Every finding on record at Jonesboro Center for Nursing and Healing LLC

Based on interview, record review, and review of the facility policy titled, Advance Beneficiary Notices, the facility failed to provide Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) as required for three of three sampled residents (Resident (R) 160, R76, and R103) reviewed for beneficiary notices out of a sample of 50 residents. This failure had the potential to lead to financial burdens for residents, as they may have to pay out-of-pocket for care that is typically covered by Medicare.Findings include:Review of the facility provided policy titled, Advance Beneficiary Notices with a revision date of 11/23 indicated Policy:. It is the policy of this facility to provide timely notices regarding Medicare eligibility and coverage. Policy Explanation and Compliance Guidelines:. 1. The Business Office Manager is the contact person for information regarding Medicare eligibility, coverage, and applying for benefits. A notice alerting residents/ representatives of this contact person shall be posted conspicuously in the facility. 2. The Business Office Manager will provide Medicare information to residents/ representatives upon request. 5. The current Centers for Medicare and Medicaid (CMS) approved version of the forms shall be used at the time of issuance to the beneficiary (resident or resident representative). Contents of the form shall comply with related instructions and regulation regarding the use of the form: a. For Part A items and services, the facility shall use the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN), Form CMS-10055. 7. To ensure that the resident, or representative, has enough time to make a decision whether or not to receive the services in question and assume financial responsibility, the notice shall be provided at least two-days before the end of a Medicare covered Part A stay when all of Part B therapies are ending. The notices must not be provided while the resident/ representative is under duress or in an emergency situation. 8. The Business Office Manager, or designee, is responsible for issuing notices. 10. Delivery requirements: a. The notice shall be written legibly in a language and/ or format that the resident/ representative understands. Verbal explanations detailing the reasons for the determination of possible non-coverage shall be provided. B. The notice shall be hand-delivered as possible to obtain beneficiary or representative signature. C. The notice shall be prepared with an original and at least two copies. The facility shall retain the original and give a copy to the resident/ representative. D. If the notice cannot be hand-delivered a telephone notice shall be made, followed up immediately with a mailed, emailed, faxed or hand-delivered notice. Documentation shall comply with form instructions regarding telephone notices. e. Mail, secure fax machine or internet e-mail may also be utilized for delivery of the notice if in-person issuance is not able to be performed and all methods of delivery must adhere to all statutory privacy requirements under HIPAA.1.Review R160's admission Record, located under the Profile tab of the electronic medical record (EMR) revealed R160 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following a stroke, chronic kidney disease, stage 3, protein calorie malnutrition, and other personal risk factors.Review of R160's Notice of Medicare Non-Coverage (NOMNC), provided by the facility revealed it was provided to R160 by the facility and revealed R160's skilled nursing therapy services would end on 12/23/25. No SNF ABN was included.2. Review of R76's admission Record, located under the Profile tab of the EMR, revealed R76 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following stroke, chronic kidney disease stage 5, vascular Dementia, type two diabetes with diabetic chronic kidney disease, dysphagia, depression, pain, and other personal risk factors.Review of R76's NOMNC, provided by the facility revealed it was provided to R76's representative and revealed R78's skilled nursing services will end on 01/25/26. No SNF ABN was included.3. Review of R103's admission Record, located under the Profile tab of the EMR, revealed R103 was admitted to the facility on [DATE] with a diagnosis of chronic kidney disease, stage 3, type 2 diabetes mellitus with diabetic arthropathy, Dementia with behavioral disturbance and Alzheimer's disease.Review of R103's NOMNC, provided by the facility revealed it was provided to R103's representative and revealed R103's skilled nursing services would end on 12/07/25. No SNF ABN was included. During an interview on 02/12/26 at 10:28 AM, the Minimum Data Set Coordinator (MDSC) revealed the new facility owners no longer have her sending NOMNC and SFN ABN to residents and their representatives but gave the responsibility to the Social Work Director (SWD) and the Business Office Manager (BOM).During an interview on 02/12/26 at 10:29 AM, the BOM revealed she does not do NOMNC and SNF ABN that the responsibility is with the SWD. She confirmed that when the new company purchased the facility, they changed it to where MDS no longer sends NOMNC and SNF ABN's out to the residents and their representatives. She confirmed MDSC previously issued Medicare Part A recipients the notices. During an interview on 02/12/26 at 10:31 AM, the SWD confirmed she did not send SNF ABN notices out with the NOMNC's. During an interview on 02/12/26 at 10:31 AM, the Director of Regulatory Compliance confirmed SNF ABN notices must be given with the NOMNC to the resident or resident representative. He confirmed the SNF ABN notices had not been sent out.During an interview on 02/12/26 at 2:19 PM, the Regional Director of Operations confirmed the facility has not sent out any SNF ABN notices.

Based on observation, interview, document review, and policy review, the facility failed to ensure tuna salad sandwiches were served at the proper temperature. This deficient practice had the potential to cause food born illnesses affect 115 out of 119 residents. Findings included: During the second kitchen observation and interview on 02/11/26 from 11:58 AM to 12:42 PM, the following observations were made with the Dietary Manager (DM):A small steam table pan was observed on the counter at the left end of the steam table. The steam table pan contained eight tuna salad sandwiches, stacked one on top of one another, in stacks of two. At 12:09 PM the [NAME] stated the tuna salad sandwiches were the alternate menu item and were ready to be served to residents in the dining room. The DM took the temperature of the tuna salad sandwiches; the temperature was 55 degrees Fahrenheit (F). The DM and the Registered Dietician (RD) stated the tuna salad sandwiches should be 41 degrees F to be served. The [NAME] stated she put the tuna sandwiches in the freezer to cool. At 12:20 PM the DM was observed making deli meat turkey sandwiches. The DM took the temperature which was 50 degrees F. There was more turkey sitting on ice next to where the DM was making sandwiches. The DM took the temperature, which was within the proper range. She proceeded to make turkey sandwiches for residents in the dining room. During an interview on 02/12/26 at 1:30 PM, the Director of Regulatory Compliance stated food that is served to residents should be served at the correct temperature.During an interview on 02/12/26 at 2:57 PM, the DM stated any cold food should be at least 41 degrees F and should be put on ice to maintain the correct temperature. Review of the facility's policy titled, Food Preparation and Service, dated 04/2024 revealed, Policy: Nutrition Services employees shall prepare and serve food in a manner that complies with safe food handling practices.All cold food on tray line should be held at 41 degrees F or colder.

Based on observation, interview, record review, and review of the facility policy titled, Promoting/ Maintaining Resident Dignity, the facility failed to ensure staff dressed residents in daily clothing for one of one (Resident (R) 30) reviewed for dignity. This failure had the potential to cause embarrassment for the resident and failed to respect the resident's autonomy to maintain their personal identity.Findings include:Review of the facility provided a policy titled, Promoting/ Maintaining Resident Dignity, with a revision date of 03/25 indicated Policy: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Compliance Guidelines:1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights.Review of R30's admission Record, located under the Profile tab of the electronic medical record (EMR) revealed R30 was admitted on [DATE] with a diagnosis of contracture of left knee.Revie of R30's Medicare five day Minimum Data Set (MDS), located under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 01/07/26 revealed a Brief Interview for Mental Status (BIMS) score of six out of fifteen which indicated severe cognitive impairment and that R30 required partial to moderate assist for upper body dressing and was dependent for lower body dressing.Review of R30's Care Plan, located under the Care Plan tab of the EMR revealed R30 had an activity of daily living (ADL) self-care performance deficit requiring extensive to total assistance by one staff to dress initiated on 12/22/25.During an observation on 02/09/26 at 10:04 AM, R30 was lying in bed wearing a brief with a sheet across himself. R30 was not wearing any clothing. During an observation on 02/10/26 at 10:06 AM, R30 was lying in bed wearing a hospital gown. During an observation on 02/11/26 at 12:26 PM, R30 was lying in bed wearing a hospital gown. During an interview on 02/11/26 at 12:58 PM, Certified Nurse Assistant (CNA)7 was at R30's bedside and confirmed the resident was dressed in a hospital gown and that the resident should be in his own clothing as it is a dignity issue. CNA7 opened R30's armoire and confirmed that the resident had clothing he could be dressed in daily. During an interview on 02/11/26 1:09 PM, the Director of Nursing-Interim Regional Director of Clinical Operations (DON) confirmed residents should be dressed in their own clothing as it is more homelike and comfortable. She confirmed R30 should be dressed in his own clothing.

Based on record review, staff interview, and review of the facility policy titled, MDS3.0 Completion, the facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the required timeframe when a resident experienced multiple areas of functional decline for one of five residents (Resident (R) 57) reviewed for resident assessments. This failure placed R57 at risk for further decline if care plan revisions and interventions addressing the resident's change in condition were delayed.Findings include:Review of the facility's policy titled, MDS3.0 Completion, dated October 2025, revealed, an SCSA within 14 days of identifying a qualifying status change that affects more than one area and requires Interdisciplinary Team review and revision of the care plan. Review of R57's admission Record, dated 02/12/26 located in the resident's electronic medical record (EMR) under the Profile tab, revealed R144 admitted to the facility on [DATE] with multiple diagnoses including Parkinson's disease (a progressive movement disorder of the nervous system).Review of R57's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/14/25, documentation revealed R57's Activities of Daily Living (ADL) assessment under the Section GG - Functional Abilities as follows: - Toileting: 05. Setup or clean-up assistance.- Upper body dressing: 05. Setup or clean-up assistance.- Lower body dressing: 05. Setup or clean-up assistance.- Personal hygiene:05. Setup or clean-up assistance. Review of R57's quarterly MDS, with an ARD of 06/13/25, revealed R57 had four areas of decline under Section GG-Functional Abilities as follows: - Toileting: 03. Partial/moderate assistance.- Upper body dressing: 03. Partial/moderate assistance.- Lower body dressing: 03. Partial/moderate assistance.- Personal hygiene:03. Partial/moderate assistance. During an interview and record review on 02/12/26 at 4:48 PM, the MDS Coordinator (MDSC) reviewed and compared R57's MDS record and confirmed that R57 had four areas of decline on the 06/13/25 quarterly MDS compared to the 03/14/25 annual MDS under Section GG. The MDSC stated that an SCSA MDS should have been completed with an ARD of 06/13/25 instead of a quarterly with an ARD of 06/13/25.

Based on record reviews, staff interviews, and review of the facility policy titled, MDS3.0 Completion, the facility failed to transmit Minimum Data Set (MDS) assessments within the federally required timeframe for two of five residents (Resident (R) 4 and R144) reviewed for Resident Assessments. This failure had the potential to affect the accuracy and timeliness of federally required resident assessments. Findings include:Review of the facility's policy titled, MDS3.0 Completion, dated October 2025, documented the MDS transmission requirements of All assessments shall be transmitted to the designated [Centers for Medicare and Medicaid Services] CMS System (iQlES) within 14 days of completion. 1. Review of R144's admission Record, dated 02/10/26 located in the electronic medical record (EMR) under the Profile tab revealed R144 was admitted to the facility on [DATE] with multiple diagnoses including type 2 diabetes, end stage renal disease, and dementia. Review of R144's admission MDS, with an Assessment Reference Date (ARD) of 06/12/25 and located in the EMR under the MDS tab indicated the admission MDS was completed on 06/18/25 and transmitted late on 07/03/25. During an interview and record review on 02/12/26 at 9:01 AM, the Minimum Data Set Coordinator (MDSC) reviewed R144's admission MDS and confirmed that the MDS was completed and dated 06/18/25 in the EMR system. She stated that the requirement was to submit the MDS to the Internet Quality Improvement & Evaluation System (iQlES) within 14 days of completion, which would have been by 07/02/25. During an interview on 02/12/26 at 10:01 AM, the MDSC confirmed that R144's admission MDS transmission to iQlES occurred on 07/03/25 and stated that it was late. 2. Review of R4's admission Record, dated 02/10/26 located in the EMR under the Profile tab, revealed R4 admitted to the facility on [DATE] with multiple diagnoses including hypertensive heart disease. R4 was discharged from the facility on 08/28/25. Review of R4's discharge returned anticipated MDS, with an ARD of 08/28/25 and found in the EMR under the MDS tab indicated that the Discharge Returned Anticipated MDS was completed and was never transmitted to iQIES. During an interview and record review on 02/12/26 at 4:43 PM, the MDSC reviewed R4's MDS records and stated that R4 was discharged on 08/28/25 and had a discharge MDS with an ARD of 08/28/25, completed on 09/02/25 that was not transmitted. She stated it should have been transmitted within 14 days of completion.

Based on interview, record review, and review of the facility policy titled, the facility failed to ensure accurate assessments were completed for four of 50 sample residents (Resident (R) 33, R117, R67 and R96) by failing to capture services the residents were receiving. This failure has the potential to prevent residents from receiving a needed service.Findings include: Review of the facility's policy titled, MDS 3.0 Completion, dated October 2025, indicated the discharge MDS assessment requirements as follows: Discharge Assessment – completed using the discharge date as the ARD and must be completed within 14 days of the discharge date /ARD. 1.Review of R33's Face Sheet, located in the electronic medical records (EMR) under the Profile tab indicated an admission date of 01/06/22 with diagnoses of chronic systolic (congestive) heart failure and dementia. Review of R33's annual Minimum Data Set (MDS), located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 12/07/25 indicated R33 was unable to complete the Brief Interview for Mental Status (BIMS) which indicated the resident was severely cognitively impaired. The inaccurate MDS revealed R33 did not have impairments on either side of the upper and lower extremities. R33 was dependent on staff for bed mobility. Review of R33's modified annual MDS, located in the EMR under the MDS tab with an ARD of 12/07/25 revealed R33 had impairments of both sides of the upper extremities and impairments on one side of the lower extremities. This remained an inaccurate MDS. Review of R33's quarterly MDS, located in the EMR under the MDS tab with an ARD of 03/10/25, revealed R33 had impairments of both sides of the upper extremities and lower extremities. Review of R33's quarterly MDS, located in the EMR under the MDS tab with an ARD of 06/09/25, revealed R33 had impairments of both sides of the upper extremities and lower extremities. Review of R33's quarterly MDS, located in the EMR under the MDS tab with an ARD of 09/08/25, revealed R33 had impairments of both sides of the upper extremities and lower extremities. During an observation on 02/09/26 at 9:55 AM, R33 was observed lying in bed, under the covers. R33 had foam wedges on both her left and right side, near her body. Both of her arms were resting on top of her chest with her arms bent at a 45-degree angle with both the right and left hand bent at the wrist with her fingers curled completely into her right and left hands. During an observation on 02/12/26 at 7:31 AM, R33 was observed lying in bed, under the covers. R33 had foam wedges on both her left and right side, near her body. Both of her arms were resting on top of her chest with her arms bent at a 45-degree angle. Both of R33's hands were bent at the wrist with her fingers curled completely into her hands. During an interview on 02/12/26 at 10:52 AM, the MDS coordinator (MDSC) stated when completing quarterly and annual MDS' she would check and compare previous assessments. She reviewed previous MDS assessments for R33 and stated the 12/07/25 MDS was inaccurate. She stated it was important for the MDS to be accurate to ensure residents received the care they needed. She stated she would correct the inaccurate MDS and resubmit. Review of the facility policy titled, MDS 3.0 Completion,'' revised on 10/2025 revealed, Policy: Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan.A Modification Request is used when an MDS record (assessment.) is already transmitted and accepted by CMS (Center for Medicare & Medicaid Services) . information in the record contains clinical or demographic errors.'' 2. Review of R117's admission Record, located under the Profile tab of the EMR revealed an admission date of 01/14/26 with diagnoses of acute and chronic respiratory failure with hypoxia, asthma, and obstructive sleep apnea. Review of R117's Orders, located under the Orders tab of the EMR revealed oxygen at three liters through nasal cannula (NC) for shortness of breath (SOB), monitor SOB when resident is lying flat, if SOB when lying flat lift head of bed, document and notify medical director (MD) of any changes, every shift starting 01/14/26. Review of R117's Medicare 5-day MDS, located under the MDS tab of the EMR with an ARD of 01/18/26 did not indicate the resident was on oxygen. During an observation on 02/09/26 at 10:57 AM, R117 had an oxygen concentrator present in her room running at one and a half (1.5) liters per minute (LPM) through NC. During an interview on 02/09/26 at 10:57 AM, R117 said she has been on oxygen for a long time and that she had oxygen at home too. R117 confirmed she has a tough time breathing without it. During an observation on 02/12/26 at 7:50 AM, R117 had an oxygen concentrator present in her room running at two (2) LPM through NC. During an interview on 02/12/26 at 8:01 AM, Licensed Practical Nurse (LPN)7 confirmed R117 was on oxygen. LPN7 also stated she never saw R117 go without her oxygen. During an interview on 02/12/26 at 1:43 PM, the MDSC confirmed R117 was admitted with oxygen and uses oxygen continuously. MDSC confirmed it was a coding error on the MDS. During an interview on 02/12/26 at 1:54 PM, the Director of Nursing- Interim Director of Clinical Operations (DON) confirmed R117 uses oxygen, a physician order was documented on admission and that the MDS should reflect R117's use of oxygen. Review of the facility provided policy titled, MDS 3.0 Completion, with a revision date on 10/25 indicated Policy:.Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. Policy Explanation and Compliance Guidelines: 1. According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI specified by the State. 3.Review of R67's admission Record, dated 02/12/26 located under the Profile tab in the EMR revealed an admission date of 09/13/25 with multiple diagnoses including stroke. R67 was discharged from the facility on 10/04/25. Review of R67's Discharge summary, dated [DATE] at 2:01 PM, and located under the Prog Note tab in the EMR indicated R67 was discharged from the facility. Review of R67's MDS, assessments completion list located in the EMR under the MDS tab included an entry MDS with ARD of 09/13/25, and an admission MDS with an ARD of 09/20/25. Review of R67's MDS, completion list revealed a discharge MDS was not completed. During an interview and record review on 02/12/26 at 4:46 PM, the MDSC reviewed R67's MDS record and stated that R67 was discharged on 10/4/25. The MDSC stated there was no discharge MDS for R67, and one should have been completed with an ARD of 10/4/25. 4. Review of R96's admission Record, dated 02/12/26 located in the EMR under the Profile tab revealed an admission date of 08/18/25 with multiple diagnoses including Type 2 diabetes mellitus. R96 was discharged from the facility on 09/19/25. Review of R96's Discharge summary, dated [DATE] at 1:32 PM, and located under the Prog Note tab in the EMR indicated R96 was discharged from the facility. Review of R96's MDS, completion list located under the MDS tab in the EMR included an entry MDS with ARD of 08/18/25, and an admission MDS with ARD of 08/25/25. Review of R67's MDS, completion list revealed a discharge MDS was not completed. During an interview and Record review on 02/12/26 at 4:44 PM, the MDSC reviewed R96's MDS record and stated that R96 was discharged on 09/19/25. The MDSC stated there was no discharge MDS for R96, and one should have been completed with an ARD of 09/19/25.

Based on record review, interview, and facility policy titled, Resident Assessment-Coordination with PASARR Program, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) Level II assessment was completed for one resident (Resident (R) 94) reviewed for PASARR, who has a diagnosis of bipolar disorder and requires specialized services. This failure had the potential of placing R94 at risk for inappropriate care and lack of specialized services. Findings include:Review of the facility policy titled, Resident Assessment-Coordination with PASARR Program, with a revision date of 12/24 indicated Policy:.This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Policy Explanation and Compliance Guidelines: 1. A11 applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. a. PASARR Level I - initial pre-screening that is completed prior to admission i. Negative Level I Screen - permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. ii. positive Level I Screen - necessitates a PASARR Level II evaluation prior to admission. b. PASARR Level II - a comprehensive evaluation by the appropriate state-designated authority (cannot be completed by the facility) that determines whether the individual has (mental disorder) MD, (intellectual disorder) ID, or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services the individual needs. 2. The facility will only admit individuals with a mental disorder or intellectual disability who the State mental health or intellectual disability authority has determined as appropriate for admission. 3. A record of the pre-screening shall be maintained in the resident's medical record. 4. Exceptions to the pre-admission screening program include those individuals who: b. Are admitted directly from a hospital, requires nursing facility services for the condition for which the individual received care in the hospital, and has been certified by the attending physician before admission that the individual is likely to require less than 30 days of nursing facility services. 5. If a resident who was not screened due to an exception above and the resident remains in the facility longer than 30 days: a. The facility must screen the individual using the State's Level I screening process and refer any resident who has or may have MD, ID, or a related condition to the appropriate state designated authority for Level II PASARR evaluation and determination. b. The Level II resident review must be completed within 40 calendar days of admission. 6. The Social Services Director shall be responsible for keeping track of each resident's PASARR screening status and referring to the appropriate authority. 7. Recommendations, such as any specialized services, from a PASARR level II determination and/or PASARR evaluation report will be incorporated into the resident's assessment, care planning, and transitions of care.Review of R94's admission Record, located under the Profile tab of the electronic medical record (EMR) indicated R94 was admitted on [DATE] with a diagnosis of bipolar disorder.Review of R94's PASSAR, evaluation provided by the facility dated 02/08/25 revealed the facility applied for R94's level II PASARR and it shows status pending.Review of R94's Care Plan, located under the Care Plan tab of the EMR revealed R94 uses antipsychotic medications related to her bipolar diagnosis initiated on 10/14/25.Review of the Initial Performance Improvement Plan, provided by the facility dated 01/23/26 revealed Description:.To ensure that residents have a qualifying diagnosis for a level II application are identified and submitted. Assessment Summary:.Performance Assessment: During an audit social service (SS) identified six potential residents that the facility failed to submit an application for level II services. Root Cause Analysis:.Previous SWD failed to submit levels on the identified resident. Plan Summary and Implementation Tracking:. Goals: To ensure all residents receive the needed care and services that all requirements are met. Implementation:.1. Perform a 100% audit of all residents for qualifying diagnoses; 2. Submit new Level and DMA6 [specific form used by Georgia regarding physician recommendation concerning nursing facility placement] on all residents identified in the audit; 3. Review all new admissions to ensure that Level I was submitted and completed accurately. Those inaccurate, submit a new Level 1 and DMA6 with accurate diagnoses; 4/ Review all resident diagnoses according to the Minimum Data Set (MDS) schedule to ensure no new diagnoses have been added. Review of R94's Preadmission Screening and Resident Review (PASARR,) evaluation provided by the facility dated 01/25/25 revealed it did not indicate the resident has bipolar disorder.Review of Performance Improvement Plan (PIP), provided by the facility dated 01/27/26 revealed State Problem or Opportunity for Improvement: PASARR/ advanced directives on all residents admitted to [facility] and do not match each other. Supportive Data (why do you believe this is a problem): Current residents are lacking PASARR's and advanced directives in their medical files upon admission, start date 01/27/26. During an interview on 02/11/26 at 4:37 PM, the Social Work Director (SWD) confirmed the facility should have followed up on the pending PASSAR before now. She revealed on 01/23/26, the facility identified PASSAR's that needed to be followed up on and put a PIP in place. During an interview on 02/12/26 at 10:43 AM, the SWD revealed that even though the facility started with a PIP on 01/27/26 and a list of residents were provided to the Business Office Manager (BOM), no one has contacted the agency that provides PASSAR to make corrections. During an interview on 02/12/26 at 10:44 AM, the Director of Nursing (DON) revealed a PIP was started but she was unaware the agency for PASSAR had not been contacted since the PIP was in place as of 01/27/26.

Based on record review, interview and review of the policy titled, Activities of Daily Living, the facility failed to ensure good hygiene was maintained for three residents (Residents (R) 1, R7, and R156) out of nine reviewed for activities of daily living (ADL) in the sample of 50 residents. This failure has the potential for the residents to develop skin infections, have poor hygiene and a general decline in health.Findings include:Review of the facility's policy titled, Activities of Daily Living, implemented October 2025, revealed, .based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs (activities of daily living) do not deteriorate unless deterioration is unavoidable.Care and services will be provided for the following activities of daily living: Bathing.1.Review of R1's Face Sheet, located in the electronic medical records (EMR) under the Profile tab indicated an admission date of 04/22/25 with diagnoses of chronic pleural effusion and chronic respiratory failure.Review of R1's quarterly Minimum Data Set (MDS), located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 10/30/25 indicated R1 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated the resident was cognitively intact. R1 required moderate assistance with bathing.Review of R1's admission MDS, located in the EMR under the MDS tab with an ARD of 04/29/25 revealed it was very important for the resident to choose between a bed bath or shower. Review of R1's Care Plan, created on 02/10/26, during the survey, located in the EMR under the Care Plan tab revealed, The resident has an ADL self-care performance deficit r/t (related to) decreased mobility, muscle weakness. The goal was for the resident to maintain current level of function in ADLs through the review date. Interventions included Bathing/Showering: Resident requires extensive assistance of one staff for bathing.Review of R1's POC (Point of Care) Response History, revealed R1 had a Scheduled bath/shower three times a week on Tuesday/Thursday/Saturday 7-3 (shift).Review of the Skin and Bath Report, revealed R1 had 42 opportunities to receive a bed bath or shower, and she received a bed bath or shower 12 times and refused once. R1 was offered a bed bath or shower 13 times since 11/01/25, which included: 11/04/25, 11/06/25, 11/11/25, 11/18/25, 11/20/25, 12/02/26, 12/11/25, 12/16/25, 01/06/26, 01/10/26, 01/13/26, and 01/24/26. She was offered and refused on 12/04/25. During an interview on 02/11/26 at 8:00 AM, R1 stated I have only gotten two showers since I've been here.2.Review of R7's Face Sheet, located in the EMR under the Profile tab indicated an admission date of 04/09/22 with diagnoses of vascular parkinsonism and dementia.Review of R7's quarterly MDS, located in the EMR under the MDS tab with an ARD of 12/11/25 indicated R7 had a BIMS score of eight out of 15 which indicated the resident was moderately cognitively impaired. R7 required moderate assistance with bathing.Review of R7's annual MDS, located in the EMR under the MDS tab with an ARD of 03/14/25 revealed it was very important for the resident to choose between a bed bath or shower. Review of R7's Care Plan, created on 02/10/26, during the survey, located in the EMR under the Care Plan tab revealed, The resident has an ADL self-care performance deficit r/t Parkinson's, decreased mobility, dementia. The goal was for the resident to maintain current level of function in ADLs through the review date. Interventions included Bathing/Showering: Resident requires extensive assistance of one staff for bathing.Review of R7's POC Response History, revealed R7 had a Scheduled bath/shower three times a week on Tuesday/Thursday/Saturday 3-11 (shift).Review of the Skin and Bath Report, revealed R7 had 42 opportunities to receive a bed bath or shower, he received a bed bath or shower eight times, and was offered a bed bath or shower 10 times since 11/01/25. He was offered and received showers on: 11/06/25, 12/06/25, 12/18/25, 01/03/26, 01/08/26, 01/22/26, 02/07/26, and 02/10/26. He was offered and refused showers on 01/17/26 and 01/31/26. During an observation on 02/10/26 at 9:15 AM, R7 was seen going through his clothes on the bed. The clothes appeared as if they had been kept in a garbage bag. R7 said he was going through his clothes. He smelled of stale urine. The clothes he pulled out of the garbage bag had a wet urine smell.During an observation and interview on 02/11/26 at 7:35 AM, R7 had a smell of old urine. His face had whiskers, and he had gray patches of dry skin. R7 stated he washes up in the sink and that's enough for me.During an interview on 02/09/26 at 10:28 AM, R38 stated when Resident Council is lead, residents talk a lot about not offering showers.During an interview on 02/10/26 at 2:30 PM, Certified Nurse Aide (CNA) 4 and Restorative Aide (RA1) stated they would use their assignment sheets to know who had showers during their shift. Both stated they did not receive an assignment sheet for 02/10/26, therefore they did not know who should have received a shower. Both said they were uncertain how to indicate in the computer that a shower was not given. During an interview on 02/10/26 at 2:30 PM, CNA 2 stated she knew who was scheduled for a shower based on her assignment sheet. She did not know how to document in the computer whether a resident took a shower or not.During an interview on 02/10/26 at 2:40 PM, Registered Nurse - Evening Supervisor (RN1) stated she expected the CNA to receive an assignment sheet at the start of their shift which would indicate which residents needed showers. She stated she would verify with CNAs if showers were completed. She stated if they were not completed, she instructed the CNA to contact their nurse. RN1 stated if the resident did not receive their shower during their assigned shift, she would expect the resident to receive their shower on the next shift. She stated completed shower sheets would also document areas of concern on residents' skin. This way nursing could determine the necessary treatment for any skin concerns. During an interview on 02/11/26 at 7:40 AM, CNA 9 stated the shower sheet should be completed after every shower and if there are skin concerns they should be documented on the shower sheet and the nurse should be notified. If a resident refuses a shower, then the nurse should be notified. CNA 9 stated residents who reside in even numbered rooms receive their shower during the day shift. She stated if a resident is in A bed (by the door) they receive a shower Tuesday, Thursday, and Saturday. She stated if a resident is in B bed (by the window) they receive their shower on Monday, Wednesday, and Friday. She stated R1 should receive her shower on Tuesday, Thursday, and Saturday because she is in A bed, in an even numbered room. CNA 9 stated if a resident lived in an odd numbered room, the same shower days would apply for bed A and bed B, but the showers would be given during the evening shift.During an interview on 02/12/26 at 11:45 AM, interim the Director of Nursing/ Regional Director of Clinical Operations (DON) stated it was a problem if a resident was not offered a shower or bed bath. She stated if the resident refuses the refusal needs to be documented. The DON stated, if necessary, the time needs to be changed if a resident has a different preference. 3. Review of R156's admission Record, located under the Profile tab of the electronic medical record (EMR) revealed R156 was admitted on [DATE] with diagnoses of stroke and muscle weakness.Review of R156's annual Minimum Data Set (MDS), located under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 01/27/26 indicated the resident was dependent for shower/ bathing.Review of R156's Care Plan, located under the Care Plan tab of the EMR revealed the dated 02/11/26 revealed R156 has an ADL self-care performance deficit related to cerebral infarction. R156 is totally dependent on staff to provide a bath/shower.Review of shower sheets provided by the facility reveal R156 was bathed on:01/27/2601/29/2602/03/2602/07/26 During an interview on 02/09/26 at 2:44 PM, R156 stated he had been showered twice. R156's hair appeared oily. During an observation on 02/10/26 at 12:21 PM, R156 was in the common area sitting in his wheelchair and his hair appeared oily. During an interview on 02/11/26 at 12:58 PM, Certified Nurse Assistant (CNA)7 was at R156's bedside and confirmed the resident's hair appeared oily and he needed a bath.During an interview on 02/12/26 at 1:53 PM, Licensed Practical Nurse (LPN)7 confirmed R156 had only received four baths since his admission on [DATE]. She confirmed R156 should be bathed two to three times per week and more if necessary to maintain proper hygiene.

Based on observation, record review, and interviews, the facility failed to ensure two residents (Resident (R) 33 and R12) of two residents reviewed for activities out of a sample of 50 residents received an ongoing activities program to support their choice of activities. This failure had the potential for the residents' physical, mental, and psychosocial well-being to worsen and potentially develop a general decline in health. Findings include:1.Review of R33's Face Sheet, located in the electronic medical records (EMR) under the Profile tab indicated an admission date 01/06/22 with diagnoses of chronic systolic (congestive) heart failure and dementia.Review of R33's annual Minimum Data Set (MDS), located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 12/07/25 indicated R33 was unable to complete the Brief Interview for Mental Status (BIMS) which indicated the resident was severely cognitively impaired. R33 had bilateral impairment of the upper extremities and on one side of her lower extremities. She was dependent on staff for all activities of daily living (ADL).Review of R33's annual MDS, located in the EMR under the MDS tab with an ARD of 12/07/25 revealed it was very important for R33 to participate in religious services or practices and somewhat important to listen to music she likes.Review of R33's Care Plan, located in the EMR under the Care Plan tab dated 01/05/26, revealed, (R33) has little or no group activity involvement at [the] time, she is on the one-to-one program. The goal was for R33 to express satisfaction with [the] type of activities and level of activity involvement. Interventions included, invite and encourage (R33) to attend group act[ivities] of her choice.post monthly calendar.praise for all efforts.provide supplies to engage (R33) with sociable activities. Continuous observations of R33 on 02/09/26 from 9:49 AM until 10:03 AM and 2:40 PM until 2:53 PM, revealed R33 was observed lying in bed. There was no music or television in the room and the lights were off.Continuous observations of R33 on 02/10/26 from 9:15 AM until 9:55 AM, 10:28 AM until 10:37 AM and 2:30 PM until 2:45 PM, revealed R33 was observed lying in bed. There was no music or television in the room and the lights were off.Continuous observations of R33 on 02/11/26 from 3:54 PM until 4:05 PM, revealed R33 was observed lying in bed. There was no music or television in the room and the lights were off.An observation of R33 revealed on 02/12/26 at 5:01 PM, R33 was observed sitting in her wheelchair along the wall next to the nurses' station.2. Review of R12's Face Sheet, located in the EMR under the Profile tab indicated an admission date of 04/14/25 with diagnosis of encephalopathy and dementia.Review of R12's annual MDS, located in the EMR under the MDS tab with an ARD of 12/06/25 indicated R12 had a BIMS score of three out of 15 which indicated the resident was severely cognitively impaired. R33 had bilateral impairment of the upper and lower extremities. She was dependent on staff for most ADLs.Review of R12's annual MDS, located in the EMR under the MDS tab with an ARD of 06/08/25 revealed it was very important for R12 to listen to music he likes, do things with groups of people, be around animals, and participate in his favorite activities. Review of R12's Care Plan, located in the EMR under the RAI tab dated 11/01/25 revealed, (R12) [is] dependent on staff for meeting emotional, intellectual, physical and social needs due to cognitive deficits. The goal was for R12 to maintain involvement in cognitive stimulation [and] social activities as desired. Interventions included, staff converse with (R12) .introduce (R12) to residents with similar background.invite (R12) to scheduled activities . provide (R12) with materials for individual activities. The care plan did not mention one-to-one as an intervention. Continuous observations of R12 on 02/09/26 from 9:49 AM until 10:03 AM and 2:40 PM until 2:53 PM, revealed R12 was observed lying in bed with his covers pulled up over his face. There was no music or television in the room and the lights were off.Continuous observations of R12 on 02/10/26 from 9:15 AM until 9:55 AM, 10:28 AM until 10:37 AM and 2:30 PM until 2:45 PM, revealed R12 was observed lying in bed with his covers pulled up over his face. R12 was observed sitting inside the doorway of his room at 4:00 PM. There was no music or television in the room and the lights were off.Continuous observations of R12 on 02/11/26 from 3:54 PM until 4:05 PM, revealed R12 was observed lying in bed, with his covers pulled up over his face. There was no music or television in the room and the lights were off.An observation of R12 on 02/12/26 at 5:00 PM revealed R12 was observed sitting in his wheelchair next to the nurse's cart across from his room.During an interview on 02/11/26 at 5:10 PM, the Activity Director (AD) stated she was new to the position. She stated her plan was to set up a one-to-one program. She stated she was going to start on 02/12/26, the last day of the survey. The AD stated she did not know what she would provide because she needed to get a feel for what they (R33 and R12) liked doing. She stated both R33 and R12 would be placed on one-to-one visits three times a week. She stated she would include puzzles, aroma therapy, nail care, massage, talking, and reading the Bible during the visits. During an interview on 02/12/26 at 1:30 PM, the Director of Regulatory Compliance stated, I'll give you these (Activity Logs), but they really do not show you much. The Director of Regulatory Compliance stated he was aware there was a limited activity program since the new company had taken over and it was important to have a good program.Review of the policy tilted, Activities, revised 01/2024, revealed, It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, an preferences.Each resident's interest and needs will be assessed on a routine basis.Activities may be conducted in different ways: (a) One-to-one programs.

Based on observations, interviews, record review, and policy review, the facility failed to ensure one resident (Resident (R) 33) reviewed for skin concerns out of a total sample of 50 residents received the proper care and monitoring to prevent an axilla rash under the left arm from worsening. This failure had the potential for R33's skin to worsen, cause pain, and potentially develop a general decline in health. Findings include:Review of R33's Face Sheet, located in the electronic medical records (EMR) under the Profile tab indicated an admission date 01/06/22, with diagnoses of chronic systolic (congestive) heart failure and dementia.Review of R33's annual Minimum Data Set (MDS), located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 12/07/25 indicated R33 was unable to complete the Brief Interview for Mental Status (BIMS) which indicated the resident was severely cognitively impaired. R33 was dependent on staff for all activities of daily living (ADL). R33 did not have Applications of ointments/medications listed under the skin conditions in the MDS.Review of R33's Care Plan, located in the EMR under the Care Plan tab, dated 01/06/26, revealed, (R33) is at risk for chronic fungal under left arm r/t (related to) moisture. L (left) arm is contracted, and resident has a purple-reddish discoloration from previous rash. The goal included, Resident will have no s/sx (signs/symptoms) of infection of the rash through the review date. Interventions included Apply PRN (as needed) antifungal cream as needed. Interventions initiated 02/12/26, during the survey, included, Monitor skin rashes for increased spread or signs of infection. Place wedges under each arms [sic] as tolerated.On 02/11/26, the Skin and Bath Reports revealed R33 had a rash on her left Axillary/Armpit.Review of the Skin Check, located in the EMR under the Assessment tab dated 02/05/26, revealed no discoloration or rashes were previously noted. The Skin Care Plan revealed, weekly skin check, daily documentation skin notes and other skin assessments were reviewed.medical conditions/medication/risk factors were reviewed, other areas reviewed (.positioning, contractures, mobility.) and changes to plan of care were updated were blank which indicated those areas were not reviewed.Review of a [Nurse Practitioner] Progress Note, provided by the facility, dated 02/12/26, revealed She is being seen for follow up after MD (Medical Doctor) initiated Fluconazole 100 mg (milligrams) daily for seven days and topical Miconazole powder for axillary candidiasis.Skin: erythema (skin redness) and moisture present under bilateral axillary folds.ICD (International Classification of Diseases) (coding system to classify diseases), B37.2: Candidiasis of skin.Review of the Clinical Physician Orders, dated 03/15/25 through the survey, revealed:-Diflucan 100 mg (milligrams), start date of 6/25/25 through 6/30/25. -Diflucan 150 mg, start date of 09/10/25 through 09/15/25. -Diflucan 100 mg, start date of 02/12/26 through 02/19/26.-Miconazole Nitrate Powder 2%, apply to left arm topically, start date 02/12/26.-Antifungal External Powder 2%, apply to underneath left arm, start date 01/06/26 and discontinued 02/11/26.During an interview on 02/10/26 at 2:40 PM, Registered Nurse - Evening Supervisor (RN1) stated she expected the Certified Nurse Aide (CNA) to receive an assignment sheet at the start of their shift which would indicate which residents needed showers. She stated she would verify with CNAs if showers were completed. She stated if they were not completed, she instructed the CNA to contact their nurse. RN1 stated if the resident did not receive their shower during their assigned shift, she would expect the resident to receive their shower on the next shift. She stated completed shower sheets would also document areas of concern on residents' skin and nursing could determine the necessary treatment for any skin concerns. During an interview on 02/10/26 at 2:45 PM, with the Director of Rehab (DOR) and the Occupational Therapist (OT). The OT stated R33 had contractures. She stated she had worked with R33 in June 2025 for her contractures and had just recently started working with her again. The OT stated when she started working with R33 last June she also had some skin breakdown in her armpit area, which was an oozing area. During an observation and interview on 02/11/26 at 5:34 PM, the Director of Nursing - Interim Regional Director of Clinical Operations (DON), the Previous Director of Nursing (PDON) and the Former Administrator observed the area in R33's left armpit. The DON stated she was not aware of the area and would investigate and determine if there was a current treatment. The PDON stated she remembered R33 having the area for quite some time. During an observation on 02/12/26 at 7:31 AM with a Registered Nurse (RN) from the survey team and Licensed Practical Nurse (LPN) 8, R33's was observed lying in bed, under the covers. R33 had foam wedges on both her left and right side, near her body. Both of her arms were resting on top of her chest with her arms bent at a 45-degree angle at the elbow, and her arms were lying close to her body, without her armpit exposed. Her arms were lying on her chest with both the right and left hand bent at the wrist with her fingers curled completely into her right and left hands. R33 was uncovered by LPN8 and R33's left arm was lifted and her armpit was exposed and observed. LPN8 stated the redness was yeast and R33 had had it for a long time. LPN8 stated you should have seen it a year ago, it was oozing. LPN8 stated it looked much better. The survey team RN agreed the area was a healing yeasty rash. LPN8 stated it was difficult to keep the area dry.During an interview on 02/12/26 at 11:17 AM, the OT stated she looked at R33's skin in her left armpit area and it looked better than it had last year. She stated because there were moisture and redness under both her left and right arm, R33 would benefit from using the wedges under both arms to improve the airflow and relieve the pressure. The OT stated she would educate CNAs again, so they are aware of how to position the wedges to help the area under R33's arms with air flow. She stated she also observed R33's right arm and observed the right armpit had moisture and redness. She stated the left arm required passive range of motion (PROM). During an interview on 02/12/26 at 11:33 AM, the Nurse Practitioner (NP) stated she had not been treating R33 with anything related to her skin. She stated she was not aware of any concerns until 02/11/26. She stated her expectation would have been to be made aware of any skin concerns since their practice took over in November of 2025 and see a skin assessment. The NP stated if she would have known she would have looked at R33's armpit and monitored the area. She stated if she were aware sooner, she would have had the opportunity to monitor the treatment and follow-up for effectiveness. She stated the risk of not knowing is that the skin could have gotten worse, become infected or become a systemic problem. During an interview on 02/12/26 at 11:45 AM, the DON stated she was not aware of any red areas under R33's right arm. She stated she would observe the area, monitor, and notify the doctor. Review of the Skin Integrity Prevention Policy, revised 08/2024, revealed, .Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable.Repeat the risk assessment weekly and upon any changes in condition.Prevention: Keep the skin clean .Review the interventions and strategies for effectiveness on an ongoing basis.

Based on observation, record review, and interviews, the facility failed to ensure two of two resident (Resident (R) 33 and R83) reviewed for range of motion (ROM) out of a sample of 50 residents received restorative services to ensure ROM did not worsen in the upper and lower extremities, splint devices were in place, and failed to ensure staff were educated on placement of splint devices. This failure had the potential for the resident's ROM to worsen, cause pain, skin break down and potentially develop a general decline in health. Findings include: 1.Review of R33's Face Sheet, located in the electronic medical records (EMR) under the Profile tab indicated an admission date of 01/06/22 with diagnoses of chronic systolic (congestive) heart failure and dementia. Review of R33's modified annual Minimum Data Set (MDS), located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 12/07/25 indicated R33 was unable to complete the Brief Interview for Mental Status (BIMS) which indicated the resident was severely cognitively impaired. R33 had bilateral upper extremity impairments and impairments on one side of the lower extremities. She was dependent on staff for all activities of daily living (ADL). Review of R33's annual Care Area Assessment (CAA), located in the EMR under the MDS tab with an ARD of 12/07/25 did not indicate the resident had contractures. Review of R33's Care Plan, located in the EMR under the Care Plan tab did not mention R33's right hand contracture until 02/11/26, during the survey. Additionally, the Care Plan included an intervention dated 02/12/26, place wedges under each arms [sic] as tolerated. Review of a [Nurse Practitioner] Progress Note, provided by the facility, dated 02/12/26, revealed Physical Debility/Geriatric Deconditioning/Contractures-chronic, unstable: Continue PT/OT (physical therapy/occupational therapy) to meet tools for endurance, strengthening and to assess for support devices, support participation in therapy to address contractures. ICD (International Classification of Diseases) (coding system to classify diseases, M24.529: Contracture of upper arm joint, M24.561: Contracture, right knee, M24.562: Contracture, left knee. Review of R33's Occupational Therapy Discharge summary, dated [DATE], revealed Short-Term Goals: Patient will safely wear [brace] to further assess and order/fabricate on left shoulder for up to [two] hours with minimal s/s (signs/symptoms) of redness, swelling, discomfort or pain. Short-Term Goal: Patient will safely wear least restrictive splinting/orthotic device at all times except bathing and exercise without redness and skin irritation in order to improve AROM/PROM (Active Range of Motion/Passive Range of Motion) for adequate hygiene, maintain joint integrity and joint mobility and reduce abnormal tone prior to splint application. Review of R33's Clinical Physician's Orders, located in the EMR under the Orders tab reviewed from 06/25/26 to current, revealed R33 did not have orders for a splint for the left hand or a shoulder wedge for the left shoulder. Review of R33's Nursing to Therapy Screen Request, dated 01/07/26, located in the EMR under the Assessment tab, revealed, left arm contracted, possible splint request. OT to eval [evaluate]. Summary of screening: hand contractures and decreased UE (Upper Extremity) ROM and axilla (armpit) skin breakdown. Review of R33's Occupation Therapy Evaluation & Plan of Treatment, provided by the facility, dated 01/21/26, revealed, A new goal: [R33] will safely wear a resting hand splint on the left hand for up to 2 (two) hours with minimal s/s of redness, swelling, discomfort or pain (Target 04/13/26). New goal: Patient will tolerate positioning wedge/lateral support on left shoulder to prevent axilla skin breakdown for up to [two] hours with minimal s/s of redness, swelling, discomfort or pain (Target 04/13/26). During an observation on 02/09/26 at 9:55 AM, R33 was observed lying in bed, under the covers. R33 had foam wedges on both her left and right side, near her body. Both of her arms were resting on top of her chest with her arms bent at a 45-degree angle with both the right and left hand bent at the wrist with her fingers curled completely into her right and left hands. The foam wedges were not under either her left or right arm. During observations of R33 on 02/09/26 at 10:03 AM and 2:53 PM, R33 was observed lying in bed with foam wedges next to her body. Splints were not observed on either hand. During an observation of R33 on 02/10/26 at 9:55 AM, 10:37 AM and 2:45 PM, R33 was observed lying in bed with foam wedges on both her left and right side, near her body. Splints were not observed on either hand. During an observation of R33 on 02/11/26 at 4:05 PM, R33 was observed lying in bed foam wedges on both her left and right side, near her body. Splints were not observed on either hand. During an observation on 02/12/26 at 7:31 AM, R33 was observed lying in bed with foam wedges on both her left and right side near her body. Both of her arms were resting on top of her chest with her arms bent at a 45-degree angle at the elbow, and her arms lying close to her body, without her armpits exposed. Her arms were lying on her chest with both the right and left hand bent at the wrist with her fingers curled completely into her right and left hands. During an interview on 02/11/26 at 7:40 AM, Certified Nurse Aide (CNA) 9 stated she was not aware of any type of splint for R33's hands. During an interview on 02/11/26 at 2:45 PM, with the Director of Rehab (DOR) and the Occupational Therapist (OT) the OT stated R33 has contractures. She stated if nursing sends a therapy referral for a resident, the therapy department will conduct an evaluation. She stated R33 was receiving Occupational Therapy in June 2025, and she recommended a restorative program upon discharge from occupational therapy. The OT stated they ordered a splint for R33 last year to wear on her left hand and recommended she have restorative therapy to improve R33's tolerance with the hand splint, once discharged from therapy. She stated at that time she had provided CNAs, Restorative CNAs and nurses who worked with R33, education about placement of the splint. The OT stated as of 11/01/25, the restorative program was discontinued, and she was not sure what happened with the splint and did not have documentation of previous education. The OT stated she evaluated R33 on 01/21/26, after receiving a request from nursing for the left-hand contracture. She stated once the evaluation was completed, they determined R33 would be added to their caseload. She stated they were currently working with R33 on ROM. The DOR stated they ordered a splint for R33, and the goal was to have R33 use a splint upon discharge from therapy. The OT stated when she started working with R33 last June she also had some skin breakdown in her armpit area, with an oozing area, and she knew the wound doctor was working with her. The OT and the DOR stated the restorative program was discontinued after the Restorative Nurse resigned and the new company took over. Both stated a restorative program was important to maintain a resident's mobility and agreed it was unfortunate the facility did not have one. During an interview on 02/12/26 at 11:17 AM, the OT stated she looked at R33's skin in her armpit area and it did look better than it had last year. She stated because moisture and redness were under both her left and right arm R33 would benefit from using the wedges under both arms to improve the airflow and relieve the pressure. The OT stated she would educate CNAs again, so they would be aware of how to position the wedges. She stated that R33 had better ROM on her right side than her left side and was able to assist with ROM when she worked with her. She stated R33's needed more stability on her left side and was unable to assist with ROM. The OT stated she had not measured R33's ROM in June of last year or during her current treatment but would start. She stated she did not think the contracture had gotten worse since June of last year and had remained the same. During an interview on 02/12/26 at 2:11 PM, Restorative Aide (RA1) stated they had a good restorative program until the nurse who oversaw the program resigned in November 2025. He stated they do not have a restorative program, and he is currently the only CNA that has worked in the restorative program but is currently working as a CNA on the floor. He stated he remembered R33 used to have a splint, but he was not sure where it was. He stated he was told they were going to reorder a splint for R33. During an interview on 02/12/26 at 5:16 PM, CNA6 stated the last ROM training she received was when she started working at the facility five years ago. During an interview on 02/12/26 at 5:21 PM, CNA8 stated she last received ROM training when she was in school. She stated she had worked at the facility for several years. 2. Review of R83's admission Record, located under the Profile tab of the EMR revealed R83 was admitted on [DATE] with diagnoses which included contracture of muscle and aphasia (impaired ability to understand or produce speech). Review of R83's quarterly MDS, located under the MDS tab of the EMR with an ARD of 12/20/25 revealed a BIMS score of 13 out of 15 which indicated R83 was cognitively intact. The resident was marked as receiving no range of motion or splint devices over the last seven calendar days. Review of R83's EMR revealed no evidence of R83 receiving any restorative services to include splint devices. Review of R83's Care Plan, located under the Care Plan tab of the EMR, revealed no mention of splint devices. During an interview on 02/09/26 at 9:48 AM, R83 stated there were no splints, and the last time one was put on was from therapy. He was observed with a contracted left hand. Review of the Occupational Therapy OT Discharge Summary, signed 09/04/25, revealed Restorative Program Established/ Trained: Restorative Splint and Brace Program. Splint and Brace Program Established/ Trained: Donning/doffing [putting on/taking off] of splint to prevent further joint deformity. During an interview on 02/11/26 at 11:14 AM, the DOR stated they used to have a training log and would do training with the staff for about one to two weeks prior to being discharged from therapy services. She stated they had three restorative CNAs but was unsure how many there were now. She confirmed they did not have a restorative nurse and that MDS was now overseeing the program. The DOR confirmed the September discharge summary was the last time they saw this resident. She stated they did not have a restorative list, and she was unable to see anything in the resident's chart about restorative services. During an interview on 02/11/26 at 11:26 AM, the MDS coordinator (MDSC) stated there was no restorative program as of 11/01/25. She stated the restorative CNAs were working as regular CNAs, getting weights as needed. She stated if the resident had a splint, it would have been care planned and the CNAs on the floor would place it on the resident. She stated that information would also have been on the Kardex. She reviewed the care plan and Kardex for R83 and confirmed there was no mention of splints. During an interview on 02/11/26 at 11:39 AM, the previous Director of Nursing (PDON) stated they had a restorative program with a nurse and a team, but they could not have a nurse anymore. She stated they were awaiting guidance from the new company. She stated they had a list and a tracker, at the nursing station. At 11:44 AM, after looking throughout the nursing station, she stated no list was available. During an interview with the resident, alongside the PDON, R83 stated there was no splint device. During an interview on 02/11/26 at 2:11 PM, the Director of Nursing – Interim Director of Clinical Operations (DON) stated they did not have a restorative nurse but was told nurses on the floor, then the supervisors, then MDS was the one who oversaw the program. She stated she would get with the DOR to see who needed restorative services. Review of the facility's policy titled, Restorative Nursing Programs, reviewed 10/23, revealed It is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level.Potential candidates for restorative nursing services may be identified through one or more of the following processes.specialized rehabilitation assessments.The Restorative Nurse, or designated licensed nurse will provide oversight of the restorative aide activities, review the documentation weekly, and evaluate the effectiveness of the plan monthly. Review of the facility's policy titled, Restorative Nursing Program, revised October 2023, revealed, It is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level.Nursing personnel are trained on basic, or maintenance nursing care that does not require the use of a qualified therapist or licensed nurse oversight. The training may include.Assisting residents in adjustment to their disabilities and use of any assistive devices. Review of the facility's policy titled, Use of Assistive Devices, implemented February 2026, revealed, The purpose of this policy is to provide a reliable process for the proper and consistent use of assistive devices for those residents requiring equipment to maintain or improve function and/or dignity. Assistive devices are . types of equipment that help individuals.Nursing.and therapy departments will work together to ensure availability of devices, such as for ordering and/or replacement.Storage and maintenance of equipment is based on the determination of the department with the responsibility for oversight.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure respiratory supplies were dated and stored in a sanitary manner in accordance with professional standards for one of two residents (Residents (R)117) reviewed for respiratory care. This failure had the potential to affect infection control and had the potential to spread infection in the facility. Findings include:Review of R117's admission Record, located under the Profile tab of the electronic medical record (EMR) revealed the resident was admitted to the facility on [DATE] with diagnoses of acute and chronic respiratory failure with hypoxia, asthma, and obstructive sleep apnea. Review of R117's Orders, located under the Orders tab of the EMR revealed an order for Oxygen at three liters through nasal cannula (NC) for shortness of breath (SOB), monitor for SOB when resident is lying flat, if SOB when lying flat lift head of bed, document and notify medical director (MD) of any changes, every shift starting 01/14/26.During an observation on 02/09/26 at 10:57 AM, R117 had an oxygen concentrator present in her room running at one and a half (1.5) liters per minute (LPM) via NC. A storage bag was not present, and the tubing was not dated. During an interview on 02/09/26 at 10:57 AM, R117 said she has been on oxygen for a long time and that she had oxygen at home too. R117 confirmed she has a hard time breathing without it. During an observation on 02/12/26 at 7:50 AM, R117 had an oxygen concentrator present in her room running at two (2) LPM through NC. No storage bag was present, and the tubing was not dated. During an observation on 02/10/26 at 9:59 AM, R117 was out of her room, and her oxygen concentrator was turned off, oxygen tubing was laying on the bed, and no storage bag was present.During an observation on 02/12/26 at 7:50 AM, R117 had an oxygen concentrator present in her room running at two (2) LPM via NC. No storage bag was present, and the tubing was not dated. During an interview on 02/12/26 at 8:01 AM, Licensed Practical Nurse (LPN)7 confirmed R117 was on oxygen and the concentrator was set on two LPM and should be set on three LPM per the physician order. LPN7 confirmed no storage bag was present and confirmed a storage bag was used to avoid contamination and bacteria when R117 leaves her room and uses portable oxygen. LPN7 also confirmed R117's oxygen tubing was not dated and should be dated to know when it should be changed for sanitary purposes.During an interview on 02/12/26 at 1:54 PM, the Director of Nursing-Interim Regional Director of Clinical Operations (DON) confirmed R117 uses oxygen, and a physician order was documented on admission. The DON confirmed that R117 should be administered oxygen at three LPM, tubing should be dated, and a storage bag should be present to avoid contamination.The facility provided a policy titled, Oxygen Administration, with a revision date of 04/25 that indicated Policy:.Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. 5. Staff shall perform hand hygiene and don gloves when administering oxygen or when in contact with oxygen equipment. Other infection control measures include:.b. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated.e. Keep delivery devices covered in plastic bag when not in use.

Based on record review, interview, and a review of the facility policy titled Hospice Services Facility Agreement, the facility failed to ensure comprehensive fall assessments were completed after a fall, and implement appropriate, individualized fall interventions, placing residents at risk for falls and fall-related injuries for one of five (Resident (R) 68) residents reviewed for falls and also failed to ensure the medical record was complete and accurate for two of three hospice residents (R14 and R36) out of the total sample of 50 residents. This failure placed residents at risk for unmet care needs. Findings include: Review of the facility's policy titled, Hospice Services Facility Agreement, reviewed 09/23, revealed d. Obtaining the following information from the hospice. i. The most recent hospice plan of care specific to each resident.e. Ensuring that the facility provides orientation to hospice staff of the following.iv. Record keeping requirements. 1. Review of R68's Progress Notes, located under the Progress Notes tab of the electronic medical record (EMR) dated 12/14/25 at 4:31 PM revealed R68 had an unwitnessed fall and was found lying on the floor on his back. R68 was sent to the hospital and left the facility via stretcher. Review of R68's discharge return not anticipated Minimum Data Set (MDS), located under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 01/20/26 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating the resident is cognitively intact. Review of R68's Care Plan, located under the Care Plan tab of the EMR revealed R68 was at risk for falls and related injuries due to generalized weakness, psychotropic drug use and had an actual fall on 12/14/25. Review of R68's Fall Assessment, located under the Assessments tab of the EMR dated 01/13/26 indicated the resident had not had a fall in the last 90 days. Review of Facility Reported Incident (FRI), provided by the facility, dated 12/14/25 at 3:30 PM, revealed during rounds, two nurses heard yelling from the resident's room, responded quickly, and found R68 on the floor, beside his bed, on his back. When asked what happened the resident stated that he was trying to go to the bathroom by himself. R68 informed the nursing staff that he recently had neck surgery, and complained of back pain on a scale of 7/10, and requested to go back to the hospital. At 4:30pm on 12/14/25, R68 was transferred to the hospital via stretcher for further evaluation and treatment. On 12/15/25, while at the hospital, R68 stated that he fell because of no assistance from the staff despite multiple attempts to use his call light. R68 stated that he believes the staff only came to check in on him because he fell. R68 sustained no injury related to the unwitnessed fall. During an interview on 02/12/26 at 1:54 PM, the Director of Nursing – Interim Director of Clinical Operations (DON) confirmed that R68's fall assessment was inaccurately completed on 01/13/26 because the resident had a fall in the facility on 12/14/25. During an interview on 02/12/26 at 2:19 PM, the Regional Director of Operations confirmed R68's fall assessment was inaccurate when it was completed on 01/13/26 because the resident had a fall in the facility a month prior. 2. Review of R14's admission Record, located under the admission tab of the EMR revealed R14 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, dementia, and hypertension. Review of R14's admission MDS, with an ARD of 11/12/25, revealed that R14 was assessed with a BIMS score of 8 out of 15, indicating that R14's cognitive function is moderately impaired. Review of R14's Order Audit Report, located under the Orders tab in the EMR dated 02/09/26, revealed that the physician order for hospice services was entered on 02/09/25 and was confirmed on 02/10/25. Review of an admission Progress Note, dated 11/11/25, and located under the Progress Note tab in the EMR, written by Licensed Practical Nurse (LPN) 9 indicated, Received hospice resident via stretcher accompanied by two hospice personnel. The resident was living in the facility's assisted living. Review of page two of the document titled, Hospice Care Communicator, and located under the MISC tab of the EMR dated 11/11/25, revealed R14 was admitted to the nursing facility on 11/11/25 with hospice services as of 11/11/25. During an interview on 02/11/26 at 12:40 PM, LPN1 stated, I called the assisted living 15 minutes ago. The nurse said the hospice staff will bring the hospice binder and documents to the facility later because when this resident was admitted , she was already on hospice services. On 02/12/26 at 12:00 PM, LPN1 brought the hospice binder with hospice documents to the conference room. During an interview on 02/12/26 at 10:31 AM, the previous DON (PDON) stated, We require a hospice binder that has the active orders, code status, care plans, and certificate of terminal illness. This should be on the unit where the resident resides. 3. Review of R136's admission Record, located under the Profile tab of the electronic medical record (EMR) revealed R136 was admitted on [DATE] with diagnoses which included dementia and hemiplegia [paralysis on one side of the body] and hemiparesis [weakness on one side of the body] following cerebral infarction affecting left non-dominant side. Review of R136's quarterly MDS, with an ARD of 12/18/25 and located under the MDS tab of the EMR, revealed a BIMS score of zero out of 15 which indicated R136 was severely cognitively impaired. The resident was marked as receiving hospice services. Review of R136's Physician Orders, located under the Orders tab of the EMR revealed an order for admission to hospice on 09/08/25. Review of R136's Care Plan, located under the Care Plan tab of the EMR, revised on 02/04/26, revealed the resident was on hospice due to a terminal condition. [The terminal condition was not listed]. Interventions included: Center staff will notify hospice of significant changes, clinical complications needing POC [plan of care] change.Assess for pain, restlessness, agitation.Hospice to provide over and beyond services other the SNF [skilled nursing facility] which includes but not limited to spiritual counseling, increased social services and increased clinical visits, expanded pain/comfort control.Provide emotional support to patient and family. Review of the hospice documentation provided by the facility revealed one page located in a folder at the nursing station. The form titled, admission Orders/Hospice Certification, dated 09/07/25, revealed the level of care was routine home care nursing home. Initial weekly staff frequency included: Nurse, Social Work (SW), Chaplain per protocol. Primary diagnoses included cerebral atherosclerosis. The form included a list of medications. The interval of plan of care renewal and care plan update: at least biweekly. The file did not contain any additional documentation from hospice. During an interview on 02/11/26 at 8:41 AM, LPN stated R136 was the only one using this hospice service. She confirmed there was only one document located in the hospice folder for this resident. She confirmed there was no documentation in the EMR from hospice services. She stated she knew a nurse came and a Certified Nurse Aide (CNA) came but was unable to report anything additional. During an interview on 02/11/26 at 11:44 AM, the previous Director of Nursing (PDON) stated the Unit Managers oversaw obtaining the documentation from hospice.

Based on staff interviews, record review, the facility failed to provide bed hold information, in writing, at the time of transfer or within 24 hours, for one of 40 sampled residents (R) (R16). This failure had the potential to contribute to possible denial of re-admission and loss of the resident's home following a hospitalization for residents transferred to the hospital. Findings include: Review of the electronic medical record (EMR) for R16 revealed they were admitted to the facility with diagnoses of but not limited to end stage renal disease, type 2 diabetes mellitus without complications acute on chronic diastolic (congestive) heart failure spinal stenosis, cervical region, generalized anxiety disorder, chronic kidney disease, stage 5, anemia in chronic kidney disease, Alzheimer's disease, unspecified, acute embolism and thrombosis of deep veins of left upper extremity, pruritus, unspecified, depression. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] for R16 documented a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive deficit. Further review of physician orders revealed R16 was prescribed Carvedilol Tab 25 MG (milligram) Give 1 tablet orally two times a day related to Acute or chronic diastolic (congestive) heart failure Pharmacy Active 2/15/2025 17:00 (5:00 pm) 2/17/2025 Supply Clopidogrel Bisulfate Tab 75 MG (Base Equiv (equivalent) Give 1 tablet orally one time a day related to Athscl (atherosclerotic) heart disease of native coronary artery w/o (without) [NAME] pctrs (angina pectoris) Pharmacy Active 2/16/2025. Review of R16's EMR revealed R16 was sent to the hospital on 2/4/2025. Further review revealed there was no bed hold policy notice in the EMR or in the paper chart. During an interview on 3/27/2025 at 2:25 pm with Licensed Practical Nurse (LPN) BB regarding the bed hold policy when a resident was transferred to the hospital, she revealed that Admissions was responsible for sending a resident to the hospital with bed hold policy notice and informing them when the bed hold was going to expire. During an interview on 3/27/2025 at 2:36 pm with the Director of Admissions, she revealed that the bed hold policy notice was included in the admission package upon resident admission. She stated that the resident or their responsible party signed the form at admission, and it stayed in the resident file. She stated that when residents transferred to the hospital, they did not send them out with a bed hold policy notice. She stated that when the business office staff came in the next day, they looked at the midnight census to know which residents transferred to the hospital and then put it in their system. During an interview on 3/27/2025 at 2:40 pm with the Business Office Manager, she revealed they were not responsible for sending out a bed hold policy notice to residents when transferring to the hospital. During an interview on 3/27/2025 at 2:37 pm with the Administrator regarding the facility bed hold policy when transferring to the hospital, she revealed that upon admission the bed hold policy was included with the admission package. She stated they do not send residents with a bed hold policy notice when they transfer to the hospital because they already had one in their chart upon admission. She stated the facility had no policy on bed holds.

Based on observations, resident and staff interviews, record review, and review of the facility policy titled, Comprehensive Person-Centered Care Plans, the facility failed to implement a care plan for oxygen (O2) therapy for one of 10 residents (R) (R53) receiving O2 therapy. The deficient practice had the potential for R53's needs to go unmet. Findings include: Review of the facility policy titled Comprehensive Person-Centered Care Plans dated January 2025 revealed under Policy: Each resident will have a person-centered plan of Care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care. Review of the Physician's Orders for R53 revealed an order dated 3/27/2025 for oxygen at 2 liters per minute (LPM) via nasal cannula (NC) as needed for O2 sats (saturations) oxygen in place for R53. Review of R53 care plan revealed a care plan intervention for the use of oxygen set at 2 L (liters). Observation and interview during the initial screening on 3/25/2025 at 10:00 am revealed R53's O2 level was set at 3 LPM. R53 stated that it should be set at 2 LPM. Observation on 3/25/2025 at 03:28 pm revealed R53's O2 level remained set at 3 LPM. Observation on 3/26/2025 at 10:56 am revealed R53's O2 level was still set at 3 LPM. During an interview on 3/26/2025 at 3:52 pm with Licensed Practical Nurse (LPN) AA regarding R53's O2 setting, she stated that the order was for O2 to be set at 2 LPM. During an interview on 3/26/2025 at 5:40 pm with LPN BB, she confirmed that R53's O2 was set at 3 LPM. She went to the EMR and confirmed that the physician order was for O2 to be set at 2 LPM. During an interview on 3/27/2025 at 8:00 am with the Director of Nursing (DON), she revealed that she expected staff to follow and adhere to the physician order and to ensure that during rounds O2 was set at the ordered level

Based on observations, record review, resident and staff interviews, and review of the facility's policies titled, Admission/Readmission Orders and Oxygen (O2) Therapy, the facility failed to transcribe and to have physician orders for catheter care for one of one resident (R) (R93) reviewed with an indwelling catheter; and failed to follow physician orders to administer O2 to one of 10 R's (R53) receiving O2 therapy. The deficient practice had the potential to cause risk of complications, urinary tract infections (UTI) and other catheter-related harm to R93, and low O2 levels to R53. Findings include: Review of the facility policy titled Oxygen Therapy dated January 2025 documented under Procedure: 1: Oxygen Therapy is to be provide under the direction of a written physician's order. A physician order for O2 therapy is to contain liter flow per minute via mask or canula/time frame. On an emergency basis, O2 may be used at 2L/minute (liters per minute-LPM) until the oxygen is ordered. Review of the facility policy titled Admission/Readmission Orders revised February 2019 documented under Policy: Upon admission/readmission, orders for care of the resident are received from attending physician, placed on physician's order sheet and filed in the medical record. Under Procedure: . 2. Re-admission to the facility after hospitalization s voids all previous orders. Therefore, all orders pertinent to resident must be re-written upon re-admission. 1. Review of the EMR revealed R93 was admitted to the facility with diagnoses including but not limited to obstructive and reflux uropathy and bladder-neck obstruction. Review of the 5 Day MDS assessment dated [DATE] documented in Section C (Cognition) a BIMS score of 8, which indicated R93 had moderately impaired cognition. Section H (Bowel and Bladder) Indwelling catheter and always incontinent. Section I (Active Diagnoses) Obstructive uropathy. Review of the Physician's Orders revealed no physician's orders for R93's foley catheter care. Review of the care plan dated 12/20/2024 documented including but not limited to: The resident has Indwelling Catheter, diagnosis (dx) of obstructive uropathy. The resident will be/remain free from catheter-related trauma through review date, The resident will show no signs and symptoms (s/sx) of Urinary infection through review date, Catheter: The resident has foley catheter. Position catheter bag and tubing below the level of the bladder and away from entrance room door; Monitor/document for pain/discomfort due to catheter; Monitor/record/report to MD (medical doctor) for s/sx UTI (urinary tract infection): pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp; Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Observation on 3/25/2025 at 10:20 am revealed R93 in her room lying in bed. A foley catheter was observed on the side of the bed and the foley catheter bag was in a drainage bag holder. Observation on 3/26/2025 at 11:25 am revealed R93 in her room sitting up in bed. A foley catheter was observed on the side of the bed and the foley catheter bag was in a drainage bag holder. Observation on 3/27/2025 at 12:50 pm revealed R93 in her room sitting in a chair beside her bed eating lunch. R93 had a leg bag attached to the foley catheter. Review of the EMR for R93's After Visit Summary from [name of hospital] dated 12/10/2024 -12/18/2024 documented included but not limited to PLAN: Bladder outlet obstruction: continue foley catheter, F/U (follow up) with Urology. Interview on 3/25/2025 at 10:30 am with R93 revealed she stated she was admitted to the facility from the hospital with the foley catheter. Interview on 3/27/2025 at 10:55 am with Unit manager (UM) CC, she confirmed and verified there were no physician orders for R93's foley catheter care. She stated there was usually an admission and discharge nurse who would write the initial orders for the residents who were admitted , but she did not. She stated she would also review the admission information and write the orders. She stated she did not write the orders for the foley catheter for R93, and she should have checked to ensure the orders were there, but she did not. UM CC stated if there were no physician's orders, the outcome would be the staff may not be aware that R93 had a foley catheter. She stated the orders should be there in the EMR so that everybody would be aware that R93 had a foley catheter in place. She further stated the staff would not be able to sign off on the orders to show that catheter care was done. Interview on 3/27/2025 at 11:00 am with Admission Nurse (AN) DD confirmed there were no physician orders for R93's foley catheter care. She stated she was familiar with R93, and she was aware she had a foley catheter. She stated she was responsible for writing the orders for the newly admitted residents and also for transcribing orders from the hospital notes. The AN stated she did not place the orders for R93's foley catheter in the EMR and she should have placed or transcribed the orders. She stated there should be orders for the foley catheter which included to be changed if needed, to notify the physician if there was leakage of the foley, and to empty the foley and document it. She stated an order should be there for the foley catheter and diagnosis to indicate the need for the foley catheter. She stated the outcome if there was no order for the foley catheter would be the staff would not know R93 had a foley catheter, they would not check it, and they would not change it if needed. AN DD stated the resident could be at risk for infection if catheter care was not done. Interview on 3/27/2025 at 11:31 am with the Director of Nursing (DON) revealed her expectations were for the nurses to ensure there were physician's orders and adhering to the physician's orders. She stated there should be physician's orders for the foley catheter and any licensed nurse was responsible for contacting the physician to put in the orders for the foley catheter or to transcribe the orders from the hospital discharge notes. The DON stated if there were no physician's orders, the outcome could be serious to the resident, such as obtaining a urinary tract infection or complications such as bleeding from the urinary tract. 44959 2. Review of the electronic medical record (EMR) revealed R53 was admitted to the facility with diagnoses of but not limited to type 2 diabetes mellitus without complications, peripheral vascular disease, unspecified, cardiovascular and coagulations, hereditary and idiopathic neuropathy, unspecified, acute neurologic, gastro-esophageal reflux disease without esophagitis, anemia, unspecified, acute embolism and thrombosis of right femoral vein cardiovascular and coagulations, unspecified, essential (primary) hypertension, major depressive disorder, single episode, unspecified, other chronic pain, unspecified. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R53 had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Review of Section O (Special Treatments and Programs) indicated oxygen use. Review of the Physician's Orders revealed an order dated 3/27/2025 for oxygen at 2 L (liters) per minute via nasal cannula (NC) as needed for o2 sats oxygen in place for R53. Observation and interview during the initial screening on 3/25/2025 at 10:00 am revealed R53's O2 level was set at 3 LPM. R53 stated that it should be set at 2 LPM. Observation on 3/25/2025 at 03:28 pm revealed R53's O2 level remained set at 3 LPM. Observation on 3/26/2025 at 10:56 am revealed R53's O2 level was still set at 3 LPM. During an interview on 3/26/2025 at 3:52 pm with Licensed Practical Nurse (LPN) AA regarding R53's O2 setting, she stated that the order was for O2 to be set at 2 LPM. During an interview on 3/26/2025 at 5:40 pm with LPN BB, she confirmed that R53's O2 was set at 3 LPM. She went to the EMR and confirmed that the physician order was for O2 to be set at 2 LPM. During an interview on 3/27/2025 at 8:00 am with the Director of Nursing (DON), she revealed that she expected staff to follow and adhere to the physician order and to ensure that during rounds O2 was set at the ordered level.

Based on observations, interviews, record review, and review of the policies titled Self-Administration Protocol and Medication Administration: General Guidelines, the facility failed to assess one of four residents (R) (R80) for the ability to self-administer medications prior to leaving medications at the bedside. Findings included: A review of the policy titled Medication Administration: General Guidelines revealed the policy was: Procedure: 2. Medications are administered, in accordance with written orders of attending physicians, taking into consideration manufacturer's specifications and professional standards of practice. 3. Residents are allowed to self-administer medications when specifically authorized by the attending physician and the Interdisciplinary Team and in accordance with procedures for self-administration of medications. A review of the policy titled Self-Administration Protocol revealed the policy was: Procedure: 1. If the resident wishes to participate, the Interdisciplinary Team will complete the Medication Self-Administration Assessment. 2. A written order for the bedside storage of medication is placed in the resident's medical record. 3. Bedside storage of medications is indicated on the resident's medication administration record (MAR) for the appropriate medications. A review of the Quarterly Minimum Data Set (MDS) assessment date 9/6/2023 revealed that R80 presented with a Brief Interview for Mental Status (BIMS) score of 14, indication no cognitive impairment. A review of the care plan dated 2/11/2023 revealed there was not a focus area for the Self-Administration of medication, nor assessment indicating it was approved to leave medication at R80's bedside. A review of the physician's orders for the months of September 2023 and October 2023 revealed there was no order for the Self-Administration of medication. A review of the Medication Administration Record (MAR) for September and October 2023 revealed there was no order for Self-Administration of the medication Vitafusion Women's Gummy Vitamins to be left at R80's bedside. A review of the Educational In-Service Record dated 6/28/2023 through 6/29/2023 signed by Staff Development Coordinator revealed training for multiple topics including never leave medication in a resident's room unless ordered by the physician. An observation during medication administration pass with the Licensed Practical Nurse (LPN) GG on 10/25/2023 at 9:05 am revealed that R80 was taking her own medication at her bedside. The nurse stated that it was Vitafusion Women's Gummy Vitamins that she has been taking herself. When asked if she had an order to take it at her bedside, she said no. The resident stated that she has been taking vitamins for quite some time. Once the nurse returned to the cart and we looked through the MAR for a self-administration order for this medication it was determined that it was not found. An interview on 10/26/2023 at 11:10 am with the DON and Administrator revealed that R80's son was not aware that she had the vitamins and did not know where she had gotten them. The DON stated that the Admission Nurse will be more observant of medication that the residents bring in and follow through with an order from the physician and follow the process.

47946 49138 49140 Based on observations, interviews, and review of facility documentation, the facility failed to maintain a clean, homelike environment as evidenced by dirty packaged terminal air conditioner (PTAC) filters and grills, detached PTAC cover, missing PTAC ventilation slats, a non-functioning bathroom emergency call light, a missing dresser drawer handle, a broken closet door handle, and detached baseboards which were observed on three of three units. Findings included: During an observation of resident rooms on 10/24/2023 revealed the following: * At 1:26 pm, room [ROOM NUMBER] was observed with dirty PTAC filters. * At 3:02 pm, room [ROOM NUMBER] was observed with dirty PTAC filters, and the bathroom emergency call light did not light up outside the room. * At 3:20 pm, room [ROOM NUMBER] was observed with dirty PTAC filters and a missing dresser drawer handle. During an observation of resident rooms on 10/25/2023 beginning at 11:35 am revealed the following: * room [ROOM NUMBER] was observed with dirty PTAC filters and grill. * room [ROOM NUMBER] was observed with dirty PTAC filters; bathroom emergency call light did not light up outside the room. * room [ROOM NUMBER]: PTAC filters were cleaned but the grill was still dirty and detached from the unit. * room [ROOM NUMBER]: PTAC filters were cleaned but the grill was still dirty; missing drawer handle from the dresser. * room [ROOM NUMBER] was observed with detached baseboards in the bathroom. * room [ROOM NUMBER] was observed with a clothes hanger holding closet door together. * room [ROOM NUMBER] was observed with peeling walls; worn/stained baseboards. A review of the electronic logbook documentation for heating, ventilation, and air conditioning (HVAC) units revealed the following steps: 1. Remove or open access cover. 2. Remove air filter and inspect for cleanliness. If the filter is dirty, either wash or replace depending on the type of filter. If clean, reinstall filter. 3. Re-install access cover. 4. Clean grill on cover. 5. Close and make sure it is secure. 6. At a minimum, air filters are to be replaced or thoroughly cleaned depending on the type of filter every three months. 7. Clean evaporator coils if lint buildup is present. 8. Inspect electrical motors and wires. A continued review of the electronic logbook documentation revealed air filters were cleaned or replaced on 8/4/2023 for half of the 200 hall and half of the 300 hall; on 9/29/2023 for half of the 300 hall and half of the 200 hall; and 10/17/2023 for the 100 hall. An observation on 10/24/2023 at 10:02 am in room [ROOM NUMBER] revealed shared bathroom base board unattached from the wall exposing caulking and sheetrock. An observation on 10/24/2023 at 10:11 am revealed room [ROOM NUMBER] had a trip hazard (loose baseboard) noted by the bathroom entrance. The Packaged Terminal Air Conditioner Unit (PTAC) was noted to be dusty and grimy. An observation on 10/24/2023 at 10:15 am and 10/25/2023 at 3:00 pm in room [ROOM NUMBER] revealed bed A headboard peeling exposing wooden bed frame material. Observation of closet doors in front of Bed A unattached and closet hinges missing screws unable to properly close. An observation of room [ROOM NUMBER] on 10/24/2023 at 10:20 am revealed the wall behind the head of the beds had peeling wall pieces with two openings in the wall. One opening measured approximately three inches tall by two inches wide and another measured one inch tall by two inches wide. An observation on 10/24/2023 at 10:21 am revealed the PTAC in room [ROOM NUMBER] had broken vents. There was wooden board noted behind the bed (320A) with scratched and missing paint. An observation on 10/24/2023 at 10:27 am revealed room [ROOM NUMBER] had wax build up on the floor in the bathroom. The PTAC was noted to be dusty and grimy with broken vents. An observation on 10/24/2023 at 10:37 am revealed room [ROOM NUMBER] PTAC was noted to be dusty and grimy. An observation of room [ROOM NUMBER] on 10/24/2023 at 1:29 pm revealed one PTAC located under the window had missing ventilation slats. Further observation revealed the PTAC had a large amount of fuzzy gray material in the fan filter. An observation of room [ROOM NUMBER] on 10/24/2023 at 1:30 pm revealed PTAC unit one located under the window had a large amount of fuzzy gray material with brown and white chunks of unknown substance in the fan filter. An observation on 10/25/2023 at 9:17 am revealed room [ROOM NUMBER] had a trip hazard (loose baseboard) noted by the bathroom entrance. The PTAC was noted to be dusty and grimy. An observation on 10/25/2023 at 9:21 am revealed that the PTAC in room [ROOM NUMBER] had broken vents. Behind bed A was a wooden board that was scratched up with missing paint. An observation on 10/25/2023 at 9:35 am revealed that room [ROOM NUMBER] had a wax buildup on the floor in the bathroom. The PTAC was noted to be dusty and grimy with broken vents. An observation on 10/25/2023 at 9:37 am revealed that the PTAC in room [ROOM NUMBER] was noted to be dusty and grimy. An observation tour on 10/26/2023 at 10:15 am with the Maintenance Director and the Executive Director verified room [ROOM NUMBER] with holes in the wall; room [ROOM NUMBER] PTAC unit with large amounts of gray, fuzzy matter and with clumps of brown and white chunks stuck in the fan filter; and room [ROOM NUMBER] PTAC unit with broken ventilation slats. During an interview on 10/26/2023 at 10:30 am with the Administrator, he stated that some PTAC units had been replaced recently but there was not a current order for PTAC units. He stated the normal delivery time for PTAC units was around three months. During an interview and walking rounds on 10/26/2023 at 10:40 am with the Administrator and Maintenance Director confirmed damaged closet doors, one peeled bed headboard, and one baseboard needing repair. During an interview with the President and [NAME] President of Operations on 10/26/2023 at 12:00 pm, the [NAME] President of Operations stated the Maintenance team does not have a policy for maintenance duties, but they do have a schedule and protocol for routine maintenance duties including the HVAC and PTAC units. He stated the PTAC filters should be inspected and cleaned at least every 90 days and have documentation to support the completion of those duties. When shown the pictures of one of the dirty filters, he confirmed the filters might need to be checked more frequently.

Based on observations, staff interviews, record review, and review of policy and procedures titled Comprehensive Person-Centered Care Plans the facility failed to implement a care plan for one of three residents (R) (R30) observed during wound care. Findings included: A review of the policy titled Comprehensive Person-Centered Care Plans dated March 2018, revealed each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care. Under the heading Procedure, number six revealed staff approaches are to be developed for each problem/strength/need and assigned disciplines will be identified to carry out the intervention. An observation of wound care for R30 with Registered Nurse (RN) AA and Certified Nursing Assistant (CNA) BB assisting RN AA was conducted on 10/25/2023 at 1:31 pm. Prior to beginning wound care, R30 voiced complaints of pain in her leg. RN AA acknowledged the resident stated she was hurting and continued with the wound care starting with the wound on R30's left lower extremity (LLE). During wound care R30 voiced pain in her leg as CNA BB positioned her left leg for the wound care. RN AA removed the dressing to R30's LLE. Each time CNA BB moved R30s leg during the dressing change R30 grimaced. A review of the electronic medical record (EMR) revealed R30 was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses listed but not limited to infection of intervertebral disc (pyogenic) sacral /sacrococcygeal region, methicillin resistant staph infection cellulitis of left lower limb, and type 2 diabetes mellitus. A review of R30's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 11, indicating moderate cognitive impairment. A review of R30's care plan initiated on 7/20/2023 and last updated on 9/26/2023 indicated a problem of potential for skin breakdown/pressure ulcers and poor healing of wounds due to impaired mobility, DM2, and incontinence. The resident refuses to turn and reposition in spite of attempts. The resident refuses to get out of bed, refuses skin assessments, and is resistive to care. Care plan update on 5/5/2023: resident has a stage four pressure ulcer to sacrum. Care plan update on 9/26/2023: venous wound to left calf. The care plan goals included but were not limited to no new skin breakdown/pressure ulcers, area will remain free from signs/symptoms of infection, pressure ulcer will decrease in size. The care plan interventions included but were not limited to accept refusal of care and try later, pain evaluation prior to wound care, and medicate as ordered. A review of the EMR revealed physician's orders for R30 included but was not limited to cleanse wound to left calf with normal saline, pat dry. Apply collagen sheets, cover with ABD pad, wrap with kerlex, secure with tape, and cover with tubigrip three times a week and as needed. Sacrum wound care: Clean area with normal saline, pat dry then pack with iodoform gauze cover with island gauze with border dressing every Tuesday, Thursday, Sunday, and as needed. Pain medications ordered included: morphine sulfate 100 mg/5 mg, orally every six hours as needed, gabapentin 300 mg capsule, orally three times a day, diclofenac sodium one percent gel, apply four grams to upper extremities topically three time a day as needed, Aspirin enteric coated 81 milligrams (mg) orally daily, Acetaminophen 325 mg, two tablets orally every six hours as needed, and Percocet 7.5/325 mg one tablet orally every six hours as needed. A review of R30's Medication Administration Record (MAR) revealed medications that R30 had received on 10/25/2023 before 1:30 pm (prior to wound care) were gabapentin 300 mg, last dose administered on 10/25/2023 at 6:00 am and Percocet 7.5/325, last administered on 10/25/2023 at 9:09 am. During an interview with RN AA on 10/25/2023 at 1:31 pm, she acknowledged R30 complained of pain in her leg and stated she receives pain medication at scheduled times throughout the day. During an interview with RN AA on 10/26/23 10:07 am, RN AA revealed she confirmed and verified R30 does take Gabapentin 300 mg scheduled and on 10/25/2023 at 1:30 pm (at time wound care was performed) R30's last dose of Gabapentin was at 6:00 am. She reviewed R30's MAR and confirmed and verified she had received percocet at 9:09 am for complaints of pain. She confirmed and verified R30 had acetaminophen 325 mg, two tablets oral every six hours as needed, morphine sulfate 100 mg/5ml every six hours as needed, diclofenac sodium gel four grams topically upper extremities three times a day as needed ordered but none were given prior to wound care. She confirmed and verified R30 voiced her leg was hurting prior to wound care and during wound care, she verified and confirmed the resident was grimacing and complaining of pain when the CNA moved her left leg during wound care. She stated the process should be when a resident complains of pain, the wound care nurse lets the nurse assigned to the care of the resident know and determine if the resident can have any medication for pain. She stated R30 was a different breed and she is a little bit different. She clarified that statement with the statement of it is hard to tell if the resident is hurting because she yells and tells the nurse she is hurting when no one is touching her and if you touch her, she complains it is painful. She stated she should have gone to check with the nurse to see when she last had pain medication and when she could have pain medication but did not do this because R30 complains with pain upon light touch. During an interview with the Director of Nursing (DON) and the [NAME] President of Operations on 10/26/2023 at 10:16 am, the DON stated pain is what the resident states it is, the nurse should assess pain and treat, then reassess effectiveness of the treatment provided. She stated her expectation was for nursing to manage pain for patients who are in pain. During an interview with the Medical Director on 10/26/2023 at 2:19 pm, he stated that it is the expectation that the resident receives medications for pain as ordered and to receive pain medication before wound care procedures. He stated he just placed R30 on hospice to address her comfort needs and he expects that she be comfortable during any procedures and wound care.

Based on observations, interviews, and record review, the facility failed provide daily oral care for two of three sampled residents (R) (R51 and R175). Findings included: A review of the undated facility policy titled, A.M. Care, revealed the following: Policy: A.M. Care will be given to residents daily. Responsibility: All Nursing Assistants Procedure: A. Oral Care: 1. Toothetts for people with no teeth 2. Brush teeth of residents with teeth A review of the undated facility policy titled, P.M. Care, revealed the following: Policy: P.M. Care is provided to the residents daily. Responsibility: All Nursing Assistants 1. An observation and interview with R51 on 10/24/2023 at 2:59 pm in her room, she was alert and oriented, dressed and groomed, and seated in her wheelchair. There was a foul odor coming from her mouth. She stated she was unsure about the frequency of her oral care stating she had very few teeth. She stated she rinses with mouthwash sometimes. A review of the Quarterly Minimum Data Set (MDS) assessment for R51, dated 8/6/2023, documented a Brief Interview for Mental Status (BIMS) score of 14, indicating little to know cognitive impairment. In addition, the assessment documented R51 as dependent for oral care, with helper performing all of the effort to complete the activity. A review of the care plan for R51 dated 4/25/2023 documented a risk for self-care deficit/impaired mobility with decline in function and mobility. Interventions included assisting with grooming, bathing, dressing, and meals as scheduled and as needed. An observation/interview with R51 on 10/25/2023 at 11:20 am in her room with family visitors. She was dressed and groomed, seated upright in her bed. She stated she had received a bed bath but no oral care. A family member asked R51 if she got oral care every day and she stated she did not. An observation and interview with R51 on 10/26/2023 at 11:10 am, she was alert and oriented, dressed and groomed, and seated in her wheelchair. She stated she had not received oral care today. 2. During an observation and interview with R175 on 10/24/2023 at 3:05 pm in her room, she was alert and oriented, dress and groomed, and seated in her wheelchair. She stated she did not receive oral care today. A review of the Admission MDS assessment was not completed for R175. R175 was admitted to the facility on [DATE]. A review of the baseline care plan for R175, dated 10/12/2023, did not address oral care. During an observation and interview with R175 on 10/25/2023 at 1:42 pm, she was dressed and groomed but stated she did not receive oral care today. In addition, she stated she could brush her own teeth but would need to have everything set up for her on her bedside table. During an observation and interview with R175 on 10/26/2023 at 11:05 am, she was dressed and groomed and seated upright in her bed. She stated she did not receive oral care this morning. During an interview with Certified Nursing Assistant (CNA) NN on 10/26/2023 at 11:20 am, she stated it was her first day working at the facility. She stated residents should receive oral care daily. During an interview with CNA OO on 10/26/2023 at 11:25 am, she stated residents should receive oral care twice a day. During an interview with CNA PP on 10/26/2023 at 1:03 pm, she stated she bathed both R51 and R175 today, but she did not perform oral care; she left that to another CNA for later today because she stated the residents often like to sleep late. When asked why she did not perform the oral care for R51 and set up R175 to perform her own oral care, she did not explain any further. She repeated that she left those tasks for other CNAs to perform. She stated she did not take care of R51 and R175 on 10/24/2023 and 10/25/2023 because she was not working on those days. During an interview with the Director of Nursing (DON) on 10/26/2023 at 3:21 pm, she stated residents should receive oral care once a shift, at least two times a day. She could not determine why R51 and R175 did not receive oral care on 10/24/2023 and 10/25/2023 along with their baths in the morning.

Based on resident clinical record review, laboratory report review, hospital History and Physical form review, hospital Consultation report review, Model Nursing Practice Act review, facility Laboratory Tests policy review, facility Printed Physician Orders policy review, attending physician interview, and staff interview, the facility failed to ensure that laboratory testing, related to [MEDICATION NAME] Time/International Normalized Ratio (PT/INR) laboratory testing, was ordered by facility staff and obtained, in accordance with facility policy and professional standards of practice, for one (1) resident (#17), who received [MEDICATION NAME] anticoagulant drug therapy and had a physician's order for PT/INR laboratory testing, and also failed to correctly transcribe physician's PT/INR orders for Resident #17 and two (2) additional residents (#6 and #9), who also had physicians' orders for [MEDICATION NAME] anticoagulant drug therapy and PT/INR laboratory testing, of thirteen (13) sampled residents who received [MEDICATION NAME] anticoagulant drug therapy and had physicians' orders for PT/INR laboratory testing, from a total survey sample of twenty-nine (29) residents. Resident #1 subsequently experienced bleeding, was transferred to the hospital, and was diagnosed with [REDACTED]. The resident was administered Vitamin K and fresh frozen plasma in the hospital. Based on the above, it was determined that the facility's failure to obtain laboratory testing as ordered by the physician caused serious harm to Resident #17. It was therefore determined that the facility's noncompliance with one or more requirements had caused, or was likely to cause, serious injury, harm, impairment or death to residents. Immediate Jeopardy was identified to have existed as of August 24, 2012, and continued through November 6, 2012, at which time a plan was implemented by the facility to remove the Immediate Jeopardy situation as of November 7, 2012. The facility's Assistant Director of Nursing was notified on November 5, 2012 at 9:00 a.m. that Immediate Jeopardy existed. Findings include: Review of Article II of the Model Nursing Practice Act, Section 2.3.2, specified that the responsibilities for Nursing Practice Implementation included seeking clarification of orders when needed. The facility's Laboratory Tests policy specified, in the Policy section, that laboratory tests were to be completed as ordered by the physician. This policy also specified, in the Procedure section, that the licensed nurse or designee would, upon obtaining laboratory orders by the physician, enter this information on the Lab Scheduling/Tracking Form, and would complete the appropriate Lab Requisition form. For new admissions with laboratory orders, this policy specified that the transcribing nurse was responsible for adding the laboratory tests to the Lab Scheduling/Tracking form. Also, the facility's Printed Physician Orders policy specified that physician's orders for the upcoming month would be accurately reconciled. 1. Please cross refer to F309 for more information regarding Resident #17. Record review for Resident #17 revealed a Physician's admission orders [REDACTED]. An 08/17/2012 laboratory report for Resident #17 documented that PT/INR laboratory tests had been completed on that date. However, further record review revealed no evidence to indicate that, after the 08/17/2012 laboratory PT/INR tests, any additional PT/INR laboratory tests were done as ordered for the remainder of August or September 2012. During an interview with Nurse "AA", the Unit Manager, conducted on 11/05/2012 at 11:40 a.m., this nurse stated that after a review of the medical record documents for Resident #17, while she had found a laboratory requisition for 09/04/2012, she did not find a laboratory requisition for this laboratory testing to be done, as ordered, between 08/17/2012 and 09/04/2012. As indicated above, the facility's Laboratory Tests policy specified that nursing staff were to, upon obtaining laboratory orders by the physician, enter this information on a Lab Scheduling/Tracking Form and complete the appropriate Lab Requisition form. There was no evidence that nursing staff completed these laboratory requisition forms, per policy, for Resident #17 in relation to the physician's 08/16/2012 physician's PT/INR order, and no evidence of an order specifying discontinuation of this laboratory testing. A Departmental Notes entry of 09/02/2012 at 12:53 p.m. documented that Resident #17's brief and toilet were noted with a very large amount of blood, and that when notified, the physician ordered to send the resident to the hospital. A 09/03/2012 hospital History and Physical form documented the resident's 09/02/2012 hospital admission, and documented admitting [DIAGNOSES REDACTED]. A hospital Consultation report of 09/03/2012 documented that Resident #17 had received Vitamin K and fresh frozen plasma. Additional review of Resident #17's nursing facility medical record revealed that despite the 08/16/2012 Physician's Admission Order referenced above to perform weekly PT/INR laboratory tests for four weeks, then monthly, and despite no evidence of a physician's order to discontinue this weekly PT/INR test, review of the resident's monthly September 2012 Physician's Order sheet revealed that a line had been drawn through the weekly times four weeks PT/INR order, indicating the discontinuation of this weekly laboratory testing. However, as of the September 1, 2012 effective date of the September 2012 monthly Physician's Order sheet, the resident, who was admitted to the facility on [DATE], had only been in the facility for fifteen (15) days, but the original physician's order had been for PT/INR laboratory tests to be done weekly for four (4) weeks. The September 2012 Physician's Orders sheet referenced above had been signed as having been reviewed by Nurse "BB" on 08/31/2012. During an interview conducted on 10/10/12 at 11:00 a.m., Nurse "BB" stated that when a physician wanted to stop weekly laboratory tests, he/she would either write an order on the laboratory sheet or give a verbal order to stop the weekly laboratory tests. However, during a telephone interview conducted on 10/12/2012 at 2:00 p.m., the attending physician stated that he had not given an order to stop the weekly laboratory draw for Resident #17. During an interview with Nurse "AA", the Unit Manager, conducted on 11/05/2012 at 11:40 a.m., this nurse stated that she did not know who had lined through the PT/INR laboratory order indicating to discontinue this order for Resident #17, and that no nurse had been found who would take responsibility for drawing a line through the order. Based on the above, the facility failed to provide resident care in accordance with professional standards of practice for Resident #17. Despite the 08/16/2012 Physician admission orders [REDACTED]'s order to discontinue these weekly laboratory tests, facility nursing staff failed to ensure that laboratory requisition forms were done, per facility policy, to ensure the completion of these laboratory tests as ordered. This laboratory testing was thus not completed as ordered. The resident was subsequently noted with bleeding, was transferred to the hospital, and was diagnosed with [REDACTED]. In addition, facility nursing staff discontinued the original physician's order for PT/INR testing upon transcription to the next month's Physician's Orders sheet, with no additional physician's order to do so. 2. Record review for Resident #6, conducted on 11/05/2012, revealed an admission face sheet which documented the resident's 10/17/2012 admission to the facility. This face sheet also documented that the resident had [DIAGNOSES REDACTED]. A Physician's Telephone Orders sheet of 10/20/2012 specified that Resident #6 receive the anticoagulant [MEDICATION NAME], 5 milligrams daily. This Physician's Telephone Orders sheet also specified that PT/INR laboratory tests be performed weekly for four weeks, then monthly, for [MEDICAL CONDITION]. A Physician's Telephone Orders sheet of 10/24/2012 specified to hold [MEDICATION NAME] for one dose, and to perform weekly PT/INR laboratory tests. Further record review revealed no evidence of a subsequent physician's order to discontinue these weekly PT/INR tests, as ordered on [DATE]. Record review revealed a laboratory report form of 10/22/2012 for Resident #6 which documented a PT of 12.5 seconds (Reference Range, 10.8 - 13.8), and an INR of 1.03 (Reference Range, 2.0 - 3.5). A notation on this laboratory report form documented physician notification of these results. A subsequent laboratory report form of 10/30/2012 documented a PT of 13.5 seconds, and an INR of 1.9, and a notation on this report documented physician notification, thus indicating that the laboratory testing had been done as ordered. However, review of the printed November 2012 Physician's Orders sheet (which the physician had signed and dated on 11/05/2012, the same date as this complaint survey record review) for Resident #6 revealed, in the Lab Orders section, that PT/INR laboratory tests were to be done monthly. But, as indicated above, the 10/24/2012 Physician's Telephone Orders form had ordered that PT/INR tests be done weekly, and record review revealed no evidence of a subsequent physician's order to discontinue or modify this weekly PT/INR order of 10/24/2012. During an interview with Nurse "AA" conducted on 11/05/2012 at approximately 4:20 p.m., this nurse acknowledged, upon review of the attending physician's orders regarding [MEDICATION NAME] drug therapy and PT/INR laboratory testing for Resident #6, that there was a problem with the laboratory orders for this resident. During an interview with the attending physician conducted on 11/06/2012 at 10:05 a.m., the attending physician indicated that he had not modified the November 2012 Physician's Orders sheet for Resident #6 related to PT/INR testing, and that an order would have been required to discontinue his 10/24/2012 weekly PT/INR test order. Record review revealed a subsequent Physician's Telephone Order sheet, dated 11/05/2012 and timed at 24:00 hours (midnight), after surveyor inquiry earlier on 11/05/2012 at 4:20 p.m. as referenced above, specifying Resident #6 receive weekly PT/INR laboratory tests for two additional weeks, then to begin monthly PT/INR tests in December, 2012. During an interview with the Director of Nursing (DON) conducted on 11/06/2012 at 10:25 a.m., the DON stated that facility staff had reviewed this order discrepancy involving Resident #6 the previous night of 11/05/2012 (after surveyor inquiry), had realized clarification was needed, and had at that time addressed the problem. Based on the above, the facility failed to provide services in accordance with professional standards of practice for Resident #6. Resident #6 had a physician's order specifying weekly PT/INR laboratory testing, but upon renewal and recapitulation of the subsequent monthly Physician's Orders sheet for this resident, nursing staff modified the order, in error, to indicate monthly PT/INR testing, without an actual physician's order to do so. 3. Record review for Resident #9 revealed a hand-written 09/07/2012 Physician's Telephone Orders sheet which ordered that the resident receive [MEDICATION NAME] 40 milligrams subcutaneously every 12 hours, [MEDICATION NAME] 5 milligrams by mouth at 5:00 p.m. daily for 3 days, then decrease to 3 milligrams daily, and PT/INR laboratory tests weekly for four weeks, then monthly. Review of laboratory report sheets revealed that PT/INR laboratory tests were done, as ordered, on 09/12/2012, 09/19/2012, 09/26/2012, 10/03/2012, and 10/29/2012. A printed Physician's Telephone Orders sheet, labeled as a transcribed order by Nurse "FF" and also dated 09/07/2012, reiterated the [MEDICATION NAME] order as referenced above on the hand-written order of that date. Also, these printed transcribed orders indicated to administer doses of [MEDICATION NAME] 40 milligrams subcutaneously every 12 hours, as referenced above, but added a reference indicating to administer the [MEDICATION NAME] until the PT/INR was within therapeutic range, which had not been included in the original physician's order. Additionally, these printed transcribed orders did not transcribe the hand-written physician's order to perform PT/INR laboratory tests weekly for four weeks, then monthly. During an interview with the attending physician conducted on 11/07/2012 at 2:30 p.m., the physician stated that he had not told the nurse to change his original orders of 09/07/2012, and that the nurse had made a transcription error. During an interview with Nurse "FF" conducted on 11/06/2012 at 3:40 p.m., Nurse "FF" acknowledged that she had made a transcription error when transcribing the physician's telephone order of 09/07/2012 for Resident #9. She stated that the pharmacy wanted a stop date, so she had added the reference to administering [MEDICATION NAME] only until the PT/INR was within therapeutic range. She also stated that she had missed the PT/INR order from the original hand-written telephone physician's order when she had transcribed the orders to the computer. During an interview with the DON conducted on 11/07/2012 at 10:32 a.m., the DON acknowledged that Nurse "FF" had transcribed the physician's orders for Resident #9 incorrectly. Based on the above, the facility failed to provide services in accordance with professional standards of practice for Resident #9. Facility nursing staff modified a physician's order for [MEDICATION NAME] administration, with no physician's order to do so, and failed to transcribe an order for [REDACTED]. It was determined that the Immediate Jeopardy was removed on November 7, 2012, at which time the facility had completed the following actions: - On 11/05/2012, the facility's Quality Assurance Committee met to discuss the issue of physicians' orders for laboratory tests not being processed and followed, and the issue of physicians' orders not being brought forward to subsequent monthly orders. Attendees at this meeting included the facility's Administrator, DON, Assistant Director of Nursing (ADON), the 100 Unit Manager, the 300 Unit Manager, the Minimum Data Set (MDS) Coordinator, the Restorative Nurse, the Staff Development Coordinator, the Treatment Nurse, Medical Records personnel, and the Business Office Manager. - On 11/05/2012, after the Quality Assurance Committee meeting referenced above, the Administrator, DON and Medical Director met to discuss the identified issues with laboratory testing and the transcription of physicians' orders. - On 11/06/2012, a one hundred percent resident chart audit of laboratory orders was completed. This audit included the review of all residents (35 of 35) who had physicians' orders for medications which required titration to ensure that all laboratory orders had been reconciled. - On 11/06/2012, the facility implemented a procedure by which the DON, ADON, 100 Hall Unit Manager/300 Hall Unit Manager will perform weekly [MEDICATION NAME] drug audits for four weeks, then monthly for two months. A 20 percent audit of medical records will be conducted to ensure laboratory order reconciliation with current and the previous month's printed physician's orders end-of-the-month change-over. Additionally, a 20 percent audit will be conducted for residents receiving medication requiring titration for two months. The findings of these audits will be presented to the Quality Assurance Committee. - On 11/06/2012, the Quality Assurance Committee met again, both in the morning and afternoon, to discuss the identified issues with laboratory testing and physician order transcription. Attendees at the morning meeting were the Administrator, DON, 100 Unit Manager, 300 Unit Manager, MDS coordinator, Restorative Nurse, Staff Development Coordinator, Treatment Nurse, Medical Records personnel, the Dietician, and the Business Office Manager. Attendees at the afternoon meeting were the Administrator, DON, 100 Unit Manager, 300 Unit Manager, MDS Coordinator, the Staff Development Coordinator, and the Treatment Nurse. - On 11/06/2012, in order to ensure that appropriate orders are brought forward to the new month's orders, and to ensure that laboratory orders are processed and followed, the licensed nurses were in-serviced on monthly change-over and general orders including, but not limited to, communication with the physician, clarification of orders and discontinuation of previous orders (including the inclusion of the discontinuation date) before writing a new order. Of 40 licensed nurses, a total of 30 nurses, 16 in person and 14 by telephone, were in-serviced on that date. The remaining 10 licensed nurses were not to be allowed to work until the in-service training is completed. - On 11/06/2012, the facility implemented the procedure by which ongoing audits regarding the processing of laboratory orders for testing and the transcription of physicians' orders, including laboratory orders, will be conducted by the DON, ADON, 100 Hall Unit Manager, and 300 Hall Unit Manager, who are all active members of the Quality Assurance Committee. Findings from these audits will be presented at Quality Assurance Committee meetings, with identified revisions made as needed. - Additionally, Quality Assurance Committee meetings were scheduled to occur on 11/08/2012 and 11/09/2012 (after the survey exit). Beginning on 11/14/2012, weekly meetings will continue for a period of four weeks. Monthly Quality Assurance Meetings will then continue for a period of two months, and will be ongoing. Based on these corrective action plans which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice had been removed on November 7, 2012. However, the effectiveness of these corrective action plans could not be fully assessed to ensure ongoing application and completion. On November 6, 2012, the facility had conducted staff in-service training regarding the accurate transcription of physicians' orders to subsequent monthly order sheets, focusing on the monthly change-over and general orders. This training involved, but was not limited to, communication with the physician, clarification of orders, discontinuing previous orders as appropriate, and the ordering and processing of laboratory orders. As of November 6, 2012, thirty (30) of forty (40) licensed nursing staff had received this in-service training on the accurate transcription and implementation of physicians' orders, per facility policy. There were, however, ten (10) remaining licensed nursing staff who had not been trained as of that date, and would not be allowed to work until having received the in-service training. In addition, on November 6, 2012, the facility had implemented a procedure by which routine audits would be performed to monitor for the accurate transcription and implementation of physicians' orders, to include orders for laboratory testing, and to ensure laboratory order reconciliation with current orders. Additionally, the Quality Assurance Committee had reviewed these procedures during meetings on 11/05/2012, 11/06/2012, and again on 11/07/2012, during the course of this complaint survey. However, additional Quality Assurance Committee meetings were scheduled to continue the review of facility procedures and the results of facility compliance audits, post this survey, on the dates of 11/08/2012 and 11/09/2012, then weekly for four weeks, with the next meeting scheduled for 11/14/2012, then monthly for two months, then ongoing. The Quality Assurance Committee, in these future meetings, is to review the audit results and formulate any needed modifications to the procedure as part of the facility's corrective action to address the identified deficient practice. However, as indicated above, as of the 11/07/2012 exit date of this survey, training regarding the new facility procedures and processes was pending for ten (10) remaining licensed nursing staff. Also, the facility's procedure for utilizing routine audits to monitor physician order implementation and laboratory order reconciliation had been implemented on November 6, 2012, the day prior to the complaint survey exit, and thus had only been in effect for one day as of the survey exit date. And, the Quality Assurance Committee will continue to meet weekly for four weeks, then monthly, to monitor and review audits and facility procedure implementation, and to identify any needed revisions, but the next scheduled weekly meeting of this Committee was not until November 14, 2012, which was one week after the survey exit date. Therefore, the facility's ongoing implementation of, and conformance with, the new procedures, intended to ensure that physicians' orders are accurately transcribed and implemented, could not be fully assessed. Thus, the non-compliance remains, with the Scope/Severity of the deficiency lowered to the "D" level.

Based on resident clinical record review, laboratory report review, hospital Emergency Department Triage Assessment form review, hospital History and Physical form review, hospital Consultation report review, and staff interview, the facility failed to obtain laboratory testing as ordered and specified in the plan of care, related to [MEDICATION NAME] Time/International Normalized Ratio (PT/INR) laboratory testing, for one (1) resident (#17), of thirteen (13) sampled residents who received [MEDICATION NAME] anticoagulant drug therapy and had physicians' orders for PT/INR laboratory testing, from a total survey sample of twenty-nine (29) residents. Resident #1 subsequently experienced significant bleeding, was transferred to the hospital, and was diagnosed with [REDACTED]. The resident was administered Vitamin K and fresh frozen plasma in the hospital. Based on the above, it was determined that the facility's failure to obtain laboratory testing as ordered and specified in the plan of care caused serious harm to Resident #17. It was therefore determined that the facility's noncompliance with one or more requirements had caused, or was likely to cause, serious injury, harm, impairment or death to residents. Immediate Jeopardy was identified to have existed as of August 24, 2012, and continued through November 6, 2012, at which time a plan was implemented by the facility to remove the Immediate Jeopardy situation as of November 7, 2012. The facility's Assistant Director of Nursing was notified on November 5, 2012 at 9:00 a.m. that Immediate Jeopardy existed. Findings include: Please cross refer to F309 for more information regarding Resident #17. Record review for Resident #17 revealed an 08/16/2012 physician's orders [REDACTED]. The resident's current Care Plan identified multiple care needs in the Problem/Need section, each with an original onset date of 07/06/2012, including the risk for the resident to experience weight loss, skin breakdown, and mood and behavioral decline in part related to the use of [MEDICAL CONDITION] medications. For each of these identified problems, an approach, as referenced in the Approaches section of the Care Plan, was for medications and laboratory testing to be done as ordered by the physician. An 08/17/2012 laboratory report for Resident #17 documented PT/INR laboratory tests of that date. But, further record review revealed no evidence to indicate that any additional PT/INR laboratory tests were done for Resident #17 for the remainder of August or September 2012, despite the Care Plan's specification that laboratory testing be provided as ordered by the physician. A facility Departmental Notes entry of 09/02/2012 at 12:53 p.m. documented that Resident #17's brief and toilet were noted with a very large amount of blood, and that the physician ordered that the resident be sent to the hospital. A 09/03/2012 hospital History and Physical form documented admitting [DIAGNOSES REDACTED]. A 09/03/2012 hospital Consultation report documented that Resident #17 had received Vitamin K and fresh frozen plasma in response to [MEDICATION NAME]-induced coagulopathy. During an 11/05/2012, 10:10 a.m. interview with the Director of Nursing (DON), the DON stated that the facility had no order to discontinue weekly PT/INR tests for four (4) weeks. Based on the above, the facility failed to provide care to Resident #17 in accordance with the resident's plan of care. Despite the 08/16/2012 physician's orders [REDACTED]. [REDACTED]. The resident was subsequently noted with bleeding, was transferred to the hospital, and was diagnosed with [REDACTED]. It was determined that the Immediate Jeopardy was removed on November 7, 2012, at which time the facility had completed the following actions: - On 11/05/2012, the facility's Quality Assurance Committee met to discuss the issue of physicians' orders for laboratory not being processed and followed, and the issue of physicians' orders not being brought forward to subsequent monthly orders. Attendees at this meeting included the facility's Administrator, DON, Assistant Director of Nursing (ADON), the 100 Unit Manager, the 300 Unit Manager, the Minimum Data Set (MDS) Coordinator, the Restorative Nurse, the Staff Development Coordinator, the Treatment Nurse, Medical Records personnel, and the Business Office Manager. - On 11/05/2012, after the Quality Assurance Committee meeting referenced above, the Administrator, DON and Medical Director met to discuss the identified issues with laboratory testing and the transcription of physicians' orders. - On 11/06/2012, a one hundred percent resident chart audit of laboratory orders was completed. This audit included the review of all residents (35 of 35) who had physicians' orders for medications which required titration to ensure that all laboratory orders had been reconciled. - On 11/06/2012, the facility implemented a procedure by which the DON, ADON, 100 Hall Unit Manager/300 Hall Unit Manager will perform weekly [MEDICATION NAME] drug audits for four weeks, then monthly for two months. A 20 percent audit of medical records will be conducted to ensure laboratory order reconciliation with current and the previous month's printed physician's orders [REDACTED]. Additionally, a 20 percent audit will be conducted for residents receiving medication requiring titration for two months. The findings of these audits will be presented to the Quality Assurance Committee. - On 11/06/2012, the Quality Assurance Committee met again, both in the morning and afternoon, to discuss the identified issues with laboratory testing and physician order [REDACTED]. Attendees at the afternoon meeting were the Administrator, DON, 100 Unit Manager, 300 Unit Manager, MDS Coordinator, the Staff Development Coordinator, and the Treatment Nurse. - On 11/06/2012, in order to ensure that appropriate orders are brought forward to the new month's orders, and to ensure that laboratory orders are processed and followed, the licensed nurses were in-serviced on monthly change-over and general orders including, but not limited to, communication with the physician, clarification of orders and discontinuation of previous orders (including the inclusion of the discontinuation date) before writing a new order. Of 40 licensed nurses, a total of 30 nurses, 16 in person and 14 by telephone, were in-serviced on that date. The remaining 10 licensed nurses were not to be allowed to work until the in-service training is completed. - On 11/06/2012, the facility implemented the procedure by which ongoing audits regarding the processing of laboratory orders for testing and the transcription of physicians' orders, including laboratory orders, will be conducted by the DON, ADON, 100 Hall Unit Manager, and 300 Hall Unit Manager, who are all active members of the Quality Assurance Committee. Findings from these audits will be presented at Quality Assurance Committee meetings, with identified revisions made as needed. - Additionally, Quality Assurance Committee meetings were scheduled to occur on 11/08/2012 and 11/09/2012. Beginning 11/14/2012, weekly meetings will continue for a period of four weeks. Monthly Quality Assurance Meetings will then continue for a period of two months, and be ongoing. Based on these corrective action plans which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice had been removed on November 7, 2012. However, the effectiveness of these corrective action plans could not be fully assessed to ensure ongoing application and completion. On November 6, 2012, the facility had conducted staff in-service training regarding the accurate transcription of physicians' orders to subsequent monthly order sheets, focusing on the monthly change-over and general orders. This training involved, but was not limited to, communication with the physician, clarification of orders, discontinuing previous orders as appropriate, and the ordering and processing of laboratory orders. As of November 6, 2012, thirty (30) of forty (40) licensed nursing staff had received this in-service training on the accurate transcription and implementation of physicians' orders, per facility policy. There were, however, ten (10) remaining licensed nursing staff who had not been trained as of that date. In addition, on November 6, 2012, the facility had implemented a procedure by which routine audits would be performed to monitor for the accurate transcription and implementation of physicians' orders, to include orders for laboratory testing, and to ensure laboratory order reconciliation with current orders. Additionally, the Quality Assurance Committee had reviewed these procedures during meetings on 11/05/2012, 11/06/2012, and again on 11/07/2012, during the course of this complaint survey. However, additional Quality Assurance Committee meetings were scheduled to continue the review of facility procedures and the results of facility compliance audits, post this survey, on the dates of 11/08/2012 and 11/09/2012, then weekly for four weeks, with the next meeting scheduled for 11/14/2012, then monthly for two months, then be ongoing. The Quality Assurance Committee, in these future meetings, is to review the audit results and formulate any needed modifications to the procedure as part of the facility's corrective action to address the identified deficient practice. However, as indicated above, as of the 11/07/2012 exit date of this survey, training regarding the new facility procedures and processes was pending for ten (10) remaining licensed nursing staff. Also, the facility's procedure for utilizing routine audits to monitor physician order [REDACTED]. And, the Quality Assurance Committee will continue to meet weekly for four weeks, then monthly, to monitor and review audits and facility procedure implementation, and to identify any needed revisions, but the next scheduled weekly meeting of this Committee was not until November 14, 2012, which was one week after the survey exit date. Therefore, the facility's ongoing implementation of, and conformance with, the new procedures, intended to ensure that physicians' orders are accurately transcribed and implemented, could not be fully assessed. Thus, the non-compliance remains, with the Scope/Severity of the deficiency lowered to the "D" level.

Based on resident clinical record review, laboratory report review, hospital Emergency Department Triage form review, hospital History and Physical form review, hospital Consultation report review, hospital Discharge Summary review, attending physician interview, and staff interview, the facility failed to obtain laboratory testing as ordered by the physician, related to [MEDICATION NAME] Time/International Normalized Ratio (PT/INR) laboratory testing, for one (1) resident (#17), of thirteen (13) sampled residents who received [MEDICATION NAME] anticoagulant drug therapy and had physicians' orders for PT/INR laboratory testing, from a total survey sample of twenty-nine (29) residents. Resident #1 subsequently experienced significant bleeding, was transferred to the hospital, and was diagnosed with [REDACTED]. The resident was administered Vitamin K and fresh frozen plasma in the hospital. Based on the above, it was determined that the facility's failure to obtain laboratory testing as ordered by the physician caused serious harm to Resident #17. It was therefore determined that the facility's noncompliance with one or more requirements had caused, or was likely to cause, serious injury, harm, impairment or death to residents. Immediate Jeopardy was identified to have existed as of August 24, 2012, and continued through November 6, 2012, at which time a plan was implemented by the facility to remove the Immediate Jeopardy situation as of November 7, 2012. The facility's Assistant Director of Nursing was notified on November 5, 2012 at 9:00 a.m. that Immediate Jeopardy existed. Findings include: Record review for Resident #17 revealed a hospital Physician Discharge Orders and Instructions Sheet for Inpatients, dated 08/16/2012, which documented the resident's discharge from the hospital to a rehabilitation facility, and also specified that weekly INR laboratory tests be drawn with the goal of maintaining an INR of 2 to 3. The nursing facility Physician's admission orders [REDACTED]'s drug therapy include a dose of [MEDICATION NAME] 5 milligrams (mgs.) daily as a blood thinner, and also specified that PT/INR laboratory tests be done weekly for four (4) weeks, then each month. This 08/16/2012 Physician's admission orders [REDACTED]. A laboratory final report for Resident #17, with a collection date of 08/17/2012, documented that on that date, the resident's PT was high at 23.2 seconds (Reference Range, 10.8-13.8)and the INR was normal at 3.34 (Reference Range, 2.0-3.5). A notation on this laboratory report indicated that the physician was notified on 08/17/2012. However, further record review revealed no evidence to indicate that, after the 08/17/2012 laboratory PT/INR tests referenced above, any additional PT/INR laboratory tests were done for Resident #17 for the remainder of August and September 2012, despite the 08/16/2012 physician's admission order specifying that PT/INR tests were to be done weekly for four (4) weeks. Record review also revealed no evidence of a physician's order to discontinue the weekly PT/INR tests, originally ordered on [DATE], during the months of August or September 2012. The resident's August and September 2012 Medication Administration Records documented that the resident did receive 5 mg. doses of [MEDICATION NAME] daily beginning on 08/17/2012 and continuing through 09/02/2012. A Departmental Notes entry of 09/02/2012 at 12:53 p.m. documented that the nurse was called to the room of Resident #17 by a certified nursing assistant, and that the resident's brief and toilet were noted with a very large amount of blood. This Notes entry documented that the physician was made aware and initially ordered a urinalysis with culture and sensitivity. However, this Notes entry also documented that the resident refused the collection of urine and was very agitated, and when notified, the physician ordered to send the resident to the hospital to be evaluated. A hospital Emergency Department Triage Assessment Form documented that Resident #17 arrived at the hospital on [DATE] with a chief complaint of hematuria. A 09/03/2012 hospital History and Physical form also documented the resident's 09/02/2012 hospital admitted , and documented in the admitting [DIAGNOSES REDACTED]. This History and Physical form documented, in the Chief Complaint and History Of Chief Complaint section, that the resident had presented to the hospital emergency department with gross hematuria. This History and Physical form documented that the resident had been receiving [MEDICATION NAME] for [MEDICAL CONDITION], and also documented that the work-up in the emergency department had shown severe [MEDICATION NAME] toxicity, with an INR level in excess of 18, and a PT of 120. A hospital Consultation report of 09/03/2012 documented that Resident #17 had been receiving [MEDICATION NAME] therapy and had presented to the hospital with a markedly increased INR of more than 18.1. This Consultation report also documented that the resident had been admitted to the hospital with [REDACTED]. Review of the subsequent hospital Discharge Summary for Resident #17 revealed that the hospital admitted was 09/02/2012 and discharge date was 09/11/2012, and that the discharge [DIAGNOSES REDACTED]. Additional review of Resident #17's nursing facility medical record revealed that despite the 08/16/2012 Physician's Admission Order to perform weekly PT/INR laboratory tests for four weeks then monthly, as referenced above, and despite no evidence of a physician's order to discontinue this weekly PT/INR test, review of the resident's September 2012 Physician's Order sheet revealed that a line had been drawn through the weekly times four weeks PT/INR order. Instead, this September Physician's Order sheet for Resident #17 referenced, in error, only monthly PT/INR laboratory testing. The September 2012 Physician's Orders sheet referenced above had been signed as having been reviewed by Nurse "BB" on 08/31/2012. During an interview with Nurse "BB" conducted on 11/05/2012 at 10:35 a.m., this nurse stated that she had not lined out the order to perform weekly PT/INR laboratory tests on this September 2012 Physician's Orders sheet, that she had not discontinued the weekly PT/INR physician's order, and that she was unaware of who had lined out the laboratory entry on the Physician's Orders sheet. During an additional interview conducted on 10/10/12 at 11:00 a.m., Nurse "BB" stated that when a physician wanted to stop weekly laboratory tests, he/she would either write an order on the laboratory sheet or give a verbal order to stop the weekly laboratory tests. However, during a telephone interview conducted on 10/12/2012 at 2:00 p.m., the attending physician said the order to do PT/INR laboratory tests weekly times four, then monthly, was standard practice at the facility. The physician stated that Resident #17 should have had PT/INR laboratory tests weekly, as he had originally ordered, unless a new physician's order was given, and further stated that he had not given an order to stop the weekly laboratory draw. During an interview with the Director of Nursing (DON) conducted on 11/05/2012 at 10:10 a.m., the DON stated that no physician's order was ever written to discontinue the original 08/16/2012 physician's order for Resident #17 to receive weekly PT/INR tests four one month. Based on the above, despite the 08/16/2012 Physician admission orders [REDACTED]'s order to discontinue these weekly laboratory tests, the facility failed to perform these laboratory tests as ordered. By not performing these laboratory tests as ordered, the facility failed to provide the appropriate care by failing to monitor the effect of, and the resident's response to, the [MEDICATION NAME] anticoagulant drug therapy. The resident was subsequently noted with significant bleeding, was transferred to the hospital, was determined to have critically elevated PT and INR levels, and was diagnosed with [REDACTED]. It was determined that the Immediate Jeopardy was removed on November 7, 2012, at which time the facility had completed the following actions: - On 11/05/2012, the facility's Quality Assurance Committee met to discuss the issue of physicians' orders for laboratory not being processed and followed, and the issue of physicians' orders not being brought forward to subsequent monthly orders. Attendees at this meeting included the facility's Administrator, DON, Assistant Director of Nursing (ADON), the 100 Unit Manager, the 300 Unit Manager, the Minimum Data Set (MDS) Coordinator, the Restorative Nurse, the Staff Development Coordinator, the Treatment Nurse, Medical Records personnel, and the Business Office Manager. - On 11/05/2012, after the Quality Assurance Committee meeting referenced above, the Administrator, DON and Medical Director met to discuss the identified issues with laboratory testing and the transcription of physicians' orders. - On 11/06/2012, a one hundred percent resident chart audit of laboratory orders was completed. This audit included the review of all residents (35 of 35) who had physicians' orders for medications which required titration to ensure that all laboratory orders had been reconciled. - On 11/06/2012, the facility implemented a procedure by which the DON, ADON, 100 Hall Unit Manager/300 Hall Unit Manager will perform weekly [MEDICATION NAME] drug audits for four weeks, then monthly for two months. A 20 percent audit of medical records will be conducted to ensure laboratory order reconciliation with current and the previous month's printed physician's orders end-of-the-month change-over. Additionally, a 20 percent audit will be conducted for residents receiving medication requiring titration for two months. The findings of these audits will be presented to the Quality Assurance Committee. - On 11/06/2012, the Quality Assurance Committee met again, both in the morning and afternoon, to discuss the identified issues with laboratory testing and physician order transcription. Attendees at the morning meeting were the Administrator, DON, 100 Unit Manager, 300 Unit Manager, MDS coordinator, Restorative Nurse, Staff Development Coordinator, Treatment Nurse, Medical Records personnel, the Dietician, and the Business Office Manager. Attendees at the afternoon meeting were the Administrator, DON, 100 Unit Manager, 300 Unit Manager, MDS Coordinator, the Staff Development Coordinator, and the Treatment Nurse. - On 11/06/2012, in order to ensure that appropriate orders are brought forward to the new month's orders, and to ensure that laboratory orders are processed and followed, the licensed nurses were in-serviced on monthly change-over and general orders including, but not limited to, communication with the physician, clarification of orders and discontinuing previous orders (including documenting the discontinuation date) before writing a new order. Of 40 licensed nurses, a total of 30 nurses, 16 in person and 14 by telephone, were in-serviced on that date. The remaining 10 licensed nurses were not to be allowed to work until the in-service training is completed. - On 11/06/2012, the facility implemented the procedure by which ongoing audits regarding the processing of laboratory orders for testing and the transcription of physicians' orders, including laboratory orders, will be conducted by the DON, ADON, 100 Hall Unit Manager, and 300 Hall Unit Manager, who are all active members of the Quality Assurance Committee. Findings from these audits will be presented at Quality Assurance Committee meetings, with identified revisions made as needed. - Additionally, Quality Assurance Committee meetings were scheduled to occur on 11/08/2012 and 11/09/2012. Beginning 11/14/2012, weekly meetings will continue for a period of four weeks. Monthly Quality Assurance Meetings will then continue for a period of two months, and will be ongoing. Based on these corrective action plans which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice had been removed on November 7, 2012. However, the effectiveness of these corrective action plans could not be fully assessed to ensure ongoing application and completion. On November 6, 2012, the facility had conducted staff in-service training regarding the accurate transcription of physicians' orders to subsequent monthly order sheets, focusing on the monthly change-over and general orders. This training involved, but was not limited to, communication with the physician, clarification of orders, discontinuing previous orders as appropriate, and the ordering and processing of laboratory orders. As of November 6, 2012, thirty (30) of forty (40) licensed nursing staff had received this in-service training on the accurate transcription and implementation of physicians' orders, per facility policy. There were, however, ten (10) remaining licensed nursing staff who had not been trained as of that date, and would not be allowed to work until having received the in-service training. In addition, on November 6, 2012, the facility had implemented a procedure by which routine audits would be performed to monitor for the accurate transcription and implementation of physicians' orders, to include orders for laboratory testing, and to ensure laboratory order reconciliation with current orders. Additionally, the Quality Assurance Committee had reviewed these procedures during meetings on 11/05/2012, 11/06/2012, and again on 11/07/2012, during the course of this complaint survey. However, additional Quality Assurance Committee meetings were scheduled to continue the review of facility procedures and the results of facility compliance audits, post this survey, on the dates of 11/08/2012 and 11/09/2012, then weekly for four weeks, with the next meeting scheduled for 11/14/2012, then monthly for two months, then ongoing. The Quality Assurance Committee, in these future meetings, is to review the audit results and formulate any needed modifications to the procedure as part of the facility's corrective action to address the identified deficient practice. However, as indicated above, as of the 11/07/2012 exit date of this survey, training regarding the new facility procedures and processes was pending for ten (10) remaining licensed nursing staff. Also, the facility's procedure for utilizing routine audits to monitor physician order implementation and laboratory order reconciliation had been implemented on November 6, 2012, the day prior to the complaint survey exit, and thus had only been in effect for one day as of the survey exit date. And, the Quality Assurance Committee will continue to meet weekly for four weeks, then monthly, to monitor and review audits and facility procedure implementation, and to identify any needed revisions, but the next scheduled weekly meeting of this Committee was not until November 14, 2012, which was one week after the survey exit date. Therefore, the facility's ongoing implementation of, and conformance with, the new procedures, intended to ensure that physicians' orders are accurately transcribed and implemented, could not be fully assessed. Thus, the non-compliance remains, with the Scope/Severity of the deficiency lowered to the "D" level.

Based on resident clinical record review, laboratory report review, hospital Consultation report review, hospital Discharge Summary review, facility Laboratory Tests policy review, and staff interview, the facility failed to obtain laboratory testing, as ordered by the physician and in conformance with the facility's Laboratory Tests policy, related to [MEDICATION NAME] Time/International Normalized Ratio (PT/INR) laboratory testing, for one (1) resident (#17), of thirteen (13) sampled residents who received [MEDICATION NAME] anticoagulant drug therapy and had physicians' orders for PT/INR laboratory testing, from a total survey sample of twenty-nine (29) residents. Resident #1 subsequently experienced significant bleeding requiring hospitalization , and and was diagnosed with [REDACTED]. The resident was administered Vitamin K and fresh frozen plasma in the hospital. Based on the above, it was determined that the facility's failure to obtain laboratory testing as ordered by the physician and as specified by facility policy caused serious harm to Resident #17. It was therefore determined that the facility's noncompliance with one or more requirements had caused, or was likely to cause, serious injury, harm, impairment or death to residents. Immediate Jeopardy was identified to have existed as of August 24, 2012, and continued through November 6, 2012, at which time a plan was implemented by the facility to remove the Immediate Jeopardy situation as of November 7, 2012. The facility's Assistant Director of Nursing was notified on November 5, 2012 at 9:00 a.m. that Immediate Jeopardy existed. Findings include: Please cross refer to F309 for more information regarding Resident #17. The facility's Laboratory Tests policy indicated, in the Suggested Lab Guidelines section, that PT/INR laboratory tests were to initially be completed weekly for residents receiving [MEDICATION NAME] ([MEDICATION NAME]). These guidelines indicated that if stable and long term, these tests could be completed monthly. A notation in this section further specified that physician's orders [REDACTED]. Record review for Resident #17 revealed a Physician's admission orders [REDACTED]. A laboratory report of 08/17/2012 documented that a PT/INR had been completed on that date. However, further record review revealed no evidence to indicate that any additional PT/INR laboratory tests were done for the remainder of August 2012 or September 2012, as ordered. A Departmental Notes entry of 09/02/2012 at 12:53 p.m. documented that Resident #17 was noted with bleeding and that the physician ordered to send the resident to the hospital. A hospital Consultation report of 09/03/2012 documented that the resident had been admitted to the hospital with [REDACTED]. During an interview with the Director of Nursing (DON) conducted on 11/05/2012 at 10:10 a.m., the DON acknowledged that absence of weekly PT/INR laboratory tests as ordered for Resident #17. Based on the above, the facility failed to provide laboratory services to Resident #17, in accordance with the physician's orders [REDACTED]. The resident was noted with bleeding, was transferred to the hospital and was diagnosed with [REDACTED]. It was determined that the Immediate Jeopardy was removed on November 7, 2012, at which time the facility had completed the following actions: - On 11/05/2012, the facility's Quality Assurance Committee met to discuss the issue of physicians' orders for laboratory not being processed and followed, and the issue of physicians' orders not being brought forward to subsequent monthly orders. Attendees at this meeting included the facility's Administrator, DON, Assistant Director of Nursing (ADON), the 100 Unit Manager, the 300 Unit Manager, the Minimum Data Set (MDS) Coordinator, the Restorative Nurse, the Staff Development Coordinator, the Treatment Nurse, Medical Records personnel, and the Business Office Manager. - On 11/05/2012, after the Quality Assurance Committee meeting referenced above, the Administrator, DON and Medical Director met to discuss the identified issues with laboratory testing and the transcription of physicians' orders. - On 11/06/2012, a one hundred percent resident chart audit of laboratory orders was completed. This audit of course included the review of all residents (35 of 35) who had physicians' orders for medications which required titration to ensure that all laboratory orders had been reconciled. - On 11/06/2012, the facility implemented a procedure by which the DON, ADON, 100 Hall Unit Manager/300 Hall Unit Manager will perform weekly [MEDICATION NAME] drug audits for four weeks, then monthly for two months. A 20 percent audit of medical records will be conducted to ensure laboratory order reconciliation with current and the previous month's printed physician's orders [REDACTED]. Additionally, a 20 percent audit will be conducted for residents receiving medication requiring titration for two months. The findings of these audits will be presented to the Quality Assurance Committee. - On 11/06/2012, the Quality Assurance Committee met again, both in the morning and afternoon, to discuss the identified issues with laboratory testing and physician order [REDACTED]. Attendees at the afternoon meeting were the Administrator, DON, 100 Unit Manager, 300 Unit Manager, MDS Coordinator, the Staff Development Coordinator, and the Treatment Nurse. - On 11/06/2012, in order to ensure that appropriate orders are brought forward to the new month's orders, and to ensure that laboratory orders are processed and followed, the licensed nurses were in-serviced on monthly change-over and general orders including, but not limited to, communication with the physician, clarification of orders and discontinuing previous orders (including the inclusion of the discontinuation date) before writing a new order. Of 40 licensed nurses, a total of 30 nurses, 16 in person and 14 by telephone, were in-serviced on that date. The remaining 10 licensed nurses were not to be allowed to work until the in-service training is completed. - On 11/06/2012, the facility implemented the procedure by which ongoing audits regarding the processing of laboratory orders for testing and the transcription of physicians' orders, including laboratory orders, will be conducted by the DON, ADON, 100 Hall Unit Manager, and 300 Hall Unit Manager, who are all active members of the Quality Assurance Committee. Findings from these audits will be presented at Quality Assurance Committee meetings, with identified revisions made as needed. - Additionally, Quality Assurance Committee meetings were scheduled to occur on 11/08/2012 and 11/09/2012. Beginning 11/14/2012, weekly meetings will continue for a period of four weeks. Monthly Quality Assurance Meetings will then continue for a period of two months, and ongoing. Based on these corrective action plans which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice had been removed on November 7, 2012. However, the effectiveness of these corrective action plans could not be fully assessed to ensure ongoing application and completion. On November 6, 2012, the facility had conducted staff in-service training regarding the accurate transcription of physicians' orders to subsequent monthly order sheets, focusing on the monthly change-over and general orders. This training involved, but was not limited to, communication with the physician, clarification of orders, discontinuing previous orders as appropriate, and the ordering and processing of laboratory orders. As of November 6, 2012, thirty (30) of forty (40) licensed nursing staff had received this in-service training on the accurate transcription and implementation of physicians' orders, per facility policy. There were, however, ten (10) remaining licensed nursing staff who had not been trained as of that date, and would not be allowed to work until having received the in-service training. In addition, on November 6, 2012, the facility had implemented a procedure by which routine audits would be performed to monitor for the accurate transcription and implementation of physicians' orders, to include orders for laboratory testing, and to ensure laboratory order reconciliation with current orders. Additionally, the Quality Assurance Committee had reviewed these procedures during meetings on 11/05/2012, 11/06/2012, and again on 11/07/2012, during the course of this complaint survey. However, additional Quality Assurance Committee meetings were scheduled to continue the review of facility procedures and the results of facility compliance audits, post this survey, on the dates of 11/08/2012 and 11/09/2012, then weekly for four weeks, with the next meeting scheduled for 11/14/2012, then monthly for two months, then ongoing. The Quality Assurance Committee, in these future meetings, is to review the audit results and formulate any needed modifications to the procedure as part of the facility's corrective action to address the identified deficient practice. However, as indicated above, as of the 11/07/2012 exit date of this survey, training regarding the new facility procedures and processes was pending for ten (10) remaining licensed nursing staff. Also, the facility's procedure for utilizing routine audits to monitor physician order [REDACTED]. And, the Quality Assurance Committee will continue to meet weekly for four weeks, then monthly, to monitor and review audits and facility procedure implementation, and to identify any needed revisions, but the next scheduled weekly meeting of this Committee was not until November 14, 2012, which was one week after the survey exit date. Therefore, the facility's ongoing implementation of, and conformance with, the new procedures, intended to ensure that physicians' orders are accurately transcribed and implemented, could not be fully assessed. Thus, the non-compliance remains, with the Scope/Severity of the deficiency lowered to the "D" level.