Every finding on record at Litchford Falls Health and Rehabilitation Center

Based on record review, resident and Responsible Party interviews and staff interviews, the facility failed to provide written grievance summaries for a grievance filed by or on behalf for 4 of 4 residents reviewed for grievances (Resident #3, Resident #33, Resident #68 and Resident #48). The findings included: 1. Resident #3 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was moderately cognitively impaired. A review of Medical Records revealed a responsible party (RP) listed for Resident #3. A review of the facility's grievance log for May 2026 through June 2026 revealed a grievance filed on behalf of Resident #3 by the RP on 5/18/26, 5/19/26 and 6/10/26. a. A grievance form filed by the RP dated 5/18/26 revealed a complaint about Resident #3's C-Pap machine (a machine that provides a steady stream of pressurized air through a mask) missing a clip. There was no resolution note documented on the grievance form or indication of what department manager was responsible for initiating any action related to the concern. There was no documentation about who completed the form. b. A grievance form dated 5/19/26 revealed a complaint filed by the RP about Resident #3's wheelchair arms needing to be repaired. There was no resolution note documented on the grievance form. The form was completed by Administrator #1 (a former Administrator). e. A grievance form dated 6/10/26 revealed a complaint about lack of teamwork amongst staff. There was no resolution note documented on the grievance form. There was no documentation about who completed the form. An interview was conducted with Resident #3's RP on 7/9/26 at 4:48 PM. The RP stated she never received any written response from the Administrator concerning any of the grievances that were submitted on behalf of Resident #3. A telephone interview was conducted with Administrator #1 on 7/10/26 at 9:44 AM. Administrator #1 stated she communicated mostly with the RP through email. She added that she spoke on the phone with the RP about concerns but could not recall which ones. An interview was conducted with Administrator #3 (the current Administrator) on 7/10/26 at 3:20 PM. Administrator #3 indicated that staff were expected to ensure that individuals who filed a grievance were informed of the grievance summary and its conclusion. 2. Resident #33 was admitted to the facility on 7/725. The quarterly MDS assessment dated [DATE] revealed Resident #33 was severely cognitively impaired. A review of Medical Records revealed a RP listed for Resident #33. A review of the facility's grievance log for November 2025 through February 2026 revealed grievances filed on behalf of Resident #33 by the RP on 9/15/25, 12/19/26, 1/13/26, and 2/11/26. a. A grievance form dated 9/15/25 revealed a complaint about Resident #33 getting out of bed at 7:30 AM, attending all activities, and having breakfast and lunch in the dining room. The form was completed by Administrator #2) (a former Administrator). There was no documentation that the RP was given a written grievance summary. b. A grievance form dated 12/19/26 revealed a complaint about Resident #33 not participating in activities, compression stockings not being applied as ordered, teeth not being brushed, skin not being moisturized, deodorant not being worn, and hair not being combed. The form was completed by Administrator #2. There was no documentation that the RP given a written grievance summary. c. A grievance form dated 1/13/26 revealed a complaint about Resident #33 not participating in activities and requesting information about primary care and therapy. There was no documentation that the RP was given a written grievance summary. d. A grievance form dated 2/11/26 revealed a complaint about Resident #33 receiving double portions of food on the weekends as agreed previously. There was no resolution note documented on the grievance form. The form was completed by Administrator #4 (a former Administrator). There was no documentation that the RP was given a written grievance summary. An interview was conducted with Resident #33's RP on 7/8/26 at 10:30 AM. The RP stated she never received any summary information or written response from the Administrator concerning any of the grievances. Administrator #2 was unable to be reached for an interview. Administrator #4 was unable to be reached for an interview. An interview was conducted with Administrator #3 (the current Administrator) on 7/10/26 at 3:20 PM. Administrator #3 indicated that staff were expected to ensure that individuals who filed a grievance were informed of the grievance summary and its conclusion. 3. Resident #68 was admitted to the facility on [DATE]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #68 was cognitively intact. A review of the facility's grievance logs from May 2025 to July 2026 revealed a grievance report had been initiated on 5/19/26 by Resident #68's Responsible Party (RP). Review of the grievance form dated 5/19/26 and completed by Administrator #1 (a former Administrator) revealed the Responsible Party spoke with Administrator #1 about concerns regarding care being provided to Resident #68. Review of the grievance form did not indicate if the grievance had been resolved, how the results of the investigation were communicated to the complainant, when the results were communicated to the complainant/resident representative and no indication that a written summary was provided. Resident #68's RP was unable to be reached for an interview. An interview with Resident #68 on 7/7/26 at 10:18 AM revealed staff were doing better with checking on him day and night. Resident #68 stated that he was aware of the grievance filed by his RP. On 7/10/26 at 8:36 AM, an interview with Administrator #1 (a former Administrator) revealed concerns about waiting 1-2 hours on a call light response was received by Resident #68 and his Responsible Party. Former Administrator #1 did not state if grievance resolution was provided to Resident #68's Responsible Party. On 7/10/26 at 3:20 PM, an interview was held with Administrator #3 (the current Administrator). She indicated that the staff were expected to ensure that individuals who filed a grievance were informed of the grievance summary and its conclusion. 4. Resident #48 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 was cognitively intact. A review of the facility's grievance log for January 2026 indicated Resident #48 filed a grievance on 1/25/26. A grievance/concern form dated 1/25/26 completed by Administrator #2 (the former Administrator) revealed Resident #48 reported a dietary complaint of not receiving two boiled eggs. The grievance was investigated by Administrator #2 and indicated an interview was conducted with the nurse on the floor who stated Resident #48 did receive two boiled eggs. There was no follow-up or resolution documented on the grievance form. The form was not signed but marked as resolved. An interview was conducted with Resident #48 on 7/7/26 at 12:55 PM and she indicated she did not receive follow up to the grievance she submitted on 1/25/26 and did not receive a written grievance summary. Administrator #2 was unable to be reached for an interview. The former Social Worker who worked at the facility when the grievance was filed was unable to be reached for an interview. An interview was conducted with Administrator #3 (the current Administrator) on 7/10/26 at 3:20 PM and she indicated that the staff were expected to ensure that individuals who filed a grievance were informed of the grievance summary and its conclusion.

Based on record review and staff interviews, the facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN, a form used by skilled nursing facilities to inform residents about potential costs and coverage limitations for services that may not be covered by Medicare) to beneficiaries who intended to continue services and the SNF believed the services may not be covered under Medicare prior to discharge from Medicare Part A skilled services for 1 of 3 residents reviewed for beneficiary notification review (Residents #113). The findings included: Resident #113 was admitted to the facility on [DATE]. Medicare Part A coverage for skilled services began on 10/29/25.A Notice of Medicare Non-Coverage (NOMNC) revealed the notice was discussed with and signed by Resident #113 on 1/5/26 which indicated his Medicare Part A coverage for skilled services would end on 1/7/26. Resident #113 remained in the facility.Resident #113's medical record revealed no evidence a SNF ABN was reviewed with or provided to Resident #113.During an interview on 7/10/26 at 12:33 PM, the Social Work Assistant revealed she was responsible for reviewing and providing residents and/or Responsible Parties with the NOMNC and SNF ABN notice and then filed a copy at the facility. She further revealed she recalled reviewing the NOMNC information with Resident #113 on 1/5/26 but could not recall if she had also reviewed the SNF ABN information with Resident #113. She further revealed she was the only staff member working in the social work department during this time and could have forgotten to provide the SNF ABN information to Resident #113.During an interview with the Administrator on 7/10/26 at 3:15 PM, the Administrator revealed she would have expected Resident #113 to have received a SNF ABN as required when his Medicare Part A services were ending.

Based on record review and staff interviews, the facility failed to maintain accurate daily nurse staffing sheets for 10 of 30 days reviewed for daily posted nurse staffing information (6/17/26, 6/19/26, 6/24/26, 6/26/26, 6/28/26, 7/1/26, 7/2/26, 7/3/26, 7/5/26, and 7/6/26).The findings included:a. On 7/7/26 (Tuesday) at 9:42 AM an initial tour was conducted at the facility. The posted daily nurse staffing information sheet was observed on the wall at the reception desk in lobby and was dated 7/4/26 (Saturday).Review of the daily nurse staffing sheets posted for 7/5/26 (Saturday) and 7/6/26 (Sunday) revealed no information was available for the days of 7/5/26 and 7/6/26.b. Review of the daily nurse staffing sheets posted for 6/17/26, 6/19/26, 6/24/26, 6/26/26, 6/28/26, 7/1/26, 7/2/26, 7/3/26 showed there was not a Registered Nurse (RN) working at the facility for those dates. Review of the timecards for the nursing staff showed there was a RN working for at least 8 consecutive hours on 6/17/26, 6/19/26, 6/24/26, 6/26/26, 6/28/26, 7/1/26, 7/2/26, and 7/3/26.An interview was conducted with the Staff Scheduler on 7/10/26 at 11:02 AM. The Staff Scheduler stated he was unaware that the Wound Care Nurse (an RN), who worked Monday-Friday, should be listed on the daily nurse staffing sheets as having a RN present and, therefore, had not been including her when she was the only RN present in the building.In a follow up interview on 7/10/26 at 11:23 AM, the Staff Scheduler stated sometimes he would create the daily nurse staffing sheets on Friday before he left and then adjusted them on Mondays when he returned. The Staff Scheduler also stated sometimes, if he got pulled to help on the floor on Fridays, he would create the daily nurse staffing sheets when he returned to the facility on Mondays for the days he had been off based on the staffing schedules and census for those days to ensure the record of them was complete and accurate. When asked about the absent daily nurse staffing sheets for 7/5/26 and 7/6/26, the Staff Scheduler stated he was pulled to the floor to work on 7/6/26 and had not gotten around to creating the daily nurse staff sheets for those days yet.During an interview with the Director of Nursing #3 (current DON) on 7/10/26 at 12:00 PM, the DON stated she had been working at the facility for only a few days. She stated the Nursing Staff Scheduler was responsible for completing and maintaining the daily nurse staffing sheets and was unaware that the Staff Scheduler was creating the weekend daily nurse staffing sheets on Fridays and then adjusting them as needed on Mondays when he returned to work.During an interview on 7/10/26 at 4:30 PM, the Administrator #3 (current Administrator) stated the Nursing Staff Scheduler was responsible for the daily nurse staffing sheets. Her expectation was for daily nurse staffing sheets to be accurate and posted daily.

Based on record review, and interviews with staff, Nurse Practitioner, and Physician, for a resident with multiple pressure sores, the facility failed to 1) have effective systems and communication in place to ensure treatment orders were entered correctly after assessments by the Wound Nurse Practitioner and Facility Wound Nurse and based on the correct anatomical site so that the plan of care would be clear and able to be followed by all staff 2) ensure a nurse knew where to access a wound vac so it could be applied per orders and 3) evaluate how a resident's nutritional status and significant weight loss were potentially contributing to multiple pressure sores developing in order to determine if additional interventions were needed. This was for 1 of 3 sampled residents reviewed for pressure sores (Resident #1).The findings included:Review of a hospital Discharge summary, dated [DATE], revealed the following information. Resident # 1 was [AGE] years of age and had a history of spondylosis (age related wear and tear in the spinal disk which can lead to pain and compression of nerves), multiple falls, and spinal cord compression. On 10/2/25 he underwent decompression (surgery which relieves pressure on the spinal cord or nerves). The decompression surgery was complicated by the development of an epidural hematoma (a collection of blood around the spinal cord) and another surgery to address the epidural hematoma was performed. This had resulted in significant bilateral leg weakness. While hospitalized he also became septic (when an individual's body has an extreme reaction to an infection and organ and tissue damage can occur from the response) secondary to hospital acquired pneumonia. Other diagnoses, which were included on the discharge summary and a 10/2/25 hospitalist's note, included the following: a history of traumatic brain injury with right frontal craniotomy and aneurysm clipping (brain surgery to place a metal clip on a bulging artery in order to prevent a stroke), chronic obstructive pulmonary disease, diabetes, hypertension, hyperlipidemia, carotid artery stenosis, chronic back pain, obesity, osteoarthritis, neuropathy, history of alcoholism. Additionally, upon hospitalization, Resident # 1 reported current illegal drug use to the hospitalist. The 10/23/25 hospital discharge summary noted Resident # 1's last weight was 240 pounds and 4.8 ounces.Record review revealed Resident # 1 was admitted to the facility on [DATE].Review of Resident # 1's facility admission weight revealed the resident weighed 226 pounds on 10/23/25.The DON (Director of Nursing) was interviewed on 1/8/26 at 12:05 PM and reported the following information. After admission residents were to be weighed weekly times four and then their weights were assessed, and a schedule was determined from looking at their first four weights.Review of facility labs revealed Resident # 1's albumin registered 3.5 on 10/24/25. (Normal levels are 3.5 to 5.5 and abnormally low levels at times may indicate nutritional problems or other medical problems).Review of Resident # 1's care plan revealed the following information. On 10/23/25 staff included that Resident # 1 was at risk for pressure sores related to advanced age, chronic health conditions, dry fragile skin, and incontinence. Interventions on 10/23/25 included to assess the resident for risk for skin breakdown, keep his skin clean and dry as possible, and perform skin assessments as indicated. On 10/24/25 information was added to the care plan noting Resident # 1 was at risk for weight loss or malnutrition related to his recent acute illness and hospitalization and chronic disease. One of the interventions added on 10/24/25 was for an RD (Registered Dietician) consultation as needed.On 10/24/25 the facility Wound Nurse completed a skin observation assessment form which noted Resident # 1 was being seen for a skin admission check. The facility Wound Nurse documented Resident # 1 had moisture associated skin damage (MASD) with an open area to the right buttock and that zinc oxide would be applied twice per day. The facility Wound Nurse also documented that the resident was educated on turning and positioning for pressure relief and skin integrity. Review of orders revealed on 10/24/25 an order was entered into Resident # 1's electronic record for Petrolatum-Zinc Oxide to be applied to the resident's right buttock MASD and open area every day and evening shift.The facility Wound Nurse and Director of Nursing were interviewed on 1/7/26 at 1:50 PM. The facility Wound Nurse reported the MASD and open area referenced on 10/24/25 to the right buttock was on the left buttock and there had been an error in documentation. There were skin protocols which the facility could utilize, and she had started zinc for the area on the left buttock. At the time of Resident # 1's admission she was newer to the role of facility Wound Nurse.Resident # 1's 10/29/25 facility admission Minimum Data Set assessment coded Resident # 1 as cognitively intact. He was assessed to need substantial to maximum assistance with his hygiene and with turning in bed. He was assessed to have no pressures sores and was at risk for developing pressure sores. His height was 67 inches, and his weight was recorded as 226 pounds. On 10/29/25 information was added to the care plan that the resident expected to be at the facility for a short-term basis and was planning to return to a community setting. On 10/29/25 the Wound NP documented she saw Resident # 1 and Resident # 1 had intact skin on that date. The Wound NP noted the resident was at moderate/high risk for skin breakdown.On 10/29/25 an order was entered into the electronic record for Petrolatum-Zinc Oxide to be applied to the resident's right buttock every day and evening shift for preventative skin care. This order was in effect until 11/3/25.On 10/30/25 the facility Wound Nurse documented on a skin assessment form that the resident's skin was intact and that the resident had MASD to both buttocks. The facility Wound Nurse documented that zinc oxide would be continued.During the facility Wound Nurse's interview on 1/7/26 at 1:50 PM, she reported Resident # 1 only had MASD on 10/29/25 and the open area was no longer present. On 10/31/25 the RD documented she reviewed Resident # 1, and he had MASD to his buttocks. He was on a diabetic diet and was consuming 50 to 75 % of his meals. His albumin was 3.5 and within normal limits. His intake did not seem to be consistently meeting his estimated nutritional needs, and she recommended the resident receive 90 milliliters of Med Plus 1.7 twice per day with his medications. (Med Plus is a nutritional supplement). According to the record there was no further documented follow up by the RD in the notes until 12/8/25.Review of the medical record revealed there was no physician order entered for the Med Plus nutritional supplement in October and November 2025.On 10/31/25 orders were entered into Resident # 1's electronic record for an indwelling urinary catheter.Interview with the facility Wound Nurse on 1/7/26 at 1:50 PM revealed Resident # 1 had been in and out catheterized since admission because of urine retention and the indwelling catheter order was written on 10/31/25 for the urine retention. According to the facility Wound Nurse the catheter continued throughout the remainer of Resident # 1's stay and therefore he was no longer incontinent of urine. On 11/3/25 the facility Wound Nurse documented on a skin assessment form the following information. Resident # 1 was being seen by the Wound NP for a report of an open area to the right buttock. The area would be cleansed and collagen particles with a border gauze would be applied daily. The resident reported lying on his back and having difficulty with repositioning even with staff assistance. A new order for a bariatric air mattress was placed. The right buttock pressure sore measured 6 cm (centimeters) x 8 cm X 0.1 cm and was a Stage II. (According to the Facility Wound Nurse's interview on 1/7/26 at 1:50 PM this right buttock pressure sore was on the left buttock).On 11/3/25 the Wound NP documented Resident # 1 had a Stage II pressure sore to the right buttock which measured 6 cm X 8 cm X 0.1 cm and was 70 % epithelium (the thin skin tissue on the outer layer body) and 30 % granulation tissue (new healthy skin and tiny blood vessels in a wound bed). The Wound NP referenced this pressure sore as Wound 1 in her progress note and noted the treatment would be collagen with a border gauze daily. She also recommended an air mattress. (According to the Facility Wound Nurse's interview on 1/7/26 at 1:50 PM this right buttock pressure sore was on the left buttock, and the Wound NP also referenced the wrong anatomical site).On 11/3/25 orders were entered into Resident # 1's electronic record for the following: Bariatric air mattress. Cleanse right buttock open area with wound cleanser or normal saline. Pat dry. Apply collagen particles followed by bordered gauze. Change daily and as needed every daily shift. (According to the facility Wound Nurse's interview on 1/7/26 at 1:50 PM this order was for the left buttock pressure sore.)On 11/10/25 the facility Wound Nurse documented the following on a skin assessment form. The resident had four pressure sore sites. Two were listed on the left buttock and were not stageable, one was on the right gluteal fold and was not stageable, and there was a right buttock pressure sore that was a Stage II. There was no notation that the resident had a pressure sore on his coccyx in this note. In the narrative note on the form, the facility Wound Nurse documented the following. Resident seen for wound care and weekly skin check. Continue current treatment to right buttock. Cleanse with wound cleanser/NS (normal saline). Pat dry. Apply collagen particles and cover with silicone bordered gauze. This wound noted to have some frank red bleeding today, wound bed is black in color. Resident noted to have discolored area under skin (2) areas to left buttock and (1) to right gluteal fold. Resident is awaiting air mattress placement as resident is non-compliant with side-to-side position. Resident often refuses to get OOB (out of bed). Resident reeducated regarding pressure relief of buttocks and importance of side-to side positioning. According to an interview with the Administrator on 1/8/26 at 4:13 PM she was not the Administrator at the beginning of November 2025 when the resident was ordered to have a bariatric air mattress on 11/3/25. The Administrator provided an order confirmation that the bariatric mattress was ordered on 11/3/25 and reported that since bariatric air mattresses were not kept on site at the facility, it could take some time for an order to be filled and shipped to them.Interview with the DON on 1/8/26 at 4:13 PM revealed all the facility mattresses were designed to provide pressure relief and although the bariatric air mattress had still not been available as noted by the facility Wound Nurse's 11/10/25 documentation, the resident did have a pressure relief mattress in place, and the bariatric air mattress did arrive by 11/12/25. There were no orders noted entered into Resident # 1's record on 11/10/25 for the new pressure sores identified on 11/10/25 in the facility Wound Nurse's note.Review of Resident # 1's November 2025 TAR (Treatment Administration Record) revealed the only documented treatment for pressure sores on 11/10/25 and 11/11/25 was the application of collagen particles to the right buttock (which was the left buttock per the Facility Wound Nurse's interview on 1/7/26).On 11/11/25 orders were entered into Resident # 1's electronic record for the following: Cleanse coccyx with normal saline or wound cleanser and apply collagen particle with a silicone bordered gauze daily and as needed. Apply skin prep to discolored areas on the left buttock and left gluteal fold daily for 21 days for wound prevention. According to the November 2025 TAR these orders were first carried out on 11/12/25.Interview with the facility Wound Nurse on 1/7/26 at 1:50 PM revealed the following information. The date of 11/10/25 corresponded to a Monday when the Wound NP normally made rounds, but she thought the Wound NP was not able to visit that day. It was difficult to recall specifically how the pressure sores looked and where they were anatomically, but she recalled the resident had developed new ones. She would have applied treatments on 11/10/25 and 11/11/25 per the wound facility protocol although it was not documented. The facility Wound Nurse was interviewed regarding how other nurses who might need to apply a treatment or dressing in her absence would know the plan if orders were not entered and replied, that was a good question. The Wound Nurse also reported the resident was not being compliant in turning and repositioning.On 11/12/25 the facility Wound Nurse documented the following information on a skin assessment form. Resident # 1 had a pressure sore to the left buttock which measured 5 cm X 3 cm X 0.1 cm and was not stageable. The resident had a pressure sore to the sacrum which measured 3 cm X 2 cm X 0.1 cm and was not stageable. The resident had a pressure sore to the right gluteal fold which was 4 cm X 3 cm X 0.1 cm and was a suspected deep tissue injury. The resident had a right gluteus pressure sore that measured 0 cm X 0 cm X 0 cm and was unstageable. The facility Wound Nurse also documented Resident # 1 was being seen by the Wound NP for worsening areas to the buttocks. The facility Wound Nurse wrote, Resident noted to have DTI (deep tissue injury) to right gluteal fold. Resident has another discolored intact area to lateral gluteus medius. New order for skin prep. Resident coccyx/sacrum area is open. New order for hydrogel AG (silver) and cover with silicone bordered gauze. Change daily and PRN (as needed). Discontinue collagen to right buttock necrotic area. Start hydrogel AG (silver) and cover with silicone bordered gauze. Change daily and PRN. Resident noted to have foul odor from necrotic wound. APRN (Advanced Practice Registered Nurse) advised. APRN to look into resident treatment in chart and verbally states will order labs and broad spectrum ABT (antibiotic) at this time. Resident currently utilizing air mattress for pressure relief as resident has been non-compliant with T & P (turning and repositioning), even with staff assistance resulting in several pressure areas to buttocks as listed above.On 11/12/25 the Wound NP documented a narrative note with the following information. Resident # 1 had a pressure sore which was referenced as Wound # 2 to the buttock (it did not note which buttock). The pressure sore was new and was unstageable. It measured 5 cm X 3 cm X 0.1 cm and was 100 % epithelium with evidence of deeper tissue injury (maroon or darkened purplish discoloration). The treatment recommendation was for hydrogel silver with a bordered gauze daily. There was a new unstageable pressure sore, which was referenced as Wound # 3 to the right buttock which measured 3 cm X 2 cm X 0.1 cm and which was 100% epithelium with evidence of deeper tissue injury ([NAME] or darkened purplish discoloration). The treatment recommendations were for a hydrogel silver with a bordered gauze daily. There was a new unstageable pressure sore to Resident # 1's left gluteal fold, which was referenced as Wound # 4 and which measured 4 cm X 3 cm X 0.1 cm. This wound was 100 % epithelium with evidence of deeper tissue injury (maroon or darkened purplish discoloration). The treatment recommendation was for skin prep to the base of the wound three times per week. This narrative note did not mention Wound # 1 which was noted by the Wound NP on 11/3/25. This narrative note did not mention pressure sores to the coccyx or sacrum nor foul odors from a wound which the Facility Wound Nurse had referenced in her documentation.On 11/12/25 the following orders were entered into Resident # 1's electronic record. Cleanse the coccyx/sacrum with wound cleanser or normal saline and apply hydrogel AG and cover with silicon bordered gauze. Change daily and as needed. May use calcium alginate until hydrogel available. The collagen particle dressing to the coccyx was discontinued. Cleanse left buttock with normal saline or wound cleanser. Pat dry. Apply hydrogel AG and cover with silicone bordered gauze daily and as needed. May use calcium alginate until hydrogel available.According to the November 2025 TAR, treatment to the left buttock and left gluteal fold continued on 11/12/25 as daily skin prep. (This had been ordered on 11/11/25).On 11/12/25 the antibiotic, Amoxicillin Potassium Clavulanate 500-125 mg, was ordered to be given three times per day for 10 days for bacterial infection.During an interview with the facility Wound Nurse on 1/7/26 at 1:50 PM, the Facility Wound Nurse reported the left buttock pressure sore was necrotic with the foul odor which was the first pressure sore the resident originally developed. It had worsened by 11/12/25 and the resident was started on antibiotics.Review of labs, dated 11/13/25, revealed Resident # 1's albumin level registered 3.0, which was an abnormally low level and signified a 0.5 drop in his albumin since the date of 10/24/25.An interview was conducted with Nurse # 1 on 1/8/26 at 3:50 PM, who reviewed weekly facility weights. Nurse # 1 reported the following information Resident # 1 was weighed on 11/14/25 but the weight had not been entered into the resident's electronic record. Nurse # 1 referenced a list of resident's weights and reported that the resident had weighed 197.2 pounds on 11/14/25 which reflected a significant weight loss from the weight of 226 pounds on 10/23/25. Nurse # 1 reported they had missed one of Resident # 1's weekly weights which should have been obtained the week prior to 11/14/25.On 11/14/25 the facility Wound Nurse documented on a skin assessment form the following information. Resident # 1 was seen by the Wound NP on rounds and the current treatment to the left buttock would be continued. According to the facility Wound Nurse's notation this was for hydrogel silver with a silicone bordered gauze daily and as needed.On 11/14/25 the Wound NP made a notation in a narrative note that Wound # 1 was stable with the current treatment and there was no treatment adjustments that visit. The Wound NP on 11/14/25 referred to Wound # 1 as appearing on the left buttock. The documentation in the 11/14/25 NP's narrative note did not address the other pressure sores. Also, on a separate 11/14/25 Wound Assessment Report the Wound NP documented that the resident had a Stage II to the left buttock which had been present on admission and was 70% epithelial tissue and 30 % granulation tissue. This report was signed on 11/14/25 by the Wound NP. The Wound NP's note did not reflect the necrosis noted that the facility Wound Nurse reported during an interview on 1/7/26 at 1:50 PM was evident in the left buttock pressure sore and which according to the facility Wound Nurse was the first pressure sore that had developed and worsened.On 11/14/25 an order was entered into Resident # 1's electronic record for the right gluteal fold treatment to be changed to an application of collagen particles with a border gauze daily and as needed. On 11/14/25 orders for the daily application of skin prep to the left buttock and left gluteal fold were discontinued.On 11/17/25 the facility Wound Nurse documented the following information in a skin assessment. Resident # 1 was being seen by the Wound NP. Current treatments as follows. Cleanse left buttock with NS/Wound cleanser. Pat dry. Apply hydrogel AG or calcium alginate until hydrogel becomes available to left buttock necrotic skin and cover with silicone bordered gauze. Change daily and PRN. Sacrum: cleanse with NS/Wound cleanser. Apply hydrogel AG or calcium alginate until hydrogel is available. Cover with silcone bordered gauze. Change daily and PRN. Right gluteal fold. Cleanse with wound cleanser NS, pat dry. Apply hydrogel AG may use calcium alginate until hydrogel is available, and cover with silicone bordered gauze. Change daily and PRN. On 11/17/25 the Wound NP noted in a narrative note that the resident's wounds were stable with current treatment and no adjustments were needed. In a separate wound assessment report the Wound NP documented the following areas had pressure sores: the left gluteal fold, the left buttock, the right buttock, and the buttock (with neither left or right delineated).On 11/17/25 an order was entered into Resident # 1's electronic record for a change in the right gluteal fold pressure sore dressing. The order was for hydrogel silver and a border gauze; calcium alginate could be used until the hydrogel was available. The application of collagen particles, which had been ordered on 11/14/25, was discontinued.Review of facility documented weights in the resident's record revealed Resident # 1 weighed 197.2 pounds on 11/19/25.On 11/22/25 at 2:00 PM Resident # 1 received his last dose of schedule Amoxicillin -Clavulanate per documentation on the November, 2025 TAR.On 11/24/25 the Wound NP noted she was seeing Resident # 1 and noted the following information. She began debridement of Wound # 1. There was an area of eschar (thick, dark dead tissue) moveable with small strands attached to adipose tissue. On exam underneath the tissue there was extensive slough (unhealthy tissue) and eschar covering the wound, making it difficult to assess and therefore, debridement was stopped with a recommendation for the resident to go for further evaluation and debridement of the wound. Review of hospital records revealed Resident # 1 was hospitalized from [DATE] to 12/5/25. The 12/5/25 hospital discharge summary noted the following information. Resident # 1 was admitted on [DATE] for a worsening left-sided sacral decubitus ulcer, with CT (computerized tomography) of the pelvis showing a 6.1 X 7.5 X 2.7 cm ulcer extending to the bony sacrum without osseous erosion or abscess. The wound was malodorous and draining purulent material on presentation with cultures growing enteric flora and blood cultures negative throughout hospitalization. Resident # 1 underwent sharp debridement (removal of dead, infected, or unhealthy tissue from a wound bed) by PT (physical therapy) and wound care on 11/25, followed by initiation of negative pressure wound care on 11/26/25. (Negative pressure wound care is provided by a wound vac which pulls fluid and bacteria from a wound and thereby assists with healing). The wound was noted to be moderately cleaner by discharge, though moderate slough remained in the upper portion. Additional superficial pressure injuries were present at the coccyx, right sacral, and right ischial regions and were managed with topical therapy. The resident had received antibiotics while hospitalized . Upon discharge, the skilled nursing facility was to resume negative pressure wound therapy as soon as possible and the resident was to be on a low air loss bed surface. There were no specific orders for other pressure sores documented in the hospital discharge summary to be superficial and located on the coccyx, right sacrum and right ischial regions. The discharge summary further noted the following: The resident was recommended to have a planned wound Physician follow up assessment appointment in two to four weeks after discharge to ensure progress towards healing. The Wound Center could be called to make an appointment for surgery wound clinic if needed. The resident needed an air loss bed mattress and strict two hour turning. The resident should not sit until wound healing of the left sacral/buttock wound was well established. Once healing was established it was recommended the resident have a specialty cushion and only be out of bed twice daily initially for two hours with close monitoring. The resident should have greater than 100 grams of protein daily. The discharge summary also noted, referral to plastic surgery placed for eventual consideration of coverage.Review of the facility record revealed Resident # 1 returned on 12/5/25 (Friday) to the facility. There were no orders entered into the resident's electronic record for his pressure sores until 12/8/25 (Monday). There were no documented treatments for Resident # 1's pressure sores on 12/6/25 and 12/7/25. The resident's weight registered 207.4 pounds on 12/5/25.Nurse # 1, who helped coordinate new admission residents, was interviewed on 1/7/26 at 3:40 PM and reported the following information. Resident # 1 had arrived at the facility late in the evening on 12/5/25 and she had only seen the resident in passing. She had not looked at his wounds or entered orders. She was also on-call during the weekend and thought she recalled getting a call from one of the nurses who reported either the wound vac was not available or was nonfunctioning. According to Nurse # 1 it was facility approved protocol that a wet to dry dressing could be applied if a wound vac was not available or there were problems with a wound vac.Nurse # 2, who had cared for Resident # 1 on 12/6/25 and 12/7/25, was interviewed on 1/8/26 at 10:35 AM and reported the following information. She thought that if a resident was ordered to have a wound vac that it needed to specifically be ordered for the resident. She did not know where to find one when she worked with Resident # 1 on 12/6/25 and 12/7/25. She did not recall calling anyone about not having the wound vac. The resident's wounds were very wide and long. She placed a wet to dry dressing on the wounds.Interview with the Director of Nursing on 1/8/26 at 9:55 AM revealed the following information. There was a wound vac in the treatment room at the facility on 12/5/25 when Resident # 1 returned. The treatment room had a code on the door, and all the nurses had been given a code to access supplies. She had not received any notice over the weekend that the resident was to have a wound vac and that the nurses did not know where to find one. Multiple nurses who worked over the weekend when Resident # 1 returned were trained in how to apply a wound vac and the wound vac should have been placed on the resident.Review of Resident # 1's care plan revealed a problem was added on 12/6/25 which noted Resident # 1 had behaviors and would refuse to get out of bed, refused medications, was easily agitated, and refused to consent for treatment from psychological services. Resident # 1's care plan was updated again on 12/8/25 to reflect the resident had a pressure sore on his sacrum, right buttock, and right gluteal fold and was at risk for worsening or development of further pressure sores due to advanced age, chronic health conditions, dry fragile skin, extended hospitalization, frequent incontinence, immobility, inability to turn and reposition independently, and MASD. Interventions included: providing an alternating air mattress which had been added to the care plan on 11/3/25, keeping the resident clean and dry which had been added on 11/3/25, assisting the resident to turn and reposition with a draw sheet while in bed which had been added on 11/3/25, pressure relieving cushion to chair which was added on 11/3/25, providing treatments per the TAR (treatment administration record) which was added on 12/15/25, wound reviews as indicated which was added on 12/15/25, skin assessments as indicated which was added on 12/15/25, supplement to promote healing which was added on 12/15/25, and referral to Wound Physician as indicated which was added on 12/15/25.Review of the facility Wound Nurse's skin assessment, dated 12/8/25, revealed the resident had a stage IV pressure to the left buttock which measured 6 cm X 7.5 cm X 3.0 cm, a stage III pressure sore to his right lower buttock which measured 3.0 cm X 1.0 cm X 0.1 cm to the right lower buttock, and a Stage III pressure sore to the right mid buttock that measured 6 cm X 4.5 cm X 0.1 cm.On 12/8/25 orders were entered into Resident # 1's electronic record to cleanse the mid buttock open area with normal saline or wound cleanser and apply calcium alginate with silver every Monday, Wednesday, and Friday and as needed. A wound vac was to be applied at 125 mm HG (milliliters of mercury) continuous pressure to the left buttock wound on Monday, Wednesday, and Friday. The lower right buttock was to be cleansed and calcium alginate with silver was to be applied Monday, Wednesday, and Friday and as needed.Review of the 2025 December TAR revealed the Wound Vac was documented as applied on 12/10/25, 12/12/25, and 12/15/25 to the left buttock pressure sore. A calcium Alginate Silver dressing was documented as applied to the lower right buttock and mid buttock wounds on 12/10/25, 12/12/15, and 12/15/25.Interview on 1/7/26 at 1:50 PM with the facility Wound Nurse revealed when she arrived on 12/8/25 (Monday) there had been no orders initiated in the electronic record for Resident # 1's pressure sores and the wound vac had not been in place. There had been a clean, wet to dry dressing on his pressure sores. She initiated the orders on 12/8/25 and started the wound vac. The worst pressure sore was still to the resident's left buttock area and in applying the wound vac and drape, the other areas would be covered to form a seal. Therefore, orders were initiated for all other pressures sores to be changed on Monday, Wednesday, and Friday with the wound vac change.On 12/8/25 the RD made her first documented assessment following 10/31/25. The RD noted the resident had experienced a more than 30-pound weight loss in the last 2 months which was considered a significant weight loss. His current weight of 207 pounds showed an increase from his weight on 11/19/25 but also showed a decrease of 18.6 pounds when compared to the resident's initial weight on first admission. The RD noted the resident had three pressure sores which were all present upon admission. He had increased nutritional needs to heal his wounds and his intake may not meet those needs. The RD recommended starting Med Plus 1.7 90 ml twice per day with medications, a daily multivitamin, Vitamin C 500 milligrams daily, and Zinc 220 milligrams daily.According to Resident # 1's Medication Administration record the supplements, which were recommended on 12/8/25 in the RD's note, were ordered and started on 12/10/25. This was the first time the Med Plus was ordered following the RD's 10/31/25 recommendation to provide it. On 12/10/25 the Wound NP documented she saw Resident # 1 and noted the following information. Wound # 1, which was on the left buttock was a Stage IV and measured 6 cm X 4 cm X 2.5 cm. The treatment recommendation was for a wound vac at 125 mm HG continuous therapy to the base of the wound to be changed three times per week. Wound # 2 which was located on the resident's sacrum was a Stage III and measured 5 cm X 3 cm X 0.1 cm and was 50 % granulation tissue and 50% slough. The treatment recommendation was for hydrogel sliver to be applied daily. Wound # 4, which was on the resident's right gluteal fold was unstageable and measured 2 cm X 1.5 cm X 0.3 cm with 50 % granulation tissue and 50% slough. The treatment recommendation was for calcium alginate to be applied three times per week with a border gauze.There were no new treatment orders entered into Resident # 1's electronic record on 12/10/25 for pressure sore care.On 12/12/25 an order was entered into Resident # 1's electronic record for metronidazole 500 mg to be crushed and inserted into the left buttock wound every Monday, Wednesday, and Friday. (Metronidazole is an antibiotic which when crushed and applied to pressures sores can help odors).On 12/16/25 the first physician order following the readmission date of 12/5/25 for the sacrum was entered into the record. The order was for hydrogel and sliver Monday, Wednesday, and Friday.On 12/17/25 according to the facility record, Resident # 1 was transferred to the hospital for evaluation of a change in mental status. According to 12/17/25 Emergency Department notations, the resident had multiple pressure sores in various stages. The resident's hospital Discharge summary, dated [DATE], did not further classify the pressure sores. The discharge summary did note that the resident had undergone a CT while hospitalized that showed no osteomyelitis (infection of the bone) underneath the resident's sacral pressure sore. The resident did not return to the facility

Based on record review and interviews with staff, Registered Dietician (RD), and Physician the facility failed to 1) initiate a supplement per the Registered Dietician's recommendation when the Registered Dietician noted the resident's intake was not consistently meeting nutritional needs and 2) obtain weights on a newly admitted resident per the facility's reported system to establish future individualized weight monitoring timeframes 3) evaluate a resident's significant weight loss and declining albumin levels for 1 of 3 residents whose weights were reviewed (Resident #1).The findings included:Record review revealed Resident # 1 was admitted to the facility on [DATE]. Review of a hospital Discharge summary, dated [DATE], revealed the following information. Resident # 1 was [AGE] years of age and had a history of spondylosis, multiple falls, and cord compression. On 10/2/25 he underwent decompression (surgery which relieves pressure on the spinal cord or nerves). The decompression surgery was complicated by the development of an epidural hematoma (a collection of blood around the spinal cord) and another surgery to address the epidural hematoma was performed. This had resulted in significant bilateral leg weakness. While hospitalized he also became septic secondary to hospital acquired pneumonia. Other diagnoses, which were included on the discharge summary and a 10/2/25 hospitalist's note, included the following: a history of traumatic brain injury with right frontal craniotomy and aneurysm clipping, chronic obstructive pulmonary disease, diabetes, hypertension, hyperlipidemia, carotid artery stenosis, chronic back pain, obesity, osteoarthritis, neuropathy, history of alcoholism. Additionally, upon hospitalization, Resident # 1 reported current illegal drug use to the hospitalist. The 10/23/25 hospital discharge summary noted Resident # 1's last weight was 240 pounds and 4.8 ounces.Review of Resident # 1's facility admission weight revealed the resident weighed 226 pounds on 10/23/25.The DON (Director of Nursing) was interviewed on 1/8/26 at 12:05 PM and reported the following information. After admission residents were weighed weekly times four and then their weights were assessed, and a schedule was determined from looking at their first four weights. Usually, the RD was in the facility weekly, and any abnormalities in weights should be reviewed by the RD. The DON indicated Nurse # 1 helped oversee the weekly weights.Review of Resident # 1's laboratory test results revealed his albumin registered 3.5 on 10/24/25. (Normal levels are 3.5 to 5.5 and abnormally low levels at times may indicate nutritional problems or other medical problems).Review of Resident # 1's care plan revealed the following information. On 10/24/25 information was added to the care plan noting Resident # 1 was at risk for weight loss or malnutrition related to his recent acute illness and hospitalization and chronic disease. Interventions on the care plan included the following: RD consult as needed (added on 10/24/25 to the care plan), record meal % intake (added on 10/24/25 to the care plan); and review dietary preferences with the resident as needed (added on 10/24/25 to the care plan), and therapeutic diet as ordered (added on 10/24/25 to the resident's care plan).On 10/24/25 the facility Wound Nurse completed a skin observation assessment form which noted Resident # 1 was being seen for a skin admission check and Resident # 1 had moisture associated skin damage (MASD) and an open area to the right buttock.Resident # 1's 10/29/25 facility admission Minimum Data Set assessment coded Resident # 1 as cognitively intact. His height was 67 inches, and his weight was recorded as 226 pounds. He was not coded as having pressure sores.On 10/31/25 the RD documented she reviewed Resident # 1, and he had MASD to his buttocks. He was on a diabetic diet and was consuming 50 to 75 % of his meals. His albumin was 3.5 and within normal limits. He had no difficulty swallowing regular texture food items and required set-up of meals. His intake did not appear to be consistently meeting his estimated nutritional needs, and she recommended the resident receive 90 milliliters of Med Plus 1.7 twice per day with his medications. (Med Plus is a nutritional supplement).According to the October and November 2025 physician orders, the Med Plus was not ordered following the RD's recommendation on 10/31/25.The RD was interviewed on 1/8/26 at 2:46 PM and reported the following information. She did not know why nutritional support for Resident #1 had not started on 10/31/25 when she documented that his intake was not meeting his nutritional needs and recommended Med Plus. The RD indicated at times she would put the order into the computer herself, or she would ask a nurse to do so.On 11/10/25 the Facility Wound Nurse documented the following on a skin assessment form. The resident had developed four pressure sore sites. Three were listed as not stageable and one was listed as a Stage II. One was described as black and bleeding.On 11/12/25 the Facility Wound Nurse documented on a skin assessment form that Resident # 1 had multiple pressure sores on that date and was being seen by the Wound NP (Nurse Practitioner). The Facility Wound Nurse documented one of the resident's pressures sores was necrotic with a foul odor and that the Wound NP's plan was to order labs.Review of labs, dated 11/13/25, revealed Resident # 1's albumin level registered 3.0, which was an abnormally low level and signified a 0.5 drop in his albumin since the date of 10/24/25.On 11/12/25 at 3:36 PM the Facility Social Worker noted a care plan conference was held with the resident and a family member. The family member attended by phone. The care conference documentation included no notations that weight loss concerns or nutritional concerns were discussed. On 11/13/25 an intervention was added to the resident's care plan to give supplements as ordered.The Minimum Data Set Assessment Nurse was interviewed on 1/8/26 at 4:22 PM and reported she did update care plans but had not attended Resident # 1's care conference. Other staff members would have done so and given her any interventions to add to the care plan. She was not familiar with Resident # 1's weight loss and could not provide further information about weight loss interventions or why they were added.An interview was conducted with Nurse # 1 on 1/8/26 at 3:50 PM, who reviewed weekly facility weights. Nurse # 1 reported the following information. Resident # 1 was weighed on 11/14/25 but the weight had not been entered into the resident's electronic record. Nurse # 1 referenced a list of residents' weights and reported that Resident # 1 weighed 197.2 pounds on 11/14/25 which reflected a significant weight loss from the weight of 226 pounds on 10/23/25. Nurse # 1 further reported the following information. The facility had also missed weighing Resident # 1 during the first four weeks following his initial admission as they should have done because the 11/14/25 weight was the first weight she (Nurse #1) could find in any of the facility's records since 10/23/25 for Resident # 1. Nurse Aide # 1 usually started obtaining weights on Mondays and would make a list of the results. She (Nurse # 1) generally reviewed weights on Wednesdays. If there was a significant loss, then a reweight was supposed to be done. If the reweight was accurate, then she usually called the RD to discuss. Nurse #1 indicated she had been out of work for a part of November 2025 when the resident's weight loss and albumin level drop had occurred, and this could have contributed to the weight loss not being evaluated in November 2025.On 1/8/26 at 5:00 PM, Nurse Aide # 1, who had obtained Resident # 1's weights while he resided at the facility, was interviewed and reported the following information. She did not recall seeing what looked like fluid in the resident when he was being weighed. If she saw that a resident looked swollen from fluid, she typically would put a note beside the weight. He did seem larger when he was initially admitted and when she weighed him in following weeks, she noticed he appeared to be losing weight.Review of facility documented weights in the resident's record revealed Resident # 1 weighed 197.2 pounds on 11/19/25. (This represented a 12.7 % weight loss since admission)There was no documentation from 11/14/25 through 11/24/25 of an assessment of what was contributing to the resident's weight loss and low albumin and possible interventions. Review of hospital records revealed Resident # 1 was hospitalized from [DATE] to 12/5/25 due to worsening of his pressure sores. Review of the facility record revealed Resident # 1 returned on 12/5/25 (Friday) to the facility. The resident's weight registered 207.4 pounds on 12/5/25.On 12/8/25 the RD made her first documented assessment following 10/31/25. The RD noted the resident had experienced a more than 30-pound weight loss in the last 2 months which was considered a significant weight loss. His current weight of 207 pounds showed an increase from his weight on 11/19/25 but also showed a decrease of 18.6 pounds when compared to the resident's initial weight on first admission. According to the RD note, the 18.6 pound weight loss from admission to the 12/5/25 weight of 207.4 pounds was considered an 8.2% weight loss. The RD noted the resident had three pressure sores which were all present upon admission. The resident had increased nutritional needs to heal his wounds and his intake may not meet those needs. The RD recommended starting Med Plus 1.7 90 ml twice per day with medications, a daily multivitamin, Vitamin C 500 milligrams daily, and Zinc 220 milligrams daily.According to Resident # 1's Medication Administration Record (MAR) the supplements, which were recommended by the RD on 12/8/25, were ordered and started on 12/10/25. This was the first time the Med Plus order was transcribed to the MAR for staff to know to administer it since the RD's initial recommendation on 10/31/25. A review of the resident's consumption of the Med Plus 1.7 revealed that between 12/10/25 and 12/17/25 Resident # 1 consumed 25 % one time, 100 % two different administration times, and 50 % one administration time. Other times the resident did not consume the Med Plus.On 12/17/25 Resident # 1 was discharged and did not return to the facility.Unit Manager # 1 was interviewed on 1/8/26 at 2:15 PM and reported the following information. Resident # 1 would eat but he only ate about 1/2 of his portions. Although he had pressure sores, he would refuse to turn and say, Why am I turning? I am not going to get better. He refused to have psychological services while at the facility to address any depression he had.During the interview with the facility's RD on 1/8/26 at 2:46 PM, the RD reported the following information. Resident # 1 did not seem to flag as a person who would be malnourished when he first was admitted on [DATE]. He was obese and not elderly. She did not recall if she talked to him personally or just reviewed his record. For a person to lose the amount of weight noted in the facility record, it would appear to her that there was some underlying cause rather than just not eating to have caused the change if the weight readings were correct. The RD indicated she could only go by documented resident weights when she assessed a resident. According to the RD, a person's outward appearance did not always reflect their nutritional status. She also found that hospital weights were not always accurate. The RD thought she recalled asking for a reweight on Resident # 1 before he was hospitalized on [DATE]. She did not recall evaluating the low albumin and weight loss prior to Resident # 1's 11/24/25 transfer to the hospital. The facility would give her residents' weights to review. She reviewed residents who had weight loss and she routinely followed residents who received enteral feedings, new admission residents, residents who had wounds, and residents whom the physician had asked for an evaluation. For residents who had wounds, she routinely saw them once per month to evaluate them. There was a wound report which would note if residents' wounds were worsening or improving and she would evaluate if they were getting enough nutrition for their wounds. She did not know what had happened that she did not evaluate Resident # 1 in November 2025. The RD stated Resident # 1's wounds would have increased his metabolic needs. Interview with Resident # 1's physician on 1/8/26 at 11:45 AM and again on 1/8/26 at 5:15 PM revealed he had seen Resident # 1 on 12/16/25 (the day before he was discharged ). The resident had a history of alcohol abuse, and he could have had some liver disease. This could have been affecting his albumin levels. When he had seen Resident # 1, the resident did not outwardly appear malnourished and was a larger resident. He thought the resident did not particularly like the facility's food and his wounds were using some of the nutrients he did eat. According to the physician, the resident did not have fluid retention problems.The DON and Nurse # 1 were again interviewed on 1/8/26 at 5:20 PM. Nurse # 1 reported the resident had a history of actively using illegal drugs prior to his hospitalization and facility residency of 10/23/25. She felt this could have contributed to an individual having a poor appetite and not wanting to eat when their body was used to having drugs in their system. Nurse # 1 also reported that Resident # 1 would order out a lot of food. According to the DON, she felt if nutritional supplements had been started sooner, the resident still would not have been compliant in consuming the supplements. The DON and Nurse # 1 were not able to identify why the RD's 10/31/25 supplementation recommendation had been initially missed and not followed up on in October and November 2025

Based on record review and interviews with staff, the facility failed to ensure the resident's medical record was accurate and complete for 1 of 7 sampled residents (Resident # 1).The findings included:1a. Resident # 1 was admitted to the facility on [DATE]. Record review revealed on 12/17/25 Nurse # 2 completed a transfer form and a SBAR form (situation, background, assessment, and recommendation form) noting Resident # 1 was being transferred to the hospital for an altered mental status. Review of the vital signs on the transfer form dated 12/17/25 revealed vital signs obtained on and dated 12/16/25 were documented and included as the resident's vital signs. The same vital signs results, which were obtained on 12/16/25 also appeared on the SBAR form dated 12/17/25. On the SBAR form there was a place to include nursing notes (for additional information on the change in condition). The form was blank where additional information was to appear. There were no vital signs from 12/17/25 documented on the transfer form or the SBAR.Review of the medical record revealed there was no narrative note in the progress notes which noted vitals when the altered mental status was first observed. Nurse # 2 was interviewed on 1/8/26 at 10:35 AM and reported the following information. On 12/17/25 she had been assigned to Resident # 1 and was with the facility Wound Nurse in the resident's room when they both noticed the resident was not responding per his baseline. Usually, Resident # 1 was conversive, alert and oriented. On that day she told him her name and asked the resident what his name was. Instead of responding appropriately, the resident only repeated her (Nurse # 2's name). She recalled she had her blood pressure cuff, and she took the resident's blood pressure and pulse. He was not having labored breathing. She did not recall what the vitals she took registered and did not document them in the record. Nurse #2 indicated she had written them on a piece of paper, but she did not know what happened to the paper.According to an interview with the Director of Nursing on 1/8/26 at 9:55 AM the vital signs which Nurse # 2 took when the resident was observed with an altered mental status on 12/17/25 had not been included in his electronic medical record which made the record incomplete.1b. Record review revealed the facility Wound Nurse completed a skin observation assessment form on 10/24/25 which noted Resident # 1 was being seen for an admission skin check. The facility Wound Nurse documented Resident # 1 had an open area to the right buttock. On 11/3/25 the facility Wound Nurse documented on a skin assessment form Resident # 1 was seen by the Wound Nurse Practitioner (NP) for a pressure sore to his right buttock.On 11/3/25 the Wound NP documented Resident # 1 had a Stage II pressure sore to the right buttock.Interview with the facility Wound Nurse on 1/7/26 at 1:50 PM revealed the following information. She was newer to the role of Facility Wound Nurse during October 2025. The facility Wound Nurse confirmed she did not document the correct location for Resident #1's open area on the skin observation assessment form dated 10/24/25. The facility Wound Nurse confirmed she and the Wound NP had inaccurately documented the open area was on the right buttock for several weeks when it was actually on the left buttock. The DON was also present on 1/7/26 at 1:50 PM during the interview with the Facility Wound Nurse. The DON reported the Wound NP was also newer to the facility in addition to the facility Wound Nurse being newer to her role. According to the DON, this may have led to the inaccurate documentation.

Based on observations and staff interviews, the facility failed to clean and maintain in good repair the floors, walls, and the individual heating and air conditioning units (PTAC units) in 5 of 7 resident rooms (room [ROOM NUMBER], #305, #306, #308, and #309) on 1 of 3 halls observed for a clean, comfortable and homelike environment (300 Hall). The findings included: Accompanied by the facility's Maintenance Director, a tour of seven (7) residents' rooms on the 300 Hall was conducted on 5/7/25 from 3:00 PM to 3:20 PM. Concerns related to the cleanliness and condition of five of these rooms included the following: --room [ROOM NUMBER]: An observation of room [ROOM NUMBER] was conducted. Two of the vent louvers on the PTAC unit were observed to be broken. The filter/coils of the unit were observed to be dirty with multiple light tan and dark brown particles lying on top of the surface inside the unit. The unit appeared to be detached from the wall on its right side. The Maintenance Director also noted that one of the two filters for the PTAC unit was missing. He acknowledged one side of the unit was pulling away from the wall and needed to be re-attached. --room [ROOM NUMBER]: An observation of room [ROOM NUMBER] revealed 1 of 4 front vents on the PTAC unit had a brown, dried substance ranging from ¼ to 1 inch in width and running all the way down the front of the unit's cover. The baseboard and flooring near the PTAC unit appeared dirty and covered with a dark gray substance. Also, the plastic plate covering an electrical outlet near the PTAC unit was observed to be broken with the top 2-inches of the outlet cover missing. --room [ROOM NUMBER]: An observation of room [ROOM NUMBER] was conducted with the Maintenance Director. Four (4) floor tiles located at the foot of Bed A were observed to be damaged with several deep scratches/etching of the tiles. The Maintenance Director reported these tiles would have to be replaced. --room [ROOM NUMBER]: An observation of room [ROOM NUMBER] was conducted. A dark gray/black adhesive located between 3 floor tiles appeared to have seeped out from under the tiles and dried. The Maintenance Director reported the adhesive could possibly be cleaned off the tiles. If not, he reported the floor tiles may need to be replaced. --room [ROOM NUMBER]: An observation of room [ROOM NUMBER] revealed the room's PTAC had multiple pieces of debris visible from its top vents lying on the filter/coils inside the unit. The debris included rubber bands and several pieces of brown, unidentified substances. The control panel on the right side of the unit was dusty/dirty with a dark gray and brown substance covering the surface. Upon conclusion of the room tour, the Maintenance Director reported his department worked with the Housekeeping Department to take care of issues such as those observed during the tour. An interview was conducted with the facility's Housekeeping Director on 5/8/25 at 3:25 PM. During the interview, the concerns identified during the tour of the residents' rooms were discussed. The Housekeeping Director reported that his staff was responsible to clean each room daily. The daily clean included emptying the trash, checking supplies, wiping down all horizontal and vertical surfaces, sweeping the room (corner to corner) and wet mopping the floors. When specifically informed of the observations of the PTAC units, the Director reported the Housekeeping Department was responsible to clean the outside surfaces of the units while the Maintenance Department took care of the inside. An interview was conducted on 5/8/25 at 4:20 PM with the facility's Administrator in the presence of the Regional Consultant. During the interview, the maintenance and housekeeping concerns identified were discussed. When asked, the Administrator reported she would expect the residents' rooms to be clean, filters changed on the PTAC units as needed, and equipment kept in working order.

2. Resident #20 admitted to the facility on [DATE]. A nursing progress note dated 11/17/24 noted Resident #20 discharged home with a family member. Review of the Minimum Data Set (MDS) assessments for Resident #20 did not include a Discharge MDS assessment. In an interview on 5/08/25 at 4:45 PM, MDS Coordinator #1 stated the Discharge MDS assessment should have been completed when Resident #20 discharged and it was an oversight and was missed. In an interview on 5/08/25 at 5:08 PM, the Administrator stated the MDS was missed and should have been done. Based on staff interviews and record reviews, the facility failed to accurately complete the Minimum Data Set (MDS) assessment to reflect the use of an antibiotic (Resident #4) and failed to complete an MDS at discharge (Resident #20). This occurred for 2 of 41 residents whose MDS assessments were reviewed. The findings included: 1. Resident #4 was admitted to the facility on [DATE] with re-entry on 7/26/24 from a hospital. His cumulative diagnoses included non-Alzheimer's dementia and a neurogenic bladder (a condition where the urinary bladder lacks control due to nerve or muscle problems). The resident's care plan included the following area of focus, in part, The resident requires a suprapubic catheter [a urinary catheter that is inserted into the bladder from a small incision in the lower abdomen] related to neurogenic bladder . (Date Initiated: 7/27/24). Resident #4's electronic medical record (EMR) indicated a physician's order was received on 3/3/25 for 1 gram (g) of ertapenem (an intravenous antibiotic) to be administered one time a day for 7 days to treat a UTI. A review of the resident's March 2025 Medication Administration Record (MAR) revealed the ertapenem was administered to Resident #4 on 3/4/25 and 3/5/25 (in accordance with the physician's orders) as part of the prescribed antibiotic treatment regimen. Resident #4's most recent MDS was a quarterly assessment dated [DATE]. The Bladder and Bowel section of the MDS assessment reported the resident had an indwelling urinary catheter. However, the Medication section of this assessment did not report this antibiotic was administered to Resident #4 during the 7-day look back period from 2/27/25 to 3/5/25. An interview was conducted on 5/8/25 at 1:45 PM with MDS Nurse #1 and the facility's Regional MDS Nurse. During the interview, Resident #4's MDS assessment was discussed. Upon review of his 3/5/25 quarterly MDS, the Regional MDS Nurse confirmed this assessment did not indicate the resident received an antibiotic. However, it was noted that Resident #4's March 2025 Medication Administration Record (MAR) documented he was administered the ertapenem on 2 days (3/4/25 and 3/5/25) during the 7-day look back period. MDS Nurse #1 reported the 3/5/25 MDS assessment would need to be corrected to reflect the use of an antibiotic given during the look back period. An interview was conducted on 5/8/25 at 4:20 PM with the facility's Administrator in the presence of the Regional Consultant. When asked, the Administrator reported she would expect the MDS information to be accurate.

Based on observations, resident and staff interviews, and record reviews, the facility failed to accurately care plan the interventions related to smoking for 1 of 2 residents reviewed and identified as an independent smoker (Resident #58). The findings included: Resident #58 was admitted to the facility on [DATE] with re-entry from a hospital on 6/21/24. His cumulative diagnoses included a history of respiratory failure. Resident #58's most recent MDS was a quarterly assessment dated [DATE]. The MDS revealed this resident had intact cognition. The MDS assessment indicated Resident #58 required set-up or clean-up assistance only for most of his Activities of Daily Living (including eating, toileting, dressing, personal hygiene, bed mobility sit to stand, and chair/bed to chair transfers). Resident #58's most recent Smoking Safety Screen was dated 4/24/25. The last section of the screening was checked to indicate the resident could smoke independently. However, this screen also indicated Resident #58 required supervision for smoking. The resident's current care plan included the following area of focus: The resident prefers to smoke (Date Initiated: 12/24/24; Date Revised 4/24/25). The planned interventions noted the following, in part: --May smoke independently (Date Initiated: 12/24/24); --Smoking assessment as needed (Date Initiated: 12/24/24); --Supervise with smoking (Date Initiated: 4/24/25). Upon entrance to the facility on 5/5/25, the facility provided a current list of residents who smoked. Resident #58 was one of two residents listed who was identified as an Independent smoker. An interview was conducted on 5/7/25 at 11:35 AM with the Unit Manager for Resident #58's hallway. During the interview, the Unit Manager stated Resident #58 was an independent and safe smoker. She reported the resident could (and did) frequently go out to smoke every day unsupervised. An interview and observation were conducted on 5/8/25 at 9:40 AM with Resident #58. At that time, the resident reported he was an independent smoker. He stated that being an independent smoker meant he did not need to be supervised and that he could smoke at times of his choosing. An interview was conducted on 5/8/25 at 1:45 PM with MDS Nurse #1 and the facility's Regional MDS Nurse. During the interview, the conflicting smoking interventions on Resident #58's care plan were discussed. When asked, the MDS Nurses reviewed Resident #58's care plan. The MDS nurses agreed the care plan should indicate that either the resident was a safe smoker and could smoke independently or he required supervision for smoking (one or the other). MDS Nurse #1 confirmed Resident #58 was an independent smoker. She also noted that MDS was ultimately responsible to make any revisions and updates on the residents' care plan. The Regional MDS Nurse stated they would need to review this area of focus on Resident #58's care plan further. She added, We will update that. An interview was conducted on 5/8/25 at 4:20 PM with the facility's Administrator in the presence of the Regional Consultant. During the interview, concern related to the conflicting information on Resident #58's Smoking Safety Screen and care plan were discussed. When asked, the Administrator reported she would expect the residents' care plans to be accurate.

Based on observations, resident and staff interviews, and record review, the facility failed to provide routine fingernail care for a dependent resident, and shave a resident's facial hair in accordance with his preference to be clean shaven. This occurred for 1 of 7 dependent residents (Resident #4) reviewed for Activities of Daily Living (ADLs). The findings included: Resident #4 was admitted to the facility on [DATE] with re-entry on 7/26/24 from a hospital. His cumulative diagnoses included non-Alzheimer's dementia and contractures of both hands. The resident's care plan included the following area of focus, in part, --The resident requires assistance with Activities of Daily Living (ADL) related to chronic health conditions and inability to perform ADL (Date Initiated: 7/27/24). Resident #4's most recent MDS was a quarterly assessment dated [DATE]. Resident #4 was assessed to have moderately impaired cognition. He did not exhibit any behaviors or rejection of care. The MDS assessment indicated Resident #4 was totally dependent on staff for bathing and personal hygiene. An observation was conducted on 5/5/25 at 12:44 PM of Resident #4 as he was lying in bed. Only the resident's fingernail of his forefinger on the left hand was visible at that time. The fingernail was observed to be 1/2 inch long beyond the nail bed with a dark brown/black substance present underneath the nail. He was observed to have facial hair during the initial observation. A second observation and an interview was conducted on 5/5/25 at 3:41 PM with Resident #4 as he was lying in bed. The resident's facial hair was noted to be approximately 1/2 inch long. All fingernails were visible on both of his hands at that time. Each of his fingernails were at least 1/2 inch long beyond the nail bed and were discolored brown with a darker brown substance appearing underneath each nail. When the resident was asked if staff would help him to trim his nails, he did not reply. Upon further inquiry as to whether he preferred to have a mustache and beard (facial hair) or to be clean shaven, Resident #4 stated he wanted to be shaved. Another observation and interview was conducted on 5/6/25 at 11:15 AM of Resident #4. At that time, the resident's fingernails were observed to be clean and neatly trimmed down to be approximately 1/8 inch long. The resident was not shaved. Upon inquiry, the resident reported the activities lady from BINGO came and trimmed his fingernails. When asked, the resident reiterated that he did want to be shaved. On 5/7/25 at 4:10 PM, an interview was conducted with Activities Staff Member #1. This staff member was identified as having recently trimmed Resident #4's fingernails. During the interview, the Staff Member reported that a family member had requested that she check Resident #4's fingernails, so she did. When asked to describe what his fingernails looked like when she went to clean and trim them, she stated, They were horrible. Upon further inquiry, the Activities Staff Member estimated Resident #4's fingernails were approximately 1/2 inch above the nail bed and were very brown with dirt under them. The Activities staff member reported she used to be an NA. She stated the NAs were supposed to clean/trim fingernails and shave residents in accordance with the resident's preference. On 5/7/25 at 11:17 AM, an interview was conducted with Nurse Aide (NA) #1. NA #1 was identified as the nurse aide who was assigned to care for this resident on the first shift of 5/6/25 and 5/7/25. Upon inquiry, the NA reported Resident #4's bath days were on Tuesdays and Fridays. She stated the resident was given a really good bed bath on 5/6/25 (a Tuesday). When asked what his shower days typically involved, the NA stated she would bathe or shower him and clean his teeth with a toothette swab (a small sponge). The NA stated she knew she was not supposed to trim his toenails but wasn't sure if she was allowed to trim his fingernails because she was relatively new to the facility. When asked, the NA confirmed the resident's fingernails had been very long (at least ½ inch long) and brown prior to being trimmed by Activities. Upon further inquiry, the NA stated she was responsible for shaving female residents if needed, but reported the facility's Scheduler shaved the male residents. An interview was conducted on 5/7/25 at 11:26 AM with the facility's Scheduler. During the interview, the Scheduler reported he shaved the male residents only when he cut their hair. The Scheduler stated that to his knowledge, the NAs typically shaved male residents who wanted to be shaved on the resident's shower days. An interview was conducted on 5/8/25 at 4:20 PM with the facility's Administrator in the presence of the Regional Consultant. During the interview, the observation of Resident #4's fingernails and facial hair were discussed. The Administrator reported she would expect facility staff to provide care exactly as the resident preferred, including grooming his/her fingernails and shaving facial hair. She stated a resident's fingernails should typically be cleaned/trimmed on his/her bath days and as needed.

Based on observations and staff interviews, the facility failed to maintain a medication cart in clean and sanitary conditions for 1 of 2 medication carts reviewed for medication storage (100 [NAME] medication cart). The findings included: An observation and interview on 05/08/2025 at 02:25 PM with Nurse#2, Unit Manager, revealed red, clear and white dried substances and pink and white powder on the bottom of the second drawer of the 100 [NAME] medication cart. The observation also revealed 6 loose circular, partially dissolved white pills on the bottom of the second drawer of the 100 [NAME] medication cart. Nurse #2, Unit Manager, stated that nurses were expected to keep the medication carts clean and dispose of loose pills. Interview with DON on 05/08/2025 at 02:35 PM revealed that she expected the nursing staff to practice according to safety and regulatory standards independently and for the unit managers to monitor and maintain compliance. Medication carts should be maintained daily, each nurse on each shift was responsible for keeping the medication cart clean. An interview with the Administrator on 05/08/2025 at 02:48PM revealed that she expected the DON to ensure that Nursing Staff and Unit Managers were maintaining medication carts and areas according to safety and regulatory standards.

Based on record review and interviews with staff, the facility failed to ensure a system was in place in order that a resident's advance directive not to be resuscitated was honored upon her death. This was for one of three (Resident # 8) residents reviewed for emergency responses by facility staff prior to emergency medical systems being called. The findings included: Resident # 8 was admitted to the facility on [DATE]. Resident # 8 had multiple diagnoses which included but were not limited to stroke, history of respiratory failure, chronic kidney disease, congestive heart failure, hyperlipidemia, insomnia, polyneuropathy, atrial fibrillation, peripheral vascular disease, thyroid disorder, and pacemaker placement. Review of Resident #8's quarterly Minimum Data Set assessment, dated [DATE] revealed the resident was cognitively impaired. Review of physician orders, dated [DATE], revealed Resident # 8 had orders for DNR (Do Not Resuscitate). Review of Resident #8's [DATE] care plan revealed on [DATE] the following was added to Resident #8's care plan and remained as part of her active care plan up until discharge. The resident has advance directive of Do Not Resuscitate Order. Honor Residents Advance Choices. On [DATE] at 11:14 PM Nurse # 1 documented a nursing entry noting the following information. Resident # 8 was found on the floor and a code blue was called. Every nurse in the building came to assist. Resident # 8 was a DNR. EMS was called and Resident #8 was pronounced deceased at 11:21 PM. Nurse # 1 was interviewed on [DATE] at 3:40 PM and reported the following information. She was assigned to care for Resident #8 on the evening shift of [DATE]. She had administered Resident # 8's evening medications. Later she was busy with other residents when she heard a code blue called. When she arrived to Resident # 8's room. Nurse # 4 was already in the room performing chest compressions trying to resuscitate Resident # 8. She (Nurse # 1) checked the resident's record and saw Resident # 8 was a DNR and instructed Nurse # 4 to stop chest compressions because the resident was a DNR. Nurse # 4 was interviewed on [DATE] at 4:45 PM and reported the following information. He heard a Nurse Aide call for help for Resident # 8 on the evening of [DATE]. He ran to the room and saw she did not have signs of life. He instructed the Nurse Aide to call for help and he started chest compressions. Other staff came to assist. There was a folder at the nursing desk with instructions about whether residents were a full code or a DNR. After chest compressions had already been started, they realized Resident #8 was a DNR and chest compressions were stopped. The Director of Nursing was interviewed on [DATE] at 10:06 AM and reported the following information. There was a book at the nursing desk which has the code status of residents. The information is also located in every resident's electronic record. If the staff find a resident not responding then the staff are to assess the resident for a pulse and breathing and call for help. The code status is to be checked quickly prior to starting to resuscitate a resident. Interview with the corporate Nurse Consultant on [DATE] at 5:30 PM revealed the code status should be checked when a resident is found to be without a pulse and breathing. She felt Nurse # 4 intended to do good and was reacting to help the resident.

Based on record review and interviews with staff and the physician, the facility failed to notify the physician when a resident experienced nausea, vomiting, and decreased urine output following an increase in her diuretic medication. (A diuretic medication increases excretion of fluid). This was for one of four sampled residents (Resident # 1) reviewed for physician notification. The findings included: Resident # 1 was admitted to facility on [DATE]. Resident # 1's diagnoses included congestive heart failure, stroke, hypertension, diabetes, history of pelvic fracture, and major depressive disorder. The resident also had a history of alcohol and drug use. Review of Resident # 1's [DATE] MDS (Minimum Data Set) assessment revealed the resident was cognitively intact. A review of Resident # 1's annual MDS, dated [DATE], revealed the resident was moderately cognitively impaired. Additionally, on [DATE], Resident # 1 was assessed as follows: She was frequently incontinent of urine and always incontinent of stool. Review of physician orders revealed an order, dated [DATE], for furosemide 20 mg (milligrams) every day. (Furosemide is a diuretic medication used for congestive heart failure.) Prior to the date of [DATE] the resident had been on a 20 mg dose of furosemide twice per day for the three days prior to [DATE]. Prior to [DATE], Resident # 1 had been on a daily dose of furosemide 20 mg. This dosage had last been ordered on [DATE]. Review of Resident # 1's weight record revealed Resident # 1 weighed 145 pounds on [DATE]. On [DATE] the resident weighted 159 pounds indicating a weight gain of 14 pounds since she had been weighed the previous month. On [DATE] the physician noted the following in the record. He was seeing Resident # 1 and the nurses had noted the resident was more irritable that day. The resident stated to the physician she felt well and denied any pain or shortness of breath. The physician noted the resident did have increased swelling in her abdomen and legs and that he would adjust her diuretic and check lab work. The physician wrote an order to increase Resident # 1's furosemide to 40 mg twice per day on [DATE]. Nurse Aide (NA) #1 was interviewed on [DATE] at 4:25 PM and reported the following information. She had cared for Resident # 1 on [DATE], [DATE], and [DATE]. On [DATE] and [DATE] Resident # 1 had vomited brown emesis once per day on her shift. On [DATE] the resident had vomited brown emesis twice on her shift. She recalled mentioning the emesis to Nurse # 1 and Nurse # 2. Review of Resident # 1's record revealed no documentation of the resident vomiting on [DATE], [DATE], and [DATE] or that the physician was notified. Nurse Aide # 2 was assigned to care for Resident # 1 on [DATE] on the dayshift. NA # 2 was interviewed on [DATE] at 11:55 AM and reported the following information. In addition to caring for Resident # 1 on [DATE], she had also cared for the resident on two other days that same week. During those days she observed Resident # 1's abdomen looked more swollen than usual, and the resident did not urinate as much as she usually did. Usually the resident was a heavy wetter and her urine had decreased. At times the resident would go all shift and not be wet. During the interview with NA # 1 on [DATE] at 4:25 PM, NA # 1 reported the following information. She had cared for Resident # 1 on the evening shift of [DATE] and the resident did not urinate. This was not her normal. She had also cared for Resident # 1 on the evening shift of [DATE]. She placed the resident back in bed around 4:00 PM and saw that her brief was completely dry. That was not her normal. She (NA # 1) thought she had asked Medication Aide # 1 if anyone else was mentioning that the resident was not urinating per her norm. Medication Aide (MA # 1) was assigned to care for Resident # 1 on [DATE] and [DATE] on dayshift. MA # 1 was interviewed on [DATE] at 11:31 AM and again on [DATE] at 10:15 AM and reported the resident always had a swollen abdomen but she did not recall anything else being different about her on [DATE] and [DATE]. Nurse # 2 had cared for Resident # 1 on [DATE] on the evening shift. Nurse # 2 was interviewed on [DATE] at 2:00 PM and again on [DATE] at 10:00 AM and reported she did not recall specifics of the date of [DATE]. She did recall that Resident # 1's furosemide had been increased and they were trying to pull off fluid but she had not noted a large change in the resident or anything being reported about repetitive vomiting or low urine output in order that she know to talk to the doctor about it. Resident # 1's Nurse Unit Manager was interviewed on [DATE] at 10:20 AM and reported the following information. She became the unit manager in [DATE]. She knew Resident # 1's abdomen was swollen and the resident was not doing well. She also had developed a pressure sore. The resident had no family and was responsible for herself. On the date of [DATE] hospice staff were in the facility and the staff talked to Resident # 1's physician about a referral to hospice for the resident. Hospice did an initial meeting with Resident # 1 on [DATE] and Resident # 1 chose to transition to hospice care after talking with them. The plan was to admit the resident to hospice on [DATE]. Nurse # 1 had cared for Resident # 1 on the evening shift of [DATE] and reported the following information during interviews on [DATE] at 11:20 AM and again on [DATE] at 10:22 AM. She did not recall anyone mentioning any nausea, vomiting, or low urine output the resident had been having on that date or any date prior and therefore she had not talked to the physician about this. On the evening of [DATE] she (Nurse # 1) had administered the resident medications, and the resident was in bed and appeared okay. Within an hour of evening medications, the resident sustained a fall and was transferred to the hospital for evaluation of possible injuries due to a fall. Review of hospital ED records, dated [DATE], revealed the resident was clinically dehydrated upon admission. Further review of hospital records from [DATE] through [DATE] revealed the resident reported to the admitting hospitalist physician reported that she had severe abdominal pain and that she had been vomiting for several days and just felt bad. Continued review of these hospital records revealed the resident was diagnosed with multiple problems which in part included sepsis, blood loss anemia, and cirrhosis. The hospital records indicated the resident did not respond to treatment and she expired on [DATE]. Resident # 1's facility medical physician was interviewed on [DATE] at 11:50 AM and again on [DATE] at 5:07 PM revealing the following information. Resident # 1's kidneys were not healthy while she resided at the facility. She also had congestive heart failure and was showing signs of heart failure on [DATE] when he saw her although she had no complaints on that date and was chatty with him. If she had been vomiting and having less urine output after he saw her, this would have been significant information for staff to have let him know. If they had let him know, he would still have kept her on the diuretic because she needed the fluid removal. The staff would have needed to monitor her. It was a fine line in trying to diurese someone and preventing dehydration when a person suffered from multiple chronic medical conditions. Resident # 1 was capable of making her own medical decision about choosing hospice on [DATE] and hospice had been appropriate for her. Her death appeared to have been a result of multiple organ failure.

Based on record review and interviews with staff and physician, the facility failed to 1) ensure labs were drawn as ordered on a resident whose diuretic medication was increased (A diuretic medication increases excretion of fluid) and 2) ensure effective communication between Nurse Aides and Nurses so that a resident with vomiting and decreased urine output could receive nausea medication as prescribed and the physician would be made aware of the resident's lower urine output after he had increased the resident's diuretic medication. This was for one of four sampled residents (Resident # 1) reviewed for professional standards of practice. The findings included: Resident # 1 was admitted to facility on [DATE]. Resident # 1's diagnoses included congestive heart failure, stroke, hypertension, diabetes, history of pelvic fracture, and major depressive disorder. The resident also had a history of alcoholism and drug addiction for which she had been in recovery since 2014. Review of Resident # 1's [DATE] MDS (Minimum Data Set) assessment revealed the resident was cognitively intact. A review of Resident # 1's annual MDS, dated [DATE], revealed the resident was moderately cognitively impaired. Additionally, on [DATE], Resident # 1 was assessed as follows: She was dependent on staff for bathing. She required substantial to maximum assistance with her hygiene needs. She was frequently incontinent of urine and always incontinent of stool. She had no pressure sores. Review of nursing notes revealed an entry dated [DATE] at 6:32 AM noting that Resident # 1 had some emesis on the previous shift but no further emesis had been noted on the current shift. On [DATE] at 11:13 AM a nurse documented the resident complained of nausea. On [DATE] an order was obtained for Zofran 4 mg (milligrams) every eight hours as needed for nausea. A review of Resident # 1's [DATE] MAR (medication administration record) revealed the resident received the Zofran twice in [DATE]. This was on [DATE] at 10:43 PM and again on [DATE] at 2:11 AM. The [DATE] dose was documented as administered by Nurse # 2 and the [DATE] dose was documented as administered by Nurse # 5. Both times there was documentation the Zofran was effective. There was no further documentation on Resident # 1's MAR that the resident received any Zofran throughout the rest of her residency. On [DATE] an order was also obtained for a KUB (an x-ray of the abdominal area) to be completed. Review of the KUB report, completed on [DATE], revealed there was no organomegaly (enlarged organs) and no bowel obstruction found. Review of lab work revealed Resident # 1 had labs completed on [DATE] which although not all inclusive showed the following results: hemoglobin 8.8 (normal 10XXX,d+[DATE].3); Blood urea nitrogen 42.2 (normal ,d+[DATE]) , and creatinine 1.8 (normal XXX,d+[DATE].20). On [DATE] the staff added to Resident # 1's care plan that she was at risk for complications secondary to diuretic use. Two of the interventions listed on the care plan included drawing labs as ordered and observing for signs and symptoms of fluid imbalance or fluid overload. Review of physician orders revealed an order, dated [DATE], for furosemide 20 mg (milligrams) every day. (Furosemide is a diuretic medication used for congestive heart failure.) Prior to the date of [DATE] the resident had been on a 20 mg dose of furosemide twice per day for the three days prior to [DATE]. Prior to [DATE], Resident # 1 had been on a daily dose of furosemide 20 mg. This dosage had last been ordered on [DATE]. Review of Resident # 1's weight record revealed Resident # 1 weighed 145 pounds on [DATE]. On [DATE] at 10:46 AM the facility wound nurse noted she was asked to assess the resident who had previously had some MASD (moisture associated skin damage). The treatment nurse further noted the resident had a 1.5 cm (centimeter) X 1.5 cm area of skin breakdown, and that the physician was notified with a treatment started. According to progress notes, the Wound NP (Nurse Practitioner) began seeing the resident on [DATE] to oversee the pressure sore care. Review of Resident # 1's weight record revealed Resident # 1 weighed 159.0 pounds on [DATE] indicating a weight gain of 14 pounds since she had been weighed the previous month. On [DATE] the physician noted the following in the record. He was seeing Resident # 1 and the nurses had noted the resident was more irritable that day. The resident stated to the physician she felt well and denied any pain or shortness of breath. The physician noted the resident did have increased swelling in her abdomen and legs and that he would adjust her diuretic and check lab work. On [DATE] the physician wrote lab orders for a complete blood count, a comprehensive metabolic panel, and a thyroid stimulating hormone to be completed on [DATE]. The physician also wrote an order to increase Resident # 1's furosemide to 40 mg twice per day. Review of Resident # 1's record revealed the lab work, which was ordered on [DATE], was never completed. Nurse Aide (NA #1) was interviewed on [DATE] at 4:25 PM and reported the following information. She had cared for Resident # 1 on [DATE], [DATE], and [DATE]. On [DATE] and [DATE] Resident # 1 had vomited brown emesis once per day on her shift. On [DATE] the resident had vomited brown emesis twice on her shift. She recalled mentioning the emesis to Nurse # 1 and Nurse # 2. Review of Resident # 1's record revealed no documentation of the resident vomiting on [DATE], [DATE], and [DATE]. On [DATE] the Wound NP noted she was seeing Resident # 1 for wound care. The Wound NP documented the following. The resident's sacrum pressure sore was worsening with eschar, slough, and odor. There had been treatment changes that day made. On that date the wound bed measured 5 cm (centimeters) X 4.5 cm X 0.2 cm and was 80% slough and 20 % granulation. The Wound NP further noted, If the sacral wound does not start to improve, or is she starts to develop more wounds, consider as possible end of life and initiate hospice discussion. Medication Aide (MA # 1) was assigned to care for Resident # 1 on [DATE] and [DATE] on dayshift. MA # 1 was interviewed on [DATE] at 11:31 AM and again on [DATE] at 10:15 AM and reported the following information. She did not recall Resident # 1 having any further vomiting and nausea since she had undergone the KUB in [DATE]. The resident's abdomen was normally swollen, and she (MA # 1) did not recall it appearing worse the last week of the resident's residency or anything different on [DATE] and [DATE]. Nurse Aide # 2 was assigned to care for Resident # 1 on [DATE] on the dayshift. NA # 2 was interviewed on [DATE] at 11:55 AM and reported the following information. In addition to caring for Resident # 1 on [DATE], she had also cared for the resident on two other days that same week. During those days she observed Resident # 1's abdomen looked more swollen than usual, and the resident did not urinate as much as she usually did. Usually the resident was a heavy wetter and her urine had decreased. At times the resident would go all shift and not be wet. She did not want to get out of bed as much as she usually did. During the interview with NA # 1 on [DATE] at 4:25 PM, NA # 1 reported the following information. She had cared for Resident # 1 on the evening shift of [DATE] and the resident did not urinate. This was not her normal. Nurse # 2 had cared for Resident # 1 on [DATE] on the evening shift. Nurse # 2 was interviewed on [DATE] at 2:00 PM and again on [DATE] at 10:00 AM and reported she did not recall specifics of the date of [DATE]. She did recall that Resident # 1's furosemide had been increased, and they were trying to pull off fluid but she had not noted a large change in the resident. She recalled one time when she cared for the resident, the resident had vomited, and she gave her Zofran but did not recall when that was or if it coincided with dates after her diuretic had been increased. She did not know about any missing lab work for the resident. Nurse Aide # 3 had cared for Resident # 1 on the dayshift of [DATE]. NA # 3 was interviewed on [DATE] at 3:17 PM and reported the following information. She had cared for the resident routinely since she had been employed at the facility for eight months. She had not noted any big change in the resident on [DATE]. The resident had no nausea and vomiting on [DATE]. The resident's stomach always appeared swollen, and she (NA # 3) had not noticed any change. On [DATE] at 5:08 PM the facility social worker noted the interdisciplinary team had met about the resident's current health condition and the resident was referred to hospice with the resident's permission. Hospice visited the resident on that date ([DATE]) and there were plans to admit to hospice on [DATE]. Resident # 1's Nurse Unit Manager was interviewed on [DATE] at 10:20 AM and reported the following information. She became the unit manager in [DATE]. She knew Resident # 1's abdomen was swollen, a KUB had been done in earlier months, and the resident was not doing well. She also had developed a pressure sore. The resident had no family and was responsible for herself. On the date of [DATE] hospice staff were in the facility doing education training with staff and inquired if there might be residents who might need their services. Resident # 1 was not doing well. The staff talked to Resident # 1's physician about a referral to hospice for the resident. Hospice did an initial meeting with Resident # 1 on [DATE] and Resident # 1 chose to transition to hospice care after talking with them. The Unit Manager further reported no one had caught that the [DATE] labs were not done while the resident was at the facility and prior to doing a hospice referral. The lab order was in the computer, but it had not been written in the lab draw book so that the phlebotomist would know to draw the lab. On [DATE] at 10:04 PM Nurse # 1 noted in a nursing entry the following information. The resident had been found on the floor after sustaining a fall. The resident's vital signs were within normal limits. She had sustained a skin tear to her finger and a small laceration to her nose. The physician was notified, and the resident was sent to the ER for evaluation following the fall. During the interview with NA # 1 on [DATE] at 4:25 PM, NA # 1 reported the following information. She had cared for Resident # 1 on the evening shift of [DATE]. She placed the resident back in bed around 4:00 PM and saw that her brief was completely dry. That was not her norm. She thought she had asked Medication Aide # 1 if anyone else was mentioning that the resident was not urinating per her norm. Later that evening she sustained a fall from the bed and EMS was called. Nurse # 1 had cared for Resident # 1 on the evening shift of [DATE] and reported the following information during interviews on [DATE] at 11:20 AM and again on [DATE] at 10:22 AM. She did not recall anyone mentioning any nausea and vomiting problems the resident had been having. She also was not aware the resident had missed lab work or why it was not done. She was aware there had been a decision to transition the resident to hospice care. On the evening of [DATE] she (Nurse # 1) had administered the resident medications and the resident was in bed and appeared okay. Within an hour of evening medications, the resident sustained a fall and was transferred to the hospital for evaluation of possible injuries due to a fall. Review of hospital ED (emergency department) records for the date of [DATE] revealed the following information was documented. The resident's vital signs were 95.7 rectal (Rectal temperature readings are one degree higher than oral readings and thus the resident's temperature would have equated to 94.7 orally), pulse 93, blood pressure ,d+[DATE], respirations 12 and pulse oximetry 98 %. The resident was assessed to have an unstageable sacral pressure sore with no purulent drainage. Lab work revealed a white blood count of 22.7 (normal 3XXX,d+[DATE].2; elevated levels can at times indicate infection), hemoglobin 8.5, sodium level 131 (normal ,d+[DATE]), Blood urea nitrogen 69, and Creatinine 3.17. The resident's lactic acid was 1.5 and bilirubin was 0.5, which were both considered normal. The resident was noted to have a large abdomen and appeared clinically dehydrated. The resident's rectal exam in the ED was guaiac negative (meaning no blood in the stool). EMS had reported the resident had coffee ground emesis in route to the hospital. Further review of hospital records for the dates of [DATE] through [DATE] revealed the following information. A CT (computerized tomography) scan was completed which showed large scale ascites and cirrhosis which had previously not been diagnosed . The admitting hospitalist physician noted a history was obtained from the resident who reported severe abdominal pain and that she had been vomiting for several days and just felt bad. [NAME] emesis was noted in the resident's mouth and in her throat. The physician noted she met the criteria for sepsis based on her white blood count and that urine and blood cultures were sent. She was also diagnosed with dehydration and acute kidney injury secondary to vomiting and dehydration. On [DATE] the resident expired in the hospital. A hospital expiration note included the following information. The resident had acute blood loss anemia, cirrhosis, kidney injury, and bacteremia likely secondary to an infected pressure sore. Regardless of antibiotics and efforts to stabilize her, her condition had deteriorated, and she expired after an ethics committee met and discussed that comfort care should be provided. Resident # 1's facility medical physician was interviewed on [DATE] at 11:50 AM and again on [DATE] at 5:07 PM and reported the following information. Resident # 1's kidneys were not healthy before being identified in the hospital as having kidney injury. Resident # 1 also had low albumin levels, and albumin helps to keep the fluid volume within the vascular system. With multiple chronic illnesses, Resident # 1 could have gotten dehydrated quickly. When he saw Resident # 1 on [DATE] she did not complain of nausea and vomiting at that time. She was chatty and had not shown signs of cirrhosis. She had a diagnosis of congestive heart failure and when he saw her on [DATE] she was showing signs of heart failure. She needed to be diuresed. There was a fine line in diruresing residents with congestive heart failure and making sure they did not get dehydrated when there were other medical conditions affecting them. If lab work had been done as ordered it would not have made a difference in her outcome. She appeared to have multiple organs which failed causing her demise. She had been capable of making her decision to transition to hospice services on [DATE], and her medical condition indicated she had been hospice appropriate.

Based on record review and interviews with staff, Wound Nurse Practitioner (NP), and Physician, the facility staff failed to communicate effectively with the Wound NP, who was assessing and overseeing the care of Resident # 1's pressure sore, to ensure timing of dressing changes and the use of a cleansing agent was done per the Wound NP's plan of care for Resident # 1's pressure sore. This was for one of one sampled resident (Resident # 1) with a pressure sore. The findings included: Resident # 1 was admitted to facility on 10/8/20. The residents diagnoses in part included stroke, hypertension, diabetes, history of pelvic fracture, and congestive heart failure. Review of Resident # 1's 11/25/24 annual Minimum Data Set assessment coded the resident as moderately cognitively impaired, as needing substantial to maximum assistance with her hygiene needs, as being always incontinent of bowel, and as being frequently incontinent of bladder. The resident was coded with no pressure sores. On 11/29/24 staff added to Resident # 1's care plan that the resident was at risk for pressure sore development due to chronic health conditions, cognitive impairment, immobility, and the inability to turn and reposition self independently. Staff were directed on the care plan to assess the resident for breakdown. On 1/2/25 at 10:46 AM the Facility Wound Care Nurse documented the following in a nursing entry. She had been asked to assess Resident # 1, who had previous moisture associated skin damage to the sacrum and had been receiving treatment with Zinc (a barrier cream). Upon assessment on 1/2/25 the resident had an unstageable wound to the sacrum measuring 1.5 cm X 1.5 cm (centimeters). The physician was made aware and a treatment was initiated. On 1/2/25 an order was entered into the record to clean the pressure sore with normal saline or wound cleanser and apply silver alginate. Then the pressure sore was to be covered with a dressing daily. On 1/3/25 Resident # 1 was seen by the Wound Nurse Practitioner who documented the following information. Resident # 1 had a pressure sore which measured 1.5 cm X 1.5 cm X 0.1 cm. The wound bed contained 20 % granulation tissue (healthy tissue), 20 % epithelial tissue, and 60 % slough (unhealthy tissue). The Wound Nurse Practitioner documented the treatment recommendation plan was as follows: The pressure sore would be cleansed with wound cleanser, silver alginate would be applied to the base of the wound, the dressing would be secured with a border gauze, and the dressing would be done three times per week and PRN (as needed.) Review of Resident # 1's orders and January 2025 TAR (treatment administration record) revealed no updated orders to reflect the dressing changes should be changed to every three days. The daily dressing changes remained in effect. On 1/7/25 the Wound NP again saw Resident # 1 and documented the following information in a progress note. The sacrum pressure sore measured 1.5 cm X 1.5 cm X 0.1 cm. The wound bed continued to have 20 % granulation tissue, 20 % epithelial tissue, and 60% slough. The Facility Wound NP did not change the treatment recommendations from her previous recommendations, which she had made on 1/3/25 for dressing changes three times per week and as needed. On 1/8/25 Resident # 1's care plan was updated to reflect she had developed a pressure sore. The care plan directed referral to wound physician as indicated and treatment per TAR. On 1/14/25 the Wound NP documented she assessed the resident again. The Wound NP noted the following information. The pressure sore measured 5 cm X 4.5 cm X 0.2 cm. The wound bed had 80 % slough and 20 % granulation tissue. The wound was worsening and included eschar, slough, and odor. The facility Wound NP further documented, If sacral wound does not start to improve, or if she starts to develop more wounds, consider as possible end of life and initiate hospice discussion. The facility Wound NP further changed the treatment recommendations to the following: The wound was to be cleansed with a 0.125 % Dakin's solution (Dakins is a special cleaning agent for wounds which can help prevent infection and odor. It consists partially of diluted sodium hypochlorite which is commonly known as bleach); after cleansing with Dakins, Santyl (an enzymatic debriding agent) was to be added to the base of the wound and calcium alginate was also to be added; the pressure sore was then to be covered with a bordered gauze and changed every three days and as needed. Review of orders revealed the Wound NP's recommendations were not followed in the entirety. An order was entered into the electronic record on 1/14/25 to cleanse the wound with normal saline or wound cleanser. Then Santyl was to be applied to the wound bed following by calcium alginate and a dry dressing. There was no mention of cleaning the wound with the Dakin's solution. The order was also again entered as a daily dressing change rather than the three times per week as the Wound NP had noted. This order remained in effect until the resident's discharge to the hospital on 1/17/25. According to facility progress notes, on the date of 1/17/25, Resident # 1 sustained a fall and was transferred to the hospital. Prior to her transfer to the hospital a hospice referral was made and Resident # 1 elected to have hospice services, which were scheduled to begin 1/19/25. The Facility Wound Nurse was interviewed on 2/12/25 at 8:50 AM and reported the following. She had been a wound care nurse for [AGE] years. Resident # 1's wound was worsening similar to other residents who she had seen in the end stage of their life. She (the Facility Wound Nurse) usually made rounds with the Wound NP and wrote the Wound NP's treatment recommendations as they saw residents together. Then she (the Facility Wound Nurse) would enter the orders following wound rounds into the electronic record. When the Wound NP initially saw Resident # 1 on 1/3/25, she (the Facility Wound Nurse) thought the Wound NP said to perform the dressing changes every day. She (the Facility Wound Nurse) did not realize the recommendation had been for three times per week. When the Wound NP saw Resident # 1 on 1/14/25 and recommended using Dakin's on the pressure sore, she (the Facility Wound Nurse) did not think that both Santyl and Dakin's could be used at the same time in the wound bed. She recalled mentioning this to the Wound NP and thought that the Wound NP then gave directions that the wound could be cleaned with wound cleanser or saline. It was her understanding that Dakin's did not have to be used in the care of Resident # 1's pressure sore while it was being treated with Santyl and that the dressing changes should be continued as daily. The Wound NP was interviewed on 2/12/25 at 1:10 PM and reported the following information. When she assessed Resident #1's sacral pressure sore on 1/14/25, she noted the pressure sore had significantly worsening. She changed the treatment but felt there might be something terminal with the resident's health that was contributing to the pressure sore worsening so quickly. It was not typical to see such a decline. The resident's cognition also seemed to be getting worse and on 1/14/25 the resident was resistive to wound care as the dressing was changed. She (the Wound NP) recalled that the Facility Wound Nurse mentioned that she did not think Dakin's solution and Santyl worked together. At the time, she (the Wound NP) had not intended that the pressure sore wound bed be packed with both Santyl and Dakin's, and the use of the Dakin's was only for cleansing purposes. At the end of wound rounds at the facility, she (the Wound NP) always placed a note in the resident's record with her assessments and recommendations. This was entered the day she saw residents or no later than the following day. She also verbally told the Facility Wound Nurse the treatments she recommended and the Wound Nurse would enter the orders. She also prepared a full wound report with recommendations for every resident she sees on wound rounds. She did not see Resident # 1 again following 1/14/25 and did not know there had continued to be a question about using Dakin's and that the recommendation was not followed. Resident # 1's primary physician was interviewed on 2/13/25 at 11:50 AM and again on 2/14/25 at 5:07 PM. According to the physician Dakins solution is primarily used to control odors in the wound. According to the physician, the resident was hospice appropriate and had multiple organ failure soon following the development of the pressure sore and prior to her expiration.

Based on record review and staff interviews, the facility failed to ensure the medical record was complete regarding circumstances of a fall and assessments following a fall when a resident was injured. This was for one of four (Resident # 5) residents reviewed for falls. The findings included: Record review revealed Resident # 5 resided at the facility from 1/27/25 until 2/8/25. A review of the record revealed one nursing note on 2/8/25 at 10:00 AM which read, Resident wife notified facility that resident was being admitted to hospital. There was no documentation of acute problems or a fall on 2/8/25 before this note on 2/8/25 at 10:00 AM. Review of the resident's record revealed an entry two days later on 2/10/25 at 10:49 AM by the Minimum Data Set assessment nurse which noted the interdisciplinary team had reviewed a fall the resident sustained on 2/8/25 when he attempted to walk to the bathroom and fell . The note indicated the resident had been sent to the emergency roiagnom on [DATE]. There was no documentation in the 2/10/25 nursing entry about when the resident fell on [DATE] or any assessment of injuries following the fall. Nurse # 5 was interviewed on 2/11/25 at 3:50 PM and reported the following information. She had cared for Resident # 5 on the night shift which ended on 2/8/25 at 7:00 AM. Resident # 5's Nurse Aide had recently checked on the resident prior to the resident being found on the floor around 6:10 AM to 6:20 AM on 2/8/25. She had assessed the resident and found him to have a hematoma on his head and the resident complained of pain. He was transferred to the hospital for evaluation. Interview with the facility's Nurse Consultant on 2/17/25 at 5:02 PM revealed documentation of circumstances of a fall and assessment should be in a resident's record.

Based on facility staff interviews, physicians' interviews, and facility and hospital record reviews, the facility failed to immediately consult with the resident's Medical Doctor (MD) for order clarification when there was a lapse in the resident's coverage of an oral anticoagulant medication (Eliquis). Eliquis is a prescription medication used to reduce the risk of stroke and blood clots in people who have atrial fibrillation (a type of irregular heartbeat). Eliquis was discontinued 11 days before Resident #6 returned for a one-month Vascular follow-up appointment by an outside provider due to a recent diagnosis of bilateral lower extremity deep vein thrombosis (or DVTs, a condition where a blood clot forms in a deep vein, typically in the legs). The facility failed to clarify with either the Vascular consultant or Resident #6's physician as to whether the Eliquis needed to be continued until the next Vascular consult on 11/8/24. This occurred for 1 of 1 resident reviewed for notification of change (Resident #6) with a history of strokes, DVTs, pulmonary embolism (or PE, a condition where a blood clot travels to the lungs), and atrial fibrillation. Resident #6 was admitted to the hospital on 12/3/24 due to a change in mental status with diagnoses which included an acute middle cerebral artery (MCA) stroke. An MCA stroke occurs when blood flow through the middle cerebral artery in the brain is interrupted. Resident #6 remained hospitalized as of the date of the review (12/17/24). Immediate jeopardy began on 10/28/24 when Resident #6's Eliquis was discontinued without consulting with the physician. Immediate jeopardy was removed on 12/14/24 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure the completion of education and monitoring systems are in place. The findings included: Resident #6 was admitted to the hospital on 2/13/24 after sustaining a left distal fibular fracture (a break in the small bone of the lower leg near the ankle) from a fall. The resident's hospital Discharge Summary dated 2/20/24 noted she was on chronic anticoagulation due to atrial fibrillation and a history of DVT and PE. Resident #6's hospital Discharge Medication List included 5 milligrams (mg) Eliquis to be administered as one tablet by mouth twice daily. She was discharged from the hospital and admitted to the facility on [DATE]. A review of Resident #6's February 2024 through September 2024 Physician Orders revealed the resident's medication regimen continued to include 5 mg Eliquis administered by mouth two times a day from 2/20/24 to 9/17/24. On 9/17/24, a venous doppler ultrasound study was conducted of Resident #6's left lower extremity due to the resident's complaint of pain in her left lower extremity and history of frequent DVTs. The Radiology Results read in part, Impression: Findings are consistent with deep venous thrombosis [DVT] .Clinical Follow-up is recommended. A Health Status Note dated 9/17/24 at 2:54 PM reported Resident #6's MD was informed of the radiology results. A new physician's order was received to discontinue the resident's Eliquis and initiate the administration of 40 mg enoxaparin (an injectable anticoagulant used for the treatment of DVTs) to be administered subcutaneously (under the skin) every 12 hours to prevent blood clotting. The physician also ordered a Vascular consult for Resident #6 at that time. Resident #6 was seen for an outside Vascular consultation on 9/27/24. Upon her return to the facility, paperwork provided from the consultation included a Doctor's Order Consult Request. A notation made on this form indicated the reason for the consultation was due to concerns for blood clots given the resident's positive history and bilateral leg pain. The Consultation Findings indicated a bilateral lower extremity (BLE) venous duplex (ultrasound) was conducted with a diagnosis of Bilateral lower extremity non-occlusive DVTs [a condition where veins are partially blocked, allowing some blood to flow around the clots]. The Recommendations read as follows: Compression stockings .daily (on in AM, off in PM) and Eliquis 5 mg BID [twice daily] x 30 days and follow-up in 1 month with a repeat BLE venous duplex [ultrasound to be completed at the next visit] to check on the status of the thrombi [clots]. Patient may need to be on low anticoagulation indefinitely with her history of DVT/PE. The Doctor's Order Consult Request form also noted the resident's 1 monthly follow-up appointment was scheduled for 11/4/24 at 3:00 PM. The form was signed by the Vascular clinic Nurse Practitioner #1 (NP #1). Upon Resident #6's return to the facility on [DATE], a physician's order was received and transcribed by Nurse #1 into the resident's electronic medical record (EMR) to re-start her Eliquis as 5 mg administered as one tablet by mouth twice daily for 30 days. The order for Eliquis included a start date of 9/28/24 and an end date of 10/28/24. A physician's order was also received and transcribed into Resident #6's EMR for the enoxaparin to be discontinued as of 9/27/24. A telephone interview was conducted on 12/16/24 at 7:56 PM with Nurse #1. Nurse #1 was identified as having transcribed the order for Resident #6's Eliquis on 9/27/24 upon the resident's return from her Vascular consultation. When asked, the nurse recalled Resident #6 but could not remember any specifics related to the orders transcribed into the resident's EMR on 9/27/24. When asked, Nurse #1 reported if she had any questions on the resident's paperwork from the consult, she would have told the Unit Manager. The nurse reported it was her understanding that the Unit Manager was responsible for any follow-up deemed necessary regarding the physician's orders. A telephone interview was conducted on 12/16/24 at 1:56 PM with the facility's former Unit Manager. During the interview, the Unit Manager reported she did not recall any specific details about the paperwork returned from Resident #6's Vascular consultation or the orders received on 9/27/24. When asked, the Unit Manager stated she was not certain the facility had a set process in place to receive and address the recommendations made by outside consultants. Upon further inquiry as to whether she recalled seeing the Doctor's Order Consult Request from Resident #6's Vascular consult on 11/8/24, the Unit Manager stated she did not. A review of the resident's September 2024 Medication Administration Record (MAR) revealed Resident #6 began to receive 5 mg Eliquis administered as one tablet by mouth twice daily on 9/28/24 in accordance with the physician's order. A Health Status Note dated 10/28/24 at 3:25 PM and authored by the facility's Director of Nursing (DON) reported Resident #6's managed care program notified facility about resident's upcoming Vascular appointment scheduled for 11/4/24, stating that the [family member] would like to reschedule due to a conflicting event .Awaiting time and date for rescheduled appt [appointment]. A telephone interview was conducted on 12/16/24 at 3:42 PM with the facility's former Director of Nursing (DON), who was currently working as the facility's Assistant Director of Nursing (ADON). During the interview, the ADON was asked about her 10/28/24 notation which indicated she was informed Resident #6's family wished to reschedule the Vascular consultation. When asked if she realized Resident #6 would no longer be receiving Eliquis after 10/28/24, the ADON responded by saying, No .not at that moment. The ADON added if she had realized at the time that the resident would be without an anticoagulant until her next Vascular consult appointment, she would have called the MD to clarify the order for the Eliquis. Upon further inquiry, the ADON was asked what the nursing staff should do if there was a question on an order for a medication such as Eliquis. The ADON responded by saying she would have wanted the nursing staff to notify Resident #6's physician that the resident would be without this pertinent drug (Eliquis) and to see what he wanted to do. A review of Resident #6's October 2024 and November 2024 MARs revealed the resident received her last dose of Eliquis on the morning of 10/28/24. No other doses of Eliquis were documented as administered on the resident's MARs from 10/28/24 to 11/8/24. This represented an 11-day lapse in the administration of Eliquis to Resident #6. On 11/8/24 at 2:00 PM, Resident #6 was seen for her outside Vascular consultation and follow-up due to her bilateral DVTs. The Doctor's Order Consult Request form provided to the facility upon conclusion of this follow-up reported the resident's thrombi were unchanged. The Consultation Findings for her Diagnosis indicated the resident had chronic bilateral lower extremity DVTs. The Recommendations on the consult form read in part: .Eliquis 5 mg BID [twice daily] po [by mouth] x 90 days #2 refills. Referral for hematology due to history of multiple DVTs and PE. A review of Resident #6's physician's orders and her November / December 2024 MARs revealed no orders were transcribed into the resident's EMR for Eliquis. No doses of Eliquis were documented as administered to the resident from 11/8/24 up to the date of her discharge to the hospital on 12/3/24. Resident #6's EMR included a Skilled Nursing Facility (SNF) to Hospital Transfer form dated 12/3/24 at 6:50 PM. The transfer form reported Resident #6 was sent out to the hospital for evaluation and treatment due to a change in mental status and possible stroke. A review of the resident's hospital Admission Note's History and Physical dated 12/3/24 at 11:36 PM was conducted. The note indicated Resident #6 was transported to the hospital via Emergency Medical Services (EMS) and presented with altered mental status, garbled speech, and confusion. The notes reported the resident had a history of stroke with left sided deficits. Resident #6's History of Present Illness also included, in part, atrial fibrillation not on anticoagulation and DVT with IVC filter (a small device that prevents blood clots from traveling from the legs to the lungs). The emergency room notes reported a computerized tomography (CT) scan of the head showed an acute to subacute ischemic event (a situation where a stroke was caused by blocked blood flow to the brain) involving the left posterior temporal lobe (a part of the brain for understanding language, learning, and remembering verbal information) and temporal parietal junction (a region of the human brain that is involved in many higher-order cognitive and motor functions). The resident was reported to have atrial fibrillation and noted she was not currently on anticoagulation. The hospital record also indicated Resident #6 was previously on Eliquis, but it been discontinued without her family being aware of the reason for the discontinuation of it. Resident #6 remained hospitalized as of the date of the review (12/17/24). A telephone interview was conducted on 12/13/24 at 12:12 PM with the Vascular MD from the outside consulting clinic. He reported the NP who saw Resident #6 on 9/27/24 was no longer employed by the Vascular clinic. When asked, the MD stated he would have wanted the facility to call his office if there was any question as to whether the Eliquis should have been continued until her follow-up appointment on 11/8/24. During the interview, the MD reported the lapse in Eliquis administration (from 10/28/24 to 11/8/24) was definitely not an intentional lapse. A telephone interview was conducted on 12/13/24 at 10:13 AM with Resident #6's Medical Doctor (MD) at the facility. During the interview, the MD stated he felt the crux of the problem was that the 9/27/24 order was written for a 30-day period. He reported that ideally, he would have thought the Eliquis should have been continued until her scheduled follow-up appointment. The MD reported if he had been called about the Eliquis being discontinued on 10/28/24, he would have asked the facility to call the Vascular consultant to see what he/she recommended. The MD added, I commonly do that kind of thing. The Administrator was notified of immediate jeopardy at F580 on 12/13/24 at 2:30 PM. The facility provided the following credible allegation of immediate jeopardy removal. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: Review of Resident #6's clinical documentation indicates; on 9/27/24 Resident #6 had a vascular appointment. The consultation resulted in recommendation to resume Apixaban (Eliquis) 5mg twice daily for 30 days. The order was transcribed onto the facility Electronic Health records and implemented as ordered. Medication was ordered to start on 9/28/2024 with the stop date of 10/28/24. Resident #6 was ordered to have a follow up appointment in 30 days. The consultation form indicated that residents' follow up appointments to be 11/4/2024 at 3pm. No indication that the attending physician was consulted regarding what to do about running out of Eliquis prior to the scheduled appointment. Review of facility clinical documentation dated 10/8/24 indicate Resident #6's daughter requested for the Vascular appointment to be rescheduled due to conflict of interest. The appointment was rescheduled for 11/8/2024. No indication that the attending physician was consulted regarding what to do about running out of Eliquis prior to the scheduled appointment. Resident #6 went to the follow up Vascular appointment on 11/8/2024. The Vascular physician ordered Eliquis 5mg to be restarted twice daily for 30 days. Review of Resident #6 Electronic Health Records from 10/28/2024 to 11/08/2024 indicated that no orders for Eliquis were transcribed onto the facility's Electronic Health Records. No indication the attending physician was notified when Eliquis run out on 10/28/2024. Resident #6 was sent to the acute care hospital on 12/3/2024 due to altered mental status. Review of Resident #6 Documentation on Resident #6's Medication Administration Records (MARs) revealed she did not receive this oral anticoagulant from 10/28/24 to 11/08/2024 after the medication was stopped after 30 days' supply run out. No indication on Resident #6's clinical records that the Attending physician was consulted before medication ran out on 10/28/24. Resident #6 is no longer in the facility. The Governing body led by the [NAME] President of Operation, the facility Administrator, Regional Director of Clinical Services, and Director of Nursing conducted the root cause analysis on 12/13/2024, to identify the causative factor for this alleged noncompliance. The Root Cause Analysis (RCA) identified the alleged noncompliance resulted from the failure of the facility employee to administer Eliquis and for DVT prevention per physician order. The RCA further identified that facility staff also failed to consult the physician when Resident #6 was running out of Eliquis before the scheduled appointment that took place on 11/8/24. The governing body put forth the following plan for identification for those residents who are likely to suffer a serious adverse outcome as a result of the alleged noncompliance and implemented the measures below to alter the process to prevent a serious adverse outcome from occurring. 100% audit of all current residents discontinued/stopped medication in the last 30 days completed on 12/13/2024, by the Director of Nursing, Assistant Director of Nursing, and/or Unit Coordinator (1 or #2) to identify any other medication that was discontinued/stopped/ran-out without consultation with an attending physician. Any resident(s) identified with a discontinued order without attending physician consultation, the Director of nursing will inform the physician for appropriate measures and or interventions and implement the interventions as ordered. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: Effective 12/13/2024, facility employees will ensure any changes in medication or treatment, to include discontinuation of medication such as Eliquis, will be reported to the physician prior to the discontinuation to ensure appropriate medical intervention/assessment is implemented to prevent possible negative consequences that may result from abruptly discontinuing medication such as Eliquis. This systemic modification will be accomplished by implementing the following measures: Effective 12/13/2024, licensed nurse on duty will inform the resident; consult with the resident's physician; and notify, the resident representative when there is; a significant change in the resident's physical, mental, or psychosocial status, a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). This notification will be documented on each resident's electronic medical records by the licensed nurse on duty. Effective 12/13/2024, the facility's clinical team, which includes Director of Nursing, Assistant Director of Nursing, Medical records coordinator, Unit coordinator #1 Unit coordinator #2, and/or Admission nurse initiated a process for reviewing clinical documentation for the last 24 hours and physician orders written in the last 24 hours (including orders to discontinue medication), or from the last clinical meeting to ensure any needed notification of changes to the physician, and/or responsible party was done in a timely manner. This systemic process will take place Monday through Friday. Any identified issues will be addressed promptly. This process will be incorporated into the daily clinical meeting. Any negative findings will be addressed promptly. The nursing administrative team will review the clinical documentation and physician orders written on Friday, Saturday, and/or Sunday at the next clinical meeting on the following Monday. 100% education of all licensed nurses to include full time, part time, and as needed licensed nurses will be completed by the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, and/or Unit Coordinators (1, #2). The emphasis of this education will be the importance of notifying an attending physician and the party responsible in a timely manner for any change in condition, change of treatment/intervention and discontinuation of medication. The education emphasized that an attending physician should be consulted before medication ran out/stopped for proper intervention. This education will be completed by 12/13/2024, any licensed nurses not educated by 12/13/2024 will not be allowed to work until educated. Director of Nursing, Assistant Director of Nursing, and/or Unit Coordinators (1, #2) will monitor and track the completion of this education and will complete this education for any newly hired licensed nurses during the new hire orientation effective 12/13/2024 100% education of all current clinical leadership team members to include Director of Nursing, Assistant Director of Nursing, Medical records coordinator, Unit coordinator #1, Unit coordinator #2 and/or Admission nurse completed by the Regional Director of Clinical services. The emphasis of this education includes, but is not limited to, the importance of ensuring residents' discontinued medication and other changes of condition is reviewed in the daily clinical meeting to ensure the attending physician was consulted before the medication ran out/stopped or discontinued. This education will be completed by 12/13/2024, any clinical team member not educated by 12/13/24, will not be allowed to work until educated. This education is added to a new hire orientation for all clinical team members effective 12/13/2024. Alleged immediate jeopardy removal date: 12/14/24 A validation of IJ removal plan was conducted on 12/17/24. A review of the audits conducted for current residents with discontinued/stopped medication within the last 30 days revealed they were completed as planned. All licensed nurses assigned to a hall within the facility were interviewed regarding the in-service education received. Additionally, sign-in sheets documented the education provided and the nursing staff who received it. When asked, the nursing staff was able to describe the education provided on the facility's procedures regarding the notification of the resident's provider and resident or Responsible Party (RP). The nurses consistently verbalized an understanding of the need to consult with the MD and notify the resident/RP when there was a significant change in the resident's medication (including medication discontinuation) and/or in the resident's condition. The IJ removal date of 12/14/24 was validated.

Based on staff interviews, consultant pharmacist and physician interviews, and facility and hospital record reviews, the consultant pharmacist failed to urgently report an irregularity related to the omission of Eliquis (an oral anticoagulant medication) for 1 of 1 resident reviewed for a significant medication error (Resident #6) with a history of strokes, deep vein thrombosis (or DVTs, a condition where a blood clot forms in a deep vein, typically in the legs), pulmonary embolism (or PE, a condition where a blood clot travels to the lungs), and atrial fibrillation (a type of irregular heartbeat). Eliquis is a prescription medication used to reduce the risk of stroke and blood clots in people who have atrial fibrillation. Resident #6 was initially seen for a Vascular consultation on 9/27/24 with a follow-up consultation conducted on 11/8/24. Both consultations recommended the resident be treated with Eliquis. The consultant pharmacist completed a monthly Medication Regimen Review (MRR) on 11/13/24. While the pharmacist identified there was a lapse in Eliquis coverage for Resident #6, she failed to notify the facility of this lapse until 11/20/24. A Physician Recommendation was not completed related to the omission of Eliquis for this resident. On 12/3/24, Resident #6 was admitted to the hospital due to a change in mental status with diagnoses which included an acute middle cerebral artery (MCA) stroke. An MCA stroke occurs when blood flow through the middle cerebral artery in the brain is interrupted. Resident #6 remained hospitalized as of the date of the review (12/17/24). Immediate jeopardy began on 11/13/24 when the facility's consultant pharmacist completed a monthly MRR, identified the omission of Eliquis from Resident #6's medication regimen, but failed to urgently address this issue with either the physician or the facility. Immediate jeopardy was removed on 12/14/24 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure the completion of education and monitoring systems are in place. The findings included: On 9/17/24, a venous doppler ultrasound study was conducted of Resident #6's left lower extremity due to the resident's complaint of pain in her left lower extremity and history of frequent DVTs. The Radiology Results read in part, Impression: Findings are consistent with deep venous thrombosis [DVT] of the left common femoral, deep femoral and proximal superficial femoral veins of indeterminate age. Clinical Follow-up is recommended. A Health Status Note dated 9/17/24 at 2:54 PM reported Resident #6's Medical Doctor (MD) was informed of the radiology results. A new physician's order was received to discontinue the resident's Eliquis and initiate the administration of 40 mg enoxaparin (an injectable anticoagulant used for the treatment of DVTs) to be administered subcutaneously (under the skin) every 12 hours to prevent blood clotting. The physician also ordered a Vascular consult for Resident #6 at that time. Resident #6 was seen for an outside Vascular consultation on 9/27/24. Upon her return to the facility, paperwork provided from the consultation included a Doctor's Order Consult Request. A notation made on this form indicated the reason for the consultation was due to concerns for blood clots given the resident's positive history and bilateral leg pain. The Consultation Findings indicated a bilateral lower extremity (BLE) venous duplex (ultrasound) was conducted with a diagnosis of Bilateral lower extremity non-occlusive DVTs [a condition where veins are partially blocked, allowing some blood to flow around the clots]. The Recommendations read in part, .Eliquis 5 mg BID [twice daily] x 30 days and follow-up in 1 month with a repeat BLE venous duplex [ultrasound to be completed at the next visit] to check on the status of the thrombi [clots]. Patient may need to be on low anticoagulation indefinitely with her history of DVT/PE. The Doctor's Order Consult Request form also noted the resident's one-month follow-up appointment was scheduled for 11/4/24 at 3:00 PM. The form was signed by the Vascular clinic Nurse Practitioner #1 (NP #1). Upon Resident #6's return to the facility on [DATE], a physician's order was received and transcribed by Nurse #1 into the resident's electronic medical record (EMR) to re-start her Eliquis as 5 mg administered as one tablet by mouth twice daily for 30 days. The order for Eliquis included a start date of 9/28/24 and an end date of 10/28/24. The resident's order for enoxaparin was discontinued as of 9/27/24. A physician's order was received and transcribed appropriately for Resident #6's enoxaparin to be discontinued as of 9/27/24. A review of the resident's September 2024 Medication Administration Record (MAR) revealed Resident #6 began to receive 5 mg Eliquis administered as one tablet by mouth twice daily on 9/28/24 in accordance with the physician's order. A review of the resident's most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. The MDS indicated Resident #6 had severely impaired cognition. The diagnoses section of the MDS assessment included atrial fibrillation as an active diagnosis. The section of the MDS related to medications indicated Resident #6 received an anticoagulant medication. A review of Resident #6's October 2024 and November 2024 MARs revealed the resident received her last dose of Eliquis on the morning of 10/28/24. No other doses of Eliquis were documented as administered on the resident's MARs from 10/28/24 to 11/8/24. On 11/8/24 at 2:00 PM, Resident #6 was seen at her outside Vascular consultation and follow-up for her bilateral DVTs. The Doctor's Order Consult Request form provided to the facility upon conclusion of this follow-up reported the resident's thrombi were unchanged. The resident's diagnosis indicated she had chronic bilateral lower extremity DVTs and her medications/treatments were noted as 5 mg Eliquis to be administered by mouth twice a day for 90 days with 2 refills. The Recommendations on the consult form included, in part: Eliquis 5 mg BID [twice daily] po [by mouth] x 90 days #2 refills. Referral for hematology due to history of multiple DVTs and PE. A follow-up Vascular appointment was recommended in 6 months. A review of Resident #6's physician's orders and her November 2024 MAR revealed the recommendations from the 11/8/24 Vascular consultation were not transcribed into the resident's EMR. No doses of Eliquis were documented as administered to the resident from 11/8/24 to 11/13/24. Resident #6's EMR included a monthly consultant pharmacist Medication Regimen Review (MRR) dated 11/13/24 at 1:27 PM. The MRR included the following, in part: .New Meds / Changes: reviewed . Notes / Recommendations: DON [Director of Nursing] x 2. The MRR progress note did not address the omission of an anticoagulant for this resident. As of 11/13/24, Resident #6 had been without an anticoagulant medication (such as Eliquis) for 16 days. A telephone interview was conducted on 12/12/24 at 2:08 PM with the facility's consultant pharmacist. At the time of the interview, the pharmacist said she did have electronic access to the facility's EMRs so she was able to review Resident #6's November MRR. When asked if she had a concern about the discontinuation of the resident's Eliquis as of 10/28/24, the pharmacist stated she noticed the resident had a Vascular consultation on 11/8/24. She was also aware of the discontinuation of Resident #6's Eliquis. The pharmacist then reported she, made a recommendation on 11/13 to the DON inquiring if the Eliquis should be re-started. Upon further inquiry, the pharmacist stated the recommendation she made would have been sent to the facility's DON and Administrator in an email dated 11/20/24, along with her consultation report and all the physician and nursing recommendations for the month of November. When asked about the delay in sending this recommendation to the facility, the pharmacist acknowledged that she could have sent an urgent request to the DON or physician to alert them of the Eliquis discontinuation. Upon request, the Assistant Director of Nursing (ADON) provided a copy of the consultant pharmacist's Nursing Summary Report dated 11/19/24 and received via email on 11/20/24. The heading of the Nursing Summary Report read, in part: Please review this report for possible updates for your Nursing system. These findings were noted by the consultant pharmacist on their most recent visit. There were 5 recommendations on page 3 (of 6) of the Nursing Summary Report. The second recommendation on this page was a notation (dated 11/13/24) that addressed the omission of Resident #6's Eliquis. The notation read, Medium Priority. Resident had a consult with Vascular [Name of Clinic] on 11/8/24. They recommended starting Eliquis 5 mg BID x 9 months. Should Eliquis be restarted? A review of Resident #6's physician orders and her November/December 2024 MARs revealed the Eliquis was not re-initiated for this resident. No doses of Eliquis were administered to Resident #6 up to the date of the resident's discharge to the hospital on 12/3/24. A total of 36 days had elapsed from 10/28/24 to 12/3/24 without Resident #6 receiving an anticoagulant (such as Eliquis). Resident #6's EMR included a Skilled Nursing Facility (SNF) to Hospital Transfer form dated 12/3/24 at 6:50 PM. The transfer form reported Resident #6 was sent out to the hospital for evaluation and treatment due to a change in mental status and possible stroke. Resident #6's EMR included a Skilled Nursing Facility (SNF) to Hospital Transfer form dated 12/3/24 at 6:50 PM. The transfer form reported Resident #6 was sent out to the hospital for evaluation and treatment due to a change in mental status and possible stroke. A review of the resident's hospital Admission Note's History and Physical dated 12/3/24 at 11:36 PM was conducted. The note indicated Resident #6 was transported to the hospital via Emergency Medical Services (EMS) and presented with altered mental status, garbled speech, and confusion. The notes reported the resident had a history of stroke with left sided deficits. Resident #6's History of Present Illness also included, in part, atrial fibrillation not on anticoagulation and DVT with IVC filter (a small device that prevents blood clots from traveling from the legs to the lungs). The emergency room notes reported a computerized tomography (CT) scan of the head showed an acute to subacute ischemic event (a situation where a stroke was caused by blocked blood flow to the brain) involving the left posterior temporal lobe (a part of the brain for understanding language, learning, and remembering verbal information) and temporal parietal junction (a region of the human brain that is involved in many higher-order cognitive and motor functions). The resident was reported to have atrial fibrillation and noted she was not currently on anticoagulation. The hospital record also indicated Resident #6 was previously on Eliquis, but it been discontinued without her family being aware of the reason for the discontinuation of it. Resident #6 remained hospitalized as of the date of the review (12/17/24). An interview was conducted on 12/13/24 at 8:19 AM with the facility's Administrator, DON (who started her position on 11/20/24), and the facility's former DON (who was currently working as the facility's ADON). The Regional Director of Clinical Operations joined the interview shortly after it began. During the interview, the ADON and Administrator confirmed they both received the consultant pharmacist's report sent via email on 11/20/24. However, they both agreed the report wasn't as timely as they would have expected and in the snapshot, there were no urgent needs mentioned. The ADON stated she would always look at the snapshot first so these issues would be addressed first. She reported the Physician Recommendations and Nursing Recommendations were typically separated and given to either the MD or the appropriate nursing staff to take care of. However, the ADON noted she did not see the pharmacist's recommendation for Resident #6's Eliquis in amongst the recommendations for other residents until she specifically looked back for it. When the Administrator, DON, and ADON were asked if the omission of Resident #6's Eliquis would have been considered an urgent issue that needed to be addressed, they each said, Yes. The Administrator added, any urgent issue should have been addressed by any means. He further stated, Urgent means right now. A telephone interview was conducted on 12/13/24 at 12:12 PM with the Vascular MD who oversaw NP #1. He reported the NP who saw Resident #6 on 9/27/24 was no longer employed by the Vascular clinic. When asked, the MD stated the lapse in Eliquis administration was definitely not an intentional lapse. Upon review of the 11/8/24 consultation notes, the MD reported it appeared the provider wanted to write a prescription with a longer duration on 11/8/24 so Resident #6 had coverage for 6 more months. Upon further review of the consultation notes, the MD also reported a referral to hematology was made for this resident. Overall, the MD stated the 11/8/24 Vascular consult recommendations were what he would have reasonably expected. A telephone interview was conducted on 12/13/24 at 10:13 AM with Resident #6's MD at the facility. During the interview, the MD stated he felt the crux of the problem was that the 9/27/24 order was written for a 30-day period. He reported that ideally, he would have thought the Eliquis should have been continued until her scheduled follow-up appointment. When asked, the MD added that he didn't know why the 11/8/24 order for Eliquis was missed. He stated that there are a few medications which are particularly important to continue, and these would include antiseizure medications and blood thinners (anticoagulants). The MD was also asked what he would have wanted the consultant pharmacist to do when she identified that Resident #6's Eliquis had been discontinued. He reported the pharmacist should have called someone at the facility and alerted them to the discontinuation of Eliquis when she noticed it. The Administrator was notified of immediate jeopardy on 12/12/24 at 5:30 PM. The facility provided the following credible allegation of Immediate Jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: Review of Resident #6's clinical documentation indicates; on 9/27/24 Resident #6 had a vascular appointment. The consultation resulted in recommendation to resume Apixaban (Eliquis) 5mg twice daily for 30 days. The order was transcribed onto the facility Electronic Health records and implemented as ordered. Medication was ordered to start on 9/28/2024 with the stop date of 10/28/24. Resident #6 was ordered to have a follow up appointment in 30 days. The consultation form indicated that resident's follow up appointments to be 11/4/2024 at 3pm. Review of facility clinical documentation dated 10/8/24 indicate Resident #6's daughter requested for the Vascular appointment to be rescheduled due to conflict of interest. The appointment was rescheduled for 11/8/2024. Resident #6 went to the follow up Vascular appointment on 11/8/2024. The Vascular physician ordered Eliquis 5mg to be restarted twice daily for 30 days. Review of Resident #6 Electronic Health Records from 11/8/2024 to 12/3/2024 indicated that no orders for Eliquis were transcribed onto the facility's Electronic Health Records. Resident #6 was sent to the acute care hospital on 12/3/2024 due to altered mental status. Review of Resident #6 Documentation on Resident #6's Medication Administration Records (MARs) revealed she did not receive this oral anticoagulant from 10/28/24 up to the date of her discharge to the hospital on 12/3/24. Review of the licensed pharmacist-nursing summary report dated 11/13/2024, completed during monthly resident's drug regimen reviews indicated a notation that Resident #6 had a consultation with Vascular solutions on 11/8/24, the recommendation questioned whether the Eliquis should be restarted per recommendation. The facility received the pharmacy recommendation on 11/20/2024. No indication that the pharmacy recommendation was sent to the physician for review and/or followed up by the facility. Resident #6 is no longer in the facility. The Governing body led by the [NAME] President of Operation, the facility Administrator, Regional Director of Clinical Services, and Director of Nursing conducted the root cause analysis on 12/12/2024, to identify the causative factor for this alleged noncompliance, to include failure to report the medication irregularities to the attending physician and implement recommendation by the licensed pharmacist given on 11/13/24, and implemented appropriate measures to correct and prevent the reoccurrences. The governing body put forth the following plan for identification for those residents who are likely to suffer a serious adverse outcome as a result of the alleged noncompliance and implemented the measures below to alter the process to prevent a serious adverse outcome from occurring. 100% audit of current residents who have had medical appointments in the last 30 days was completed by the Director of Nursing and/or Assistant Director of Nursing on 12/5/2024 to validate any orders/recommendation from the consulting physician were transcribed to the facility electronic health records and implemented as ordered. No other resident identified with any deficiency. Findings of this audit are documented on a appointment consultation audit tool located in the facility compliance binder. 100% of all consulting pharmacist nursing recommendations and MD recommendations for current residents given in the last 30 days were audited on 12/13/2024 by the Director of Nursing, Assistant Director of Nursing, and/or Admission nurse to identify any other recommendations that were not transcribed/implemented/acted upon correctly in the facility. The audit also focusses on ensuring any medication irregularities were reported to the attending physician and acted upon timely. Findings of this audit are documented on the pharmacy recommendation tool order audit tool located in the facility compliance binder. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: Effective 12/13/2024, the licensed pharmacist will review each resident drug regimen monthly and report any irregularities to the attending physician and the Director of Nursing to be acted upon in a timely manner. The consultant pharmacist will accomplish this systemic change by addressing any medication irregularities on a physician recommendation form that will be provided to the attending physician for review. Findings of this systemic change will be documented on the Monthly pharmacy consultation review form and maintained in the Pharmacy binder. Effective 12/13/2024, the facility's clinical team, which includes Director of Nursing, Assistant Director of Nursing, Medical records coordinator, Unit coordinator #1 Unit coordinator #2, and/or Admission nurse initiated a process for reviewing pharmacy recommendations completed by the licensed pharmacist to ensure the recommendations to include any irregularities on drug regimen are reported to the attending physician and acted upon in a timely manner. This systemic process will take place within three days or receipt of pharmacy consultation reports. Any identified issues will be addressed promptly, and appropriate actions will be implemented by the DON, ADON, and/or Unit coordinator #1/#2 Findings of this systemic change will be documented on the Monthly pharmacy consultation review form and maintained in the Pharmacy binder. 100% education of all current clinical leadership team members to include Director of Nursing, Assistant Director of Nursing, Medical records coordinator, Unit coordinator #1, Unit coordinator #2 and/or Admission nurse completed by the facility administrator. The emphasis of this education includes, but is not limited to, the importance of reviewing all pharmacy recommendations and implementing the recommendation in a timely manner. This education will be completed by 12/13/2024, any clinical team member not educated by 12/13/24, will not be allowed to work until educated. This education is added to a new hire orientation for all clinical team members effective 12/13/2024. Facility Administrator will monitor and track the completion of this education and will complete this education for any newly hired Clinical leader during the new hire orientation effective 12/13/2024. The facility Administrator conducted a phone Inservice education to the facility medical director, attending physician, and the licensed pharmacist who provide services to the facility on [DATE]. The emphasis of this education includes, but is not limited to, the importance of ensuring any medication irregularity is communicated to the attending physician timely for proper follow through. Alleged immediate jeopardy removal date: 12/14/24 A validation of the IJ removal plan was conducted on 12/17/24. The facility provided documentation of the audits conducted for current residents who had medical appointments in the last 30 days and the validation check of any new orders prompted by the recommendations. These audits were completed as planned. Documentation was also reviewed of the education provided to the clinical leadership team members related to the importance of a timely review to ensure the pharmacy recommendations made by the consultant pharmacist are promptly addressed. Also, the facility's Administrator held in-service (via telephone) with the facility's Medical Doctors and consulting pharmacist on 12/13/24 to encourage the coordination of reporting and addressing any medication irregularities identified by the pharmacist. The IJ removal date of 12/14/24 was validated.

Based on facility staff interviews, physicians' interviews, and facility and hospital record reviews, the facility failed to provide an uninterrupted course of Eliquis (an oral anticoagulant or blood thinner used to reduce the risk of stroke and blood clots in people who have atrial fibrillation) when the medication was discontinued 11 days before Resident #6 returned for a one-month follow-up from an outside Vascular consultation. The resident was seen for the follow-up Vascular consultation on 11/8/24. At that time, the facility failed to transcribe an order for the Eliquis into her electronic medical record (EMR), which resulted in the resident missing this medication for a total of 36 days until she was discharged to the hospital on 12/3/24. This occurred for 1 of 1 resident reviewed (Resident #6) with a history of strokes, deep vein thrombosis (or DVTs, a condition where a blood clot forms in a deep vein, typically in the legs), pulmonary embolism (or PE, a condition where a blood clot travels to the lungs), and atrial fibrillation (a type of irregular heartbeat). Resident #6 was admitted to the hospital on 12/3/24 due to a change in mental status with diagnoses which included an acute middle cerebral artery (MCA) stroke. An MCA stroke occurs when blood flow through the middle cerebral artery in the brain is interrupted. Resident #6 remained hospitalized as of the date of the review (12/17/24). Immediate jeopardy began on 10/28/24 when Resident #6's Eliquis was discontinued from Resident #6's medication orders. Immediate jeopardy was removed on 12/14/24 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure the completion of education and monitoring systems are in place. The findings included: Resident #6 was admitted to the hospital on 2/13/24 after sustaining a left distal fibular fracture (a break in the small bone of the lower leg near the ankle) from a fall. The resident's discharge medical history noted she was on chronic anticoagulation due to atrial fibrillation and a history of DVT and PE. Resident #6's discharge medication list included 5 milligrams (mg) Eliquis to be administered as one tablet by mouth twice daily. She was discharged from the hospital and admitted to the facility on [DATE]. A review of Resident #6's February 2024 through August 2024 Physician Orders revealed the resident's medication regimen continued to include 5 mg Eliquis administered by mouth two times a day from 2/20/24 to 9/17/24 due to her diagnosis of atrial fibrillation. On 9/17/24, a venous doppler ultrasound study was conducted of Resident #6's left lower extremity due to the resident's complaint of pain in her left lower extremity and history of frequent DVTs. The Radiology Results read in part, Impression: Findings are consistent with deep venous thrombosis [DVT] .Clinical Follow-up is recommended. A Health Status Note dated 9/17/24 at 2:54 PM reported Resident #6's Medical Doctor (MD) was informed of the radiology results. A new physician's order was received to discontinue the resident's Eliquis and initiate the administration of 40 mg enoxaparin (an injectable anticoagulant used for the treatment of DVTs) to be administered subcutaneously (under the skin) every 12 hours to prevent blood clotting. The physician also ordered a Vascular consult for Resident #6 at that time. Resident #6 was seen for an outside Vascular consultation on 9/27/24. Upon her return to the facility, paperwork provided from the consultation included a Doctor's Order Consult Request. A notation made on this form indicated the reason for the consultation was due to concerns for blood clots given the resident's positive history and bilateral leg pain. The Consultation Findings indicated a bilateral lower extremity (BLE) venous duplex (ultrasound) was conducted with a diagnosis of Bilateral lower extremity non-occlusive DVTs [a condition where veins are partially blocked, allowing some blood to flow around the clots]. The Recommendations read as follows: Compression stockings .daily (on in AM, off in PM) and Eliquis 5 mg BID [twice daily] x 30 days and follow-up in 1 month with a repeat BLE venous duplex [ultrasound to be completed at the next visit] to check on the status of the thrombi [clots]. Patient may need to be on low anticoagulation indefinitely with her history of DVT/PE. The Doctor's Order Consult Request form also noted the resident's 1 monthly follow-up appointment was scheduled for 11/4/24 at 3:00 PM. The form was signed by Nurse Practitioner #1 (NP #1) with an additional notation which read, Reviewed by Attending Physician. Upon Resident #6's return to the facility on [DATE], a physician's order was received and transcribed by Nurse #1 into the resident's EMR to re-start her Eliquis as 5 mg administered as one tablet by mouth twice daily for 30 days. The order for Eliquis included a start date of 9/28/24 and an end date of 10/28/24. A physician's order was received and transcribed appropriately for Resident #6's enoxaparin to be discontinued as of 9/27/24. A telephone interview was conducted on 12/16/24 at 7:56 PM with Nurse #1. Nurse #1 was identified as having transcribed the order for Resident #6's Eliquis on 9/27/24 upon her return from the Vascular consultation. When asked, the nurse recalled Resident #6 but could not remember any specifics related to the orders transcribed into her EMR on 9/27/24. Nurse #1 stated she did recall the resident was put back on her usual dose of Eliquis after the injectable enoxaparin was discontinued. The nurse reported if she had any questions on the recommendations or orders put on the resident's paperwork from the consult, she would have told the Unit Manager. Nurse #1 reported the Unit Manager was responsible for any follow-up deemed necessary for the physician's orders. Upon inquiry, the nurse stated that usually when a resident returned from an outside appointment, the Unit Manager would review the consultation paperwork, and she would often be the staff member who put any new or changed physician's orders into the resident's EMR. A review of the resident's September 2024 Medication Administration Record (MAR) revealed Resident #6 began to receive 5 mg Eliquis administered as one tablet by mouth twice daily on 9/28/24 in accordance with the physician's order. A review of the resident's most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. The MDS indicated Resident #6 had severely impaired cognition. The diagnoses section of the MDS assessment included atrial fibrillation as an active diagnosis. The section of the MDS related to medications indicated Resident #6 received an anticoagulant medication. Resident #6's most recent care plan included the following area of focus, in part: --Anticoagulant: The resident is at risk for bleeding, hemorrhage, excessive bruising, and complications related to anticoagulant use secondary to atrial fibrillation, DVT (Date Initiated 9/6/24; Revision on 10/24/24). The interventions included the administration of medications as ordered (Date Initiated 9/5/24). A review of Resident #6's October 2024 and November 2024 MARs revealed the resident received her last dose of Eliquis on the morning of 10/28/24. No other doses of Eliquis were documented as administered on the resident's MARs from 10/28/24 to 11/8/24. A Health Status Note dated 10/28/24 at 3:25 PM and authored by the facility's Director of Nursing (DON) reported Resident #6's managed care program notified facility about resident's upcoming Vascular appointment scheduled for 11/4/24, stating that the [family member] would like to reschedule due to a conflicting event . Awaiting time and date for rescheduled appt [appointment]. A telephone interview was conducted on 12/16/24 at 3:42 PM with the facility's former Director of Nursing (DON), who was currently working as the facility's Assistant Director of Nursing (ADON). During the interview, the ADON was asked about her 10/28/24 notation which indicated she was informed that Resident #6's family wished to reschedule the Vascular consultation. When asked if she realized that Resident #6 would no longer be receiving Eliquis after 10/28/24, the ADON responded by saying, No .not at that moment. On 11/8/24 at 2:00 PM, Resident #6 was seen for her outside Vascular consultation and follow-up for her bilateral DVTs. The Doctor's Order Consult Request form provided to the facility upon conclusion of this follow-up reported the resident's thrombi were unchanged. The resident's diagnosis indicated she had chronic bilateral lower extremity DVTs. Resident #6's medications/treatments were noted as 5 mg Eliquis to be administered by mouth twice a day for 90 days with 2 refills. The Recommendations on the consult form read as follows: Compression stockings .daily (on in morning off in evening), Eliquis 5 mg BID [twice daily] po [by mouth] x 90 days #2 refills. Referral for hematology due to history of multiple DVTs and PE. A follow-up Vascular appointment was recommended in 6 months. A review of Resident #6's physician's orders and her November / December 2024 MARs revealed no orders were transcribed into the resident's EMR for Eliquis. No doses of Eliquis were documented as administered to the resident from 11/8/24 up to the date of her discharge to the hospital on 12/3/24. A telephone interview was conducted on 12/16/24 at 1:42 PM with Nurse #2. Nurse #2 was the nurse identified to have been assigned to care for Resident #6 at the time she returned from her 11/8/24 Vascular consultation. During the telephone interview, Nurse #2 reported she recalled Resident #6 having an appointment on 11/8/24 but she didn't remember seeing the resident until she went to the resident's room to pass medications around 9:30 PM. Nurse #2 stated, Nobody gave me any reports. Upon further inquiry, the nurse stated paperwork from outside consultations was usually given to the hall nurse. However, Nurse #2 reiterated she was not given any papers from the Vascular consultation on this occasion. A telephone interview was conducted on 12/16/24 at 1:56 PM with the facility's former Unit Manager. During the interview, the Unit Manager was asked what the facility's process was for addressing any recommendations made by outside consultations. The Unit Manager reported that she herself would sometimes have to put the orders into the resident's EMR if the hall nurse did not. Upon further inquiry, the Unit Manager stated that sometimes a resident would not come back with the Doctor's Order Consult Request form sent with them to the consultation. If that was the case, the facility would then have to call the consulting provider to try to obtain the form and the information shared on it. When asked if she was given the Doctor's Order Consult Request form upon Resident #6's return from her Vascular consult on 11/8/24, the Unit Manager stated she did not recall. A telephone interview was conducted on 12/16/24 at 10:49 AM with the facility's Administrator. During the interview, the Administrator was asked who would have been responsible to review and transcribe the Vascular consultation recommendations / MD orders into the Resident #6's EMR after her Vascular consultation on 11/8/24. The Administrator reported the hall nurse would have had the initial responsibility for this task. However, he added the Unit Manager was responsible as a second check to ensure this task had been completed. Resident #6's EMR included a Skilled Nursing Facility (SNF) to Hospital Transfer form dated 12/3/24 at 6:50 PM. The transfer form reported Resident #6 was sent out to the hospital for evaluation and treatment due to a change in mental status and possible stroke. A review of the resident's hospital Admission Note's History and Physical dated 12/3/24 at 11:36 PM was conducted. The note indicated Resident #6 was transported to the hospital via Emergency Medical Services (EMS) and presented with altered mental status, garbled speech, and confusion. The notes reported the resident had a history of stroke with left sided deficits. Resident #6's History of Present Illness also included, in part, atrial fibrillation not on anticoagulation and DVT with IVC filter (a small device that prevents blood clots from traveling from the legs to the lungs). The emergency room notes reported a computerized tomography (CT) scan of the head showed an acute to subacute ischemic event (a situation where a stroke was caused by blocked blood flow to the brain) involving the left posterior temporal lobe (a part of the brain for understanding language, learning, and remembering verbal information) and temporal parietal junction (a region of the human brain that is involved in many higher-order cognitive and motor functions). The resident was reported to have atrial fibrillation and noted she was not currently on anticoagulation. The hospital record also indicated Resident #6 was previously on Eliquis, but it been discontinued without her family being aware of the reason for the discontinuation of it. Resident #6 remained hospitalized as of the date of the review (12/17/24). A telephone interview was conducted on 12/13/24 at 12:12 PM with the Vascular MD who oversaw NP #1. He reported the NP who saw Resident #6 on 9/27/24 was no longer employed by the Vascular clinic. When asked, the MD stated the lapse in Eliquis administration was definitely not an intentional lapse. He reported it appeared to him to be a logistical issue having to do with the timing of the next month's appointment. Upon review of the 11/8/24 consultation notes, the MD reported it appeared the provider wanted to write a prescription with a longer duration on 11/8/24 so she had coverage for 6 more months. Upon review of the consultation notes, the MD also noted a referral to hematology was made for this resident. Overall, the MD stated the 11/8/24 Vascular consult recommendations were what he would reasonably expect. A telephone interview was conducted on 12/13/24 at 10:13 AM with Resident #6's MD at the facility. During the interview, the MD stated he felt the crux of the problem was that the 9/27/24 order was written for a 30-day period. He reported that ideally, he would have thought the Eliquis should have been continued until her scheduled follow-up appointment. When asked, the MD added that he didn't know why the 11/8/24 order for Eliquis was missed. He stated that there are a few medications which are particularly important to continue, and these would include antiseizure medications and blood thinners (anticoagulants). The Administrator was notified of immediate jeopardy on 12/12/24 at 5:30 PM. The facility provided the following credible allegation of Immediate Jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: Review of Resident #6's clinical documentation indicates; on 9/27/24 Resident #6 had a vascular appointment. The consultation resulted in recommendation to resume Eliquis 5mg twice daily for 30 days. The order was transcribed onto the facility Electronic Health records and implemented as ordered. Medication was ordered to start on 9/28/2024 with the stop date of 10/28/24. Resident #6 was ordered to have a follow up appointment in 30 days. The consultation form indicated that residents' follow up appointments to be 11/4/2024 at 3pm. No indication that the attending physician was consulted regarding what to do about running out of Eliquis prior to the scheduled appointment. Review of facility clinical documentation dated 10/8/24 indicate Resident #6's daughter requested for the Vascular appointment to be rescheduled due to conflict of interest. The appointment was rescheduled for 11/8/2024. No indication that the attending physician was consulted regarding what to do about running out of Eliquis prior to the scheduled appointment. Resident #6 went to the follow up Vascular appointment on 11/8/2024. The Vascular physician ordered Eliquis 5mg to be restarted twice daily for 30 days. Review of Resident #6 Electronic Health Records from 11/8/2024 to 12/3/2024 indicated that no orders for Eliquis was transcribed onto the facility's Electronic Health Records. Resident #6 was sent to the acute care hospital on 12/3/2024 due to altered mental status. Review of Resident #6 Documentation on Resident #6's Medication Administration Records (MARs) revealed she did not receive this oral anticoagulant from 10/28/24 up to the date of her discharge to the hospital on 12/3/24. Review of the licensed pharmacist-nursing summary report dated 11/13/2024, completed during monthly resident's drug regimen reviews indicated a notation that Resident #6 had a consultation with Vascular solutions on 11/8/24, the recommendation questioned whether the Eliquis should be restarted per recommendation. No indication that the pharmacy recommendation was followed up by the facility. Resident #6 is no longer in the facility. The Governing body led by the [NAME] President of Operation, the facility Administrator, Regional Director of Clinical Services, and Director of Nursing conducted the root cause analysis (RCA) on 12/13/2024, to identify the causative factor for this alleged noncompliance and implemented appropriate measures to correct and prevent the reoccurrences. The Root Cause Analysis (RCA) identified the alleged noncompliance resulted from the failure of the facility employee to administer Eliquis and apply compression stockings for DVT prevention per physician order. The RCA further identified that facility staff also failed to consult the physician when Resident #6 was running out of Eliquis before the scheduled appointment that took place on 11/8/24. The RCA further identified that the significant medication error resulted from the failure of the facility licensed nurses to follow the professional standard of practice on transcribing physician order for Resident #6 ordered by the outside Vascular consultant on 11/8/2024. The RCA further concluded that the failure to transcribe the ordered medication by the outside vascular consultant resulted from lack of systemic approach on reviewing outside appointments to validate all recommendations are carried out effectively and timely. The governing body put forth the following plan for identification for those residents who are likely to suffer a serious adverse outcome as a result of the alleged noncompliance and implemented the measures below to alter the process to prevent a serious adverse outcome from occurring. 100% audit of current residents who have had medical appointments in the last 30 days was completed by the Director of Nursing and/or Assistant Director of Nursing on 12/13/2024 to validate any orders/recommendation from the consulting physician were transcribed to the facility electronic health records and implemented as ordered. No other resident identified with any deficiency. Findings of this audit are documented on a appointment consultation audit tool located in the facility compliance binder. 100% audit of current residents' medication discontinues in the last 30 days was completed by the Director of Nursing and/or Assistant Director of Nursing on 12/13/2024 to validate any discontinued medication that was done based on the physician orders to ensure such actions are done based on the medical guidance to prevent significant medication error. Findings of this audit are documented on a discontinued medication audit tool located in the facility compliance binder. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: Effective 12/13/24, a licensed nurse on duty will review a consultation report for any resident who returned from medical appointment while on duty and transcribe any orders in facility electronic health records. Effective 12/13/24 employees will administer medication based on physician orders, to include Eliquis, to treat a specific condition as diagnosed , and document the administration of such medication in each resident's clinical record. Effective 12/13/2024, the facility's clinical team, which includes Director of Nursing, Assistant Director of Nursing, Medical records coordinator, Unit coordinator #1 Unit coordinator #2, and/or Admission nurse initiated a process for reviewing clinical documentation to include the review of medical appointments ordered and/or scheduled in the last 24 hours or from the last held clinical meeting to ensure the appointment is scheduled and take place as ordered. The review will also validate the consultation form from a completed medical appointment is reviewed for any orders/recommendation and ensure such orders are transcribed onto the facility's electronic health records. This systemic process will take place daily (Monday through Friday). Any identified issues will be addressed promptly, and appropriate actions will be implemented by the DON, ADON, and/or Unit coordinator #1/#2 Findings of this systemic change will be documented on the daily clinical report form and maintained in the daily clinical meeting binder. 100% education of all current clinical leadership team members to include Director of Nursing, Assistant Director of Nursing, Medical records coordinator, Unit coordinator #1, Unit coordinator #2 and/or Admission nurse completed by the Regional Clinical Director. The emphasis of this education includes, but is not limited to, the importance of ensuring residents' medical appointments is reviewed in the daily clinical meeting to ensure ordered appointments are scheduled, completed, and the consultation forms from the completed appointments are reviewed for any new orders and recommendations. The education also covered the importance of reviewing all medication discontinues in the last 24 hours or from the last held clinical meeting to validate any discontinued medication was done based on the physician orders to prevent significant medication errors. This education will be completed by 12/13/2024, any clinical team member not educated by 12/13/24, will not be allowed to work until educated. This education is added to a new hire orientation for all clinical team members effective 12/13/2024. Assistant Director of Nursing provide will provide 100% education of all licensed nurses and Medication aides, to include full time, part time, and as needed nursing employees will be completed by the Director of Nursing, Assistant Director of Nursing, and/or Unit Coordinators (1, #2). The emphasis of this education includes but is not limited to: 1. The importance of administering medication to include Eliquis, and other medications per physician order. 2. The importance of consulting the attending physician before medication stopped/discontinued, such as Eliquis, to avoid the possible serious consequences that can happen when abruptly stopping the medication. 3. The importance of ensuring each resident is assigned to a licensed nurse to oversee his/her care including provision for assessing, monitoring, and addressing a change in condition. 4. The importance of ensuring the consultation forms for residents who returned from the medical appointment while on duty are reviewed for any new orders/recommendation and transcribe such orders/recommendation onto resident's electronic medical records and implement such per physician order. This education will be completed by 12/13/24. Any licensed nurses and/or medication aide not educated by 12/13/24 will not be allowed to work until educated. Director of Nursing, Assistant Director of Nursing, and/or Unit Coordinators (1, 2) will monitor and track the completion of this education and will complete this education for any newly hired licensed nurses and/or medication aides during the new hire orientation effective 12/13/2024. Alleged immediate jeopardy removal date: 12/14/24 A validation of IJ removal plan was conducted on 12/17/24. A review of the audits conducted for current residents who had medical appointments in the last 30 days and for current residents' medication discontinuation in the last 30 days revealed they were completed as planned. All nurses and one Medication Aide (MA) assigned to a hall within the facility were interviewed in regard to the in-service education received. Additionally, sign-in sheets documented the education provided and the nursing staff who received it. When asked, the nursing staff was able to describe the education provided on the facility's procedures and the process employed to review a resident's paperwork upon his/her return from an outside consultation. The nurses verbalized an understanding of the need to notify the resident's physician and RP of any new recommendations made and to transcribe the new orders into the electronic medical record. They were also able to consistently describe the need for communication with several other departments, including the resident's physician, the transportation department (for follow-up appointments), and medical records. The IJ removal date of 12/14/24 was validated.

Based on facility staff interviews, physicians' interviews, and facility and hospital record reviews, the facility failed to initiate the use of compression stockings for 1 of 1 resident reviewed (Resident #6) with a history of deep vein thrombosis or DVTs (a condition where a blood clot forms in a deep vein such as the legs), pulmonary embolism or PE (a condition where a blood clot travels to the lungs) and atrial fibrillation (a type of irregular heartbeat). The findings included: Resident #6 was admitted to the hospital on 2/13/24 after sustaining a left distal fibular fracture (a break in the small bone of the lower leg near the ankle) from a fall. She was discharged from the hospital and admitted to the facility on [DATE]. Her diagnoses included a personal history of DVTs, PE and atrial fibrillation. On 9/17/24, a venous doppler ultrasound study was conducted of Resident #6's left lower extremity due to the resident's complaint of pain in her left lower extremity and history of frequent DVTs. The Radiology Results read in part, Impression: Findings are consistent with deep venous thrombosis [DVT] .Clinical Follow-up is recommended. A Health Status Note dated 9/17/24 at 2:54 PM reported Resident #6's Medical Doctor was informed of the radiology results. The physician ordered a Vascular consult for Resident #6 at that time. Resident #6 was seen for an outside Vascular consultation on 9/27/24. Upon her return to the facility, paperwork provided from the consultation included a Doctor's Order Consult Request. The Consultation Findings indicated a bilateral lower extremity (BLE) venous duplex (ultrasound) was conducted with a diagnosis of Bilateral lower extremity non-occlusive DVTs [a condition where veins are partially blocked, allowing some blood to flow around the clots]. The Recommendations read in part: Compression stockings .daily (on in AM, off in PM) . Upon Resident #6's return to the facility on [DATE], the recommendation to initiate compression stockings was not transcribed into the resident's electronic medical record (EMR). A telephone interview was conducted on 12/16/24 at 7:56 PM with Nurse #1. Nurse #1 was identified as having worked on 9/27/24 at the time of Resident #6's return from the Vascular consultation. When asked, the nurse recalled Resident #6 but could not remember any specifics related to the orders transcribed into her EMR on 9/27/24. Nurse #1 stated she did recall the resident had a change in her medications after the Vascular consult, but did not recall seeing an order for compression stockings to be initiated for Resident #6. The resident's physician's orders, September 2024 Medication Administration Record (MAR), and September 2024 Treatment Administration Record (TAR) revealed there were no orders for compression stockings to be applied for Resident #6. The resident's most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. The MDS indicated Resident #6 had severely impaired cognition. She was dependent on staff for all her Activities of Daily Living (ADL), except for requiring only set-up or clean up assistance with meals and partial to moderate assistance for personal hygiene. The diagnoses section of the MDS assessment included atrial fibrillation as an active diagnosis. The section of the MDS related to medications indicated Resident #6 received an anticoagulant medication. Resident #6's most recent care plan included the following area of focus, in part: -Anticoagulant: The resident is at risk for bleeding, hemorrhage, excessive bruising, and complications related to anticoagulant use secondary to atrial fibrillation, DVT (Date Initiated 9/6/24; Revision on 10/24/24). The interventions included the administration of medications as ordered (Date Initiated 9/5/24). The interventions did not include compression stockings. Resident #6's physician's orders and October / November 2024 MARs revealed there were no orders for compression stockings to be applied for this resident. On 11/8/24 at 2:00 PM, Resident #6 was seen for her outside Vascular consultation and follow-up for her bilateral DVTs. The Doctor's Order Consult Request form provided to the facility upon conclusion of this follow-up reported the resident's thrombi were unchanged. The resident's diagnosis indicated she had chronic bilateral lower extremity DVTs. The Recommendations on Resident #6's consult form included, in part: Compression stockings .daily (on in morning off in evening) . Resident #6's physician's orders and her November / December 2024 MARs revealed no orders were transcribed into the resident's EMR for the compression stockings. A review of the resident's most recent Kardex (not dated) revealed it did not include a note to indicate Resident #6 was supposed to use compression stockings. The Kardex is an electronic resource utilized by Nursing Assistants (NAs) to provide a summary of the resident's care needs. A telephone interview was conducted on 12/16/24 at 1:42 PM with Nurse #2. Nurse #2 was the nurse identified as having been assigned to care for Resident #6 at the time she returned from her 11/8/24 Vascular consultation. Upon inquiry, the nurse stated paperwork from outside consultations was usually given to the hall nurse. However, Nurse #2 reiterated she was not given any papers from the Vascular consultation on this occasion. A telephone interview was conducted on 12/16/24 at 1:56 PM with the facility's former Unit Manager. During the interview, the Unit Manager was asked what the facility's process was for addressing any recommendations made by outside consultations. The Unit Manager reported that she herself would sometimes have to put the orders into the resident's EMR if the hall nurse did not. When asked if she was given the Doctor's Order Consult Request form upon Resident #6's return from her Vascular consult on 11/8/24, the Unit Manager stated she did not recall. A telephone interview was conducted on 12/16/24 at 10:49 AM with the facility's Administrator. During the interview, the Administrator was asked who would have been responsible to review and transcribe the Vascular consultation recommendations / MD orders into the Resident #6's EMR after her consultations. The Administrator reported the hall nurse would have had the initial responsibility for this task. However, he added the Unit Manager was responsible as a second check to ensure this task had been completed. An interview was conducted on 12/12/24 at 1:50 PM with Nursing Assistant (NA) #1. During the interview, the NA stated she has worked full time at the facility for several months and was typically assigned to care for Resident #6. When asked, NA #1 reported Resident #6 did not wear compression stockings. Upon further inquiry, the NA stated a resident's Kardex would note if he/she was supposed to wear compression stockings. An interview was conducted 12/12/24 at 1:30 PM with Nurse #3. Nurse #3 was identified as having frequently cared for Resident #6. When asked, Nurse #3 stated she did not recall compression stockings being used for Resident #6. Upon further inquiry, the nurse stated if a resident had an order to use compression stockings, she thought the order would typically be documented on the resident's MAR. An interview was conducted on 12/13/24 at 8:45 AM with the facility's Assistant Director of Nursing (ADON). During the interview, the ADON was asked to describe what she would have expected to be done to implement the Vascular consult's recommendation for Resident #6 to use compression stockings. The ADON reported that once the resident came back from her outside Vascular consult, the nurse should have reviewed the new orders, called the provider for approval of the order, and then transcribed the order into Resident #6's EMR. She stated that once the order was put into the EMR, it would typically show up on the resident's Treatment Administration Record (TAR) for the nurse to document its completion. The order would also be put on the resident's Kardex so the NA caring for Resident #6 would know that he/she needed to assist the resident with the compression stockings. A telephone interview was conducted on 12/13/24 at 12:12 PM with the Vascular MD. During the interview, the MD was asked about the recommendation made to utilize compression stockings for Resident #6. He stated that although compression stockings were primarily used to prevent chronic edema, they also served another purpose. The MD explained that compressing the veins in the leg would lower the risk of venous stasis (a condition where blood flow in the veins is slowed or stagnant) and DVT.