 3 residents reviewed for infection control. 1. CNA C and CNA E failed to sanitize her hands between cleaning Resident #2's pubic area and the resident's rectum or change gloves before touching Resident's bed sheets and blanket. 2. CNA D and CNA A failed to provide Resident #4 with catheter care cleaning during incontinence care. 3. CNA G failed to sanitize her hands or remove gloves after cleaning Resident #5's pubic area and the resident's rectum and did not change gloves before touching bed sheets and blanket. 4. The facility failed to provide an Infection Control tracking and tending system to identify residents with infections or the spread of infections. These failures could place 27 residents with urine incontinence, 14 with bowel incontinence and 4 residents with urinary catheters residents at risk for the development and/or spread of infection. Findings included: 1. Resident #2's MDS (Minimum Data Sheet) assessment, dated 04/04/17, reflected the resident was a [AGE] year-old male re-admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident required extensive assistance of one person physical assist for toilet use and was always incontinent of bowel and requiring a Foley catheter for urinary incontinent. Resident #2's current Care Plan Report, updated on 02/17/17, reflected the resident had bowel incontinence. A care plan intervention included to provide incontinent/peri-care after each incontinent episode. An observation on 04/04/17 at 11:10 a.m. revealed Resident #2 transferred to his bed via Hoyer Lift. Resident was positioned flat in bed and incontinent care was provided. CNA C failed to provide incontinent care in the proper order, starting at the meatus, cleaning the groin area and failed to clean the catheter tubing in and around the urethra. CNA E assisted with positioning. CNA C used disposable moistened wipes, cleansed the each groin fold, using a separate disposable wipe with each swipe. The resident was rolled onto his right side and his buttocks were cleansed. CNA E failed to change gloves after incontinent care and repositions and pulled up sheets and blanket without removing gloves. 2. Resident #4's MDS assessment, dated 04/04/17, reflected the resident was a 80 -year-old male re-admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident required extensive assistance of one person and two person transfer. Resident #4's current Care Plan Report, updated on 07/25/16, reflected the resident had bowel incontinence. A care plan intervention included to provide incontinent/peri-care after each incontinent episode. An observation on 04/04/17 at 9:20 a.m. revealed Resident #4 lying in bed, CNA C and CNA A provided incontinent care. During incontinent care CNA C failed to clean around the catheter tubing in and around the urethra. CNA A used disposable moistened wipes, cleansed each groin fold, cleanse the meatus (opening of the urethra), using a separate disposable wipe with each swipe failing to clean the catheter tubing to the connecting hub going to the drain bag. The resident was rolled onto his left side and his buttocks were cleansed. An interview on 04/04/17 at 9:45 a.m. with CNA A related to incontinent care stated she learned in CNA School catheters should be washed with soap and water when providing care. CNA A said, they should have used soap and water during incontinent care when cleaning the catheter. 3. Resident #5's admission assessment, dated 02/09/17, reflected the resident was a [AGE] year-old female re-admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident required extensive assistance of one person and two persons for transfers and was always incontinent of bowel and bladder. An observation on 04/04/17 at 9:30 a.m. revealed Resident #5 lying in bed. CNA G failed to change gloves and wash hands after incontinence care repositioning resident lowered bed put away wipes and adjusting sheets and bed linens without changing gloves or washing hands. The resident was rolled onto his left side and his buttocks was cleansed. CNA F failed to change and gloves assisted CNA G to reposition Resident #5. An interview on 04/04/17 at 11:05 a.m. with the DON (Director of Nursing) revealed CNAs should wash hands between cleaning different areas of the body when providing incontinent care and properly wash the catheter tube. When it was revealed one CNA said she was taught to use soap and water to clean the catheter tube but just did not do it. DON said she should do what she is trained to do in providing incontinent care. 4. An interview on 04/04/17 at 11:05 a.m. with the DON in relations to providing a tracking and trending for infections the DON said since they have changed over to a new computer system they are not able to print out a map of the facility and give locations of residents with infections. She also said they are unable to provide a tracking and trending system at this time and did not have a system to track and trend infections for residents in the facility. Facility's policy and procedure titled, Hand washing/Hand Hygiene dated April 2012 reflects the following: .c. Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice) .r. After handling soiled or used linens, dressings, bedpans, catheters and urinals. CMS-672 provided by the ADON on 04/03/17 indicated 27 residents with urine incontinence, 14 with bowel incontinence and 4 residents with urinary catheters.

Based on Interview, record review, and observation, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistance devices to prevent accidents. One of seven residents (Resident #1) reviewed for falls was injured when she fell . The facility failed to: A) Re-assess Resident #1 following a fall to determine whether her risk of falling had increased. B) Change Resident #1's plan of care after she fell on [DATE] to provide new interventions that would increase safety and protect the resident from the same type of fall again. The facility failure resulted in Resident #1 falling a second time and receiving injuries to her face and a fractured wrist. These failures resulted in actual harm to Resident #1 and could affect any of the 13 residents identified by the facility with dementia who were at risk for falls. Findings include: Review of Resident #1's quarterly minimum data set ((MDS) dated [DATE] indicated the [AGE] year-old female resident was admitted to the facility on [DATE]. The resident had both short-term and long-term memory problems and was moderately impaired in daily decision making. Resident #1 needed extensive assistance from two or more staff for bed mobility, transfers and personal hygiene and the resident was non-ambulatory. The resident was frequently incontinent of urine but always continent of bowels. [DIAGNOSES REDACTED]. According to the MDS the resident did not have any restraints. Review of Resident #1's care plan, dated 09/03/12, indicated the resident had a potential for injury from falls related to impaired judgment and mental deterioration. Approaches for care included: -- identify resident's routine and pattern of falls -- provide consistent schedule for care so the Resident will remain calm -- check the resident's status every 2 hours and as needed -- change the resident's location -- position resident to prevent restlessness every 2 hours as needed -- avoid environmental hazards such as spills, rugs or furniture -- provide activities for distraction -- check the resident status every 2 hours and as needed -- ensure the resident is wearing well fitted shoes and clothing -- assist the resident in putting on eyeglasses Review of Resident #1's fall risk assessments dated 12/31/12, 03/01/13 and 06/06/13 all indicated the resident was at high risk for falls. Review of Resident #1's consolidated physician orders [REDACTED]. The resident was transferred with the assistance of two staff. In an observation on 08/12/13 at 8:15 a.m., Resident #1 was sitting in a geri chair at the dining table eating her breakfast independently. Resident #1 was noted to have a splint on her right arm and wrist from her hand to the middle of her lower arm. Review of incident accident reports revealed on 07/14/13 at 3:45 p.m., CNA D was walking down the hall and passed Resident #1's room. The CNA heard Resident #1 moving around so she looked in to check the resident. She said the resident was sitting on the floor between the wall and the bed. (Note: The resident had a fall mat on one side of the bed, but there was no fall mat on the other side, between the wall and the bed.) The bed was in the low position. According to the report, Resident #1 denied any pain at that time. Review of incident accident report dated 07/25/13 at 4:40 p.m., revealed CNA A heard someone calling out and recognized Resident #1's voice. CNA A went to the resident's room to see what she needed and found the resident face down on the floor between the wall and the bed (on the side without the fall mat). The CNA observed that the resident had blood on her face and called the nurse. In an interview on 08/12/13 at 9:50 a.m. the DON said Resident #1 had a recent fall resulting in a laceration over her eyebrow and another laceration below her eye, as well as possibly a small fracture to the resident's upper cheek and a fracture to the resident's right wrist. According to the DON, Resident #1 called out for help, saying she fell , but then the resident was not able to tell staff what happened when staff went into her room. The resident was transported to the emergency room next door and received sutures to the two lacerations. The following day the resident went for a CT scan of her head since she was on a blood thinner and she had facial injuries. According to the DON, in the past Resident #1 had a bed alarm, but a family member had asked that it be removed. At the time of Resident #1's fall, the resident did not have a bed alarm. Review of a Provider Investigation Report dated 08/01/13 revealed on 07/25/13 at 5:00 p.m. the resident, who had been in bed, was heard to call out that she fell . The resident was found on the floor beside her bed. The bed was in the low position and locked. A description of injury included a 3-cm laceration to the resident's left forehead and a 2-cm laceration on the resident's left cheek below the eye. Both lacerations were actively bleeding. According to the report the resident was on Coumadin, a blood-thinning medication, at the time of the incident. According to the Provider Investigation Report, the resident was taken to the hospital at 5:11 p.m. on 07/25/13. According to the hospital emergency room report, a full head-to-toe assessment in the emergency room by the physician assistant was done and it was determined the resident did not require transport to a larger hospital in a nearby city. The two lacerations were sutured by the physician assistant. No fractures of the resident's face were identified by radiology at the local hospital. According to the Provider Investigation Report, the resident was sent to a near-by city for a CT scan of the head on 07/26/13. The CT scan revealed a small fracture of the lower orbital bone under the resident's left eye. An X-ray of the resident's right hand on 07/26/13, done due to increased swelling, indicated a fracture of the right wrist. A splint was placed on the resident's right arm at that time. The resident was placed on an antibiotic on for prophylaxis. Review of the Investigation Summary, Resident #1 was in bed in her room with her bed in the low position and wheels locked. CNA A said she heard the resident calling out and found her on the floor. The resident did not have a bed alarm per the family's request. The resident apparently tried to get up by herself and hit her face on the wall as there was a blood stain on the wall approximately 8 inches above the floor. The stain on the wall was approximately 6 inches wide. The resident was found lying on her left side on the floor facing the wall. Review of Resident #1's nurses' notes dated 07/25/13 at 05:05 p.m. indicated the nurse was called to the resident's room. CNA A told the nurse that the resident was hollering out that she fell . When the nurse entered the room Resident #1 was lying on the floor between her bed and the wall. The bed was in low position and the call light was in reach. A large laceration was noted above the resident's left eyebrow and a smaller laceration was noted below the resident's left eye. There was bright red bleeding from both lacerations and pressure was applied. The resident was awake and alert, oriented to self, and complaining of pain to her head and her right arm. The resident was transported next door to the hospital emergency room . Review of the nurses notes revealed Resident #1 returned from the emergency room with five sutures to the laceration above her left eye and two sutures to the laceration below her left eye on 07/25/13 at 6:05 p.m. According to the nurses' notes on 07/26/13 at 8:30 a.m., Resident #1 was resting in the geri chair. When asked, Resident #1 complained of a little bit of pain in her right wrist. According to the notes there was swelling and discoloration to the resident's right wrist. The resident was sent to the emergency room at 9:00 a.m. for an x-ray of the right hand. At 11:00 a.m. the resident returned from the clinic. According to the nurses' notes the x-ray indicated Resident #1 had a fracture to her right wrist and the physician assistant applied a splint to the resident's right hand and wrist. At 3:50 p.m. on 07/26/13 the resident was transferred to a neighboring city for a CT scan to the head. A notation on Resident #1's care plan indicated the resident fell from her low bed on 7/14/13, without injury, when she was attempting to get up by herself. According to the care plan the resident had another fall from her low bed to the floor on 07/25/13. During this fall the resident hit her head and right hand. There was no indication that a new fall risk assessment was done after the first fall (07/14/13) onto the floor between the wall and the bed and there were no updated interventions to the care plan after the first fall to protect the resident from the same type of fall again. A notation in the nurses' notes on 07/31/13 revealed the following: New order on 07/31/13 for a bed alarm on the resident's bed. In an observation on 8/12/13 at 11:25 a.m. CNA B and CNA C attempted to transfer Resident #1 from the geri chair to a bedside commode. The resident was unable to stand. Both CNAs said the resident was a 2 person transfer but called for additional help due to the resident's weakness. LVN A came and assisted the 2 CNAs. In an observation on 08/13/13 at 10:45 a.m. Resident #1 was taken to the shower by CNA C. The resident was assisted to stand by CNA C, CNA E, and RN F. Resident #1 held to the grab bar with her left hand. The resident was transferred to the bedside commode. CNA C said Resident #1 was a 2 person transfer but over the past several days they had needed 3 staff to transfer the resident. In an interview on 08/13/13 at 9:50 a.m., Resident #1 said she was doing okay. The resident said she broke her arm, so they put the splint on it. When asked if she fell , Resident #1 said no. When asked what happened to her arm the resident said she did not know. In an interview on 08/13/13 at 4:00 p.m. Resident #1 complained to staff of pain all over her body. The resident said all her bones hurt. In an interview on 08/15/13 at 9: 40 a.m. the DON said there were 13 Residents in the facility with dementia who were at risk for falls.

THIS IS A REPEAT DEFICIENCY. Based on observation, interviews and record review the facility failed to ensure the residents remained as free of accidents as possible by receiving adequate supervision and assistance devices to prevent accidents and injuries. This failure affected (1) of four residents with alarms that were reviewed for falls.(Resident # 8) The facility failed to: (A) ensure the Resident # 8's alarm was in working order and functioning when he was up in the wheelchair.. This failure could affect any of the 13 residents identified by the facility as being a fall risk and having either a bed or chair alarm or both. Findings include: Review of Resident # 8's admission face sheet indicated he was admitted to the facility on [DATE] and was [AGE] years old at the time of admission. Review of the residents annual Minimum Data Set ((MDS) dated [DATE] indicated the following: - Active Disease Diagnosis: [REDACTED]. - The Resident's Brief Interview for Mental Status (BIMS) was 10 out of a possible score of 15. Indicating cognitive impairment with fluctuating disorganized thinking. - Resident # 8's functional status indicated he needed the limited assistance of one person for bed mobility, transfers, dressing and toilet use. The resident did not walk and required extensive assistance of one person for locomotion off the unit. - According to the assessment Resident # 8 required physical help of one person for bathing with only supervision for personal hygiene and was independent in eating. - Resident # 8 was not steady moving on and off the toilet or from surface to surface, such as bed to chair or wheelchair and required staff assistance. The resident utilized a wheelchair for mobility. - Resident # 8 was occasionally incontinent of bowel and bladder. - According to this MDS the resident had two falls without injury since admission/entry or re-entry or prior assessment CARE PLAN: Review of Resident # 8's care plan dated 08/06/13 indicated a potential of injury related to poor balance or unsteady gait, resulting in frequent falls. The goal was for resident to be free from injury by not falling during the next 90 days. Interventions were to keep his bed in a low position and a fall mat in place. Ascertain resident's ambulation/mobility status Consider resident's medication to see if potential side effects could make resident prone to fall Physical therapy/occupational therapy evaluation if ordered Provide equipment for safety: Wheelchair Keep environment free from hazards, spills, rugs, furniture Educate resident re: postural hypotension and how to stand Encourage exercise to maintain strength and mobility Teach resident to call for assistance when unsteady or transferring Fall risk assessment dated [DATE] indicated a score of 18. According to the assessment any score over 10 meant the resident would be considered at high risk for falls. Fall one: 08/21/13 Review of nurse's notes dated 08/21/13 at 5:15 a.m. indicated a nurse was walking to Resident # 8's room and found the resident on the floor in the hallway in front of his neighbor's room to the north. The resident's boxers were wet with urine. According to the nurse's note the resident was confused as to where he was or where he was going. The resident denied pain and he was helped into his wheelchair and back to his room. Resident # 8 had a 2 centimeter (cm) skin tear on his right elbow and a pinpoint wound to the back of his head. Neurological (Neuro) checks were started and were within normal limits, Family and Director of Nurses were notified. A verbal order was received from the doctor to apply steri strips to right wrist. According to the note there was old bruising noted from a previous fall, there was a purple bruise to left eye and a 4 cm swelling to right knee, as well as a small bruise noted to buttocks and left and right upper thigh. Resident # 8 was sent to clinic next door for evaluation. At 12:10 p.m. Resident # 8 returned from the clinic with orders for APAP # 3 (Tylenol with Codeine) 1 at bedtime, Ibuprofen 400 mg as needed for pain, continue Neuro checks every hour and as needed. There was a late entry in the nurse's notes on 08/21/13 at 1:30 p.m. that documented a interdisciplinary meeting was held with the administrator, maintenance person and nurse to discuss fall prevention for Resident # 8. According to the note one hour checks and 2 hour toileting schedule was to be started today. The note stated the Resident was not able to toilet self safely and refuses to use call light for assistance. Resident's daughter was out of town and unavailable by phone. Will discuss instituting bed alarm for resident when family is available. There was no documentation in this entry about instituting a chair alarm for this resident. Care Plan update: Review of care plan dated 08/21/13 indicated the staff were to do one hour checks and two hour toileting for the resident. The family was to be contacted when they returned to town regarding a bed alarm. Fall two: 08/24/13 Review of nurse's noted dated 08/24/13 at 3:45 a.m. indicated Resident # 8 was found in his room sitting on the floor at his bedside. Neuro checks were initiated, the doctor was sent a fax. On-coming shift (day shift) was to notify family. 6 a.m. to 6 p.m. shift note stated Resident # 8 complained of both hips being sore, but was feeling better. The resident continues to have yellowish, green bruising to left side of head, abrasion to left cheek and bruising to the left eye with slight swelling. Neuro checks are continuing. Review of the resident's care plan dated 08/06/13 revealed no updates or further interventions concerning the fall on 08/24/13. Nurse's note on 08/26/13 at 2:15 p.m. stated Resident's daughter gave permission for bed alarm. Call placed to resident's Psychiatrist and message left to discuss reduction of Lexapro (anti-depressant) and Trazodone (anti-depressant). There was no documentation the Psychiatrist had returned the call or changed any of the residents medications to help reduce falls. Review of the October 2013 current doctor's orders indicated the resident was still receiving Lexapro as ordered on [DATE] and Trazodone as originally ordered on [DATE]. Care plan update 8/26/13: Bed alarm consent signed by family 8/26/13. Pharmacist to review medications that may contribute to fall risk. Restorative for lower extremity strengthening. Monthly summary dated 08/30/13 indicated Resident required frequent staff intervention for re-orientation and forgetfulness. Resident now has a bed and chair alarm due to increased falls. Resident has declined since last months summary. Review of the Pharmacist recommendation on 08/30/13 suggested the possibility of discontinuing Zantac (used for gastric reflux) and Periactin (antihistamine) because these medications might be contributing to the resident falls. Review of the October 2013 doctor's orders indicated the resident continued to be on both medications no changes had been made. Fall risk assessment completed on 09/13/13 indicated a score of 21. According to the form any score over 10 would make the resident at high risk for falls. This was a decline since the previous fall risk assessment completed on 08/06/13 when the resident's score was 18. Fall Three: 09/22/13 According to an untimed nurse's note dated 09/22/13 staff heard a strange noise coming out of Resident's 8's room. Found resident sitting in the shower/tub in his bathroom calling for help. The resident stated he was trying to use the restroom. A Registered Nurse (RN), A Licensed Vocation Nurse (LVN) and a Certified Nurse Aide (CNA) came into the room. Resident was assessed and had a skin tear to his left hand and wrist. Resident stated he may have hit his head. Resident assisted up to his wheelchair. Blood was noted on the back of his shirt. A large abrasion was noted to left lower back. Steri strips applied to area on hand, wrist and lower back. Documentation at 2:15 p.m. Neuro checks were normal. Family, Director of Nurses and Physician Assistant notified. There was not any documentation in the nurse's notes of the alarm sounding. There was an update to the care plan dated 09/22/13 which documented "Fall in resident bathroom." Has low bed, fall mat, voice recorded alarm. New order for orthostatic blood pressure, twice a day for 7 days. Sign to be placed on bathroom door to remind resident to call for help. Interview with Director of Nurses (DON) on 10/24/13 at 1:00 p.m. revealed she did not think the alarm went off when Resident # 8 fell on [DATE]. She said Resident # 8 takes off or turns his alarm off all the time. The DON said the facility was slowly changing over to Wireless alarms, but that Resident # 8 did not have one yet. During an observation 10/24/13 at 2:45 p.m. of residents with chair alarms with the DON Resident # 8 was observed to be in the activity room playing dominos. Observation of the resident's chair alarm at this time revealed it was not functioning. The DON looked at the alarm and said the wires were pulled loose and that Resident # 8 must have pulled them loose. The DON said she had helped the resident transfer to his wheelchair about 10 or 11 a.m. and the alarm was working then. According to the DON the maintenance supervisor checks the alarms every week to make sure they are working. According to a maintenance weekly safety check list dated 10/21/13 provided by the DON there were 13 residents who were fall risks and required alarms.