Every finding on record at Cypress Point Nursing & Rehabilitation Center

Based on observations, interviews, and policy review, the facility failed to ensure infection control measures were practiced to prevent the development and transmission of communicable diseases and infections by failing to ensure appropriate PPE was available and utilized by staff while handling soiled linens and laundry in the laundry facility. This deficient practice had the likelihood to affect all of the 138 residents in the facility who had laundry services available for laundering of personal clothing and/or linens. Findings:Review of the facility's Soiled Laundry and Linen Pick Up Operational Procedures policy (undated) revealed in part: Policy:a. to maintain a clean and safe environment for resident, staff and visitors, b. to keep the facility free from the accumulation of soiled laundry and linen,c. to maintain an adequate supply of clean laundry linen on hand at all times. Operational Procedures: The following procedures shall apply for soiled laundry linen pick up assignments:b. soiled laundry and linens are placed in laundry hampers. Hampers are kept covered at all times. e. nursing personnel pick up soiled laundry and linen from the storage area (including resident clothing) and take it to the laundry room for sorting and washing. The facility shall reserve the right to launder all residents' clothing should isolation, quarantines or other health related situations make it necessary for the safety and well-being of all. Observation of the facility's laundry service area on 08/24/2026 beginning at 9:20 a.m. accompanied by S4 Laundry, revealed multiple dirty laundry barrels about 4 feet in height and a hopper sink located on the dirty side of the laundry. Further observation revealed there were no impermeable gowns/aprons or face shields available for staff in the laundry area. During an interview on 08/24/2026 at 9:20 a.m., S4 Laundry reported they had to tilt the soiled laundry barrels downward and use an extended reach grabber to get the soiled laundry out of the barrels without soiling their uniforms. S4 Laundry further reported all laundry had to be sorted prior to washing. S4 Laundry further reported they frequently received bagged linens soiled with feces that had to be removed from the bags and rinsed out in the hopper sink before placing them in the washing machines. S4 Laundry reported they had not seen impermeable gowns/aprons, face masks, or goggles available in the laundry area during the 2-3 months they had been working in the laundry. S4 Laundry reported the facility laundry services for linens and/or personal clothing were available to all residents. During an interview on 08/24/2026 at 9:55 a.m., S5 Maintenance reported part of his maintenance position included supervision of the laundry. S5 Maintenance observed the laundry area and confirmed the required PPE was not available and should be. During an interview on 08/24/2026 at 10:00 a.m., S1 Administrator also observed the laundry area and confirmed the required PPE was not available and should be.

Based on record review and interview, the facility failed to conduct a comprehensive assessment of a resident within 14 days after admission for 1 (#58) of 9 residents reviewed for falls. Findings:Review of Resident #58's medical record revealed a facility admission date of 08/04/2026 and diagnoses including but not limited to Alzheimer's disease, anxiety disorder, restlessness and agitation, and encounter for palliative care. Review of Resident #58's MDS assessments revealed an admission MDS assessment dated [DATE] with a status of in progress. Further review revealed all applicable sections had a status of in progress. During an interview on 08/26/2026 at 10:20 a.m., S3 MDS Nurse confirmed Resident #58's admission MDS assessment was not completed and should be.

Based on record review and interviews, the facility failed to ensure resident assessments were transmitted within the required timeframe for 3 (#4, #55, #150) of 4 (#4, #15, #55, #150) residents investigated for Resident Assessment. Findings: Resident #4 Review of Resident #4's medical records revealed an admit date of 09/08/2025. Review of Resident #4's MDS submissions revealed a 02/26/2026 Quarterly MDS was completed on 03/12/2026 and was not accepted/transmitted until 04/06/2026. Further review of Resident #4's MDS submissions revealed a 04/23/2026 Quarterly MDS was completed on 05/07/2026 and was not accepted/transmitted until 06/03/2026. During an interview on 08/26/2026 at 2:19 p.m., S3 MDS Nurse reviewed resident #4's MDS Summary and agreed the MDSs had not been transmitted within 14 days after the assessment was completed and they should have. Resident #55 Review of Resident #55's medical record revealed an admit date of 05/30/2023. Review of Resident #55's MDS submissions revealed a 01/22/2026 Quarterly MDS was completed on 02/05/2026 and was not accepted/transmitted until 03/06/2026. Further review of Resident #55's MDS submissions revealed a 02/27/2026 Quarterly MDS was completed on 03/13/2026 and was not accepted/transmitted until 04/06/2026. During an interview on 08/25/2026 at 4:03 p.m., S6 MDS Nurse reviewed Resident #55's 01/22/2026 and 02/05/2026 Quarterly MDSs and confirmed the transmission dates were late. Resident #150 Review of Resident #150's medical record revealed an admit date of 01/16/2026. Review of Resident #150's MDS submissions revealed a 04/23/2026 Annual MDS was completed on 05/07/2026 and was not accepted/transmitted until 06/09/2026. During an interview on 08/25/2026 at 4:03 p.m., S6 MDS Nurse reviewed Resident #150's 04/23/2026 Annual MDS and reported the 04/23/2026 annual MDS was transmitted late. During an interview on 08/26/2026 at 4:45 p.m., S9 Corporate Nurse confirmed the MDS must be transmitted 14 days after the completion date on quarterly and annual MDSs.

Based on record review and interviews, the facility failed to notify a resident or their representative and the State's Long-Term Care Ombudsman in writing of a resident discharge for 1 (#157) of 3 closed records reviewed.Findings:Review of the facility's Transfer/Discharge Notice of the Ombudsman Program policy with an effective date of April 2026 revealed in part:POLICY: Notify Ombudsman of discharged residentsThe Ombudsman Notification Log should be submitted on a monthly basis to the facility's Local Ombudsman. The email subject line should read: Facility Name-Ombudsman Log (e.g. Sunny Day Nursing Home- Ombudsman Log). Sending the Ombudsman Notification Log does not replace the requirement of sending a written notice per S483.15(c)(5) to residents and their representatives.Review of the facility's Ombudsman Notification Log revealed under Written Notification to Resident/Representative Date, Resident #157 was documented as N/A (Not Applicable), for receiving a written notification of discharge. Further review revealed Resident #157 was discharged on 06/07/2026.During an interview on 08/25/2026 at 11:51 a.m., S7 SS reported not being aware the Ombudsman had to be notified of a resident's discharge home. S7 SS confirmed the State's Long-Term Care Ombudsman was not notified of Resident #157's discharge on [DATE] and should have been. During an interview on 08/25/2026 at 5:10 p.m., S8 Assistant Administrator confirmed the State's Long-Term Care Ombudsman and the Resident/Representative were not provided written documentation of Resident #157's discharge and should have been.

Based on observations and interviews, the facility failed to post address and telephone numbers of pertinent state agencies in a form and manner accessible and understandable to residents/resident representatives. Findings:Observation on 07/29/2025 at 9:55 a.m. revealed a framed document with state agency complaint address and phone number posted outside of the business office, at the end of a hallway, off of the facility's main hallway. The posting was on a letter size document and framed, with the bottom of the frame being 64 inches up from the floor. Observation further revealed the posting was not in a location easily noticeable from the main hallway. Further observation revealed only the business office and two staff bathrooms were on the hallway. Review of facility's admission packet revealed a document titled State Survey that included, in part, In accordance with LAC (Louisiana Administrative Code) Title 48:1 9715.F., and as required by R.S. (Revised Statute) 40: 2010.10, this facility is providing notification to the applicant that they may receive a copy of the annual licensing survey as well as the telephone number to report complaints. The telephone number is posted in the facility hallway in an accessible and visible location. During an interview on 07/30/2025 at 8:25 a.m., S1Administrator reported the posting was on the wall next to the business office and on the two televisions by the nursing stations. S1Administrator further acknowledged the print could be larger and the document could be positioned lower on the wall. Observation of television adjacent to a nursing station on 07/30/2025 from 9:31 a.m. to 9:41 a.m. failed to show information which indicated state agency complaint address/phone number to file a complaint. During an interview on 07/30/2025 at 9:45 a.m., S1Administrator was notified of the lack of state agency complaint address/phone number information on the television and reported he thought it was on there but maybe it was not.

Based on record reviews and interview, the facility failed to provide to the resident and/or the resident representative (RP) written notice which specified the reason for transfer, effective date, location and statement of the resident's appeal rights, and duration of the bed hold policy for 4 (#10, #52, #116 and #147) of 4 (#10, #52, #116 and #147) residents reviewed for transfer/discharge. Findings: Review of the facility’s “Bed-Hold and Readmission” undated policy revealed in part: Purpose: To explain and give written information to the resident and family member or legal representative of our bed-hold and readmission policy. General Information: Upon admission and when leaving the facility, the resident, family member or legal representative will be given instructions of the times allowed out of the facility for hospitalization and/or therapeutic leave… The policy states that a resident, family member or representative agrees that the facility holds the bed for specified number of days at a designated amount of charge. Note: If the resident wished to reserve the bed, there must be a signed agreement between the resident or responsible party and the nursing facility. Resident #10 Review of Resident #10's medical record revealed an admit date of 05/18/2022 with diagnoses of, but not limited to paraplegia, major depressive disorder and bipolar disorder. Review of Resident #10’s medical record revealed Resident #10 was sent to local ED (Emergency Department) on 04/21/2025 for wound evaluation. Further review of Resident #10’s medical record failed to reveal a written notice of transfer/discharge had been provided. Resident #52 Review of Resident #52's medical record revealed an admit date of 05/30/2023 with diagnoses of, but not limited to Parkinson’s disease with dyskinesia and age related osteoporosis without current pathological fracture. Review of Resident #52’s medical record revealed Resident #52 was sent to local ED on 02/20/2025 for evaluation after a fall. Further review of Resident #52’s medical record failed to reveal a written notice of transfer/discharge had been provided. Resident #116 Review of Resident #116's medical record revealed an admit date of 10/26/2023 with diagnoses of, but not limited to chronic obstructive pulmonary disease and other specified anxiety disorders. Review of Resident #116’s medical record revealed Resident #116 was sent to local ED on 06/01/2025 for altered mental status. Further review of Resident #116’s medical record failed to reveal a written notice of transfer/discharge had been provided. Resident #147 Review of Resident #147's medical record revealed an admit date of 04/24/2025 with diagnoses of, but not limited to metabolic encephalopathy and osteoarthritis. Review of Resident #147’s medical record revealed Resident #147 was sent to local ED on 04/30/2025 per RP’s request. Further review of Resident #147’s medical record failed to reveal a written notice of transfer/discharge had been provided. During an interview on 07/30/2025 at 1:00 p.m., S3DON (Director of Nursing) reported Residents #10, #52, #116, #147 and/or RPs had not been provided a written transfer/discharge notice upon transfer from the facility and should have been.

Based on record review and interview, the facility failed to refer a resident with newly evident or possible severe mental disorder, intellectual disability, or a related condition for a Level II PASARR (Pre-admission Screening and Resident Review) services for 1 (#3) of 6 (#3, #7, #13, #15, #34, and #135) residents reviewed for PASARR.This failure had the potential for residents to not be provided with specialized rehabilitation services, causing feelings of boredom, hopelessness and a diminished quality of life. Findings: Review of Resident #3's medical revealed an admit date of 06/28/2024 with a diagnosis of unspecified dementia, moderate without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of Resident #3's medical record revealed a diagnosis of Delusional Disorder was added on 07/02/2024. Review of Resident #3's Level I PASARR screen and determination record dated 06/21/2024 revealed Resident #3 was not suspected to have or had ever been diagnosed with a mental illness. Further review of Resident #3's medical record failed to reveal a new PASARR was completed after the new diagnosis of Delusional Disorder was added on 07/02/2024. During an interview on 07/30/2025 at 11:30 a.m., S2Corporate Nurse acknowledged a new PASARR had not been completed/submitted when Resident #3 was diagnosed with a new mental illness and should have been.

Based on record reviews, observations and interviews, the facility failed to provide services that met professional standards for 2 (#9 and #105) of 6 (#9, #22, #25, #52, #105, and #132) residents reviewed for accident hazards and supervision. The facility failed to ensure safe medication administration practices by leaving medication at the bedside.Findings:Review of the facility's undated Self-Administration of Medications policy revealed in part:3. To assess whether the resident is able to self-administer medications, the criteria on the Assessment for self-administration of medications form will be used. If the Interdisciplinary Team (IDT) determines that the resident is unable to self-administer medications, because this would be a danger to the resident or to others, then the Interdisciplinary Team may not grant the right to self-administer medications. If the right is granted, a specific order to self-administer must be obtained which includes how, when and for what reason the medication can be used.7. Self-administration of bedside medications must be care planned, including the specific order, granting of approval by IDT, and monitoring for compliance. Review of the facility's undated General Guidelines policy revealed in part:5. Residents are allowed to self-administer medications when specifically authorized by the IDT which includes the attending physician and in accordance with procedures for self-administration of medications. (See policy for self-administration of medications)Resident #9Review of Resident #9's medical record revealed an admission date of 08/16/2023 with diagnoses which included, in part, metabolic encephalopathy, personal history of transient ischemic attack (TIA) and cerebral infarction without residual deficits. Review of Resident #9's Quarterly MDS (minimum data set) assessment dated [DATE] revealed, in part, a BIMS (Brief Interview of Mental Status) score of 08/15, indicating moderate cognitive impairment).Review of Resident #9's medical record revealed a physician order dated 11/04/2024 Cleanse buttocks with soap and water pat dry apply zeasorb powder for preventative care leave open to air daily until resolved; every day shift and every 15 minutes as needed for preventative skin care. Further review of Resident #9's medical record failed to reveal a physician's order for self-administration of medication. Review Resident #9's care plan failed to reveal Resident #9 had been care planned for self-administration of medication.An observation on 07/28/2025 at 8:15 a.m. revealed one medication cup of powder with illegible/smeared label on Resident #9's bedside table. During an interview on 07/28/2025 at 9:25 a.m., with S4CNA (certified nursing assistant) and S5LPN (licensed practical nurse), S4CNA reported the medication in the cup on Resident #9's bedside table was for wound care on Resident #9's buttocks. S5LPN acknowledged medication was at the bedside. S5LPN reported she was unable to read the medication cup label. S5LPN reported medications of any kind should not be at the bedside. During an interview 07/28/2025 at 9:30 a.m., S5LPN reported the medication could be Zeasorb. Upon review of Resident #9's orders, S5LPN reported the powder in the medication cup was is Zeasorb and there was not an order for medication to be left at Resident #9's beside for self-administration. Resident #105Review of Resident #105's medical record revealed an admission date of 08/16/2023 with diagnoses which included, in part, dry eye syndrome of bilateral lacrimal glands, chronic obstructive pulmonary disease with (acute) exacerbation, chronic respiratory failure with hypoxia.Record of Quarterly MDS Assessment for Resident #105 dated 06/05/2025 revealed in a BIMS score of 15/15, indicating cognitively intact.Review of Resident #105's medical record revealed a physician's order dated 03/20/2025 refresh liquigel ophthalmic gel 1% (carboxymethylcellulose sodium [ophthalmic]); instill 2 drop in both eyes two times a day related to dry eye syndrome of bilateral lacrimal glands and instill 1 drop in both eyes every 2 hours as needed for dry eye. Further review of Resident #105's medical record failed to reveal a physician's order for self-administration of medication. Review of Resident #105's care plan failed to reveal Resident #105 had been care planned for self-administration of medication.An observation on 07/28/2025 at 9:05 a.m. revealed medication on Resident # 105's bedside table labeled Refresh Tears. During an interview on 07/28/2025 at 9:05 a.m., Resident #105 reported medication had been on the bedside table since last night, and she had just put the eye drops in her eyes. During an interview on 07/28/2025 at 9:15 a.m., S6LPN acknowledged Refresh Tears medication was at Resident #105's bedside and should not be in the room. S6LPN further acknowledged Resident #105 did not have an order for self-administration

Based on record reviews, observations and interviews, the facility failed to provide respiratory care consistent with professional standards of practice for 2 (#116 and #139) of 3 (#116, # 39, and #141) residents reviewed for respiratory services. The facility failed to ensure respiratory supplied were stored properly.Findings:Review of the facility's undated Oxygen Administration (Concentrator or Tank) policy revealed in part: Humidifier bottles, cannulas and 02 tubing will be changed at least once weekly and dated. Concentrator filter should be cleaned weekly or as needed as well. When not in use. Cannula or mask should be placed in a plastic bag.Resident #116Review of Resident #116's Quarterly MDS Assessment (minimum data sheet) dated 06/19/2025 revealed, in part, admission date to facility of 10/26/2023. Review of Resident #116's medical record diagnoses included, in part, other specified chronic obstructive pulmonary disease, history of falling, other specified anxiety disorders, muscle wasting and atrophy, not elsewhere classified, multiple sites, pain, unspecified and restless legs syndrome. Review of Resident #116's physician orders included an order dated 07/11/2025 Change O2 (oxygen) tubing, nasal cannula, humidifier bottle and clean filter; one time a day every Wednesday.An observation on 07/28/2025 at 7:55 a.m. revealed Resident #116's oxygen humidified water container and tubing were dated 07/18/2025. During an interview on 07/28/2025 at 8:00 a.m., S3DON (Director of Nursing) reported Resident #116's oxygen tubing was dated 07/18/2025 and should have been changed weekly.Resident #139Review of Resident #139's Quarterly MDS assessment dated [DATE] included an admission date to facility of 11/01/2024.Review of Resident #139's diagnoses included other specified chronic obstructive pulmonary disease and chronic systolic (congestive) heart failure. An observation on 07/28/2025 at 8:45 a.m. revealed Resident #139's nebulizing mask placed on top of nebulizing machine and was not stored in a bag.During an interview on 07/28/2025 at 9:30 a.m., S5LPN (licensed practical nurse) acknowledged Resident #139's nebulizing mask was undated, not stored a bag, and should have been.

Based on record reviews, observations, and interviews the facility failed to provide appropriate treatment and services for 3 (#1, #19 and #34) of 3 (#1, #19, and #34) residents reviewed for tube feeding. The facility failed to ensure the tube feeding container was labeled with the time it was started. Findings: Review of the facility's undated Nasogastric/Gastrostomy Tube Feedings policy revealed in part: Essential Points to Remember . 7. Labels should be completed with resident's name, date, start time, initials of nurse and rate. Resident #1 Review of Resident #1's medical record revealed an admitted [DATE] and diagnoses which included, in part, diffuse traumatic brain injury, dysphagia, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, encounter for attention to gastrostomy. Review of Resident #1's physician's orders revealed, in part: 06/03/2024 Isosource 1.5 at 45 ml (milliliters)/hr (hour) via peg tube continuously per feeding pump. An observation on 06/24/2024 at 9:22 a.m. revealed Resident #1 was receiving Isosource 1.5 at 45 ml/hr. Further observation revealed Resident #1's tube feeding formula label failed to include the time the feeding was started. During an interview on 06/24/2024 at 9:25 a.m. S3 LPN (Licensed Practical Nurse) confirmed Resident #1's tube feeding formula was not labeled with time it was started and should have been. Resident #19 Review of Resident #19's medical record revealed an admitted [DATE] and diagnoses which included, in part, aphasia, cognitive impairment, diffuse traumatic brain injury, persistent vegetative state, and encounter for attention to gastrostomy. Review of Resident #19's physician's orders revealed, in part: 06/03/2024 Promote with fiber 1.0 at 35ml/hr via peg tube continuously per feeding pump. An observation on 06/24/2024 at 9:13 a.m. revealed Resident #19 was receiving Promote with fiber 1.0 at 35 ml/hr. Further observation revealed Resident #19's tube feeding formula label failed to include the time the feeding was started. During an interview on 06/24/2024 at 9:24 a.m. S3 LPN confirmed Resident #19's tube feeding formula was not labeled with time it was started and should have been. Resident #34 Review of Resident #34's medical record revealed an admitted [DATE] and diagnoses which included, in part, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, dysphagia following cerebral infarction, and encounter for attention to gastrostomy. Review of Resident #34's physician's orders revealed, in part: 06/03/2024 Isosource 1.5 at 45ml/hr via peg tube continuously per feeding pump. An observation on 06/24/2024 at 9:05 a.m. revealed Resident #34 was receiving Isosource 1.5 at 45 ml/hr. Further observation revealed Resident #34's tube feeding formula label failed to include the time the feeding was started. During an interview on 06/24/2024 at 9:23 a.m. S3 LPN confirmed Resident #34's tube feeding formula was not labeled with time it was started and should have been.

Based on record reviews and interviews the facility failed to ensure 1 (# 62) of 1 resident reviewed for pain management received the treatment and care consistent with professional standards of practice and in accordance with the resident's Comprehensive Plan of Care. The facility failed to perform daily pain assessments including monitoring for worsening of pain symptoms. Findings: Review of resident #62's Comprehensive Plan of Care revealed a potential problem of altered comfort and pain. Intervention start date of 09/03/2021 and remain active for - Assess pain daily using 1-10 scale. Monitor for worsening of pain symptoms and notify physician of changes. Administer pain medication as ordered. Review of resident #62's clinical records revealed diagnoses that include other intervertebral disc degeneration lumbar region, poisoning by unspecified drugs, medicaments and biological substances, accidental (unintentional), initial encounter and chronic pain. Review of resident #62's June 2024 MAR (Medication Administration Record) revealed pain medications were administered on a routine basis, however, the record did not reflect the resident's response to the administration of the pain medication. Further review of resident #62's medical records failed to reveal daily pain assessments were done. Review of resident #62's June 2024 Physician Orders revealed the following orders: 03/15/2023 Hydrocodone-Acetaminophen (controlled drug) oral tablet 10-325 mg (milligram) Give 1 tablet by mouth every 8 hours as needed for pain related to chronic pain syndrome. Do not exceed 4,000 mg APAP (Acetaminophen) in 24 hours. 02/29/2024 Morphine Sulfate (controlled drug) ER (extended release) oral tablet 15 mg. Give 1 tablet by mouth two times a day related to chronic pain syndrome. 03/16/2023 Acetaminophen oral tablet 325 mg. Give 2 tablets by mouth every 4 hours as needed for pain/headache, dose alert (650mg). Do not exceed 4,000 mg APAP in 24 hours. During an interview on 06/24/2024 at 8:40 a.m., resident #62 complained of pain in both arms from exercises during therapy. Resident #62 reported she had been given her routine medications and she was still hurting. Resident #62 reported she would probably not be given anything else for pain and she would talk with her doctor whenever he visited. During an interview 06/26/2024 at 7:57 a.m. S3 LPN (License Practical Nurse) reported resident #62 receives routine pain meds but daily pain assessments were not being done.

Based on record review, observations, and interviews the facility failed to ensure an appropriate intervention was utilized for 1 (Resident #23) of 2 (#23 and #56) residents reviewed for falls by failing to ensure landing strips were in place at Resident #23's bedside. Review of the facility's Fall Prevention Program policy (not dated) revealed in part: Policy: It is the policy of the facility to promote safety, dignity, and overall quality of life for residents. A safe and hazard free environment, as possible, will be provided as well. It is our goal to prevent falls by enabling staff to recognize those residents who have been identified as high risk for potential falls so appropriate interventions can be implemented. We also hope to decrease the risk of injury when falls cannot be prevented. g. Plan of Care: Based on the nursing assessment, preventive measures will be implemented and care planned for residents identified at high risk for falls. Review of Resident #23's medical record revealed in part, Resident #23 was initially admitted to the facility on [DATE] with re-entry on 11/29/2023. Diagnoses, included in part, fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing, anxiety disorder and dementia. Review of Resident #23's Quarterly MDS (Minimum Data Set) dated 03/07/2024 revealed in part, Resident #23 had a BIMS (Brief Interview of Mental Status) score of 11 out of 15 indicating moderately impaired cognition. Review of Resident #23's comprehensive care plan revealed in part, Resident #23 was high risk for falls with interventions including but not limited to, anticipate resident #23's needs, encourage to call for assistance, and ensure landing strips x (times) 2 to each side of bed at all times. Review of Resident #23's Physician's orders revealed an order dated 02/21/2024 which read, Landing strips x 2 to each side of bed at all times, every day. Observation on 06/25/2024 at 11:50 a.m. revealed Resident #23 lying in bed asleep with bed in low position. Further observation failed to reveal landing strips were in place to each side of Resident #23's bed. Observation on 06/26/2024 at 8:40 a.m. revealed Resident #23 asleep in bed with bed in low position. Further observation failed to reveal landing strips were in place to each side of Resident #23's bed. Observation on 06/26/2024 at 10:15 a.m. revealed Resident #23 awake in bed with bed in low position. Further observation revealed Resident #23's landing strips were folded up and sitting in the corner of Resident #23's room. During an interview on 06/26/2024 at 10:15 a.m., S4RN (Registered Nurse) acknowledged bilateral landing strips were not in place at Resident #23's bedside and should be. During an interview on 06/26/2024 at 10:40 a.m., Resident #23's Responsible Party reported upon arrival to Resident #23's room, fall mats were not in place at times and this concerned her.

Based on observation and interviews the facility failed to ensure the nurse staffing data was posted daily at the beginning of each shift. The facility failed to ensure the nurse staffing data was readily accessible to residents and visitors. The facility had a total census of 114 residents. Findings: Observations of the facility 06/26/2023 at 12:15 p. m. with S2 Corporate Nurse failed to reveal the nursing staffing data report was posted. During an interview on 06/26/2023 at 12:25 p.m. S2 Corporate Nurse reported the nursing staffing data should have been posted and it was not. During an interview on 06/26/2023 at 12:30 p.m. S3 [NAME] Clerk responsible for posting of the nurses staffing data reported she had not posted the nurse staffing data since the move to the new building. During an interview on 06/26/2023 at 12:30 p.m. S1 Assistant Administrator reported the nurse staffing report should have been completed and posted daily by S3 [NAME] Clerk and it was not.

Based on record reviews and interviews the facility failed to implement a care plan for 1 (#3) out 1 resident reviewed for [CONDITION(S)]. The facility failed to obtain lab as ordered by physician and notify physician of Resident #3 refusal to allow facility to obtain lab. Findings: Review of Resident #3's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #3's July 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Review of lab from January 2022 through June 2022 revealed the facility failed to obtain Renal Panel as ordered. Review of lab reports with S1 DON (Director of Nursing) revealed lab reports received from [CONDITION(S)] failed to include Renal Panel. During an interview on 7/20/2022 at 12:30 PM S1 DON reported Resident # 3 had refused lab draws from the facility and the facility obtained lab results from [CONDITION(S)]. S1 DON confirmed lab was not obtained as ordered by physician. During an interview 7/20/2022 at 12:30 PM on S4 Corporate Nurse confirmed Resident # 3 refused lab and the physician ordering the lab should have been contacted to have lab discontinued.

FACILITY Based on record review and interview, the facility failed to ensure each resident's MDS (Minimum Data Set) assessment was transmitted within 14 days of completion for 1 (#2) of 4 (#2, #3, #5, #7) residents reviewed for MDS transmission. Findings: Review of resident #2's MDS (Minimum Data Set) Assessment with Assessment Reference Date 6/9/2022 revealed: Section A - Identification Information Type of Record: Add new record Type of assessment: OBRA (Omnibus Budget Reconciliation Act): Quarterly Review Assessment Further review revealed the MDS data was signed and dated 6/9/2022, was transmitted to a 3rd Party, and had not been transmitted to CMS. During an interview on 7/19/2022 at 9:30 am S3 RN (Registered Nurse) confirmed resident #2's MDS data was signed and dated as completed by her on 6/9/2022, was transmitted to a 3rd Party, and was not transmitted to CMS within 14 days of completion as required and should have been.

Based on record review, observations, and interview, the facility failed to provide respiratory care consistent with professional standards for 1 (#50) out of 1 resident reviewed for respiratory care. The facility failed to ensure Resident #50's nebulizer mask and tubing was stored properly. Findings: Review of facility's Oxygen Administration Policy revealed humidifier bottles, cannulas and 02 tubing will be changed at least weekly and dated. Concentrator filter should be cleaned weekly or as needed as well. When not in use, cannula or mask should be placed in a plastic bag. Review of Resident # 50's July 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of face sheet revealed Resident # 50 was admitted to facility on 6/7/2022 with following diagnoses, but not limited to atherosclerosis of aorta, hypertensive heart & [CONDITION(S)] with heart failure and stage 1-4/ unspecified [CONDITION(S)], acute systolic (congestive) heart failure During an interview on 7/18/2022 at 10:00 AM Resident #50 reported she received breathing treatments daily to keep her lungs clear. Resident #50 reported staff place the nebulizer mask on for a breathing treatment but do not always return to remove mask after breathing treatment. Observation on 7/18/2022 at 10:00 AM revealed Resident #50's nebulizer, nebulizer mask and tubing labeled 7/14/2022 in geri chair and not in plastic bag. Observation on 7/19/2022 at 8:00 AM revealed Resident #50's nebulizer, nebulizer mask and tubing labeled 7/14/2022 in geri chair and not in plastic bag. Observation on 7/19/2022 at 12:00 PM revealed Resident #50's nebulizer, nebulizer mask and tubing labeled 7/14/2022 in geri chair and not in plastic bag. During an interview on 7/19/2022 at 12:05 PM S2 LPN (Licensed Practical Nurse) confirmed Resident #50's nebulizer mask and tubing should be stored in a plastic bag when not in use and was not. During an interview on 7/20/2022 at 9:30 AM S1 DON (Director of Nursing) reported nebulizer mask should be stored in plastic bag when not in use.

Based on observation, interview and record reviews, the facility failed to provide current pharmaceutical services to meet the needs of each resident as evidenced by having an expired medication available for resident use. This deficient practice had the potential to affect any of the 66 residents who resided in the facility as documented on the facility's Resident Census and Conditions of Residents Form (CMS-672). Findings: Observation of the Medication Cart for the back end of 200 hall with S5 LPN (Licensed Practical Nurse) on [DATE] at 10:15am revealed Resident #41's medication card for [MEDICATION(S)]-Acetaminophen ,d+[DATE] mg (milligrams) had an expiration date of [DATE] with 19 remaining tablets on the card. Review of Resident #41's Individual Narcotic Record for [MEDICATION(S)]-Acetaminophen ,d+[DATE] mg with S5 LPN revealed [MEDICATION(S)]-Acetaminophen ,d+[DATE] mg was administered after the [DATE] expiration date on [DATE] at 18:12, [DATE] at 6am, [DATE] at 6am, and [DATE] at 1:50am. During an interview on [DATE] at 10:15am, S5 LPN reviewed Resident #41's Medication Card and Individual Narcotic Record for [MEDICATION(S)]-Acetaminophen ,d+[DATE] mg and agreed the medication had expired on [DATE] and the medication was administered after [DATE] and should not have been. S5 LPN further indicated the medication should have been removed from the cart and discarded appropriately. During an interview on [DATE] at 10:28am S2 ADON (Assistant Director of Nursing) reviewed Resident #41's Medication Card and Individual Narcotic Record for [MEDICATION(S)]-Acetaminophen ,d+[DATE] mg and agreed the medication had expired on [DATE] and was administered after the expiration date and should not have been. Review of Resident #41's [DATE] Physician orders revealed a [DATE] order for [MEDICATION(S)]-Acetaminophen ,d+[DATE] mg give one PO (by mouth) every 6 hours prn (as needed) moderate-severe pain **If intoxicated do not give hold med and notify MD (Medical Doctor)**. Review of Resident #41's [DATE] MAR (Medication Administration Record) revealed [MEDICATION(S)]-Acetaminophen ,d+[DATE] mg was given on [DATE] at 6:13pm, [DATE] at 6:14am, [DATE] at 6:14am, and [DATE] at 1:49am. Review of policy titled Medication Storage in the Facility revealed: Policy: Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier . Procedure: 13. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction, and reordered from the pharmacy, if a current order exits.

Based on record reviews and an interviews, the facility failed to ensure residents were free from unnecessary medications for 2 (#17, #51) out of 5 (#17, #14, #20, #25, #51) residents reviewed for unnecessary medications. The facility failed to ensure Resident #17 and Resident #51 were monitored for behaviors and side effects while receiving [CONDITION(S)] medications. Findings: Resident #17 Review of Resident #17's Medical Records revealed the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #17's July 2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Ordered on 06/30/2021 - Monitor for side effects of [CONDITION(S)] meds Ordered on 06/30/2021 - Monitor for behaviors/[CONDITION(S)] meds Ordered on 04/04/2020 - [MEDICATION(S)] 5mg (milligram) one tablet PO (by mouth) BID (twice a day) Ordered on 01/30/2020 - [MEDICATION(S)] 10mg tablet one tablet PO Q (every) day Ordered on 01/30/2020 - [MEDICATION(S)] 5mg tablet PO Q daily Review of Resident #17's April, May and June 2021 MARs (Medication Administration Record) failed to reveal monitoring for [CONDITION(S)] behaviors and side effects from April - June 29th 2021 while receiving [CONDITION(S)] medications [MEDICATION(S)] 5mg, [MEDICATION(S)] 10mg and [MEDICATION(S)] 5mg. During an interview on 07/28/2021 at 2:38 PM S3 RN (Registered Nurse) confirmed Resident #17 was not monitored for behaviors and side effects while receiving [CONDITION(S)] medications [MEDICATION(S)] 5mg, [MEDICATION(S)] 10mg and [MEDICATION(S)] 5mg for April, May and June 1-29th and should have been. Resident #51 Review of Resident #51's Medical Record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #51's July 2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #51 July 2021's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 7/28/2021 at 2:30 pm S1 DON (Director of Nurses) confirmed resident #51 had not been monitored for target behaviors and side effects of [CONDITION(S)] medication while taking [MEDICATION(S)].

Based on observations, interviews, and record review the facility failed to ensure residents' rooms received housekeeping services necessary to maintain a sanitary, orderly, and comfortable interior for 1 (#1) out of 66 residents residing in the facility according to the Residents Census and Conditions of Residents. Findings: Observation on 07/26/21 at 9:15 AM revealed Resident #1's toilet with a dried brown substance appearing to be feces on the front of toilet base near lid. During an interview on 07/26/2021 at 10:45 AM S7 LPN (Licensed Practical Nurse) verified Resident #1 is able to go to the bathroom by herself. Review of Resident #1's Medical Records revealed the following diagnoses: mild cognitive impairment, need for assistance with personal care, and unspecified intellectual disabilities. Observation on 07/26/21 at 3:00 PM revealed Resident #1's toilet with a dried brown substance appearing to be feces on the front of toilet base near lid. Observation on 07/27/21 at 12:22 PM revealed Resident #1's toilet with a dried brown substance appearing to be feces on the front of toilet base near lid. During an interview on 07/27/2021 at 3:10 PM S6 Housekeeper reported resident rooms are cleaned every day to include disinfecting the bathroom. During an interview and observation on 07/27/2021 at 3:20 PM S3 RN (Registered Nurse) acknowledged Resident #1's toilet had a dried brown substance appearing to be feces on it and should have been cleaned. RN further indicated Resident #1 is messy sometimes when she uses the bathroom. During an interview on 07/27/2021 at 3:30 PM S6 Housekeeper acknowledged Resident #1's bathroom was dirty and should have been cleaned.

Based on observations, record review, and interviews, the facility failed to ensure a resident who was unable to complete their activities of daily living received the necessary services to maintain grooming and hygiene for 1(#52) of 1 resident reviewed for activities of daily living. The facility failed to ensure resident #52's fingernails were clean and trimmed. Findings: Observation on 7/26/2021 at 9:45 am revealed resident #52 had jagged fingernails with dark brown residue underneath the nailbeds. Observation on 7/27/2021 at 9:00 am revealed resident #52 had jagged fingernails with dark brown residue underneath the nailbeds. Observation on 7/28/2021 at 9:15 am revealed resident #52 had jagged fingernails with dark brown residue underneath the nailbeds. Review of resident #52's July 2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident #52's Quarterly Minimum Data Set, dated dated dated [DATE] revealed resident #52 was assessed as, one person physical assistance with bathing and hygiene. Review of resident #52's Comprehensive Care Plan revealed a problem of Self Care Deficit with an approach of: fingernails cleaned and trimmed as needed. During an interview on 7/28/2021 at 9:20 am S4LPN confirmed resident #5 required total assistance with activities of daily living and was unable to perform her own nail care. S4LPN further confirmed resident #52's nail care should have been done by a nurse or certified nursing assistant.

Based on observation, record reviews, interviews, review of the facility's policies and procedures, and review of the Louisiana State Board of Practical Nurse Examiners website, the facility failed to ensure nursing professional standards of quality were provided for 1 (#4) of 6 (#1, #2, #3, #4, #5, #6) residents reviewed out of a total resident sample of 12. The facility failed to: 1. Ensure nursing staff followed physician's orders [REDACTED]. First lab was drawn on 11/23/12 (#4). 2. Accurately identify, assess, and document a resident's anticoagulant therapy status upon admission to the facility on [DATE] (#4). 3. Have a system in place to ensure that physician's orders [REDACTED].#4). 4. Have a working system in place to ensure nursing staff notified lab of new orders. 5. Have a working system in place to ensure nursing staff reviewed physician's orders [REDACTED]. 6. Have a working system in place to ensure resident labs were reviewed by nursing staff and the physician notified. 7. Have a working system in place to ensure nursing staff assessed residents for signs or symptoms of bleeding related to being on anticoagulant therapy. The Immediate Jeopardy began for resident #4 on 11/9/12 when the facility failed to obtain ordered daily PT/INR levels. The Immediate Jeopardy continued on 11/21/12 when S6 LPN noted that the labs had not been drawn and failed to notify the lab to obtain the PT/INR on 11/21/12. S5 LPN and S6 LPN were aware on 11/21/12 that no levels had been drawn. Neither LPN checked the physician's orders [REDACTED]. S5 LPN called the lab so that the PT/INR could be drawn on 11/23/12. The PT/INR drawn on 11/23/12 had the following results reported: PT greater than 82.5 seconds (Normal= 8.9-12.1 seconds) and INR greater than 9.0 critical high (Normal= 0.9-1.2). The Immediate Jeopardy ended for resident #4 on 11/26/12 when he was admitted to a local hospital with abdomen pain and [MEDICATION NAME] toxicity. The Immediate Jeopardy continued for residents #1, #3, #6, #7, #8, #9, #10, #11, #12 who were still in the facility and were receiving [MEDICATION NAME] therapy. S1 Administrator, S2 DON (Director of Nursing), S3 ADON (Assistant Director of Nursing), and S4 Corporate Nurse were notified on 11/30/12 at 5:45 p.m. of the Immediate Jeopardy situation regarding resident #4's lab not being drawn as ordered that begun 11/9/12 when the first lab was missed and continued not to be drawn until 11/23/12. The facility's Plan of Removal was documented as follows: 1. All the residents who receive [MEDICATION NAME] (Jantoven) therapy have had PT/INRs drawn and results reviewed by their physician. a. DON reviewed all the PT/INR results and spoke with all the physicians on 12/1/12 regarding the residents' lab results, current dosages of [MEDICATION NAME] (Jantoven), and received new orders (if necessary) for continued monitoring or dosages. 2. All the residents who receive [MEDICATION NAME] (Jantoven) therapy have had their plans of care updated to reflect accurate monitoring of their lab work and monitoring of bleeding precautions. a. The DON reviewed and revised the plans of care on the residents receiving [MEDICATION NAME] (Jantoven) and updated the plans to reflect the monitoring of lab work and bleeding precaution monitoring on 12/1/12. 3. All the residents who receive [MEDICATION NAME] (Jantoven) therapy have bleeding precaution monitoring being completed by the nurses every shift. a. This was verified to be on all the Medication Administration Records (MARs) for the residents receiving [MEDICATION NAME] (Jantoven) therapy on 11/30/12 and again on 12/1/12 by nursing administration. 4. In-servicing for licensed staff began on 11/29/12 and continued through 12/2/12 focusing on ordering and monitoring PT/INRs by the DON, nursing administration, and Silver Chair (online training) module on [MEDICATION NAME] (Jantoven) administration. a. On 11/29/12 the DON implemented in-service training for all the nursing staff regarding ordering and receiving PT/INRs, following physician's orders [REDACTED]. This in-service is continuing until all the licensed staff have had this information reviewed with them. b. On 12/1/12 a module in the Silver Chair computer training system was activated for the nurses at the facility. This module is to be completed by all the licensed staff to provide additional training regarding [MEDICATION NAME] (Jantoven) administration. c. The ADON was in-serviced on 11/29/12 with return demonstration provided on how to access the complete monthly lab list. d. Newly hired licensed staff members will be trained by nursing administration upon hire on lab notification with new order, admits, and readmit orders. 5. All residents who receive [MEDICATION NAME] (Jantoven) have had their medication reconciled to assure that what medication currently ordered is being given accurately. a. On 12/1/12 the weekend RN (Registered Nurse) reconciled the medications with the physician's orders [REDACTED]. 6. All the residents receiving [MEDICATION NAME] (Jantoven) therapy have had their PT/INR orders reviewed and are now being tracked by the DON, or nursing administration designee for completion, results, physician notification, and new orders for changes in [MEDICATION NAME] (Jantoven) dosages if necessary. a. The DON completed a monitor regarding the tracking and monitoring of the residents on [MEDICATION NAME] (Jantoven) therapy. She will continue on with this monitoring as PTs are drawn on a daily, if necessary, basis for the next 6 weeks then weekly for 6 weeks and as necessary until compliance is reached and maintained. b. New admission and readmission residents will have their orders reviewed by nursing supervisor on duty for lab work orders and lab notifications. A monitor will be completed by the DON or designee to review orders and lab notification with each admit/readmit for 6 weeks and then weekly for the next 6 weeks and as necessary until compliance is maintained. c. On a daily basis the new telephone orders and 24 hour report will be reviewed by the DON or nursing administration for new orders related to lab work and those orders will be verified as being called to lab by reviewing the notes and, if necessary, double checking the lab, a monitor will be completed to assure compliance of this task by nursing administration 5 times a week for 6 weeks and then weekly for 6 weeks and then as necessary until compliance is maintained. 7. Results of this corrective action will be reviewed by the TQM (Total Quality Management) committee as necessary until compliance is reached and maintained as necessary. The facility provided their plan of removal on 12/3/12 at 9:00 a.m. The plan of removal was accepted at 9:30 a.m. and the Immediate Jeopardy was lifted as of 12/1/12 at 11:15 a.m. when it was determined by the surveyors that each resident who received blood thinner therapy had their physician's orders [REDACTED]. The deficient practice continued at a scope and severity of third level pattern. Findings: Observation on 11/30/12 at 10:15 a.m. revealed resident #4 seated in a wheelchair in his room. During an interview at that time, resident #4 stated when he was first admitted to the facility he was receiving blood thinner medications and that the facility never collected any lab from him. Resident #4 stated he went to the hospital on Monday (11/26/12) with his abdomen hurting. Resident #4 stated he did not have any type of bleeding. Review of resident #4's electronic November 2012 physician's orders [REDACTED].>2.0, and obtain PT/INR daily and fax results to the Primary Care Physician (PCP). Further review revealed an order to monitor for abnormal signs or symptoms of bleeding related to anticoagulant (blood thinners) therapy each shift. Review of resident #4's medical record revealed a PT/INR drawn on 11/23/12 with the following results: PT greater than 82.5 seconds (normal = 8.9-12.1 seconds) and INR greater than 9.0 critical high (normal = 0.9-1.2). Further review of the medical record failed to reveal any other PT/INR results. Review of resident #4's November 2012 Medication Administration Record (MAR) failed to reveal documentation each shift of monitoring for abnormal signs or symptoms of bleeding related to anticoagulant therapy as ordered. Review of the facility's printed physician's orders [REDACTED]. Review of the [MEDICATION NAME] management tracking sheet revealed a list of 10 residents with partial documentation of the expected requirements of the form. Multiple forms failed to reveal a date for the next PT/INR or were not specific as to when it was to be drawn. During an interview on 11/30/12 at 11:50 a.m. S2 DON, with S3 ADON also present, stated the facility discovered a data entry error on 11/29/12 which caused the lab to not receive a complete list of all residents and their ordered lab tests. S2 DON further stated S3 ADON began to enter resident information and orders at the beginning of November. S2 DON stated the information entered is for the lab to know the schedule of lab draws for each resident. During an interview on 11/30/12 at 5:45 p.m., S1 Administrator, S2 DON, S3 ADON, and S4 Corporate Nurse agreed resident #4's physician's orders [REDACTED]. S1 Administrator, S2 DON, S3 ADON, and S4 Corporate Nurse further agreed resident #4 went 2 weeks without having his lab drawn and the nurses should have noticed the lab was not drawn before that time. S2 DON agreed resident #4's lab was not monitored and levels assessed daily as ordered. S2 DON agreed the [MEDICATION NAME] management tracking sheet that was put into place was not working because the nurses did not complete the form as indicated. During an interview on 12/3/12 at 10:20 a.m. LPN #S6 stated resident #4 received his [MEDICATION NAME] (Jantoven) on her shift and she was not aware of his PT/INR results because they were not done. LPN #S6 further stated normally she would look at new orders for resident's to see if anything had changed, but she did not have time. LPN #S6 stated she and the evening nurse LPN #S5 were discussing that resident #4 had been receiving Jantoven, but no levels had been drawn the day before Thanksgiving (11/21/12). LPN #S6 stated she did not notify lab at that time and LPN #S5 called for the lab to be drawn on Friday 11/23/12. LPN Hicks stated she should discovered resident #4's PT/INR levels had not been drawn, but usually it would be written on the MAR and was not. LPN #S6 stated she should have been aware that resident had no labs drawn and was on Jantoven. During an interview on 12/3/12 at 10:40 a.m. LPN #S5 stated she readmitted resident #4 on 11/8/12. LPN #S5 further stated resident #4 had orders for [MEDICATION NAME] and [MEDICATION NAME], but did not know he had lab ordered, but assumed he should have. LPN #S5 stated she did not double check until resident #4 asked about his [MEDICATION NAME] shot being stopped. LPN #S5 sated she told resident #4 the [MEDICATION NAME] would be stopped when the level reached 2.0. LPN #S5 further stated she checked on it and realized the lab had not been done so she called the lab on 11/23/12. LPN #S5 stated they usually double check the hospital pack, but it was not left out and the front office staff wrote the orders and brought them too her. LPN #S5 stated she thought the other nurse had been getting the lab and had not checked. During an interview on 12/3/12 at 10:55 a.m. ADON #S3 stated discharge paperwork comes over the fax and is brought to her or DON #S2 to review for orders that may be needed special. ADON #S3 further stated the nurse's are responsible for writing the orders and MARs, but she would review the orders and assist at times with completing the orders and MARs because the nurses are usually passing medications and are busy. ADON #S3 stated the nurses are ultimately responsible for the admission and completing the paperwork. ADON #S3 stated she received the faxed copy of resident #4's orders on 11/8/12 and wrote the orders out and called the physician at which time, he agreed with the orders. ADON #S3 reviewed resident #4's MAR and agreed she did not transcribe the lab order over to the MAR and should have. ADON #S3 stated the nurse is responsible for contacting the physician and double checking the written orders against the hospital admit pack. Review of the facility's Policy and Procedures Manual revealed the following policy: Physician order [REDACTED]. Policy - To accurately transcribe and carry out physician's orders [REDACTED]. Procedure - If the 90L orders do not arrive with the resident, the transferring facility should be called and a 90L requested immediately. A 90L must accompany a resident to be admitted . If telephone orders are received, a 3-copy telephone order slip is filled out. One copy is placed in the medical record temporarily until the original copy is returned by the physician. (The original copy is sent to the physician for signature). When the original copy is returned, signed and dated by the physician, it is placed in the resident's chart and the other copy in the chart is destroyed. The third copy will be given to the Data Entry (or other personnel) to update computer. Review of the Louisiana State Board of Practical Nurse Examiners website (http://www.lsbpne.com/scope_of_practice.htm) revealed the following: According to this law, practical nursing is the performance, for pay, of acts in the care, treatment or observation of the ill and for the maintenance of the health of others and the promotion of health care. Practical nurses may train and/or supervise other nurses, and subordinate personnel. They may also instruct patients. A licensed practical nurse must practice under the direction of one of the following: licensed physician, optometrist, dentist, psychologist, or registered nurse. A licensed practical nurse may perform duties consistent with his/her educational preparation. The licensed practical nurse may also, with appropriate training (which is approved by this Board, and documented), perform additional specified acts which are authorized by the Board of Practical Nurse Examiners when directed to do so by the licensed physician, optometrist, dentist, psychologist, or registered nurse. The Louisiana State Board of Practical Nurse Examiners (LSBPNE) has no "laundry list" of tasks/skills an LPN can perform. Such lists tend to limit practice. Scope of practice is a fluid concept. It changes as knowledge and technology expand. LPNs must possess the knowledge, skill, and ability to perform their duties, therefore, scope of practice comes down to the competency of the individual LPN.

Based on observations, record reviews, and interviews the facility failed to ensure the Physician's orders and resident's plan of care was followed for 2 (#4, #5) of 6 (#1, #2, #3, #4, #5, #6) resident reviewed for following the plan of care out of a total sample of 12. The facility failed to: Resident #4 1. Ensure nursing staff followed Physician's orders to obtain daily Pro-time/International Normalized Ratio (PT/INR) labs from 11/9/12 through 11/22/12 as specified by Physician's orders written on 11/9/12 for a resident receiving [MEDICATION NAME] (Jantoven) therapy. First lab was drawn on 11/23/12 (#4). 2. Ensure staff immediately obtained ordered blood work for daily PT/INR levels when it was discovered on 11/21/12 that the daily labs for PT/INR were not obtained daily as ordered (#4). 3. Ensure staff notified the Physician and Supervisory facility personnel on 11/21/12 when it was noted that lab tests ordered to be drawn daily were not drawn on a resident receiving [MEDICATION NAME] therapy (#4). 4. Have a system in place to ensure that Physician's orders to obtain daily blood work were transcribed and implemented for a resident receiving [MEDICATION NAME] therapy (#4). 5. Have a working system in place to ensure nursing staff assessed residents for signs or symptoms of bleeding related to being on anticoagulant therapy (#4). Resident #5 6. Ensure a resident received her pain medication as ordered (#5). 7. Ensure a resident had her pain assessed as ordered (#5). The Immediate Jeopardy began for resident #4 on 11/9/12 when the facility failed to obtain ordered daily PT/INR levels. The Immediate Jeopardy continued on 11/21/12 when S6 LPN noted that the labs had not been drawn and failed to notify the lab to obtain the PT/INR on 11/21/12. S5 LPN and S6 LPN were aware on 11/21/12 that no levels had been drawn. Neither LPN checked the Physician's order to verify when PT/INR labs were ordered to be drawn. S5 LPN called the lab so that the PT/INR could be drawn on 11/23/12. The PT/INR drawn on 11/23/12 had the following results reported: PT greater than 82.5 seconds (Normal= 8.9-12.1 seconds) and INR greater than 9.0 critical high (Normal= 0.9-1.2). The Immediate Jeopardy ended for resident #4 on 11/26/12 when he was admitted to a local hospital with abdomen pain and [MEDICATION NAME] toxicity. The Immediate Jeopardy continued for residents #1, #3, #6, #7, #8, #9, #10, #11, #12 who were still in the facility and were receiving [MEDICATION NAME] therapy. S1 Administrator, S2 DON (Director of Nursing), S3 ADON (Assistant Director of Nursing), and S4 Corporate Nurse were notified on 11/30/12 at 5:45 p.m. of the Immediate Jeopardy situation regarding resident #4's lab not being drawn as ordered that begun 11/9/12 when the first lab was missed and continued not to be drawn until 11/23/12. The facility's Plan of Removal was documented as follows: 1. All the residents who receive [MEDICATION NAME] (Jantoven) therapy have had PT/INRs drawn and results reviewed by their physician. a. DON reviewed all the PT/INR results and spoke with all the physicians on 12/1/12 regarding the residents' lab results, current dosages of [MEDICATION NAME] (Jantoven), and received new orders (if necessary) for continued monitoring or dosages. 2. All the residents who receive [MEDICATION NAME] (Jantoven) therapy have had their plans of care updated to reflect accurate monitoring of their lab work and monitoring of bleeding precautions. a. The DON reviewed and revised the plans of care on the residents receiving [MEDICATION NAME] (Jantoven) and updated the plans to reflect the monitoring of lab work and bleeding precaution monitoring on 12/1/12. 3. All the residents who receive [MEDICATION NAME] (Jantoven) therapy have bleeding precaution monitoring being completed by the nurses every shift. a. This was verified to be on all the Medication Administration Records (MARs) for the residents receiving [MEDICATION NAME] (Jantoven) therapy on 11/30/12 and again on 12/1/12 by nursing administration. 4. In-servicing for licensed staff began on 11/29/12 and continued through 12/2/12 focusing on ordering and monitoring PT/INRs by the DON, nursing administration, and Silver Chair (online training) module on [MEDICATION NAME] (Jantoven) administration. a. On 11/29/12 the DON implemented in-service training for all the nursing staff regarding ordering and receiving PT/INRs, following physician's orders, and monitoring for bleeding precautions on residents receiving [MEDICATION NAME] (Jantoven) therapy. This in-service is continuing until all the licensed staff have had this information reviewed with them. b. On 12/1/12 a module in the Silver Chair computer training system was activated for the nurses at the facility. This module is to be completed by all the licensed staff to provide additional training regarding [MEDICATION NAME] (Jantoven) administration. c. The ADON was in-serviced on 11/29/12 with return demonstration provided on how to access the complete monthly lab list. d. Newly hired licensed staff members will be trained by nursing administration upon hire on lab notification with new order, admits, and readmit orders. 5. All residents who receive [MEDICATION NAME] (Jantoven) have had their medication reconciled to assure that what medication currently ordered is being given accurately. a. On 12/1/12 the weekend RN (Registered Nurse) reconciled the medications with the physician's orders and Medication Administration Records (MARs) on residents who receive [MEDICATION NAME] (Jantoven). 6. All the residents receiving [MEDICATION NAME] (Jantoven) therapy have had their PT/INR orders reviewed and are now being tracked by the DON, or nursing administration designee for completion, results, physician notification, and new orders for changes in [MEDICATION NAME] (Jantoven) dosages if necessary. a. The DON completed a monitor regarding the tracking and monitoring of the residents on [MEDICATION NAME] (Jantoven) therapy. She will continue on with this monitoring as PTs are drawn on a daily, if necessary, basis for the next 6 weeks then weekly for 6 weeks and as necessary until compliance is reached and maintained. b. New admission and readmission residents will have their orders reviewed by nursing supervisor on duty for lab work orders and lab notifications. A monitor will be completed by the DON or designee to review orders and lab notification with each admit/readmit for 6 weeks and then weekly for the next 6 weeks and as necessary until compliance is maintained. c. On a daily basis the new telephone orders and 24 hour report will be reviewed by the DON or nursing administration for new orders related to lab work and those orders will be verified as being called to lab by reviewing the notes and, if necessary, double checking the lab, a monitor will be completed to assure compliance of this task by nursing administration 5 times a week for 6 weeks and then weekly for 6 weeks and then as necessary until compliance is maintained. 7. Results of this corrective action will be reviewed by the TQM (Total Quality Management) committee as necessary until compliance is reached and maintained as necessary. The facility provided their plan of removal on 12/3/12 at 9:00 a.m. The plan of removal was accepted at 9:30 a.m. and the Immediate Jeopardy was lifted as of 12/1/12 at 11:15 a.m. when it was determined by the surveyors that each resident who received blood thinner therapy had their physician's orders reviewed, lab results were obtained, the dosage and lab results were verified with each resident's physician to ensure accuracy, and the plan of care had been revised for each resident to ensure accurate monitoring. The deficient practice continued at a scope and severity of third level pattern. Findings: 1. Observation on 11/30/12 at 10:15 a.m. revealed resident #4 seated in a wheelchair in his room. During an interview at that time, resident #4 stated when he was first admitted to the facility he was receiving blood thinner medications and that the facility never collected any lab from him. Resident #4 stated he went to the hospital on Monday (11/26/12) with his abdomen hurting. Resident #4 stated he did not have any type of bleeding. Review of resident #4's electronic November 2012 Physician's Orders revealed orders dated 11/8/12 to: discontinue (D/C) [MEDICATION NAME] (blood thinner) 7.5 milligram (mg) tablet, give Jantoven (blood thinner) 7.5 mg by mouth (po) daily, [MEDICATION NAME] (injectable blood thinner) 60 mg subcutaneously (SQ) daily until INR >2.0, and obtain PT/INR daily and fax results to the Primary Care Physician (PCP). Further review revealed an order to monitor for abnormal signs or symptoms of bleeding related to anticoagulant (blood thinners) therapy each shift. Review of resident #4's medical record revealed a PT/INR drawn on 11/23/12 with the following results: PT greater than 82.5 seconds (normal = 8.9-12.1 seconds) and INR greater than 9.0 critical high (normal = 0.9-1.2). Further review of the medical record failed to reveal any other PT/INR results. Review of resident #4's November 2012 Medication Administration Record (MAR) failed to reveal documentation each shift of monitoring for abnormal signs or symptoms of bleeding related to anticoagulant therapy as ordered. Review of resident #4's 5-day Minimum Data Set (MDS) with Assessment Reference Date (ARD) 11/15/12 and 14-day MDS with ARD 11/21/12 revealed resident was assessed as having a [DIAGNOSES REDACTED]. Further review of the 5-day and 14-day MDSs failed to revealed resident #4 was assessed as having received any type of injection during the last 7 days or since admission/entry or reentry if less than 7 days and failed to reveal resident was assessed as having received an anticoagulant. Resident #4 was assessed as having received an anticoagulant for "0" days. Review of resident #4's plan of care revealed a problem of potential for abnormal bleeding related to anticoagulant therapy. Resident takes [MEDICATION NAME] daily for status [REDACTED]. Approaches included: Administer medication as ordered by physician, obtain PT/INR as ordered, monitor for abnormal signs or symptoms of bleeding related to anticoagulant therapy every shift (abnormal bruising, nosebleeds, hematuria, bleeding gums, etc.), and notify physician with signs or symptoms of bleeding. The approaches were updated as of 11/30/12 to d/c [MEDICATION NAME] and continue PT/INR every Monday & Thursday until further notice. Resident #4's medical records were obtained from the local hospital on [DATE] at 1:00 p.m. regarding his emergency room visit on 11/26/12. Review of the medical records revealed resident #4's PT/INR that was completed in the emergency room at 8:40 p.m. on 11/26/12 was PT >112 seconds (normal=10.1-13.6) and INR >8.8 (normal=0.9-1.2). During an interview on 11/30/12 at 4:10 p.m. with S1 Administrator, S2 DON, and S3 ADON, S2 DON stated when resident #4's orders were taken off, they were handed to S5 LPN and she did not notify lab of the daily PT/INR level. S2 DON stated the information should be documented in the nurse's notes, but was not. S2 DON stated S5 LPN realized resident #4 had daily PT/INRs that had not been completed and had a level drawn on 11/23/12. S2 DON stated on Tuesday or Wednesday (11/27/12 or 11/28/12) the hospital case manager had called to see what resident #4's previous PT/INR levels were before being readmitted to the hospital on [DATE] and that was when they realized that resident #4's lab had not been drawn. S2 DON stated 24 hour chart checks are not completed because there was just not time for them. S2 DON stated S11 LPN Treatment Nurse pulled a daily report of new orders and verified them with the Physician's orders and MARs to ensure there were no missed orders. S2 DON stated a [MEDICATION NAME] monitoring sheet was put into place as of 11/29/12. S2 DON stated the nurses reviewed the resident's chart and completed the form with the resident's name, current PT/INR results, current dose, new orders, and next scheduled PT/INR. S2 DON stated the nurse's are to monitor this log at the nurse's station each shift and when the new lab results are obtained, complete the form again. S2 DON agreed there was no documentation in the nurse's notes regarding resident's lab orders. S2 DON stated all residents on blood thinners had the new [MEDICATION NAME] management tracking sheet completed on them as of 11/29/12. Review of the facility's printed Physician's Order List provided by S1 Administrator revealed 9 residents currently received blood thinner therapy. Review of the [MEDICATION NAME] management tracking sheet revealed a list of 10 residents with partial documentation of the expected requirements of the form. Multiple forms failed to reveal a date for the next PT/INR or were not specific as to when it was to be drawn. During an interview on 11/30/12 at 11:50 a.m. S2 DON, with S3 ADON also present, stated the facility discovered a data entry error on 11/29/12 which caused the lab to not receive a complete list of all residents and their ordered lab tests. S2 DON further stated S3 ADON began to enter resident information and orders at the beginning of November . S2 DON stated the information entered is for the lab to know the schedule of lab draws for each resident. During an interview on 11/30/12 at 5:45 p.m., S1 Administrator, S2 DON, S3 ADON, and S4 Corporate Nurse agreed resident #4's physician's orders and plan of care were not followed by the nurses. S1 Administrator, S2 DON, S3 ADON, and S4 Corporate Nurse further agreed resident #4 went 2 weeks without having his lab drawn and the nurses should have noticed the lab was not drawn before that time. S2 DON agreed resident #4's lab was not monitored and levels assessed daily as ordered. S2 DON agreed the [MEDICATION NAME] management tracking sheet that was put into place was not working because the nurses did not complete the form as indicated. During an interview on 12/3/12 at 10:20 a.m. S6 LPN stated resident #4 received his [MEDICATION NAME] (Jantoven) on her shift and she was not aware of his PT/INR results because they were not done. S6 LPN stated normally she would look at new orders for resident's to see if anything had changed, but she did not have time. S6 LPN stated her and the evening nurse S5 LPN were discussing that resident #4 had been receiving Jantoven, but no levels had been drawn and that was the day before Thanksgiving (11/21/12). S6 LPN stated she did not notify lab at that time and S5 LPN called lab so the PT/INR could be drawn on that Friday 11/23/12. S6 LPN stated she should have picked up that resident's PT/INR levels had not been drawn, but usually it would be written on the MAR and was not. S6 LPN stated she should have been aware that resident had no labs drawn while taking the Jantoven. During an interview on 12/3/12 at 10:40 a.m. S5 LPN stated she readmitted resident #4 on 11/8/12. S5 LPN stated resident #4 had orders for [MEDICATION NAME] and [MEDICATION NAME]. S5 LPN stated she did not see the admit orders and the lab was not on the MAR to be drawn as it usually was. S5 LPN stated she did not know resident #4 had lab ordered, but figured he should have. S5 LPN stated she did not double check resident #4's medical record for lab orders until resident #4 asked about his [MEDICATION NAME] shot being d/c'd and she told him when the INR level was >2.0. S5 LPN stated she checked the orders and realized the lab had not been done so she called the lab on 11/23/12. S5 LPN stated Thanksgiving day she told S6 LPN she did not see any lab that had been done for resident #4. S5 LPN stated they usually double check the hospital pack, but it was not left out and the front office staff wrote the orders and brought them too her. S5 LPN stated the only thing brought to her was the MARs and not the admit orders. S5 LPN stated she thought the other nurse had been getting the lab on the day shift and had not checked to verify. S5 LPN stated they normally use a 24 hour report sheet for communication between shifts and they will also speak with the physician to clarify any questions. S5 LPN stated she had never looked back over resident #4's orders until the resident questioned her. During an interview on 12/3/12 at 10:55 a.m. S3 ADON stated the discharge paperwork comes over the fax and is brought to her or S2 DON to review for orders that may be needed special. S3 ADON stated the nurse's are responsible for writing the orders and MARs, but she would review the orders and assist at times with completing the orders and MARs because the nurses are usually passing medications and are busy. S3 ADON stated the nurses are ultimately responsible for admitting the residents and completing the paperwork. S3 ADON stated she received the faxed copy of resident #4's orders and wrote the orders out, called the physician, and the physician agreed with the orders. S3 ADON reviewed resident #4's MAR and agreed she did write out the information on the MAR, but did not transcribe the lab order over to the MAR and it should have been. S3 ADON stated the nurse is responsible for contacting the physician and double checking the written out orders against the hospital admit pack. During an interview on 12/3/12 at 12:00 p.m. DON #S2 stated the facility had no specific policy regarding monitoring of labs that require levels to be drawn, other than just as physician ordered. 2. Review of resident #5's medical record revealed resident was re-admitted to the facility on [DATE]. Review of resident #5's admission orders [REDACTED]. Further review of resident #5's medical record revealed resident was on the [MEDICATION NAME] mg po bid prior to her discharge to the hospital on [DATE]. Review of resident #5's November 2012 Physician's Orders revealed an order dated 8/23/12 for [MEDICATION NAME] 30 mg tablet give 1 tablet po bid **Do Not Crush** Review of resident #5's November 2012 MAR revealed resident received her [MEDICATION NAME] mg po bid from 11/1/12 - 11/6/12. Further review revealed resident received the [MEDICATION NAME] mg once daily on 11/7/12 and 11/8/12. Review of the MAR revealed resident #5 did not receive the ordered [MEDICATION NAME] the 5:00 p.m. dose on 11/7/12 and 11/8/12, nor did she receive both doses on 11/9/12 - 11/11/12. Resident #5 also did not receive her 6:00 a.m. dose of [MEDICATION NAME] 11/12/12, but received the 5:00 p.m. dose and has received both doses from 11/13/12-11/29/12 as ordered. Review of resident #5's November 2012 MAR revealed an order for [REDACTED]. Review of the November 2012 MAR revealed resident #5 received her [MEDICATION NAME] dose once on 11/8/12, 11/9/12, 11/10/12, 11/11/12, 11/23/12, 11/28/12, and 11/29/12. Resident received her [MEDICATION NAME] dose twice on 11/18/12. Further review of resident #5's November 2012 MAR revealed documentation on the back of the MAR: 11/9/12-[MEDICATION NAME] given at 12 A & 4 A-[MEDICATION NAME] available-Effective. 11/10/12-[MEDICATION NAME] given at 12 A & 4 A-[MEDICATION NAME] available-Effective. 11/11/12-[MEDICATION NAME] given at 12 A & 4 A-[MEDICATION NAME] available-Effective. 11/12/12-[MEDICATION NAME] given at 12 A & 4 A-[MEDICATION NAME] available-Effective. Review of resident #5's plan of care revealed a problem on-set date of 10/1/11 with the following problem: Potential for Comfort Altered related to [DIAGNOSES REDACTED]. Goal included pain will be effectively managed as evidenced by no reports of pain and medication being effective. Approaches included the following: Encourage resident to report pain at onset, notify physician of uncontrolled pain, evaluate reported pain on a scale of 1-10, observe for non-verbal indicators of pain, encourage repositioning to assist in easing pain, and administer pain medications as ordered. Also, report potential complications related to the medication, and provide diversional activities to help ease pain. Observation on 11/29/12 at 3:00 p.m. revealed resident #5 lying in bed with her eyes closed. During an interview at that time resident stated she was hurting about 10 out of 10 right now, but she had her pain medication already and that it did work once she relaxed and let it take effect. Resident #5 stated the facility ran out of her [MEDICATION NAME] few weeks ago for a few days and no one told her why it was out. Resident #5 stated no one told her what the trouble was getting it refilled and no one had told her anything. Resident #5 stated she received the [MEDICATION NAME] she had ordered and got relief, but was not as good of relief as she received when she took the MS Contin. Resident #5 stated she did not ask why she did not get the [MEDICATION NAME] did not tell anyone that she was not getting it. Resident #5 stated she thought maybe the doctor had stopped it and that no one told her anything about it. Resident #5 stated she stayed in the bed most of the time due to her pain. Resident #5 stated there was no increase in her pain level when she did not receive her [MEDICATION NAME] the nurses did give her the [MEDICATION NAME] when she asked for it and it kept her controlled until she started receiving the [MEDICATION NAME]. During an interview on 11/30/12 at 8:55 a.m. S7 LPN stated he gave resident #5 her dose of [MEDICATION NAME] 11/7/12 and 11/8/12 that was scheduled for 6:00 a.m. S7 LPN stated he did not remember if the dose he administered on 11/8/12 was the last dose in the card or not. S7 LPN stated he was not aware of why the evening shift nurse did not administer resident #5's dose of [MEDICATION NAME] 11/7/12 and did not know why it was not re-ordered. During an interview on 11/30/12 at 9:15 a.m. S8 LPN stated resident #5 ran out of her [MEDICATION NAME] was not sure why there was trouble getting it refilled. S8 LPN stated resident #5 normally complained of pain anywhere from a 6-8 out of 10 to her bottom or back. S8 LPN stated the pain was more of an "8" when she was being turned and repositioned. S8 LPN stated resident #5 did not complain of increased pain because she was receiving her [MEDICATION NAME]. S8 LPN stated they normally chart resident #5's pain level on the MAR and agreed she had not documented the pain level since she was giving the [MEDICATION NAME] in place of the MS Contin. During an interview on 11/30/12 at 9:30 a.m. S2 DON stated they were having trouble getting a hard script from S9 Physician. S2 DON stated she could not remember when she was notified of the problem, but she thought S3 ADON had ended up calling and texting S9 Physician and getting the order. During an interview on 11/30/12 at 9:55 a.m. S3 ADON provided a copy of resident #5's hard script written by S9 Physician for [MEDICATION NAME] 30 mg 1 po bid dated 11/8/12. S3 ADON stated they had 24/7 access to the pharmacy via a pharmacy on-call number and the pharmacy would call back. S3 ADON stated she was not able to find any documentation in the nurse's notes regarding resident #5 being out of her [MEDICATION NAME] the nurse's attempts to get it filled. During an interview on 11/30/12 at 10:05 a.m. S2 DON stated the hard scripts for narcotics were usually faxed to the pharmacy directly by the physician and then the pharmacy would fax them a copy at the facility. S2 DON stated if it was after hours there was an on-call Pharmacist number and the medication would be filled and delivered to the facility. S2 DON stated she was not aware of whether the hard script dated 11/8/12 came from the physician or the pharmacy. S2 DON provided a Consolidation Delivery Sheet from the pharmacy that showed the [MEDICATION NAME] prepared by the Pharmacist on 11/12/12 at 5:28 p.m. S2 DON stated they may not have actually received the medication at the facility until 9:30 p.m. though, but could not say for sure. During an interview on 11/30/12 at 10:20 a.m. S3 ADON was asked to contact the Pharmacist regarding the 11/8/12 hard script for resident #5's [MEDICATION NAME] 30 mg tablets. S3 ADON stated she spoke with the Pharmacist and the [MEDICATION NAME] filled on 11/12/12. S3 ADON stated the Pharmacist was not able to locate when the script came in and would try to find it and call back. During an interview on 11/30/12 at 10:30 a.m. S2 DON provided copies of resident #5's Individual Narcotic Record for her [MEDICATION NAME] mg and her [MEDICATION NAME] 7.5/500 mg. Review of resident #5's Individual Narcotic Record revealed resident #5's last dose of [MEDICATION NAME] mg was signed out on 11/6/12 at 6:00 p.m. with the remaining pills left being "0." Review of resident #5's Individual Narcotic Record for the [MEDICATION NAME] 7.5/500 mg revealed resident had the [MEDICATION NAME] given on: 11/7/12 at 9:00 a.m., 11/8/12 at 7:30 a.m. and 7:30 p.m., 11/9/12 at 12:00 a.m., 4:00 a.m., 8:00 a.m., and 7:30 p.m., 11/10/12 at 12:00 a.m., 4:00 a.m., and 7:00 p.m., 11/11/12 at 12:00 a.m., 4:00 a.m., and 1:00 p.m., 11/12/12 at 12:00 a.m., 4:00 a.m., 1:00 p.m., and 5:00 p.m. Further review of resident #5's Individual Narcotic Record revealed [MEDICATION NAME] mg was received on 11/13/12 starting with 60 pills and the first dose administered on 11/13/12 at 6:00 a.m. S2 DON reviewed resident #5's MARs and stated she did not know why S7 LPN documented he gave resident #5 her [MEDICATION NAME] mg on 11/7/12 and 11/8/12 at 6:00 a.m. when the last dose was signed out on the Individual Narcotic Record on 11/6/12 at 6:00 p.m. leaving no remaining medication. S2 DON also was unable to explain how resident #5 received her dose of [MEDICATION NAME] mg on 11/12/12 at 5:00 p.m. when the Individual Narcotic Record did not show receipt of the medication until 11/13/12 with the first dose being signed out on 11/13/12 at 6:00 a.m. S2 DON further stated resident #5 did received her [MEDICATION NAME] 7.5/500 mg, but the nurses did not document correctly on the MAR and that every dose that was signed out on the Narcotic record was not documented as being given on the MAR and should have been. S2 DON further agreed the nurses were not documenting resident #5's pain assessments and that should be completed each time the pain medication was given and again after the medication was administered to show its effectiveness. During an interview on 11/30/12 at 10:48 a.m. S3 ADON stated the Pharmacist called back and told her the pharmacy received the faxed order for resident #5's [MEDICATION NAME] 11/12/12 from the facility. S3 ADON stated she was the one who faxed the order to the pharmacy. S3 ADON stated she was not aware if the pharmacy had the original hard script to see when it was received, because pharmacy will not usually fill the medication unless they have the actual hard script. S3 ADON stated she would contact the pharmacy again to see if they still had the original hard script and when it was received. S3 ADON stated she sent the original hard script in the pharmacy box on 11/9/12 and did not know why it took them until 11/12/12 to fill it. During an interview on 11/30/12 at 10:55 a.m. the Pharmacist stated she did not know when the hard script was sent, but the fax for the [MEDICATION NAME] received from the facility on 11/12/12 and that was when it was filled. The Pharmacist stated the medication orders were filled from the faxed copy of the order and that they do not wait for the hard script because there was no way to know when the hard script would arrive. The Pharmacist further stated resident #5's order for [MEDICATION NAME] filled upon receipt of the faxed script and if they would have received an order on 11/9/12 it would have been filled on 11/9/12. During an interview on 11/30/12 at 11:00 a.m. S3 ADON stated she did not have a copy showing the [MEDICATION NAME] was faxed to the pharmacy on 11/12/12. During an interview on 11/30/12 at 11:15 a.m. S2 DON agreed there was lack of documentation and inaccurate documentation related to resident #5 pain medication. S2 DON reviewed resident #5's plan of care and agreed it was not followed because staff were not evaluating resident #5's pain on a scale of 1-10 and had not administered medications as ordered. S2 DON further agreed the physician's orders were not followed because resident #5 was out of her [MEDICATION NAME] mg and did not receive it as ordered. During an interview on 11/30/12 at 3:15 p.m. S9 Physician stated he was notified on 11/8/12 that resident #5 was out of her [MEDICATION NAME] needed it sent to the pharmacy immediately to be filled. S9 Physician stated he wrote the script and had his clerk fax it to the pharmacy directly on 11/8/12 from the hospital he was working at in another town. S9 Physician stated no one called him prior to 11/8/12 to inform him resident #5 had been out of her [MEDICATION NAME] 11/6/12. S9 Physician stated he did not know resident #5's [MEDICATION NAME] not filled until 11/12/12 and no one called to let him know resident #5 still did not have her medications prior to that or when he made rounds at the facility on 11/9/12.

Based on observation, record reviews, and interviews, the facility failed to ensure each resident's drug regimen is free from unnecessary drugs for 1 (#4) of 4 (#1, #3, #4, #6) sampled residents who received anticoagulant therapy out a total sample of 12. The facility failed to: 1. Obtain daily Pro-time/International Normalized Ration (PT/INR) labs from 11/9/12 through 11/22/12 as specified by physician's orders [REDACTED]. First lab was drawn on 11/23/12 (#4). 2. Monitor for abnormal signs or symptoms of bleeding as ordered (#4). 3. Accurately identify, assess, and document a resident's anticoagulant therapy status upon admission to the facility on [DATE] (#4). 4. Ensure staff immediately obtained ordered blood work for daily PT/INR levels when it was discovered on 11/21/12 that the daily labs for PT/INR were not obtained daily as ordered (#4). 5. Ensure staff notified the Physician and Supervisory facility personnel on 11/21/12 when it was noted that lab tests ordered to be drawn daily were not drawn on a resident receiving [MEDICATION NAME] therapy (#4). 6. Have a system in place to ensure that physician's orders [REDACTED].#4). 7. Have a working system in place to ensure nursing staff notified lab of new orders (#4). 8. Have a working system in place to ensure nursing staff reviewed physician's orders [REDACTED].#4). 9. Have a working system in place to ensure resident labs were reviewed by nursing staff and the physician notified (#4). The Immediate Jeopardy began for resident #4 on 11/9/12 when the facility failed to obtain ordered daily PT/INR levels. The Immediate Jeopardy continued on 11/21/12 when S6 LPN noted that the labs had not been drawn and failed to notify the lab to obtain the PT/INR on 11/21/12. S5 LPN and S6 LPN were aware on 11/21/12 that no levels had been drawn. Neither LPN checked the physician's orders [REDACTED]. S5 LPN called the lab so that the PT/INR could be drawn on 11/23/12. The PT/INR drawn on 11/23/12 had the following results reported: PT greater than 82.5 seconds (Normal= 8.9-12.1 seconds) and INR greater than 9.0 critical high (Normal= 0.9-1.2). The Immediate Jeopardy ended for resident #4 on 11/26/12 when he was admitted to a local hospital with abdomen pain and [MEDICATION NAME] toxicity. The Immediate Jeopardy continued for residents #1, #3, #6, #7, #8, #9, #10, #11, #12 who were still in the facility and were receiving [MEDICATION NAME] therapy. S1 Administrator, S2 DON (Director of Nursing), S3 ADON (Assistant Director of Nursing), and S4 Corporate Nurse were notified on 11/30/12 at 5:45 p.m. of the Immediate Jeopardy situation regarding resident #4's lab not being drawn as ordered that begun 11/9/12 when the first lab was missed and continued not to be drawn until 11/23/12. The facility's Plan of Removal was documented as follows: 1. All the residents who receive [MEDICATION NAME] (Jantoven) therapy have had PT/INRs drawn and results reviewed by their physician. a. DON reviewed all the PT/INR results and spoke with all the physicians on 12/1/12 regarding the residents' lab results, current dosages of [MEDICATION NAME] (Jantoven), and received new orders (if necessary) for continued monitoring or dosages. 2. All the residents who receive [MEDICATION NAME] (Jantoven) therapy have had their plans of care updated to reflect accurate monitoring of their lab work and monitoring of bleeding precautions. a. The DON reviewed and revised the plans of care on the residents receiving [MEDICATION NAME] (Jantoven) and updated the plans to reflect the monitoring of lab work and bleeding precaution monitoring on 12/1/12. 3. All the residents who receive [MEDICATION NAME] (Jantoven) therapy have bleeding precaution monitoring being completed by the nurses every shift. a. This was verified to be on all the Medication Administration Records (MARs) for the residents receiving [MEDICATION NAME] (Jantoven) therapy on 11/30/12 and again on 12/1/12 by nursing administration. 4. In-servicing for licensed staff began on 11/29/12 and continued through 12/2/12 focusing on ordering and monitoring PT/INRs by the DON, nursing administration, and Silver Chair (online training) module on [MEDICATION NAME] (Jantoven) administration. a. On 11/29/12 the DON implemented in-service training for all the nursing staff regarding ordering and receiving PT/INRs, following physician's orders [REDACTED]. This in-service is continuing until all the licensed staff have had this information reviewed with them. b. On 12/1/12 a module in the Silver Chair computer training system was activated for the nurses at the facility. This module is to be completed by all the licensed staff to provide additional training regarding [MEDICATION NAME] (Jantoven) administration. c. The ADON was in-serviced on 11/29/12 with return demonstration provided on how to access the complete monthly lab list. d. Newly hired licensed staff members will be trained by nursing administration upon hire on lab notification with new order, admits, and readmit orders. 5. All residents who receive [MEDICATION NAME] (Jantoven) have had their medication reconciled to assure that what medication currently ordered is being given accurately. a. On 12/1/12 the weekend RN (Registered Nurse) reconciled the medications with the physician's orders [REDACTED]. 6. All the residents receiving [MEDICATION NAME] (Jantoven) therapy have had their PT/INR orders reviewed and are now being tracked by the DON, or nursing administration designee for completion, results, physician notification, and new orders for changes in [MEDICATION NAME] (Jantoven) dosages if necessary. a. The DON completed a monitor regarding the tracking and monitoring of the residents on [MEDICATION NAME] (Jantoven) therapy. She will continue on with this monitoring as PTs are drawn on a daily, if necessary, basis for the next 6 weeks then weekly for 6 weeks and as necessary until compliance is reached and maintained. b. New admission and readmission residents will have their orders reviewed by nursing supervisor on duty for lab work orders and lab notifications. A monitor will be completed by the DON or designee to review orders and lab notification with each admit/readmit for 6 weeks and then weekly for the next 6 weeks and as necessary until compliance is maintained. c. On a daily basis the new telephone orders and 24 hour report will be reviewed by the DON or nursing administration for new orders related to lab work and those orders will be verified as being called to lab by reviewing the notes and, if necessary, double checking the lab, a monitor will be completed to assure compliance of this task by nursing administration 5 times a week for 6 weeks and then weekly for 6 weeks and then as necessary until compliance is maintained. 7. Results of this corrective action will be reviewed by the TQM (Total Quality Management) committee as necessary until compliance is reached and maintained as necessary. The facility provided their plan of removal on 12/3/12 at 9:00 a.m. The plan of removal was accepted at 9:30 a.m. and the Immediate Jeopardy was lifted as of 12/1/12 at 11:15 a.m. when it was determined by the surveyors that each resident who received blood thinner therapy had their physician's orders [REDACTED]. The deficient practice continued at a scope and severity of third level pattern. Findings: Observation on 11/30/12 at 10:15 a.m. revealed resident #4 seated in a wheelchair in his room. During an interview at that time, resident #4 stated when he was first admitted to the facility he was receiving blood thinner medications and that the facility never collected any lab from him. Resident #4 stated he went to the hospital on Monday (11/26/12) with his abdomen hurting. Resident #4 stated he did not have any type of bleeding. Review of resident #4's electronic November 2012 physician's orders [REDACTED].>2.0, and obtain PT/INR daily and fax results to the Primary Care Physician (PCP). Further review revealed an order to monitor for abnormal signs or symptoms of bleeding related to anticoagulant (blood thinners) therapy each shift. Review of resident #4's medical record revealed a PT/INR drawn on 11/23/12 with the following results: PT greater than 82.5 seconds (normal = 8.9-12.1 seconds) and INR greater than 9.0 critical high (normal = 0.9-1.2). Further review of the medical record failed to reveal any other PT/INR results. Review of resident #4's November 2012 Medication Administration Record (MAR) failed to reveal documentation each shift of monitoring for abnormal signs or symptoms of bleeding related to anticoagulant therapy as ordered. Review of resident #4's 5-day Minimum Data Set (MDS) with Assessment Reference Date (ARD) 11/15/12 and 14-day MDS with ARD 11/21/12 revealed resident was assessed as having a [DIAGNOSES REDACTED]. Further review of the 5-day and 14-day MDSs failed to revealed resident #4 was assessed as having received any type of injection during the last 7 days or since admission/entry or reentry if less than 7 days and failed to reveal resident was assessed as having received an anticoagulant. Resident #4 was assessed as having received an anticoagulant for "0" days. Review of resident #4's plan of care revealed a problem of potential for abnormal bleeding related to anticoagulant therapy. Resident takes [MEDICATION NAME] daily for status [REDACTED]. Approaches included: Administer medication as ordered by physician, obtain PT/INR as ordered, monitor for abnormal signs or symptoms of bleeding related to anticoagulant therapy every shift (abnormal bruising, nosebleeds, hematuria, bleeding gums, etc.), and notify physician with signs or symptoms of bleeding. The approaches were updated as of 11/30/12 to d/c [MEDICATION NAME] and continue PT/INR every Monday & Thursday until further notice. Resident #4's medical records were obtained from the local hospital on [DATE] at 1:00 p.m. regarding his emergency room visit on 11/26/12. Review of the medical records revealed resident #4's PT/INR that was completed in the emergency room at 8:40 p.m. on 11/26/12 was PT >112 seconds (normal=10.1-13.6) and INR >8.8 (normal=0.9-1.2). During an interview on 11/30/12 at 4:10 p.m. with S1 Administrator, S2 DON, and S3 ADON, S2 DON stated when resident #4's orders were taken off, they were handed to S5 LPN and she did not notify lab of the daily PT/INR level. S2 DON stated the information should be documented in the nurse's notes, but was not. S2 DON stated S5 LPN realized resident #4 had daily PT/INRs that had not been completed and had a level drawn on 11/23/12. S2 DON stated on Tuesday or Wednesday (11/27/12 or 11/28/12) the hospital case manager had called to see what resident #4's previous PT/INR levels were before being readmitted to the hospital on [DATE] and that was when they realized that resident #4's lab had not been drawn. S2 DON stated 24 hour chart checks are not completed because there was just not time for them. S2 DON stated S11 LPN Treatment Nurse pulled a daily report of new orders and verified them with the physician's orders [REDACTED]. S2 DON stated a [MEDICATION NAME] monitoring sheet was put into place as of 11/29/12. S2 DON stated the nurses reviewed the resident's chart and completed the form with the resident's name, current PT/INR results, current dose, new orders, and next scheduled PT/INR. S2 DON stated the nurse's are to monitor this log at the nurse's station each shift and when the new lab results are obtained, complete the form again. S2 DON agreed there was no documentation in the nurse's notes regarding resident's lab orders. S2 DON stated all residents on blood thinners had the new [MEDICATION NAME] management tracking sheet completed on them as of 11/29/12. Review of the facility's printed physician's orders [REDACTED]. Review of the [MEDICATION NAME] management tracking sheet revealed a list of 10 residents with partial documentation of the expected requirements of the form. Multiple forms failed to reveal a date for the next PT/INR or were not specific as to when it was to be drawn. During an interview on 11/30/12 at 11:50 a.m. S2 DON, with S3 ADON also present, stated the facility discovered a data entry error on 11/29/12 which caused the lab to not receive a complete list of all residents and their ordered lab tests. S2 DON further stated S3 ADON began to enter resident information and orders at the beginning of November . S2 DON stated the information entered is for the lab to know the schedule of lab draws for each resident. During an interview on 11/30/12 at 5:45 p.m., S1 Administrator, S2 DON, S3 ADON, and S4 Corporate Nurse agreed resident #4's physician's orders [REDACTED]. S1 Administrator, S2 DON, S3 ADON, and S4 Corporate Nurse further agreed resident #4 went 2 weeks without having his lab drawn and the nurses should have noticed the lab was not drawn before that time. S2 DON agreed resident #4's lab was not monitored and levels assessed daily as ordered. S2 DON agreed the [MEDICATION NAME] management tracking sheet that was put into place was not working because the nurses did not complete the form as indicated. During an interview on 12/3/12 at 10:20 a.m. S6 LPN stated resident #4 received his [MEDICATION NAME] (Jantoven) on her shift and she was not aware of his PT/INR results because they were not done. S6 LPN stated normally she would look at new orders for resident's to see if anything had changed, but she did not have time. S6 LPN stated her and the evening nurse S5 LPN were discussing that resident #4 had been receiving Jantoven, but no levels had been drawn and that was the day before Thanksgiving (11/21/12). S6 LPN stated she did not notify lab at that time and S5 LPN called lab so the PT/INR could be drawn on that Friday 11/23/12. S6 LPN stated she should have picked up that resident's PT/INR levels had not been drawn, but usually it would be written on the MAR and was not. S6 LPN stated she should have been aware that resident had no labs drawn while taking the Jantoven. During an interview on 12/3/12 at 10:40 a.m. S5 LPN stated she readmitted resident #4 on 11/8/12. S5 LPN stated resident #4 had orders for [MEDICATION NAME] and [MEDICATION NAME]. S5 LPN stated she did not see the admit orders and the lab was not on the MAR to be drawn as it usually was. S5 LPN stated she did not know resident #4 had lab ordered, but figured he should have. S5 LPN stated she did not double check resident #4's medical record for lab orders until resident #4 asked about his [MEDICATION NAME] shot being d/c'd and she told him when the INR level was >2.0. S5 LPN stated she checked the orders and realized the lab had not been done so she called the lab on 11/23/12. S5 LPN stated Thanksgiving day she told S6 LPN she did not see any lab that had been done for resident #4. S5 LPN stated they usually double check the hospital pack, but it was not left out and the front office staff wrote the orders and brought them too her. S5 LPN stated the only thing brought to her was the MARs and not the admit orders. S5 LPN stated she thought the other nurse had been getting the lab on the day shift and had not checked to verify. S5 LPN stated they normally use a 24 hour report sheet for communication between shifts and they will also speak with the physician to clarify any questions. S5 LPN stated she had never looked back over resident #4's orders until the resident questioned her. During an interview on 12/3/12 at 10:55 a.m. S3 ADON stated the discharge paperwork comes over the fax and is brought to her or S2 DON to review for orders that may be needed special. S3 ADON stated the nurse's are responsible for writing the orders and MARs, but she would review the orders and assist at times with completing the orders and MARs because the nurses are usually passing medications and are busy. S3 ADON stated the nurses are ultimately responsible for admitting the residents and completing the paperwork. S3 ADON stated she received the faxed copy of resident #4's orders and wrote the orders out, called the physician, and the physician agreed with the orders. S3 ADON reviewed resident #4's MAR and agreed she did write out the information on the MAR, but did not transcribe the lab order over to the MAR and it should have been. S3 ADON stated the nurse is responsible for contacting the physician and double checking the written out orders against the hospital admit pack. During an interview on 12/3/12 at 12:00 p.m. DON #S2 stated the facility had no specific policy regarding monitoring of labs that require levels to be drawn, other than just as physician ordered.

Based on observation, record reviews, and interviews the facility failed to be administered in a manner that used resources effectively and efficiently for 1 (#4) of 10 (#1, #3, #4, #6, #7 #8, #9, #10, #11, #12) sampled residents who received anticoagulant (blood thinners) therapy out of a total sample of 12 that resulted in actual harm when resident #4 was sent to a local hospital and admitted with a critical high lab value related to the anticoagulant therapy. The facility further failed to be administered in a manner that used resources effectively and efficiently for 9 of 9 (#1, #3, #6, #7, #8, #9, #10, #11, #12) residents currently receiving anticoagulant therapy in the facility out of a total sample of 12. Administration failed to: 1. Have a working system in place to ensure nursing staff notified lab of new orders (#4). 2. Have a working system in place to ensure nursing staff reviewed physician's orders [REDACTED].#4). 3. Have a working system in place to ensure resident labs were reviewed by nursing staff and the physician notified (#4). 4. Have a working system in place to ensure nursing staff assessed residents for signs or symptoms of bleeding related to being on anticoagulant therapy (#4). The Immediate Jeopardy began for resident #4 on 11/9/12 when the facility failed to obtain ordered daily PT/INR levels. The Immediate Jeopardy continued on 11/21/12 when S6 LPN noted that the labs had not been drawn and failed to notify the lab to obtain the PT/INR on 11/21/12. S5 LPN and S6 LPN were aware on 11/21/12 that no levels had been drawn. Neither LPN checked the physician's orders [REDACTED]. S5 LPN called the lab so that the PT/INR could be drawn on 11/23/12. The PT/INR drawn on 11/23/12 had the following results reported: PT greater than 82.5 seconds (Normal= 8.9-12.1 seconds) and INR greater than 9.0 critical high (Normal= 0.9-1.2). The Immediate Jeopardy ended for resident #4 on 11/26/12 when he was admitted to a local hospital with abdomen pain and [MEDICATION NAME] toxicity. The Immediate Jeopardy continued for residents #1, #3, #6, #7, #8, #9, #10, #11, #12 who were still in the facility and were receiving [MEDICATION NAME] therapy. S1 Administrator, S2 DON (Director of Nursing), S3 ADON (Assistant Director of Nursing), and S4 Corporate Nurse were notified on 11/30/12 at 5:45 p.m. of the Immediate Jeopardy situation regarding resident #4's lab not being drawn as ordered that begun 11/9/12 when the first lab was missed and continued not to be drawn until 11/23/12. The facility's Plan of Removal was documented as follows: 1. All the residents who receive [MEDICATION NAME] (Jantoven) therapy have had PT/INRs drawn and results reviewed by their physician. a. DON reviewed all the PT/INR results and spoke with all the physicians on 12/1/12 regarding the residents' lab results, current dosages of [MEDICATION NAME] (Jantoven), and received new orders (if necessary) for continued monitoring or dosages. 2. All the residents who receive [MEDICATION NAME] (Jantoven) therapy have had their plans of care updated to reflect accurate monitoring of their lab work and monitoring of bleeding precautions. a. The DON reviewed and revised the plans of care on the residents receiving [MEDICATION NAME] (Jantoven) and updated the plans to reflect the monitoring of lab work and bleeding precaution monitoring on 12/1/12. 3. All the residents who receive [MEDICATION NAME] (Jantoven) therapy have bleeding precaution monitoring being completed by the nurses every shift. a. This was verified to be on all the Medication Administration Records (MARs) for the residents receiving [MEDICATION NAME] (Jantoven) therapy on 11/30/12 and again on 12/1/12 by nursing administration. 4. In-servicing for licensed staff began on 11/29/12 and continued through 12/2/12 focusing on ordering and monitoring PT/INRs by the DON, nursing administration, and Silver Chair (online training) module on [MEDICATION NAME] (Jantoven) administration. a. On 11/29/12 the DON implemented in-service training for all the nursing staff regarding ordering and receiving PT/INRs, following physician's orders [REDACTED]. This in-service is continuing until all the licensed staff have had this information reviewed with them. b. On 12/1/12 a module in the Silver Chair computer training system was activated for the nurses at the facility. This module is to be completed by all the licensed staff to provide additional training regarding [MEDICATION NAME] (Jantoven) administration. c. The ADON was in-serviced on 11/29/12 with return demonstration provided on how to access the complete monthly lab list. d. Newly hired licensed staff members will be trained by nursing administration upon hire on lab notification with new order, admits, and readmit orders. 5. All residents who receive [MEDICATION NAME] (Jantoven) have had their medication reconciled to assure that what medication currently ordered is being given accurately. a. On 12/1/12 the weekend RN (Registered Nurse) reconciled the medications with the physician's orders [REDACTED]. 6. All the residents receiving [MEDICATION NAME] (Jantoven) therapy have had their PT/INR orders reviewed and are now being tracked by the DON, or nursing administration designee for completion, results, physician notification, and new orders for changes in [MEDICATION NAME] (Jantoven) dosages if necessary. a. The DON completed a monitor regarding the tracking and monitoring of the residents on [MEDICATION NAME] (Jantoven) therapy. She will continue on with this monitoring as PTs are drawn on a daily, if necessary, basis for the next 6 weeks then weekly for 6 weeks and as necessary until compliance is reached and maintained. b. New admission and readmission residents will have their orders reviewed by nursing supervisor on duty for lab work orders and lab notifications. A monitor will be completed by the DON or designee to review orders and lab notification with each admit/readmit for 6 weeks and then weekly for the next 6 weeks and as necessary until compliance is maintained. c. On a daily basis the new telephone orders and 24 hour report will be reviewed by the DON or nursing administration for new orders related to lab work and those orders will be verified as being called to lab by reviewing the notes and, if necessary, double checking the lab, a monitor will be completed to assure compliance of this task by nursing administration 5 times a week for 6 weeks and then weekly for 6 weeks and then as necessary until compliance is maintained. 7. Results of this corrective action will be reviewed by the TQM (Total Quality Management) committee as necessary until compliance is reached and maintained as necessary. The facility provided their plan of removal on 12/3/12 at 9:00 a.m. The plan of removal was accepted at 9:30 a.m. and the Immediate Jeopardy was lifted as of 12/1/12 at 11:15 a.m. when it was determined by the surveyors that each resident who received blood thinner therapy had their physician's orders [REDACTED]. The deficient practice continued at a scope and severity of third level pattern. Findings: Observation on 11/30/12 at 10:15 a.m. revealed resident #4 seated in a wheelchair in his room. During an interview at that time, resident #4 stated when he was first admitted to the facility he was receiving blood thinner medications and that the facility never collected any lab from him. Resident #4 stated he went to the hospital on Monday (11/26/12) with his abdomen hurting. Resident #4 stated he did not have any type of bleeding. Review of resident #4's electronic November 2012 physician's orders [REDACTED].>2.0, and obtain PT/INR daily and fax results to the Primary Care Physician (PCP). Further review revealed an order to monitor for abnormal signs or symptoms of bleeding related to anticoagulant (blood thinners) therapy each shift. Review of resident #4's medical record revealed a PT/INR drawn on 11/23/12 with the following results: PT greater than 82.5 seconds (normal = 8.9-12.1 seconds) and INR greater than 9.0 critical high (normal = 0.9-1.2). Further review of the medical record failed to reveal any other PT/INR results. Review of resident #4's November 2012 Medication Administration Record (MAR) failed to reveal documentation each shift of monitoring for abnormal signs or symptoms of bleeding related to anticoagulant therapy as ordered. Review of resident #4's 5-day Minimum Data Set (MDS) with Assessment Reference Date (ARD) 11/15/12 and 14-day MDS with ARD 11/21/12 revealed resident was assessed as having a [DIAGNOSES REDACTED]. Further review of the 5-day and 14-day MDSs failed to revealed resident #4 was assessed as having received any type of injection during the last 7 days or since admission/entry or reentry if less than 7 days and failed to reveal resident was assessed as having received an anticoagulant. Resident #4 was assessed as having received an anticoagulant for "0" days. Review of resident #4's plan of care revealed a problem of potential for abnormal bleeding related to anticoagulant therapy. Resident takes [MEDICATION NAME] daily for status [REDACTED]. Approaches included: Administer medication as ordered by physician, obtain PT/INR as ordered, monitor for abnormal signs or symptoms of bleeding related to anticoagulant therapy every shift (abnormal bruising, nosebleeds, hematuria, bleeding gums, etc.), and notify physician with signs or symptoms of bleeding. The approaches were updated as of 11/30/12 to d/c [MEDICATION NAME] and continue PT/INR every Monday & Thursday until further notice. Resident #4's medical records were obtained from the local hospital on [DATE] at 1:00 p.m. regarding his emergency room visit on 11/26/12. Review of the medical records revealed resident #4's PT/INR that was completed in the emergency room at 8:40 p.m. on 11/26/12 was PT >112 seconds (normal=10.1-13.6) and INR >8.8 (normal=0.9-1.2). During an interview on 11/30/12 at 4:10 p.m. with S1 Administrator, S2 DON, and S3 ADON, S2 DON stated when resident #4's orders were taken off, they were handed to S5 LPN and she did not notify lab of the daily PT/INR level. S2 DON stated the information should be documented in the nurse's notes, but was not. S2 DON stated S5 LPN realized resident #4 had daily PT/INRs that had not been completed and had a level drawn on 11/23/12. S2 DON stated on Tuesday or Wednesday (11/27/12 or 11/28/12) the hospital case manager had called to see what resident #4's previous PT/INR levels were before being readmitted to the hospital on [DATE] and that was when they realized that resident #4's lab had not been drawn. S2 DON stated 24 hour chart checks are not completed because there was just not time for them. S2 DON stated S11 LPN Treatment Nurse pulled a daily report of new orders and verified them with the physician's orders [REDACTED]. S2 DON stated a [MEDICATION NAME] monitoring sheet was put into place as of 11/29/12. S2 DON stated the nurses reviewed the resident's chart and completed the form with the resident's name, current PT/INR results, current dose, new orders, and next scheduled PT/INR. S2 DON stated the nurse's are to monitor this log at the nurse's station each shift and when the new lab results are obtained, complete the form again. S2 DON agreed there was no documentation in the nurse's notes regarding resident's lab orders. S2 DON stated all residents on blood thinners had the new [MEDICATION NAME] management tracking sheet completed on them as of 11/29/12. Review of the facility's printed physician's orders [REDACTED]. Review of the [MEDICATION NAME] management tracking sheet revealed a list of 10 residents with partial documentation of the expected requirements of the form. Multiple forms failed to reveal a date for the next PT/INR or were not specific as to when it was to be drawn. During an interview on 11/30/12 at 11:50 a.m. S2 DON, with S3 ADON also present, stated the facility discovered a data entry error on 11/29/12 which caused the lab to not receive a complete list of all residents and their ordered lab tests. S2 DON further stated S3 ADON began to enter resident information and orders at the beginning of November . S2 DON stated the information entered is for the lab to know the schedule of lab draws for each resident. During an interview on 11/30/12 at 5:45 p.m., S1 Administrator, S2 DON, S3 ADON, and S4 Corporate Nurse agreed resident #4's physician's orders [REDACTED]. S1 Administrator, S2 DON, S3 ADON, and S4 Corporate Nurse further agreed resident #4 went 2 weeks without having his lab drawn and the nurses should have noticed the lab was not drawn before that time. S2 DON agreed resident #4's lab was not monitored and levels assessed daily as ordered. S2 DON agreed the [MEDICATION NAME] management tracking sheet that was put into place was not working because the nurses did not complete the form as indicated. During an interview on 12/3/12 at 10:20 a.m. S6 LPN stated resident #4 received his [MEDICATION NAME] (Jantoven) on her shift and she was not aware of his PT/INR results because they were not done. S6 LPN stated normally she would look at new orders for resident's to see if anything had changed, but she did not have time. S6 LPN stated her and the evening nurse S5 LPN were discussing that resident #4 had been receiving Jantoven, but no levels had been drawn and that was the day before Thanksgiving (11/21/12). S6 LPN stated she did not notify lab at that time and S5 LPN called lab so the PT/INR could be drawn on that Friday 11/23/12. S6 LPN stated she should have picked up that resident's PT/INR levels had not been drawn, but usually it would be written on the MAR and was not. S6 LPN stated she should have been aware that resident had no labs drawn while taking the Jantoven. During an interview on 12/3/12 at 10:40 a.m. S5 LPN stated she readmitted resident #4 on 11/8/12. S5 LPN stated resident #4 had orders for [MEDICATION NAME] and [MEDICATION NAME]. S5 LPN stated she did not see the admit orders and the lab was not on the MAR to be drawn as it usually was. S5 LPN stated she did not know resident #4 had lab ordered, but figured he should have. S5 LPN stated she did not double check resident #4's medical record for lab orders until resident #4 asked about his [MEDICATION NAME] shot being d/c'd and she told him when the INR level was >2.0. S5 LPN stated she checked the orders and realized the lab had not been done so she called the lab on 11/23/12. S5 LPN stated Thanksgiving day she told S6 LPN she did not see any lab that had been done for resident #4. S5 LPN stated they usually double check the hospital pack, but it was not left out and the front office staff wrote the orders and brought them too her. S5 LPN stated the only thing brought to her was the MARs and not the admit orders. S5 LPN stated she thought the other nurse had been getting the lab on the day shift and had not checked to verify. S5 LPN stated they normally use a 24 hour report sheet for communication between shifts and they will also speak with the physician to clarify any questions. S5 LPN stated she had never looked back over resident #4's orders until the resident questioned her. During an interview on 12/3/12 at 10:55 a.m. S3 ADON stated the discharge paperwork comes over the fax and is brought to her or S2 DON to review for orders that may be needed special. S3 ADON stated the nurse's are responsible for writing the orders and MARs, but she would review the orders and assist at times with completing the orders and MARs because the nurses are usually passing medications and are busy. S3 ADON stated the nurses are ultimately responsible for admitting the residents and completing the paperwork. S3 ADON stated she received the faxed copy of resident #4's orders and wrote the orders out, called the physician, and the physician agreed with the orders. S3 ADON reviewed resident #4's MAR and agreed she did write out the information on the MAR, but did not transcribe the lab order over to the MAR and it should have been. S3 ADON stated the nurse is responsible for contacting the physician and double checking the written out orders against the hospital admit pack. During an interview on 12/3/12 at 12:00 p.m. DON #S2 stated the facility had no specific policy regarding monitoring of labs that require levels to be drawn, other than just as physician ordered.