Every finding on record at Oakwood Community Living Center

Based on policy review, medical record review, observation, and interview, the facility failed to store medication in accordance with facility policy when medication was found unsecured at the beside for 1 of 39 (Resident #35) residents. The findings include: 1. Review of the facility policy titled, Medication Labeling and Storage, dated 2/2023, revealed .The facility stores all medications and biologicals in locked compartments .Only authorized personnel have access to keys .nursing staff is responsible for maintaining medication storage . 2. Review of the medical record revealed that Resident #35 was admitted to the facility on [DATE] with diagnoses including Dementia, Arthritis, and Back Pain. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 3 which indicated Resident #35 was severely cognitively impaired. Observation in Resident #35's room on 9/22/2025 at 9:43 AM and 10:10 AM, revealed 1 bottle of [Named] topical pain relief roll on and 1 bottle of [Named] oral rinse mouthwash for dry mouth in a clear basket on a shelf. During an observation and interview on 9/22/2024 at 10:40 AM, the Director of Nursing (DON) was asked if [Named] medications should be in Resident #35's room unsecured. The DON stated, Absolutely not.

Based on policy review, medical record review, and interview, the facility failed to ensure dental services were provided for 1 of 1 (Resident #22) sampled resident reviewed for dental services. The findings include: 1. Review of the facility policy titled, Dental Services, dated 4/13/2021, revealed .It is the policy of this facility to make dental services available to residents requiring such services.Dental services are available to all residents requiring routine and emergency dental care.Social services will be responsible for assisting the resident/family in making necessary appointments. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE] with diagnoses including Cerebral Aneurysm, Anxiety, and Depression. Review of the [Named Dental Provider] Summary Report . revealed .3/5/2024 .Resident [#22] was diagnosed with a potential need to consult with an Oral Maxillofacial Surgeon.has multiple teeth that need to be removed in 4-6 [4 to 6] areas of the oral cavity. 3/06/2024.Extraction Review - supports referral to Oral Surgeon due to multiple teeth.Referral was sent to facility.Medicaid resident-resources sent to facility.The appointment should be scheduled with a Medicaid provider.location will be determined by the facility.10/15/2024.was diagnosed with a potential need to consult with an Oral Maxillofacial Surgeon.has multiple teeth that need to be removed in 4-6 areas of the oral cavity. Patient will be referred to oral surgeon for multiple teeth extractions.10/16/2024.supports referral to Oral Surgeon due to multiple teeth.Referral was sent to facility.Medicaid resident-resources sent to facility.should be scheduled with a Medicaid provider.location to be determined by facility. Review of the Nurse Progress Notes dated 3/8/2024, revealed the facility attempted to schedule Resident #22 for a referral to oral surgeon. Review of the Nurse Progress Notes, dated 10/18/2024, revealed the facility attempted to schedule Resident #22 for a referral to oral surgeon. Resident #22 was referred to an oral surgeon on 3/5/2024 and 10/15/2024 and still has not been seen by an oral surgeon as of 9/24/2025. Review of the Comprehensive Care plan dated 2/19/2025, revealed .I have several missing teeth, carious [areas of the tooth structure that has been damaged by bacteria and acids]/broken teeth.Coordinate arrangements for dental care, transportation as needed/as ordered. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #22 was cognitively intact. During an interview on 9/22/2025 at 10:53 AM, Resident #22 stated, .I was told about a year ago I was supposed to have my teeth pulled and replaced with dentures . During an interview on 9/24/2025 at 10:59 AM, the Social Services Director (SSD) was asked about the previous referrals for Resident #22 to be seen by an oral surgeon. The SSD stated .I'm unsure if a referral had been made . The SSD was unable to locate any notes related to referral to oral surgeon in Resident #22's medical chart. The SSD stated .I was not in the role at the time the referrals were made, and I will have to ask the Director of Nursing (DON). During an interview on 9/24/2025 at 11:40 AM, the DON was asked if referral to an oral surgeon for Resident #22 should have been followed up on and scheduled per the facility policy. The DON confirmed the referral should have been followed up on before now.

Based on policy review, medical record review, and interview the facility failed to ensure the resident was free from unnecessary medication use when an as needed (PRN) order for a psychotropic medication was not updated for 1 of 2 (Resident #1) sampled residents reviewed for unnecessary medications.The findings include: 1. Review of the facility policy titled, Psychotropic Medication Use, dated 2/2025, revealed .Residents do not receive psychotropic medications that are not clinically indicated and necessary to treat a specific condition documented in the medical record.Medications in the following categories are considered psychotropic medications Antianxiety medications .When determining whether to initiate, modify, or discontinue medication therapy, the interdisciplinary team conducts and documents an evaluation of the resident. The evaluation includes.physical, behavioral, mental, and psychosocial status.resident complaints, behaviors, and symptoms.Psychotropic medications are not prescribed or administered on a PRN [as needed] basis unless the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record PRN orders for psychotropic medications are limited to 14 days.If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, they will document the rationale for extending the use and include the duration for the PRN order. 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Dementia, Anxiety, and Depressive Disorder. Review of the significant change Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status score of 10, which indicated Resident #1 had moderately impaired cognition. Resident #1 received Antipsychotic and Antidepressant medications. Review of the Physician's Order dated 6/23/2025, revealed .Xanax [medication used for anxiety] Oral Tablet 0.5 MG [milligram].Give 1 tablet by mouth every 12 hours . During an interview on 9/24/2025 at 1:06 PM, the Director of Nurses (DON) was asked how long a PRN psychotropic medication order is good for. The DON stated, .14 days.when the 14 days are up.the nurse should contact the provider and say the resident continues to need.what do you want us to do. The DON was asked was a new order needed. The DON stated, Yes. The DON was asked was a new order given for the as needed Xanax. The DON stated, No, the date on her order says 6/23/2025.

Based on policy review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were followed during dining when 3 of 5 staff members (Certified Nursing Assistant (CNA) #1, #2, and #3) failed to perform hand hygiene after touching contaminated objects while serving residents meals, failed to perform hand hygiene after removing gloves, failed to perform hand hygiene between serving residents, and failed to don proper Personal Protective Equipment (PPE) in isolation rooms, and when 1 of 2 dietary staff (Dietary Staff #1) observed washing dishes failed to perform hand hygiene after removing dirty gloves and donning clean gloves. The findings include: Review of the facility's policy titled, .Handwashing/Hand Hygiene revised 6/2010, revealed .This facility considers hand hygiene the primary means to prevent the spread of infections .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub .for all the following situations .Before and after direct contact with residents .after contact with objects .in the immediate vicinity of the resident .After removing gloves . Observation in the residents' room on 6/21/2021 beginning at 12:25 PM, revealed CNA #1 knocked on the door of Resident #22, handled the bed control, placed a lunch tray on the overbed table, picked up a grabber and moved it, and touched the pillow on the bed. CNA #1 did not perform hand hygiene and then set up the lunch tray for Resident #22, opened the milk, took the top off of the tea and added sweetener, handled the silverware, sprinkled salt and pepper on the food, and moved the overbed table closer to Resident #22. CNA #1 did not perform hand hygiene, knocked on the door and entered Resident #30's room, used the television remote to change the channel, placed the lunch tray on the overbed table, obtained a cup of coffee and added the cream and sugar and stirred it with a spoon and handed it to Resident #30. Observation in the resident's room on 6/21/2021 beginning at 12:40 PM, revealed CNA #1 knocked on the door, entered Resident #8's room, touched the bed, touched the foot of the bed and the crank to adjust the bed, touched the overbed table, and placed the tray on the table. CNA #1 failed to perform hand hygiene, opened the silverware, and sprinkled salt and pepper on the food. CNA #1 then performed hand hygiene with alcohol-based hand rub, wiped her hands on her pants, and prepared a cup of coffee for Resident #8. CNA #1 failed to perform hand hygiene, adjusted the air conditioner temperature, picked a towel up off the floor, obtained a clean towel from the linen cart, and placed it on Resident #8. Review of the facility's undated policy titled, Level One Isolation-Respiratory Precautions . revealed .PPE-Mask, gloves, face shield . Review of the medical record, revealed Resident #238 was admitted to the facility on [DATE] with a Physician's Order for Level One Isolation for 14 days. Observation in the resident's room on 6/21/2021 at 12:55 PM, revealed CNA #3 did not don a shield or gloves and entered Resident #238's Level One Isolation room, stood beside the resident and asked them about their intake, cleaned up the lunch tray on the overbed table, and took the tray out of the room. Review of the medical record, revealed Resident #88 was admitted to the facility on [DATE] with a Physician's Order for Level One Isolation for 14 days. Observation in the resident's room on 6/22/2021 at 7:35 AM, revealed CNA #2 did not don a shield or gloves and entered Resident #88's Level One Isolation room to give him a cup of coffee. Observation in the resident's room on 6/22/2021 at 7:38 AM, revealed CNA #2 did not don a shield or gloves and entered Resident #88's Level One Isolation room to give him some sugar. Review of the facility's undated policy titled, .SAFE FOOD HANDLING, revealed .Illness causing bacteria can survive in many places around the kitchen, including your hands, utensils, and cutting boards .When to Wash Your Hands .When you enter the kitchen before you touch any food or equipment .between food items or between clean and dirty items . The facility's undated policy titled, .HANDWASHING PROCEDURE FOR DINING SERVICES, revealed .Gloves are not meant to be used as a replacement for handwashing. They are only effectively [effective] if proper handwashing is completed .Employees must wash their hands immediately after they remove gloves .some situations that require hand hygiene .After handling soiled equipment or utensils .In between glove changes .After removing gloves .Before putting on a fresh pair of gloves .After handling dirty dishes or trash . Observation in the Kitchen on 6/22/2021 beginning at 9:50 AM, revealed Dietary Staff #1 was wearing gloves and rinsing dirty dishes and placing them in the dishwasher. He rinsed off the dirty plates, trays, plate lids and cups and placed them in racks on the dirty side of the dishwasher. Dietary Staff #1 then lifted the handle on the dishwasher to open it, removed his gloves, did not perform hand hygiene, pulled the clean dishes out of the dishwasher, wiped his hands on a cloth and donned new gloves. He then placed a rack of dirty dishes in the dishwasher for a wash cycle and continued to rinse dirty dishes and place them in the rack on the dirty side. He removed his gloves, donned new gloves, pulled out a rack of clean plates from the dishwasher on the clean side. He stacked the plates in his hands and placed them in the plate dispenser. Dietary Staff #1 failed to perform hand hygiene after removing the dirty gloves and before donning clean gloves before stacking the clean plates. He then pulled a clean rack of bowls out of the dishwasher on the clean side, returned to the dirty side of the dishwasher, and continued to rinse dirty dishes, putting them in racks, and loading them into the dishwasher. He then opened the dishwasher and pulled out a rack of clean trays wearing the same gloves he was wearing on the dirty side of the dishwasher. He removed his gloves, did not perform hand hygiene, and donned clean gloves. He picked up the cloth he had wiped his hands on and used it to wipe down a tray cart that had been sprayed with bleach. After he wiped down the cart, he took it out into the hall, and obtained another dirty cart and brought it back into the kitchen. During an interview on 6/22/2021 at 10:05 AM, the Dietary District Manager confirmed she had been observing Dietary Staff #1 wash the dishes. She confirmed Dietary Staff #1 was not washing his hands between removing dirty gloves and donning clean gloves and stated dietary staff should always perform hand hygiene after removing gloves and between handling dirty dishes and clean dishes. During an interview on 6/22/2021 at 4:29 PM, the Administrator confirmed staff should wear a mask, gloves, and face shield when they enter Level One Isolation. The Administrator confirmed staff should sanitize their hands when they remove gloves and before they don clean gloves. She confirmed staff should perform hand hygiene between residents during dining and stated they should perform hand hygiene if they touch contaminated surfaces before serving residents during dining.

Based on policy review, observation, and interview, the facility failed to ensure 1 of 5 nurses (Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) #3) administered medications through a Percutaneous Endoscopic Gastrostomy (PEG) tube by gravity. The findings include: The facility's policy titled, ENTERAL TUBE MEDICATION ADMINISTRATION, dated 8/9/2013, revealed .To safely and accurately administer oral medications through an enteral tube .Allow medication to flow down tube via gravity .Do not push medications through the tube . Observation in the resident's room on 6/22/2021 at 1:06 PM, revealed RN #1 pulled 25 milliliters (ml) of water into a syringe, used the plunger to push the water into Resident #5's PEG tube. RN #1 added 5 ml of water with the crushed medications in the medication cup, poured the medications and water into the syringe and used the plunger to push the medications and water through the PEG tube. RN #1 took a cup to the bathroom for tap water. RN #1 retrieved 30 ml of water and poured the water into the syringe and used the plunger to push the water through the PEG tube. RN #1 retrieved 20 ml of water and used the plunger to push the water through the PEG tube. Observation in the resident's room on 6/23/2021 at 7:25 AM, revealed LPN #3 poured 30 ml of water into the syringe, replaced the plunger, and pushed the water into Resident #5's PEG tube. LPN #3 poured water with the crushed medications into the syringe, replaced the plunger, and pushed the medications and water through the PEG tube. LPN #3 added more water into the cup of residual medication, replaced the plunger and pushed the water into the PEG tube. During an interview on 6/23/2021 at 2:10 PM, the Director of Nursing (DON) was asked how PEG medications should be administered. The DON stated, .by gravity .

Based on review of the Geriatric Medication Handbook, medical record review, observation, and interview, the facility failed to ensure 2 of 5 nurses (Licensed Practical Nurses (LPN #1 and #2) administered medications with a medication error rate less than 5 percent (%) for Resident #29 and Resident #11. A total of 2 medication errors were observed out of 27 opportunities, resulting in a medication error rate of 7.41%. The findings include: Review of the Geriatric Medication Handbook, tenth edition, page 41 and 43 revealed .DIABETES: INJECTABLE MEDICATIONS .Novolog .Rapid-Acting Insulin Analog .ONSET .15 min [minutes] .15 minutes .prior to meals .[MEDICATION(S)] [Lispro] .Rapid-Acting Insulin Analog .ONSET .15 min .15 minutes prior to meals . Review of medical record, revealed Resident #11 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Order Summary Report dated 9/30/2020, revealed .Insulin [MEDICATION(S)] Solution [Novolog] 100 UNIT/ML inject as per sliding scale: if 0 - 150 = 0 units BS [blood sugar] <50 units use Emergency [MEDICATION(S)] kit and call MD; 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401 - 450 =12 units BS>450, Give 12 units and call MD, subcutaneously before meals related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS . Observation in the resident's room on 6/22/2021 at 11:42 AM, revealed LPN #2 administered 2 units of [MEDICATION(S)] insulin subcutaneously to Resident #11. Resident #11 received a meal tray and took the first bite of food at 12:17 PM in the Assisted Dining Room, which was 35 minutes after receiving the insulin. This resulted in medication error #1. Review of medical record, revealed Resident #29 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Order Summary Report dated 2/1/2021, revealed .NovoLOG Solution 100 UNIT/ML (Insulin [MEDICATION(S)]) Inject as per sliding scale: if 0 - 150 = 0; 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; GREATER THAN 400 GIVE 12 UNITS AND CALL MD [Medical Doctor] .subcutaneously before meals and at bedtime related to TYPE 2 DIABETES MELLITUS WITH DIABETIC [CONDITION(S)] . Observation in the resident's room on 6/22/2021 at 4:54 PM, revealed LPN #1 administered 2 units of Novolog insulin subcutaneously to Resident #29. Resident #29 received a meal tray and took the first bite of food at 5:32 PM, which was 38 minutes after receiving the insulin. This resulted in medication error #2. During an interview on 6/23/2021 at 7:45 AM, the Director of Nursing (DON) confirmed that Resident #11 and 29 should have received a substantial snack or a meal tray within 15 minutes of administrating the insulin.

Based on review of the Geriatric Medication Handbook, medical record review, observation, and interview, the facility failed to ensure a residents were free from significant medication errors when 2 of 5 nurses (Licensed Practical Nurse (LPN) #1 and #2) failed to administer insulin within the proper time frame related to meals for Resident #11 and 29. The failure to provide a substantial snack or meal within 15 minutes of insulin administration resulted in significant medication errors. Finding Include: Review of the Geriatric Medication Handbook, tenth edition, page 41 and 43 revealed .DIABETES: INJECTABLE MEDICATIONS .Novolog .Rapid-Acting Insulin Analog .ONSET .15 min [minutes] .15 minutes .prior to meals .[MEDICATION(S)] [Lispro] .Rapid-Acting Insulin Analog .ONSET .15 min .15 minutes prior to meals . Review of medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Order Summary Report dated 9/30/2020, revealed .Insulin [MEDICATION(S)] Solution [Novolog] 100 UNIT/ML inject as per sliding scale: if 0 - 150 = 0 units BS [blood sugar] <50 units use Emergency [MEDICATION(S)] kit and call MD; 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401 - 450 =12 units BS>450, Give 12 units and call MD, subcutaneously before meals related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS . Observation in the resident's room on 6/22/2021 at 11:42 AM, revealed LPN #2 administered 2 units of [MEDICATION(S)] insulin subcutaneously to Resident #11. Resident #11 received a meal tray and took the first bite of food at 12:17 PM in the Assisted Dining Room, which was 35 minutes after receiving the insulin. This resulted in a significant medication error. Review of medical record, revealed Resident #29 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Order Summary Report dated 2/1/2021, revealed .NovoLOG Solution 100 UNIT/ML (Insulin [MEDICATION(S)]) Inject as per sliding scale: if 0 - 150 = 0; 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; GREATER THAN 400 GIVE 12 UNITS AND CALL MD [Medical Doctor] .subcutaneously before meals and at bedtime related to TYPE 2 DIABETES MELLITUS WITH DIABETIC [CONDITION(S)] . Observation in the resident's room on 6/22/2021 at 4:54 PM, revealed LPN #1 administered 2 units of Novolog insulin subcutaneously to Resident #29. Resident #29 received a meal tray and took the first bite of food at 5:32 PM, which was 38 minutes after receiving the insulin. This resulted in a significant medication error. During an interview on 6/23/2021 at 7:45 AM, the Director of Nursing (DON) confirmed that Resident #11 and 29 should have received a substantial snack or a meal tray within 15 minutes of administrating the insulin.

Based on policy review, observation, and interview, the facility failed to ensure medications were stored properly when expired medications were in 1 of 4 medication storage areas (Medication Room). The findings include: Review of the facility's policy titled, Specific Procedures For All Medications, dated 11/1/2008, revealed .Check expiration date on package/container . Observation in the Medication Room on 6/22/2021 at 4:05 PM, revealed 1 box of [MEDICATION(S)] Suppositories containing 26 suppositories with an expiration date of 4/30/2021 and 1 box of [MEDICATION(S)] Suppositories containing 46 suppositories with an expiration date of 4/30/2021. During an interview on 6/22/2021 at 4:10 PM, Licensed Practical Nurse (LPN) #1 confirmed the both boxes of suppositories had expired on 4/30/2021. During an interview on 6/23/2021 at 2:17 PM, the Director of Nursing (DON) was asked how should expired medications be handled. The DON stated, .should be placed in a sharps container to be disposed of .

Based on policy review, observation, and interview, the facility failed to ensure food was served under sanitary conditions when a cook served food with contaminated gloves. The facility's failure had the potential to affect 42 of the 43 residents receiving a meal tray from the kitchen. The findings include: 1. The facility's Meal Distribution policy revised 9/2017 documented, .Proper handling techniques to prevent contamination and temperature maintenance controls will be used for point-of-service dining . 2. Observations in the Kitchen on 10/15/19 beginning at 12:15 PM, revealed Cook #1 washed her hands, applied gloves, pulled the meal trays toward her, removed the lids to the steam table, served the dinner plates, dessert bowls, and touched the tongs. Cook #1 untwisted the tie on the bread sacks and pulled the rolls from the sack and placed the rolls on the resident's plates with her contaminated gloved hand. Cook #1 reached into the pan of green beans with her contaminated gloved hand and pulled green bean steams out, and then moved a sausage to the side of a dinner plate with her contaminated gloved hand. 3. Interview with the Certified Dietary Manager (CDM) on 10/15/19 at 12:35 PM, in the Kitchen, the CDM was asked if it was appropriate to touch the resident's food with her contaminated gloves. The CDM stated, No.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained for 2 of 3 (Resident #11 and #35) residents observed during a dressing change, and when 2 of 4 (Licensed Practical Nurse (LPN) #2 and #4) nurses failed to ensure infection control practices were maintained during medication administration. The findings include: 1. Medical record review revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].Clean blister to bottom of left foot with wound cleanser, apply [MEDICATION NAME], apply silver alginate and non stick [MEDICATION NAME] pad, and wrap with Kerlix for padding . Observations in Resident #11's room on 10/15/19 at 11:10 AM, revealed LPN #1 performed a dressing change to Resident #11's left lateral foot. After LPN #1 removed the old dressing and cleaned the wound, he asked a staff member that was assisting him to cover the resident while he washed his hands and gloved. The bed linens touched the wound, re-contaminating the wound. 2. Medical record review revealed Resident #35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].Cleanse wound to L (left) hip with wound cleanser, apply [MEDICATION NAME] and dressing . Observations in Resident #35's room on 10/15/19 at 11:40 AM, revealed LPN #1 performed a dressing change to Resident #35's left hip. After LPN #1 removed the old dressing and cleaned the wound, he asked a staff member that was assisting him to cover the resident while he washed his hands and gloved. The bed linens touched the wound, re-contaminating the wound. Interview with Director of Nursing (DON) on 10/15/19 at 3:30 PM, at the North Nurses' Station, the DON was asked if it was appropriate to cover a resident during wound care with bed linens after a wound had been cleaned and prior to a applying a new dressing to the wound. The DON stated, .No, that would be re-contaminating the wound . 3. The facility's MEDICATIONS, INSTILLATION OF EYE DROPS policy dated 8/25/14 documented, .Should both eyes require instillation, wash and dry your hands thoroughly before and after treating each eye .Clean your equipment and return it to its designated storage area .Clean the over-bed table and return it to its proper position .wash and dry your hands thoroughly . 4. The facility's CLEANING, DISINFECTION AND STERILIZATION . policy dated 6/3/13 documented, .Respiratory therapy equipment that touches membranes .it will receive high-level disinfection .Noncritical (touches intact skin) Stethoscopes, tabletops . The facility's MEDICATIONS, NASAL INHALER SPRAY AND PUMP ADMINISTRATION policy dated 8/25/14 documented, .Rinse the pump, pray (spray), or inhaler with hot water . Observations in Resident #16's room on 10/15/19 at 8:49 AM, revealed LPN #4 entered the room and placed the inhaler and eye drops on the over bed table without cleaning the table or using a barrier. LPN #4 donned gloves, administered the eye drops in each eye and did not perform hand hygiene. LPN #4 used the same gloves, picked up the inhaler and administered the medication. LPN #4 took the medications back to the cart and placed them in the drawer with the other medications without cleaning the inhaler or bottle of eye drops. Interview with the Director of Nursing (DON) and the Regional Nurse Consultant on 10/16/19 at 5:15 PM, in the Administrator Office, they were asked should a barrier be used to place medication on a bedside during medication administration. The Regional Nurse Consultant stated, Yes. They were asked should multiuse medication items be cleaned after use. The DON stated, Yes, at lease before returning to the medication cart. Observations in Resident #1's room on 10/15/19 at 2:23 PM, revealed LPN #2 was administering Percutaneous Endoscopic Gastrostomy (PEG) medications. LPN #2's stethoscope that was around her neck and the stethoscope slipped from her neck to the floor. LPN #2 picked up the stethoscope from the floor, placed the earpieces in her ears, auscultated Resident #1's abdomen with the stethoscope, and did not clean the stethoscope. LPN #3 placed the syringe into the bag and hung the bag on the pole without rinsing the syringe after administering the PEG medications. Interview with the Director of Nursing (DON) and the Regional Nurse Consultant on 10/16/19 at 5:15 PM, in the Administrator Office, they were asked should a stethoscope be used after it was dropped on the floor to check PEG placement. The Regional Nurse Consultant stated, No ma'am . The DON was asked should the syringe be rinsed after administration of PEG medication. The DON stated, Yes, it should be rinsed.

Based on policy review, observation, and interview, the facility failed to date 2 multi-dose vials of medication when opened for 1 of 4 (Medication Room) medication storage areas. The findings include: 1. The facility's Specific Procedures For All Medications policy dated 11/1/08, documented, .When opening a multi-dose container, place the date on the container . 2. Observations in the Medication Room on 10/16/19 at 5:32 PM, revealed (2)[MEDICATION NAME] multi-dose vials opened and undated. Interview with Licensed Practical Nurse (LPN) #3 on 10/16/19 at 5:32 PM, in the Medication Room, LPN #3 was asked if it was appropriate to have an opened and undated medication. LPN #3 stated, They should have a date on it. Interview with the Regional Nurse Consultant (RNC) on 10/16/19 at 5:35 PM, in the Administrator office, the RNC was asked if it was appropriate to have opened and undated medication. The RNC stated, No, they should have open dates.

Based on medical record review, observation, and interview, the facility failed to document behaviors for 1 of 5 (Resident #38) sampled residents reviewed receiving [MEDICAL CONDITION] medications. The findings include: 1. Medical record review revealed Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] documented Resident #38 had moderate cognitive deficits, no behaviors, and received antipsychotic, and antidepressant. The quarterly MDS dated [DATE] documented Resident #38 had severe cognitive deficits, no behaviors, and received antipsychotic and antidepressant medications. The physician's orders [REDACTED].[MEDICATION NAME] .5 mg (milligram) .by mouth at bedtime . A Nurses' Note dated 10/7/19 documented, .Resident noted to have increased confusion and increased incontinence this night . A Nurses' Note dated 10/7/19 documented, .Med (medication) change to [MEDICATION NAME] 2.5 mg PO (by mouth) daily with AM (morning) medications. [MEDICATION NAME] 5mg PO @ (at) HS (hour of sleep). Pt noted to have increased confusion and increased incontinence through out the night on 10/6/19. MD (Physician) notified. Family notified . The physician's orders [REDACTED].[MEDICATION NAME] .5 mg .Give 0.5 tablet by mouth one time a day . The August, September, and (MONTH) 2019 Medication Administration Records (MAR)s documented a 11 indicating the resident had no behaviors on that shift. 3. Interview with Licensed Practical Nurse (LPN) #1 on 10/15/19 at 3:56 PM, at the North Nurses Station, LPN #1 was asked what the 11 indicated on the MARS. LPN #1 stated 11 means no behavior occurred . Interview with the Director of Nursing (DON) on 10/16/19 at 12:18 PM, in room [ROOM NUMBER], the DON was asked why was Resident #38's [MEDICATION NAME] was increased. The DON stated, I asked the same thing when I saw the order .He doesn't have any behaviors that I've seen . The DON was asked if incontinence and increased confusion was appropriate [DIAGNOSES REDACTED].I wouldn't think you'd want to increase it, the [MEDICATION NAME] is making him drowsier . The DON was shown the MARS and was asked if the nursing staff had documented any behaviors. The DON stated No. The DON was asked if Resident #38s behaviors should have been documented. The DON stated, If he had them .

Based on policy review, medical record review, observation, and interview, the facility failed to ensure 1 of 4 (Licensed Practical Nurse (LPN) #2) nurses followed physician's orders [REDACTED]. The findings included: The facility's MEDICATION, ADMINISTRATION THROUGH AN ENTERAL TUBE policy with a revision date 8/25/14 documented, Empty capsule contents into 30 ml (milliliters) of water Flush the tube with 15-30 ml of water prior to medication administration .flushing tube with 5 ml of water after each dose . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The (MONTH) 2019 physician's orders [REDACTED].Order Date .04/03/2019 . The (MONTH) 2019 Medication Administration Record [REDACTED]. Observations in Resident #1's room on 10/15/19 at 2:23 PM, revealed LPN #2 emptied medication capsules into the medication cup, poured 15 ml water into the medication cup, administered the medication, and flushed the PEG tube with 15 ml of water. LPN #1 did not flush the PEG prior to the medication administration and did not flush with the appropriate amount after the medication administration. Interview with the Director of Nursing (DON) and the Regional Nurse Consultant on 10/16/19 at 5:15 PM, in the Administrator Office, they were asked should the nurse flush before and after administering medication via PEG tube. They both stated, Yes.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure 1 of 3 (Licensed Practical Nurse (LPN) #1) nurses administered medications with a medication error rate of less than 5 percent (%). A total of 4 errors were observed out of 29 opportunities, resulting in a medication error rate of 13.79%. The findings include: The facility's MEDICATIONS, ADMINISTRATION THROUGH AN ENTERAL TUBE policy, dated (MONTH) 25, 2014 documented, .Administer medication separately, flushing tube with 5 ml (milliliters) of water after each dose . Medical record review revealed Resident #27 was admitted on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Crush each med (medication) and give individually flushing with 5ml H2O (water) before and after each med .Aspirin Tablet Give 81 mg (milligrams) via (by way of) PEG (Percutaneous Endoscopic Gastrostomy)-Tube (a tube placed through the abdominal wall and into the stomach, which allows nutrition, fluids and/or medications to be administered) .[MEDICATION NAME] HCL ([MEDICATION NAME]) Capsule 10 MG .via PEG tube .Memantine HCL Tablet 5 MG Give via PEG Tube .[MEDICATION NAME] Tablet 5 MG .via PEG Tube . Observations in the North hallway on 11/27/18 at 8:39 AM revealed LPN #1 prepared to administer Resident #27's medications. LPN #1 crushed an Aspirin, a Memantine, and a [MEDICATION NAME] together, emptied the medications into a cup of water, then opened the [MEDICATION NAME] capsule and emptied it into the cup with the other medications. LPN #1 then administered the combined medications to Resident #27 via PEG tube. Interview with the Director of Nursing (DON) on 11/28/18 at 9:15 AM in the DON office, the DON was asked if medications administered via PEG tube should be crushed, combined and administered together. The DON stated, No.

Based on the manufacturer's Professional Blood Glucose Monitoring System User's Guide, FACILITY policy review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection when 1 of 3 (Licensed Practical Nurse (LPN) #1) nurses failed to perform hand hygiene during medication administration and following glove use, and when 1 of 3 (Registered Nurse (RN #1) nurses failed to use manufacture approved disinfectant when cleaning a glucose monitoring machine. The findings include: 1. The facility's MEDICATIONS, INSTILLATION OF EYE DROPS policy dated (MONTH) 25, 2014, documented, .Should both eyes require instillation, wash and dry your hands thoroughly before treating each eye .Put on gloves . The facility's HAND HYGIENE policy dated (MONTH) 27, (YEAR) and GLOVE USE policy dated (MONTH) 6, 2013, documented, .Perform hand hygiene after removing gloves . The facility's MEDICATIONS, ADMINISTRATION THROUGH AN ENTERAL TUBE policy dated (MONTH) 25, 2014, documented, .Wash hands and wear gloves .Perform hand hygiene . 2. Observations in Resident #14's room on 11/27/18 at 8:21 AM, revealed LPN #1 administered an eye drop with ungloved hands into Resident #14's left eye, then without performing hand hygiene, LPN #1 administered an eye drop with ungloved hands into Resident #14's right eye. 3. Observations in Resident #27's room on 11/27/18 at 8:39 AM, revealed LPN #1 donned gloves, removed the enteral syringe from the plastic bag, placed the syringe on the bed without a barrier, with the tip of the syringe touching the bedding. Then LPN #1 picked up the syringe, placed the syringe into the Percutaneous Endoscopic Gastrostomy(PEG, a tube placed through the abdominal wall and into the stomach, which allows nutrition, fluids and/or medications to be administered) opening and checked tube placement. After the medication administration by PEG was completed, LPN #1 removed her gloves and exited the room, and failed to perform hand hygiene. LPN #1 then entered a different room, donned gloves, and stated, I've got to take her to the bathroom. Interview with the Director of Nursing (DON) on 11/28/18 at 9:15 AM in the DON office, the DON was asked if staff should perform hand hygiene and wear gloves when administering eye drops to a resident and perform hand hygiene after glove use. The DON stated, Yes. The DON was asked if an enteral syringe should be used after being placed on a bed, without a barrier with the tip of the syringe touching the bedding. The DON stated, No. 4. The manufacturer's Professional Blood Glucose Monitoring System User's Guide documented, .DO NOT use .household cleaners on the meter . 5. Observations in Resident #21's room on 11/27/18 at 11:56 AM revealed RN #1 completed the blood glucose monitoring procedure on Resident #21, returned to the South medication cart and cleaned the glucose monitor with a Clorox (a household cleaner) disinfecting wipe. Interview with the DON on 11/27/18 at 4:20 PM in the DON office, the DON was asked if the staff should use a household cleaning wipe to clean the glucometer machine. The DON stated No.

Based on medical record review and interview, the facility failed to send the ombudsman a notice of transfer or discharge for 3 of 3 (Resident #20, 36, and 37) residents reviewed for transfer/discharge requirements. The findings included: 1. Medical record review revealed Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #20 had a brief interview for mental status (BIMS) score of 15, which indicated normal cognition. Further review of the MDS revealed there was no active discharge planning and Resident #20 .Expects to remain in this facility . Review of a Situation, Background, Assessment, Recommendation (SBAR) Communication Form dated 11/9/17 documented, .Decreased level of consciousness .Increased Confusion .Personality change .Abrupt onset of significant change from usual . Review of a progress note dated 11/9/17 documented, .called EMS (Emergency Management System) .orders to send to (named hospital) ER (emergency room ) to eval (evaluate) and treat . The facility was unable to provide documentation the ombudsman had been notified when Resident #20 had been discharged to the hospital. 2. Medical record review revealed Resident #36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE] revealed Resident #36 had a BIMS score of 15. Further review of the MDS revealed there was an active discharge plan in place for Resident #36 to return to the community. Review of the facility's Discharge Evaluation and Plan dated 11/6/17 revealed that Resident #36 was discharged . The facility was unable to provide documentation the ombudsman had been notified when Resident #36 was discharged . 3. Medical record review Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE] documented Resident #37 had severely impaired cognition. Further review of the MDS revealed there was no active discharge planning and Resident #20 .Expects to remain in this facility . Review of a Nursing Home to Hospital Transfer Form dated 11/5/17 revealed that Resident #37 was discharged to the hospital with left leg pain with swelling. The facility was unable to provide documentation the ombudsman had been notified when Resident #36 was transferred to the hospital. 4. Interview with the Social Services Director on 1/31/18 at 8:15 AM, in the Social Services Director's office, the Social Services Director was asked if the facility could provide documentation that resident transfer/discharge information had been communicated to the ombudsman. The Social Services Director stated, No ma'am. Interview with the Administrator on 1/31/18 at 9:18 AM, in the Administrator's office, the Administrator was asked how the facility communicated resident transfer/discharge information to the ombudsman. The Administrator stated, We got the notice .it was not passed on evidently .it was not done .

Based on policy review, observation, interview, the facility failed to prevent the potential spread of infections for 1 of 2 (Licensed Practical Nurse (LPN) #1) nurses observed during wound care. The findings included: 1. The facility's Hand Hygiene policy documented, .Dry hands with a clean paper towel .Use a dry paper towel to turn off the faucet, then discard . 2. Observations in Resident #22's room on 1/30/18 at 9:59 AM, revealed LPN #1 applied an isolation gown, gloves and mask, gathered her supplies and placed them on top of a barrier on the over bed table, opened the supplies, removed her gloves, washed her hands, turned the faucet off with the same wet paper towel she dried her hands with, and applied gloves. LPN #1 proceeded to remove the old dressing, removed her gloves, washed her hands and turned the faucet off with the same wet paper towel she dried her hands with, applied new gloves. LPN #1 cleaned the wound with wound cleanser, patted the wound dry, and removed her gloves. LPN #1washed her hands, turned the facet off with her bare hands, dried her hands with a paper towel, applied new gloves, applied medication to the wound with an applicator, applied dressing, and removed her gloves. LPN #1 covered Resident #22 with a blanket, placed the biohazard bag in a red trash can in the residents room, removed her gown, gloves, and mask, washed and dried her hands with a paper towel, and turned the faucet off with the same wet paper towel she dried her hands with. Observation in Resident #22's room on 1/31/18 at 9:34 AM, revealed LPN #1 donned an isolation gown, gloves and mask, gathered her supplies and placed them on a barrier on the over bed table, placed a biohazard bag on the residents bed, and positioned Resident #22 on her right side. LPN #1 removed her gloves, washed her hands, turned the faucet off with her bare hand, dried her hands with a paper towel. LPN #1 applied new gloves, removed the old dressing, removed her gloves, washed her hands and turned the faucet off with the same wet paper towel she used to dry her hands. LPN #1 applied new gloves, cleaned the wound with wound cleanser, patted the wound dry, measured the wound, removed her gloves, washed her hands and turned the faucet off with the same wet towel she had dried her hands with. LPN #1 applied clean gloves, cleansed the wound, patted the wound dry, applied [MEDICATION NAME] powder to the wound bed, placed the dirty supplies into the biohazard bag, placed the biohazard bag in the red can in the residents room. 3. Interview with LPN #1 on 1/31/18 at 9:56 AM, in Resident #22's bathroom LPN #1 was asked if it was acceptable to turn off the faucet with her bare hands during wound care. LPN #1 stated, No ma'am .I should have used a clean paper towel. LPN #1 was asked if it was appropriate to turn off the faucet with the same wet paper towel she dried her hands with. The LPN #1 stated, No. Interview with the Director of Nursing (DON) on 1/31/18 at 9:57 AM, in the DON's office, the DON was asked if it was acceptable for the nurses to turn off the faucet with bare hands during dressing change. The DON stated, No. The DON was asked if it was appropriate to turn off the faucet with the same paper towel the staff member dried their hands with. The DON stated, No.

Based on policy review, medical record review, observation, and interview the facility failed to ensure the right of residents to make choices regarding aspects of their care was respected for 1 of 1 (Resident #38) sampled resident reviewed for choices. The findings included: 1. The facility's Dignity and Respect policy documented, .Residents' individual preferences regarding such things as menus, clothing, homelike environment, religious activities, friendships, activity programs, entertainment and customary routine are elicited and respected by this facility . 2. Medical record review revealed Resident #38 was admitted to the facility 7/16/12 with [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE], and the quarterly MDS dated [DATE], documented Resident #38 was severely cognitively impaired, and required extensive staff assistance for all activities of daily living (ADLs), including toileting and personal hygiene, and total dependence on staff for bathing. A behavior note dated 11/25/16 documented, .Res (Resident) in bed and a little combative during transfer with cna (Certified Nursing Assistant) and pericare. Will cont. (continue) to observe . Observations in Resident #38's room on 12/6/16 at 10:05 AM, revealed a sign on the wall over Resident #38's bed that documented, .ATTENTION STAFF!!! .DO NOT USE WIPES ON (named Resident #38)!!! YOU MUST USE WASH CLOTH AND WASH . There was 1 package of personal cleansing wipes on the bedside table. Interview with Family Member #1 on 12/6/16 at 10:05 AM, in Resident #38's room, Family Member #1 stated the staff continued to use the wipes to provide personal care to Resident #38, even though he had requested they use wash cloths. Family Member #1 stated Resident #38 complained the wipes are too cold. Interview with CNA #1 on 12/7/16 at 12:07 PM, in Resident #38's room, CNA #1 was asked whether she used wipes on Resident #38 when providing incontinence care. CNA #1 stated, Yes. There was a package of personal cleansing wipes in the top drawer of the bedside table. Interview with the Director of Nursing (DON) on 12/6/16 at 12:20 PM, in Resident #38's room, the DON was whether she expected staff to use wipes on this resident when providing care. The DON stated, No.

Based on policy review, medical record review, observation, and interview the facility failed to promote care that ensured the resident's dignity, respect, and quality of life for 1 of 13 (Resident #38) sampled residents in the stage 2 review. The findings included: 1. The facility's Dignity and Respect policy documented, .Residents' individual preferences regarding such things as menus, clothing, homelike environment, religious activities, friendships, activity programs, entertainment and customary routine are elicited and respected by this facility .Dignity means .staff carries out activities that assist the resident to maintain their self-esteem . The facility's DIGNITY and RESPECT guidance form documented, .This is a list of examples of how staff may enhance, maintain, or promote a resident's dignity .Examples .Maintaining an environment in which there are no signs posted in residents' rooms .that may be seen by others that include personal or clinical information . 2. Medical record review revealed Resident #38 was admitted to the facility 7/16/12 with [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE], and the quarterly MDS dated [DATE], documented Resident #38 was severely cognitively impaired, and required extensive staff assistance for all activities of daily living (ADLs), including toileting and personal hygiene, and total dependence on staff for bathing. Observations in Resident #38's room on 12/6/16 at 10:05 AM, revealed a sign on the wall over Resident #38's bed that documented, .ATTENTION STAFF!!! .DO NOT USE WIPES ON (Named Resident #38)!!! YOU MUST USE WASH CLOTH AND WASH . Interview with the Director of Nursing (DON) on 12/6/16 at 12:20 PM, in Resident #38's room, the DON was asked whether having the sign above Resident #38's bed was acceptable. The DON stated, We don't normally post things like that .

Based on policy review, observation and interview the facility failed to provide effective housekeeping services to maintain resident care equipment in a sanitary condition as evidenced by 1 of 1 standing lift was observed to be soiled and stained. The findings included: 1. The facility's Cleaning/Disinfection of Resident Care Items and Equipment policy documented, .Resident care equipment, including reusable items and durable medical equipment, will be cleaned and disinfected .Reusable items are cleaned and disinfected between residents .Durable medical equipment must be cleaned and disinfected between residents . 2. Observations on the south hall on 12/5/16 at 9:15 AM, and 12/6/16 at 8:32 AM and 11:34 AM, revealed a standing lift that was soiled with dust build-up and gray colored stains. Interview with Certified Nursing Assistant (CNA) #2 on 12/6/16 at 11:35 AM, on the south hall, CNA #2 was asked who was responsible for cleaning the standing lift. The CNA stated, We clean it after every use with disinfectant wipes. The CNA was asked if the standing lift looked dirty. The CNA stated, Yes, Ma'am. Interview with CNA #3 on 12/6/16 at 11:37 AM, on the south hall, CNA #3 was asked if the lift had been cleaned today. CNA #3 stated, I just used it, I haven't had time yet. CNA #3 was asked if the lift was clean. CNA #3 stated, No. Interview with Licensed Practical Nurse (LPN) #1 on 12/6/16 at 11:39 AM, at the south hall nurses' station, LPN #1 was asked if a dirty lift should be used for a resident. LPN #1 stated, No. Clean it before and after (use). CNA #3 began to clean the standing lift with Sani-wipes. The Sani-wipes were covered in a black substance after they were used on the standing lift. CNA #3 was asked if she could remember when she last cleaned the standing lift. CNA #3 stated, No. Interview with the Director of Nursing (DON) on 12/7/16 at 10:39 AM, in the DON's office, the DON was asked who was responsible for cleaning the standing lift. The DON stated, The CNA's. The DON was asked how often it should be cleaned. The DON stated, Before and after resident use.

A. Based on policy review, review of the maintenance supervisor's logbook documentation, review of the facility's census and condition (Centers of Medicare Medicaid Services (CMS) 672), observation, and interview, it was determined the facility failed to ensure the environment was free from accident hazards when hot water temperatures were measured between 120 to (-) 132.8 degrees Fahrenheit (F) in 26 of 26 (rooms #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25 and 26 ) resident rooms and 118-128 degrees F in 2 of 2 (North and South hall shower rooms) shower rooms and unsecured chemicals in 1 of 30 (Resident #54) residents' room include in the stage 1 sample. The failure of the facility to maintain safe hot water temperatures placed 36 of 38 residents in immediate jeopardy (a situation in which the provider's noncompliance has caused, or is likely to cause serious injury, harm, impairment,or death) of being being scalded or burned. The Administrator, Director of Nursing (DON), and Maintenance Supervisor were informed of this immediate jeopardy (IJ) on 3/7/14 at 4:01 PM. The IJ is ongoing. The IJ for F-323 "L" constitutes Substandard Quality of Care. The findings included: 1. Review of the facility's "Weekly Water Temperature Checklist-Notes" documented, "Resident room temperature should be no less than 100 degrees and no more than 115 degrees... If water temperatures exceed 115 degrees, check water heater for that area and adjust or repair ASAP (as soon as possible)... If water temperatures exceed 115 degrees, temperatures must be recorded daily on each shift until adjustments have been made and temperatures are back to normal... If temperatures exceed 115 degrees, notify Administrator and the Safety Director immediately..." 2. Review of the census and condition of residents dated 3/6/14 documented a total of 38 residents residing in the facility, with 2 of those residents being bedfast most of the time. 3. The surveyors thermometer was calibrated before water temperatures were obtained. The surveyor's observations of the hot water temperatures in residents' room on 3/5/14 beginning at 9:50 AM revealed the following: a. Room 8-9 was 125 degrees F. b. Room 10-11 was 130 degrees F. c. Room 12-13 was 128 degrees F. d. Room 14-15 was 124 degrees F. e. Room 16-17 was 120 degrees F. The surveyor's observations of the hot water temperatures in residents' room on 3/5/14 beginning at 3:34 PM revealed the following: a. Room 1 was 124 degrees F. b. Room 4-5 was 124 degrees F. c. Room 6-7 was 130 degrees F. d. Room 8-9 was 128 degrees F. When the hot water was turned on there was steam noted to rise. e. Room 20-21 was 120 degrees F. f. Room 22-23 was 122 degrees F. The surveyor's observations of the hot water temperatures in residents' room on 3/6/14 beginning at 7:30 AM revealed the following: a. Room 1 was 122 degrees F. b. Room 2-3 was 120 degrees F. c. Room 4-5 was 130 degrees F. d. Room 6-7 was 130 degrees F. e. Room 8-9 was 128 degrees F. When the hot water was turned on there was steam noted to rise. f. Room 10-11 was 122 degrees F. g. Room 12-13 was 121 degrees F. h. Room 16-17 was 122 degrees F. i. Room 20-21 was 124 degrees F. j. Room 22-23 was 124 degrees F. k. Room 24-25 was 124 degrees F. l. Room 26 was 120 degrees F. The surveyor's observations of the hot water temperatures in residents' room on 3/7/14 beginning at 7:35 AM revealed the following: a. Room 1 was 126 degrees F. b. Room 2-3 was 121 degrees F. c. Room 4-5 was 122 degrees F. d. Room 6-7 was 122 degrees F. e. Room 8-9 was 124 degrees F. f. Room 10-11 was 122 degrees F. g. Room 12-13 was 124 degrees F. h. Room 14-15 was 120 degrees F. I. Room 16-17 was 124 degrees F. j. Room 20-21 was 118 degrees F. k. Room 22-23 was 124 degrees F. l. Room 24-25 was 120 degrees F. m. Room 26 was 128 degrees F. Observations in room 20-21 on 3/7/14 at 9:00 AM, revealed the maintenance supervisor checking the hot water temperature using his thermometer, with a reading of 109 degrees F. The temperature was rechecked by the maintenance supervisor at 9:05 AM and the reading was 109 degrees F. The surveyor's thermometer registered 118 degrees F. During an interview at the South hall nurse's station on 3/7/14 at 9:06 AM, the maintenance supervisor was asked when his thermometer had been calibrated. The maintenance supervisor stated, "I calibrated it, last week was the last time I did it. The maintenance supervisor was then asked if he would calibrate his thermometer before checking water temperatures. He stated, "Yes, ma'am, I will." The maintenance supervisor proceeded to calibrate his thermometer with a reading of 28 degrees F. The thermometer's reading was incorrect, with a correct reading at calibration time it should have been 32 degrees F. After the above calibration, observations of the hot water temperatures by the maintenance supervisor (MS) and the surveyor (S), in residents' rooms on 3/7/14 beginning at 9:07 AM, F revealed the following: a. Room 1 MS - 114 degrees F and S - 126 degrees F. b. Room 2-3 MS - 114 degrees F and S - 126 degrees F. c. Room 4-5 MS - 118 degrees F and S - 126 degrees F. d. Room 6-7 MS - 118 degrees F and S - 124 degrees F. e. Room 8-9 MS - 117 degrees F and S - 122 degrees F. f. Room 10-11 MS - 120 degrees F and S - 130 degrees F. g. Room 12 MS - 119 degrees F and S - 130 degrees F. h. Room 14-15 MS - 116 degrees F and S - 124 degrees F. i. Room 16-17 MS - 119 degrees F and S - 122 degrees F. j. Room 18-19 MS - 117 degrees F and S - 124 degrees F. k. Room 22-23 MS - 110 degrees F and S - 120 degrees F. l. Room 26 MS - 115 degrees F and S - 122 degrees F. m. North hall shower stall MS - 118 degrees F and S - 122 degrees F. n. North hall shower sink MS - 104 degrees F and S - 118 degrees F. o. South hall shower room MS - 117 degrees F and S - 126 degrees F. During an interview in bathroom between rooms 10 and 11 on 3/7/14 at 9:25 AM, the maintenance supervisor stated, "I didn't check that one (referring to bathroom between rooms 10 and 11) this week. I skipped around..." In the bathroom between rooms 12 and 13 the maintenance supervisor placed his hand under water and stated, "This one feels warm... I skip around a couple of rooms on one side and then the other side, sometimes I get three. Apparently I need to check more than 3 to 4 rooms." During an interview on the North hall on 3/7/14 at 9:40 AM, after the maintenance supervisor and the surveyor checked hot water temperatures together, the maintenance supervisor stated, "My thermometer must be wrong. It's new." The maintenance supervisor then went to the kitchen and retrieved a digital thermometer and the hot water temperatures were rechecked. Observations of the hot water temperatures in residents' room on 3/7/14 beginning at 9:48 AM, with the maintenance supervisor's new calibrated digital thermometer revealed the following: a. Room 2-3 was 130 degrees F. b. Room 4-5 was 130.3 degrees F. c. Room 6-7 was 129.5 degrees F. d. Room 8-9 was 122 degrees F. e. Room 10-11 was 126.7 degrees F. f. Room 12 -13 was 132.8 F. g. Room 14-15 was 126 degrees F. h. Room 16-17 was 126 degrees F. i. Room 18-19 was 125 degrees. j. Room 20-21 was 126 degrees F. k. Room 22-23 was 120 degrees F. l. Room 26 was 122 degrees F. During an interview in resident room 2-3 on 3/7/14 beginning at 9:48 AM, after checking the water temperature (130 degrees F) the maintenance supervisor stated, "That's way dangerous..." In room 16-17 the maintenance supervisor placed his hand under water and stated, "I can tell this is hot (126 degrees F)..." After checking the hot water temperature in room 6-7, the maintenance supervisor stated, "I knew that was warmer (129.5 degrees F) that it should have been, but my hands were cold, so I misjudged it..." 4. Observations and interview in the North hall shower room on 3/7/14 beginning at 9:00 AM with the maintenance supervisor present the hot water temperature of the shower stall was 118 degrees F and rechecked with the digital thermometer was 122 degrees F. The maintenance supervisor stated, "Haven't checked the shower room this morning..." 5. Observations and interview in the South hall shower room on 3/6/14 at 9:20 AM, revealed the hot water temperature at the sink was was 128 degrees F and the shower stall was 126 degrees F. The maintenance supervisor was asked how often water temperatures are checked in the shower room. The maintenance supervisor stated, "I check them everyday..." 6. During an interview in Resident #1's room on 3/5/14 at 3:00 PM, Resident #1 was asked about the water temperature. Resident #1 stated, "...sometimes may be a little hot..." 7. During an interview in the Resident #20's room on 3/7/14 at 7:55 AM, Resident #20 was asked about the hot water temperature. Resident #20 stated, "The water is hot..." 8. Review of the facility's maintenance supervisor's logbook documented the following hot water temperature ranges in the resident and shower rooms:a. November 2013 - Room 6 116-117 degrees F; Room 8 117-118 degrees F; Room 18 117-118 degrees F; Room 20 116-118 degrees F and Room 21 116-118 degrees F; North hall shower 116-118 degrees F and South hall shower 116-118. b. December 2013 - Room 9 116-118 degrees F; Room 20 116-118 degrees F and Room 34 116-118 degrees F and the North hall shower 116-118 degrees F and the South hall shower 116-118 degrees F. c. January 2014 - Room 7 116-118 degrees F; Room 12 116-118 degrees F and Room 19 116 degrees F. d. February 2014 - Room 9 116-117 degrees F and Room 21 116-118 degrees F and the North hall shower 116-117 degrees F and South hall shower 116-117 degrees F. During an interview at the North nurses' station on 3/7/14 at 1:30 PM, the maintenance supervisor was shown the temperature log and asked how often water temperatures are checked when they are high. The maintenance supervisor stated, "Usually check them 5 days a week try to check them around eight o'clock everyday." The maintenance supervisor was then asked about a shower stall water temperature that was recorded as 118 degrees and if he checked the temperature again. The maintenance supervisor stated, "No, didn't check anymore that day. I knew it was going to go down because they hadn't done any showers. I give it the benefit of being 118 degrees. The water temperatures are only checked once a day..." The maintenance supervisor failed to follow the facility's policy to monitor hot water temperatures when they exceed 115 degrees. The facility was unable to provide documentation of when the maintenance supervisor had checked the water heater for that area and adjust or repair ASAP. The facility was unable to provide documentation where the maintenance supervisor had recorded temperatures daily on each shift until adjustments have been made and temperatures were back to normal and there was no documentation where the administrator and the safety director were notified of this immediately. During an interview at the North hall nurse's station on 3/7/14 at 3:15 PM, the maintenance supervisor was asked if he had made the Administrator aware of these hot water temperatures. The maintenance supervisor stated, "Yes, told her when I got done checking them with you this morning. I was told to do a closer check and to check them more than once a day if needed..." During an interview in the breakroom on 3/7/14 at 3:45 PM, the maintenance supervisor was asked about the hot water temperatures. The maintenance supervisor stated, "...When it (weather) gets cold in this is an old building have to adjust it (water temperatures) constantly because of the boilers... got it (hot water) a little too hot... thought thermometer reading normal (accurate)... I messed up... I got busy shoveling snow... It was my mistake... Everywhere I've been has been 118 degrees. I didn't realize my own company (policy for water temperatures) said 115 degrees..." The failure of the facility to maintain safe hot water temperatures placed 36 of 38 residents in IJ of being scalded or burned. 9. Observations in Resident #54's room on 3/5/14 at 10:40 AM, on 3/6/14 at 7:59 AM, 10:30 AM, 11:30 AM and 12:26 PM and 4:00 PM and on 3/7/14 at 7:40 AM and 2:10 PM, revealed a bottle of nail polish remover, three bottles of nail polish and a bottle of hand sanitizer on Resident #54's overbed table. During an interview in the Director of Nursing's (DON) office on 3/7/14 at 2:10 PM, the DON was asked what toiletries are residents allowed to keep at their bedside. The DON stated, "Peri-wash, lotion, and barrier cream, no over the counter meds (medications)." The DON was then asked if nail polish remover, nail polish and hand sanitizer should be at the resident's bedside. The DON stated, "No, it shouldn't be in the resident's room..." During an interview outside Resident #54's room on 3/7/14 at 2:15 PM, the DON confirmed there was nail polish remover, nail polish and hand sanitizer on Resident #54's overbed table. B. Based on policy review, medical record review and interview, it was determined the facility failed to ensure that two unwitnessed falls were investigated and neurological checks were done for 1 of 4 (Resident #61) sampled residents of the 8 residents reviewed with falls. The findings included: Review of the facility's "ACCIDENTS AND INCIDENTS" policy documented, "...Investigations should begin when the incident is identified. The nurse in charge should identify staff, visitors, or there residents who may have knowledge of the occurrence. These individuals should be interviewed and asked to provide a statement when necessary..." Review of the facility's "NEUROLOGICAL CHECKS" policy documented, "...Purpose To conduct a 5 point neurological check to identify gross neurological deficits in the event of a head, neck, or face injury, a suspected neurological event, or for unwitnessed, unexplained events involving an observed change in the resident's position (ex. (example) Observed on the floor even if there is no injury obvious at the time of the event.)... Timing of Neurological Checks If the resident remains in the facility, neuro (neurological) checks are to be done as follows until 72 hours are completed or as ordered by the physician. Every 15 minutes x (times) 4 Every 30 minutes x 4 Every 1 hour x 4 Every 4 hours x 4 Every 8 hours x 3... Document findings on the Neurological Assessment Flow Sheet (located in the Forms and Guidelines Manual). The Neurological Assessment Flow Sheet may be placed in the MAR (medical administration record) until completion, then it is placed in the active medical record..." Medical record review for Resident #61 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #61's "Progress Notes" documented the following: a. 6/23/13 at 1:15 AM - "Approached per res (resident) in room (number), Res stated that res in room (number) had fallen. Entered res room, observed res lying on left side, on floor, in front of bathroom door. Res stated she was trying to go to the bathroom, unassisted, became weak, & (and) fell . Res assessed for injuries. Appears left knee may be beginning to bruise. Res moves all ext (extremities) wnl (within normal limits). Res assisted back to bed. Res reminded not to transfer/amb (ambulate) unassisted. Res re-oriented to call light & demonstrates ability to use properly. BSC (bedside commode) placed at res bedside..." b. 6/25/13 at 9:43 AM - "Called to room per CNA (Certified Nurse Assistant), rsdt (resident) noted to be laying in floor beside bed on back, rsdt states, 'I tried to get up by myself and fell and hit my head.' No apparent injury noted. Rsdt stated, 'I wanna go to the hospital.' PCP (primary care physician) called, N.O. (new order) Send to (name of hospital) to eval (evaluate) and treat." During an interview in the breakroom on 3/10/14 at 6:60 PM the DON was asked about the investigation and neurological assessments for Resident #61's falls on 6/23/13 and 6/25/13. The DON stated, "...This is all there is, no investigations were found..." The Regional Nurse Consultant then stated, "I looked through everything and there are none (neurological assessments)." The facility failed to follow the neurological check policy for obtaining neuro checks for 72 hours to be done every 15 minutes x 4, every 30 minutes x 4, every 1 hour x 4, every 4 hours x 4 and every 8 hours x 3. The facility was unable to provide documentation of an investigation for the 6/23/13 and 6/25/13 falls.

A. Based on policy review, review of the maintenance supervisor's logbook documentation, review of the facility's census and condition (Centers of Medicare Medicaid Services (CMS) 672), observation, and interview, it was determined the facility failed to ensure the environment was free from accident hazards when hot water temperatures were measured between 120 to (-) 132.8 degrees Fahrenheit (F) in 26 of 26 (rooms #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25 and 26 ) resident rooms and 118-128 degrees F in 2 of 2 (North and South hall shower rooms) shower rooms and unsecured chemicals in 1 of 30 (Resident #54) residents' room include in the stage 1 sample. The failure of the facility to maintain safe hot water temperatures placed 36 of 38 residents in immediate jeopardy (a situation in which the provider's noncompliance has caused, or is likely to cause serious injury, harm, impairment,or death) of being being scalded or burned. The Administrator, Director of Nursing (DON), and Maintenance Supervisor were informed of this immediate jeopardy (IJ) on 3/7/14 at 4:01 PM. The IJ was effective 9/11/13. The IJ for F-323 "L" constitutes Substandard Quality of Care. The facility provided an acceptable Allegation of Compliance on 3/26/14, and a revisit on 3/31/14, revealed corrective actions implemented on 3/20/14, removed the Immediate Jeopardy. Noncompliance for F 323 continues at a "F" level citation, which constitutes Substandard Quality of Care. The findings included: 1. Review of the facility's "Weekly Water Temperature Checklist-Notes" documented, "Resident room temperature should be no less than 100 degrees and no more than 115 degrees... If water temperatures exceed 115 degrees, check water heater for that area and adjust or repair ASAP (as soon as possible)... If water temperatures exceed 115 degrees, temperatures must be recorded daily on each shift until adjustments have been made and temperatures are back to normal... If temperatures exceed 115 degrees, notify Administrator and the Safety Director immediately..." 2. Review of the census and condition of residents dated 3/6/14 documented a total of 38 residents residing in the facility, with 2 of those residents being bedfast most of the time. 3. The surveyors thermometer was calibrated before water temperatures were obtained. The surveyor's observations of the hot water temperatures in residents' room on 3/5/14 beginning at 9:50 AM revealed the following: a. Room 8-9 was 125 degrees F. b. Room 10-11 was 130 degrees F. c. Room 12-13 was 128 degrees F. d. Room 14-15 was 124 degrees F. e. Room 16-17 was 120 degrees F. The surveyor's observations of the hot water temperatures in residents' room on 3/5/14 beginning at 3:34 PM revealed the following: a. Room 1 was 124 degrees F. b. Room 4-5 was 124 degrees F. c. Room 6-7 was 130 degrees F. d. Room 8-9 was 128 degrees F. When the hot water was turned on there was steam noted to rise. e. Room 20-21 was 120 degrees F. f. Room 22-23 was 122 degrees F. The surveyor's observations of the hot water temperatures in residents' room on 3/6/14 beginning at 7:30 AM revealed the following: a. Room 1 was 122 degrees F. b. Room 2-3 was 120 degrees F. c. Room 4-5 was 130 degrees F. d. Room 6-7 was 130 degrees F. e. Room 8-9 was 128 degrees F. When the hot water was turned on there was steam noted to rise. f. Room 10-11 was 122 degrees F. g. Room 12-13 was 121 degrees F. h. Room 16-17 was 122 degrees F. i. Room 20-21 was 124 degrees F. j. Room 22-23 was 124 degrees F. k. Room 24-25 was 124 degrees F. l. Room 26 was 120 degrees F. The surveyor's observations of the hot water temperatures in residents' room on 3/7/14 beginning at 7:35 AM revealed the following: a. Room 1 was 126 degrees F. b. Room 2-3 was 121 degrees F. c. Room 4-5 was 122 degrees F. d. Room 6-7 was 122 degrees F. e. Room 8-9 was 124 degrees F. f. Room 10-11 was 122 degrees F. g. Room 12-13 was 124 degrees F. h. Room 14-15 was 120 degrees F. I. Room 16-17 was 124 degrees F. j. Room 20-21 was 118 degrees F. k. Room 22-23 was 124 degrees F. l. Room 24-25 was 120 degrees F. m. Room 26 was 128 degrees F. Observations in room 20-21 on 3/7/14 at 9:00 AM, revealed the maintenance supervisor checking the hot water temperature using his thermometer, with a reading of 109 degrees F. The temperature was rechecked by the maintenance supervisor at 9:05 AM and the reading was 109 degrees F. The surveyor's thermometer registered 118 degrees F. During an interview at the South hall nurse's station on 3/7/14 at 9:06 AM, the maintenance supervisor was asked when his thermometer had been calibrated. The maintenance supervisor stated, "I calibrated it, last week was the last time I did it. The maintenance supervisor was then asked if he would calibrate his thermometer before checking water temperatures. He stated, "Yes, ma'am, I will." The maintenance supervisor proceeded to calibrate his thermometer with a reading of 28 degrees F. The thermometer's reading was incorrect, with a correct reading at calibration time it should have been 32 degrees F. After the above calibration, observations of the hot water temperatures by the maintenance supervisor (MS) and the surveyor (S), in residents' rooms on 3/7/14 beginning at 9:07 AM, F revealed the following: a. Room 1 MS - 114 degrees F and S - 126 degrees F. b. Room 2-3 MS - 114 degrees F and S - 126 degrees F. c. Room 4-5 MS - 118 degrees F and S - 126 degrees F. d. Room 6-7 MS - 118 degrees F and S - 124 degrees F. e. Room 8-9 MS - 117 degrees F and S - 122 degrees F. f. Room 10-11 MS - 120 degrees F and S - 130 degrees F. g. Room 12 MS - 119 degrees F and S - 130 degrees F. h. Room 14-15 MS - 116 degrees F and S - 124 degrees F. i. Room 16-17 MS - 119 degrees F and S - 122 degrees F. j. Room 18-19 MS - 117 degrees F and S - 124 degrees F. k. Room 22-23 MS - 110 degrees F and S - 120 degrees F. l. Room 26 MS - 115 degrees F and S - 122 degrees F. m. North hall shower stall MS - 118 degrees F and S - 122 degrees F. n. North hall shower sink MS - 104 degrees F and S - 118 degrees F. o. South hall shower room MS - 117 degrees F and S - 126 degrees F. During an interview in bathroom between rooms 10 and 11 on 3/7/14 at 9:25 AM, the maintenance supervisor stated, "I didn't check that one (referring to bathroom between rooms 10 and 11) this week. I skipped around..." In the bathroom between rooms 12 and 13 the maintenance supervisor placed his hand under water and stated, "This one feels warm... I skip around a couple of rooms on one side and then the other side, sometimes I get three. Apparently I need to check more than 3 to 4 rooms." During an interview on the North hall on 3/7/14 at 9:40 AM, after the maintenance supervisor and the surveyor checked hot water temperatures together, the maintenance supervisor stated, "My thermometer must be wrong. It's new." The maintenance supervisor then went to the kitchen and retrieved a digital thermometer and the hot water temperatures were rechecked. Observations of the hot water temperatures in residents' room on 3/7/14 beginning at 9:48 AM, with the maintenance supervisor's new calibrated digital thermometer revealed the following: a. Room 2-3 was 130 degrees F. b. Room 4-5 was 130.3 degrees F. c. Room 6-7 was 129.5 degrees F. d. Room 8-9 was 122 degrees F. e. Room 10-11 was 126.7 degrees F. f. Room 12 -13 was 132.8 F. g. Room 14-15 was 126 degrees F. h. Room 16-17 was 126 degrees F. i. Room 18-19 was 125 degrees. j. Room 20-21 was 126 degrees F. k. Room 22-23 was 120 degrees F. l. Room 26 was 122 degrees F. During an interview in resident room 2-3 on 3/7/14 beginning at 9:48 AM, after checking the water temperature (130 degrees F) the maintenance supervisor stated, "That's way dangerous..." In room 16-17 the maintenance supervisor placed his hand under water and stated, "I can tell this is hot (126 degrees F)..." After checking the hot water temperature in room 6-7, the maintenance supervisor stated, "I knew that was warmer (129.5 degrees F) that it should have been, but my hands were cold, so I misjudged it..." 4. Observations and interview in the North hall shower room on 3/7/14 beginning at 9:00 AM with the maintenance supervisor present the hot water temperature of the shower stall was 118 degrees F and rechecked with the digital thermometer was 122 degrees F. The maintenance supervisor stated, "Haven't checked the shower room this morning..." 5. Observations and interview in the South hall shower room on 3/6/14 at 9:20 AM, revealed the hot water temperature at the sink was was 128 degrees F and the shower stall was 126 degrees F. The maintenance supervisor was asked how often water temperatures are checked in the shower room. The maintenance supervisor stated, "I check them everyday..." 6. During an interview in Resident #1's room on 3/5/14 at 3:00 PM, Resident #1 was asked about the water temperature. Resident #1 stated, "...sometimes may be a little hot..." 7. During an interview in the Resident #20's room on 3/7/14 at 7:55 AM, Resident #20 was asked about the hot water temperature. Resident #20 stated, "The water is hot..." 8. Review of the facility's maintenance supervisor's logbook documented the following hot water temperature ranges in the resident and shower rooms:a. November 2013 - Room 6 116-117 degrees F; Room 8 117-118 degrees F; Room 18 117-118 degrees F; Room 20 116-118 degrees F and Room 21 116-118 degrees F; North hall shower 116-118 degrees F and South hall shower 116-118. b. December 2013 - Room 9 116-118 degrees F; Room 20 116-118 degrees F and Room 34 116-118 degrees F and the North hall shower 116-118 degrees F and the South hall shower 116-118 degrees F. c. January 2014 - Room 7 116-118 degrees F; Room 12 116-118 degrees F and Room 19 116 degrees F. d. February 2014 - Room 9 116-117 degrees F and Room 21 116-118 degrees F and the North hall shower 116-117 degrees F and South hall shower 116-117 degrees F. During an interview at the North nurses' station on 3/7/14 at 1:30 PM, the maintenance supervisor was shown the temperature log and asked how often water temperatures are checked when they are high. The maintenance supervisor stated, "Usually check them 5 days a week try to check them around eight o'clock everyday." The maintenance supervisor was then asked about a shower stall water temperature that was recorded as 118 degrees and if he checked the temperature again. The maintenance supervisor stated, "No, didn't check anymore that day. I knew it was going to go down because they hadn't done any showers. I give it the benefit of being 118 degrees. The water temperatures are only checked once a day..." The maintenance supervisor failed to follow the facility's policy to monitor hot water temperatures when they exceed 115 degrees. The facility was unable to provide documentation of when the maintenance supervisor had checked the water heater for that area and adjust or repair ASAP. The facility was unable to provide documentation where the maintenance supervisor had recorded temperatures daily on each shift until adjustments have been made and temperatures were back to normal and there was no documentation where the administrator and the safety director were notified of this immediately. During an interview at the North hall nurse's station on 3/7/14 at 3:15 PM, the maintenance supervisor was asked if he had made the Administrator aware of these hot water temperatures. The maintenance supervisor stated, "Yes, told her when I got done checking them with you this morning. I was told to do a closer check and to check them more than once a day if needed..." During an interview in the breakroom on 3/7/14 at 3:45 PM, the maintenance supervisor was asked about the hot water temperatures. The maintenance supervisor stated, "...When it (weather) gets cold in this is an old building have to adjust it (water temperatures) constantly because of the boilers... got it (hot water) a little too hot... thought thermometer reading normal (accurate)... I messed up... I got busy shoveling snow... It was my mistake... Everywhere I've been has been 118 degrees. I didn't realize my own company (policy for water temperatures) said 115 degrees..." The failure of the facility to maintain safe hot water temperatures placed 36 of 38 residents in IJ of being scalded or burned. 9. Observations in Resident #54's room on 3/5/14 at 10:40 AM, on 3/6/14 at 7:59 AM, 10:30 AM, 11:30 AM and 12:26 PM and 4:00 PM and on 3/7/14 at 7:40 AM and 2:10 PM, revealed a bottle of nail polish remover, three bottles of nail polish and a bottle of hand sanitizer on Resident #54's overbed table. During an interview in the Director of Nursing's (DON) office on 3/7/14 at 2:10 PM, the DON was asked what toiletries are residents allowed to keep at their bedside. The DON stated, "Peri-wash, lotion, and barrier cream, no over the counter meds (medications)." The DON was then asked if nail polish remover, nail polish and hand sanitizer should be at the resident's bedside. The DON stated, "No, it shouldn't be in the resident's room..." During an interview outside Resident #54's room on 3/7/14 at 2:15 PM, the DON confirmed there was nail polish remover, nail polish and hand sanitizer on Resident #54's overbed table. Validation of the Credible Allegation of Compliance was accomplished on-site March 31, 2013, by records review, policy review, observation of water temperatures in sampled resident rooms, bathrooms, common shower rooms, observation of water temperature logs, and interviews with nursing, maintenance staff and administrative staff. Water temperatures were checked on 3/31/14 in sampled resident bathrooms, resident rooms, north and south shower rooms and were found to be from 105 - 110 degrees F, which is within acceptable temperature range. The facility provided evidence of a log monitoring the water temperatures. The log was reviewed and water temperatures documented were found to be within acceptable range. The facility provided evidence of a work order dated 3/13/14 which documented,"re-routed water lines to separate the dietary and residents room. Added a new circulation cold water line to keep temperatures regulated and added 2 on demand water heaters for the showers". Review of service documentation dated 3/7/14 documented, "Checked the water heaters in the Nursing Home, found them in working condition and operating at the set point levels." The facility provided evidence of an in-service for Maintenance Director on 3/7/14 concerning correct water temperatures and how to calibrate thermometer. The facility provided evidence of in-sevice of all facility staff (all disciplines) on the new policy, "Safety of Water Temperatures", which included nurses reporting water temperatures either too hot or too cold, risk factors for scalding of residents. The policy for "Safety of Water Temperatures" was reviewed. Interviews with the Administrator, DON, Regional Nurse Consultants and Director of Operations confirmed the facility had Quality Assessment and Assurance meetings which discussed Survey results, audits of water temperatures, new policy for Safety of Water Temperatures, Administrator look back checks of water temperatures, and continued monitoring of water temperatures. The facility will remain out of compliance at a Scope and Severity level "F" a pattern of deficient practice that constitutes no actual harm with potential for more than minimal harm, that is not Immediate Jeopardy, until it provides an acceptable plan of correction. B. Based on policy review, medical record review and interview, it was determined the facility failed to ensure that two unwitnessed falls were investigated and neurological checks were done for 1 of 4 (Resident #61) sampled residents of the 8 residents reviewed with falls. The findings included: Review of the facility's "ACCIDENTS AND INCIDENTS" policy documented, "...Investigations should begin when the incident is identified. The nurse in charge should identify staff, visitors, or there residents who may have knowledge of the occurrence. These individuals should be interviewed and asked to provide a statement when necessary..." Review of the facility's "NEUROLOGICAL CHECKS" policy documented, "...Purpose To conduct a 5 point neurological check to identify gross neurological deficits in the event of a head, neck, or face injury, a suspected neurological event, or for unwitnessed, unexplained events involving an observed change in the resident's position (ex. (example) Observed on the floor even if there is no injury obvious at the time of the event.)... Timing of Neurological Checks If the resident remains in the facility, neuro (neurological) checks are to be done as follows until 72 hours are completed or as ordered by the physician. Every 15 minutes x (times) 4 Every 30 minutes x 4 Every 1 hour x 4 Every 4 hours x 4 Every 8 hours x 3... Document findings on the Neurological Assessment Flow Sheet (located in the Forms and Guidelines Manual). The Neurological Assessment Flow Sheet may be placed in the MAR (medical administration record) until completion, then it is placed in the active medical record..." Medical record review for Resident #61 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #61's "Progress Notes" documented the following: a. 6/23/13 at 1:15 AM - "Approached per res (resident) in room (number), Res stated that res in room (number) had fallen. Entered res room, observed res lying on left side, on floor, in front of bathroom door. Res stated she was trying to go to the bathroom, unassisted, became weak, & (and) fell . Res assessed for injuries. Appears left knee may be beginning to bruise. Res moves all ext (extremities) wnl (within normal limits). Res assisted back to bed. Res reminded not to transfer/amb (ambulate) unassisted. Res re-oriented to call light & demonstrates ability to use properly. BSC (bedside commode) placed at res bedside..." b. 6/25/13 at 9:43 AM - "Called to room per CNA (Certified Nurse Assistant), rsdt (resident) noted to be laying in floor beside bed on back, rsdt states, 'I tried to get up by myself and fell and hit my head.' No apparent injury noted. Rsdt stated, 'I wanna go to the hospital.' PCP (primary care physician) called, N.O. (new order) Send to (name of hospital) to eval (evaluate) and treat." During an interview in the breakroom on 3/10/14 at 6:60 PM the DON was asked about the investigation and neurological assessments for Resident #61's falls on 6/23/13 and 6/25/13. The DON stated, "...This is all there is, no investigations were found..." The Regional Nurse Consultant then stated, "I looked through everything and there are none (neurological assessments)." The facility failed to follow the neurological check policy for obtaining neuro checks for 72 hours to be done every 15 minutes x 4, every 30 minutes x 4, every 1 hour x 4, every 4 hours x 4 and every 8 hours x 3. The facility was unable to provide documentation of an investigation for the 6/23/13 and 6/25/13 falls.

Based on policy review, review of a [MEDICATION NAME] package insert, review of the Lippincott Nursing Drug Handbook, review of the maintenance supervisor's log book, pharmacy review, observation and interview, it was determined the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable physical and psychosocial well-being by failing to educate the staff on [MEDICATION NAME]; failing to document the parameters of the desired therapeutic range of the [MEDICATION NAME]/International Normalization Ratio (PT/INR) with instructions on when to hold the dose on the physician order [REDACTED].#13, 14 and 61), which resulted in an immediate jeopardy (a situation in which the provider's noncompliance has caused, or is likely to cause serious injury, harm, impairment, or death) for Resident #13, 14, and 61. The facility failed to ensure the environment was free from accident hazards when hot water temperatures were measured above 120 degrees Fahrenheit (F) in 26 of 26 (rooms #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25 and 26 ) resident rooms and 118-128 degrees F in 2 of 2 (North and South hall shower rooms). The failure of the facility to maintain safe hot water temperatures placed 36 of 38 residents in immediate jeopardy (IJ) of being scalded or burned. The Administrator, the Director of Nursing (DON), the Regional Administrator and the Regional Nurse Consultant were informed of this IJ on 3/11/2014 at 5:15 PM in the breakroom. The IJ was ongoing. The findings included: 1. During an interview in the breakroom on 3/7/14 at 3:49 PM, the Administrator was asked if she had ever been notified if any hot water temperatures. The Administrator stated, "No... I am in and out of the rooms..." The Administrator was asked what would be expected if there were hot water temperatures. The Administrator stated, "Maintenance should get the thermometer, fix immediately..." The Administrator was shown the maintenance supervisor's log book of increased water temperatures, with temperatures above 115 degrees Fahrenheit (policy states should not be above 115 degrees F). The Administrator was questioned if she had been notified of these increased temperatures. The Administrator stated, "No" The maintenance supervisor then stated, "I thought 118 (degrees F) was OK..." The maintenance supervisor was not aware the facility's policy stated 115 degrees F. The facility failed to ensure the environment was free from accident hazards when hot water temperatures were measured between 120 to (-) 132.8 degrees Fahrenheit (F) in resident rooms #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25 and 26; 118-128 degrees in the North and South hall shower rooms. The failure of the facility to maintain safe hot water temperatures placed 36 of 38 residents in IJ of being scalded or burned. Refer to F323. 2. The facility failed to educate the staff on [MEDICATION NAME], failed to document the parameters of the desired therapeutic range of the [MEDICATION NAME]/International Normalization Ratio (PT/INR) with instructions on when to hold the dose on the physician order [REDACTED].#13, 14 and 61 in IJ. Refer to F282, F309, F385 and F428. 3. The administration failed to ensure the Quality Assurance Committee established and implemented a method for identifying concerns in the facility. Refer to F520.

Based on policy review, review of a [MEDICATION NAME] package insert, review of the Lippincott Nursing Drug Handbook, review of the maintenance supervisor's log book, pharmacy review, observation and interview, it was determined the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable physical and psychosocial well-being by failing to educate the staff on [MEDICATION NAME]; failing to document the parameters of the desired therapeutic range of the [MEDICATION NAME]/International Normalization Ratio (PT/INR) with instructions on when to hold the dose on the physician order [REDACTED].#13, 14 and 61), which resulted in an immediate jeopardy (a situation in which the provider's noncompliance has caused, or is likely to cause serious injury, harm, impairment, or death) for Resident #13, 14, and 61. The facility failed to ensure the environment was free from accident hazards when hot water temperatures were measured above 120 degrees Fahrenheit (F) in 26 of 26 (rooms #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25 and 26 ) resident rooms and 118-128 degrees F in 2 of 2 (North and South hall shower rooms). The failure of the facility to maintain safe hot water temperatures placed 36 of 38 residents in immediate jeopardy (IJ) of being scalded or burned. The Administrator, the Director of Nursing (DON), the Regional Administrator and the Regional Nurse Consultant were informed of this IJ on 3/11/2014 at 5:15 PM in the breakroom. The IJ was effective 9/11/14. The facility provided an acceptable Allegation of Compliance on 3/26/14, and a revisit on 3/31/14, revealed corrective actions implemented on 3/20/14, removed the Immediate Jeopardy. Noncompliance for F 490 continues at a "F" level citation The findings included: 1. During an interview in the breakroom on 3/7/14 at 3:49 PM, the Administrator was asked if she had ever been notified if any hot water temperatures. The Administrator stated, "No... I am in and out of the rooms..." The Administrator was asked what would be expected if there were hot water temperatures. The Administrator stated, "Maintenance should get the thermometer, fix immediately..." The Administrator was shown the maintenance supervisor's log book of increased water temperatures, with temperatures above 115 degrees Fahrenheit (policy states should not be above 115 degrees F). The Administrator was questioned if she had been notified of these increased temperatures. The Administrator stated, "No" The maintenance supervisor then stated, "I thought 118 (degrees F) was OK..." The maintenance supervisor was not aware the facility's policy stated 115 degrees F. The facility failed to ensure the environment was free from accident hazards when hot water temperatures were measured between 120 to (-) 132.8 degrees Fahrenheit (F) in resident rooms #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25 and 26; 118-128 degrees in the North and South hall shower rooms. The failure of the facility to maintain safe hot water temperatures placed 36 of 38 residents in IJ of being scalded or burned. Refer to F323. 2. The facility failed to educate the staff on [MEDICATION NAME], failed to document the parameters of the desired therapeutic range of the [MEDICATION NAME]/International Normalization Ratio (PT/INR) with instructions on when to hold the dose on the physician order [REDACTED].#13, 14 and 61 in IJ. Refer to F282, F309, F385 and F428. 3. The administration failed to ensure the Quality Assurance Committee established and implemented a method for identifying concerns in the facility. Refer to F520. Validation of the Credible Allegation of Compliance was accomplished on-site 3/31/14, through medical record review, review of facility documents, observation, and interviews with nursing and administrative staff. The facility provided evidence of new and revised policies and procedures: Physician' Order Policy, [MEDICATION NAME] policy, [MEDICATION NAME] Therapy Management Alert, Changes in Residents Condition policy, QAPI policy, and Safety of Water Temperatures policy. The facility provided evidence that the Administrator, DON, Medical Director, Consultant Pharmacist had reviewed and approved the policies. The facility provided evidence that administration/corporate staff completed in-service with the consulting pharmacist on 3/15/14, with the Medical Director on 3/12/14, with the Maintenance Director on 3/7/14, with the DON on 3/13/14 on their responsibilities to the facility and compliance with the new and revised policies. The facility provided documentation the Medical Director reviewed [MEDICATION NAME] Policy on 3/14/14 and on 3/24/14 with each of the 6 attending physicians of residents in the facility, along with the importance of addressing condition changes such as bruising, petechiae, fever, and providing treatment and noting this in their physician progress notes [REDACTED]. The facility provided evidence of in-service training with sign-in sheets for all licensed nursing staff related to [MEDICATION NAME] policy, [MEDICATION NAME] therapy, [MEDICATION NAME] Management Alert, Physician orders [REDACTED]. Interviews with licensed nurses conducted 3/31/14 revealed nursing staff were knowledgeable of [MEDICATION NAME] Policy, physician orders [REDACTED]. The facility provided evidence of new auditing logs for [MEDICATION NAME], physician's orders [REDACTED]. Review of the auditing logs revealed the facility was utilizing, and monitoring the logs. physician's orders [REDACTED]. The facility had one resident present and receiving [MEDICATION NAME], Resident # 14. Medical record review for Resident # 14 confirmed physician orders [REDACTED]. Medical record review documented physician order [REDACTED]. Resident # 14 was observed on 3/31/14 in bed with geri-sleeves in place. The facility provided documentation of a work order dated 3/13/14 documented,"re-routed water lines to separate the dietary and residents room. Added a new circulation cold water line to keep temperatures regulated and added 2 on demand water heaters for the showers" Review of a service documentation dated 3/7/14 documented, "Checked the water heaters in the Nursing Home, found them in working condition and operating at the set point levels." The log for monitoring the water temperatures was reviewed and temperatures documented were within the acceptable range. Interviews with the Administrator, DON, Regional Nurse Consultants and Director of Operations confirmed the facility had Quality Assessment and Assurance meetings which discussed Survey results, [MEDICATION NAME] policy, [MEDICATION NAME] therapy, Safety of Water Temperatures policy, physician orders, PT/INR tracking, Medical Director responsibilities, Pharmacy responsibilities, audits, care plan updates, continued monitoring of residents on [MEDICATION NAME], audits of water temperatures, and continued monitoring of water temperatures. The facility will remain out of compliance at a Scope and Severity level "F" a pattern of deficient practice that constitutes no actual harm with potential for more than minimal harm, that is not Immediate Jeopardy, until it provides an acceptable plan of correction.

Based on policy review, review of the [MEDICATION NAME] package insert, review of Lippincott Nursing 2014 Drug Handbook, medical record review, pharmacy review, observation and interview, it was determined the facility failed to educate the staff on [MEDICATION NAME]; failed to document the parameters of the desired therapeutic range of the [MEDICATION NAME]/International Normalization Ratio (PT/INR) with instructions on when to hold the dose on the physician orders [REDACTED].#13, 14 and 61) sampled residents reviewed of the 3 residents receiving [MEDICATION NAME]. The facility failed to follow care plan interventions for sheep skin to chair arms for 1 of 2 (Resident #53) sampled residents reviewed of the 2 residents at risk for skin conditions. The failure of the facility to educate the staff on [MEDICATION NAME]; failure to obtain and monitor the PT/INR laboratory test used to determine therapeutic levels for a blood thinning medication, failure to obtain a PT/INR as ordered by the physician; the failure of the pharmacy consultant to identify and notify the facility for potential drug interactions related to [MEDICATION NAME]; and/or the failure to document the parameters of the desired therapeutic range of the PT/INR with instructions on when to hold the dose on the physician order [REDACTED].#13, 14, and 61. The Administrator, Director of Nursing, and the Regional Nurse Consultant were informed of the immediate jeopardy (IJ) on [DATE] at 12:40 PM in the break room. The IJ was effective [DATE]. The immediate jeopardy for F309 "K" constitutes Substandard Quality of Care. The facility provided an acceptable Allegation of Compliance on [DATE], and a revisit on [DATE], revealed corrective actions implemented on [DATE], removed the Immediate Jeopardy. Noncompliance for F 309 continues at a "E" level citation. The findings included: 1. Review of the facility's "[MEDICATION NAME] THERAPY" policy with an effective date of [DATE] documented, "...Policy: A process is in place to promote the safe and therapeutic administration of [MEDICATION NAME] Guidelines... PT/INR... The physician's orders [REDACTED]. When an antibiotic is ordered, the nurse should inform the physician if the resident is receiving [MEDICATION NAME] PT/INRs should be drawn every three days or a minimum of twice weekly during antibiotics treatment and continue for one week after completion of the antibiotics... Education Nurses should be trained on [MEDICATION NAME] and on the process in place for monitoring. The training should include side effects, adverse reactions, drug interactions, facility process, and the use of the [MEDICATION NAME] Flowsheet..." The facility was unable to provide documentation that staff were educated on the [MEDICATION NAME] Therapy policy that went into effect [DATE]. 2. Review of the facility's "New Admission Lab (laboratory) Guidelines" with a revised date of [DATE] documented, "[MEDICATION NAME] ([MEDICATION NAME])... ANY NEW ADMISSION REQUIRES PT/INR... PT/INR q (every) week for first month DAY 2 OF ADMIT FOR BASELINE... PT/INR q (every) month after first month... PT/INR recheck in 1 week after dosage change..." 3. Review of Lippincott Nursing 2014 Drug Handbook documented, "[MEDICATION NAME] INTERACTIONS Drug-drug. [MEDICATION NAME]: May increase bleeding with long-term therapy (more than 2 weeks) at high doses (more than 2 g (grams) / (per) day) of [MEDICATION NAME]. Monitor patient very carefully..." 4. Review of the [MEDICATION NAME] ([MEDICATION NAME]) package insert documented, "[MEDICAL CONDITION] Fibrillation In patients with non-valvular AF ([MEDICAL CONDITION] Fibrillation), anticoagulate with [MEDICATION NAME] ([MEDICATION NAME]) to target INR of 2.5 (range, 2XXX,[DATE].0)... 5 WARNINGS AND PRECAUTIONS 5.1 Hemorrhage [MEDICATION NAME] can cause major or fatal bleeding. Bleeding is more likely to occur within the first month. Risk factors for bleeding include high intensity of anticoagulation (INR (greater than) > 4.0)... 7 DRUG INTERACTIONS... 7.1... have the potential to increase the effect (increase INR) of [MEDICATION NAME] Closely monitor INR if a concomitant drug is... fluconazole... [MEDICATION NAME] 10 OVERDOSAGE... 10.1 Signs and Symptoms Bleeding (...appearance of blood in stools... excessive bruising...) is a manifestation of excessive anticoagulation... DRUG INTERACTIONS... Antibiotics and antifungals: Closely monitor INR when initiating or stopping an antibiotic or antifungal course of therapy..." 5. Medical record review for Resident #61 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a care plan dated [DATE] documented, "...Problem... potential for bleeding related to anticoagulant therapy... Approach... 2) Monitor for s/s (signs and symptoms) of bleeding (bruises, petechiae, tarry stools, blood in urine). Notify MD (Medical Doctor) if noted. 3) Obtain lab work as ordered by MD, PT/INR... 4.) Report labs to MD... Problem... Actual Resident on 9 or more medications... Approach... 1) Monitor resident closely for s/s of adverse medications reactions. 2) Notify MD of any problems noted... pharmacy consultant to review Prn (as needed)... [DATE]... Problem... Actual Infection: UTI (Urinary Tract Infection)... [MEDICATION NAME]([MEDICATION NAME]) 500 mg (milligrams) BID (twice per day) PO (by mouth) x (times) 10 days..." Review of the admission Minimum Data Set ((MDS) dated [DATE] documented Resident #61 received Anticoagulant ([MEDICATION NAME]) for 7 of 7 days during the look back period, and a Brief Interview Mental Status (BIMS) score of 13 which indicates the resident is cognitively intact. Review of the admission orders [REDACTED]" Based on the physician's orders [REDACTED]. Review of the physician's orders [REDACTED]." Review of the Medication Administration Record [REDACTED]. Review of the Medication Administration Record [REDACTED] Review of the Medication Administration Record [REDACTED]. Review of the Medication Administration Record [REDACTED]. The medications listed above ([MEDICATION NAME], Fluconazole and Cipro) can potentiate the effects of [MEDICATION NAME] and can increase the risk of bleeding. Resident #61 received these medications from admitted [DATE] through discharge date [DATE]. There were days during her stay when Resident #61 received up to a total dose of [MEDICATION NAME] of up to 6,500 mg (6.5 grams). Review of the Pharmacy recommendation dated [DATE] documented, "...(Resident #61)... No Recommendations..." Review of the Pharmacy recommendation dated [DATE] documented, "...Recommendation to Physician Services... (Resident #61) is currently receiving [MEDICATION NAME] therapy. Please make sure INR is drawn ASAP (as soon as possible) and repeated monthly if stable..." Review of the Pharmacy recommendation dated [DATE] documented, "...(Resident #61)... NEW MEDS/CHANGES?: [MEDICATION NAME] incr (increased)... RISK MEDS?: None... NOTE/RECOM (recommend): no med-related problems noted- No Recommendations..." The only recommendation from the Pharmacy Consultant during Resident #61's nursing home stay was to draw an INR ASAP and repeat monthly if stable. During a telephone interview in the breakroom on [DATE] at 3:00 PM, the Pharmacy Consultant was asked if he had any guidelines for PT/INR values for residents on [MEDICATION NAME] therapy. The Pharmacy Consultant stated, "...INR is recommended to stay within 2 to (-) 3 range. When asked would antibiotics affect the PT/INR, the Pharmacy Consultant stated, "...with antibiotics as well, they recommend a PT/INR every ,[DATE] days... With Cipro, INR's can shoot up, also Fluconazole can be a major offender..." When asked how long should the PT/INR be in the ,[DATE] range before considering it stable. The Pharmacy Consultant stated, "The physician has the big picture of the event. I come in and get a snapshot." During an interview in the breakroom on [DATE] beginning at 8:43 AM, the Director of Nursing (DON) was asked what her expectations were for pharmacy recommendations. The DON stated, "...If it is alerting, he needs to bring my attention to it. If no alarm, it will come in email. If it's an alert, I should be called..." Review of a "Health Status Note" dated [DATE] at 12:35 documented, "...rsdt (Resident) stating, "There is a little blood in my stool" Rsdt noted to have a small amount of bright red blood in stool at this time... PCP (Primary Care Physician) notified at this time..." Review of a physician's telephone order dated [DATE] documented, " ...Obtain GI (gastrointestinal) consult for... blood in stool..." Resident #61 was admitted to the hospital on [DATE] and returned to this facility on [DATE]. Review of the hospital Progress Note documented, "...ADM (admission) DATE: [DATE]... LABORATORY DATA... PT 85.1, INR 8.1... ASSESSMENT: 1. Acute lower [MEDICAL CONDITION], probably secondary to [MEDICATION NAME] toxicity..." Review of a physician's telephone order dated [DATE] documented, "...PT/INR in 2 days on Sunday [DATE]..." Review of the "...(Named Hospital) PATIENT REPORT..." dated [DATE] documented, "...PT WITH INR... INR 1.1... PT... 11.8..." Based on the [MEDICATION NAME] package insert this INR result is below the therapeutic range for patients with [MEDICAL CONDITION]. Review of a "Health Status Note" dated [DATE] at 16:40 documented, "...Lab results in via (Named Hospital) fax. Normal results at this time. MD notified. No new orders at this time (for a non therapeutic level)..." Review of a "Health Status Note" dated [DATE] documented, "...Rsdt states, "I have had some blood in my stools." No blood noted at this time. PCP aware..." Review of a physician's telephone order dated [DATE] documented, "...(symbol for increase) [MEDICATION NAME] to 7.5 mg q day... PT/INR per lab in 1 week on [DATE]..." This is the first physician's orders [REDACTED].#61's [MEDICATION NAME] dosage since the laboratory result dated [DATE] which was below therapeutic range. Review of the "...(Named Laboratory)... FINAL REPORT..." dated [DATE] documented, "[MEDICATION NAME] 72.7 C (critical) H (high)... CONFIRMED BY REPEAT ANALYSIS... INR 6.67 CH... CONFIRMED BY REPEAT ANALYSIS..." Review of a physician's telephone order dated [DATE] documented, "...Hold [MEDICATION NAME] 7.5 for 3 days Recheck PT/INR Friday [DATE]..." Review of a "Health Status Note" dated [DATE] at 16:33 documented, "...Hold [MEDICATION NAME] 7.5mg for 3 days. Recheck PT/INR Friday [DATE]..." and at 21:48 documented, "...Labs faxed to (Resident #61's physician's) office and contacted by phone on critical labs..." Review of the "...(Named Laboratory)... FINAL REPORT..." dated [DATE] documented, "[MEDICATION NAME] 64.6 H... INR 5.92 H..." Review of a physician's telephone order dated [DATE] documented, "...Hold [MEDICATION NAME] ,[DATE] + (and) ,[DATE]... Recheck PT INR on ,[DATE] & (and) Call MD c (with) results for further orders..." Review of the "...(Named Laboratory)... FINAL REPORT..." dated [DATE] documented, "[MEDICATION NAME] 15.2... INR 1.37..." Based on the [MEDICATION NAME] package insert this INR result is below the therapeutic range for patients with [MEDICAL CONDITION]. Review of a physician's orders [REDACTED]. Recheck PT/INR in 1 month [DATE]..." There was no documented physician's orders [REDACTED].#61's admission date of [DATE] through [DATE] (1 month with no baseline). Of the 4 PT/INR's that were obtained during Resident #61's entire nursing home stay ([DATE] through [DATE]), none were in the therapeutic range of 2XXX,[DATE].0 as stated in the [MEDICATION NAME] package insert. Review of a "Health Status Note" dated [DATE] documented, "...Res stated she was having rectal bleeding... Upon examining contents of toilet, observed toilet tissue with 2 quarter size spots of blood. Upon examining res. (resident) Observed 0.5 cm (centimeter) hemorrhoid. (Named Doctor) (on call for (Resident #61's physician) notified) N/O (new order) [MEDICATION NAME] HC ([MEDICATION NAME] Cream) suppository (treatment for [REDACTED]. Review of a "Health Status Note" dated [DATE] at 20:32 documented, "...Late Entry for [DATE], (Resident #61's physician) office was called, (Resident #61) wanted him (Resident #61's physician) to come and look at her stomach, (Resident #61) told them (staff) she was concerned about spots on stomach, these were not new areas but she still wanted him to look at them (spots), I (Nurse #6) asked to see if we needed to draw a pt/inr, (Resident #61's physician) showed up at facility and went in and assessed resident, (Resident #61's physician) stated that there was no need for a pt/inr at this time, but he (Resident #61's physician) did order a [MEDICATION NAME] shot for her hip, nurse (#6) drew up shot and,(Resident #61's physician) administered shot..." During an interview in the breakroom on [DATE] at 1:55 PM, Nurse #7 was asked if she ever saw blood in Resident #61's stool. Nurse #7 stated, "Yes, and I remember I contacted the GI doctor and I don't know what happened after that..." During an interview in the breakroom on [DATE] at 2:10 PM, Nurse #6 was asked about the late entry nurse note entered in the computer on [DATE] and those "spots" on Resident #61's abdomen. Nurse #6 stated, "...She (Resident #61) wanted to know if there were more than usual. I told her I did not know but would call the doctor. He (Resident #61's Physician) came and saw her..." Nurse #6 was asked what was his response when asked about drawing another PT/INR. Nurse #6 stated, "He said we didn't need to draw one..." Nurse #6 was asked if she notified the DON or anyone about her concern. Nurse #6 stated, "I did not go anywhere else with my concern." During an interview in the breakroom on [DATE] beginning at 8:43 AM, the DON was asked what was her expectation of the nurses when asking a physician regarding a concern they have and the physician doesn't validate the concern. The DON stated, "They should come to me and I'll call the Medical Director, or they could go directly to him. He is there for us. We also have RNs (Registered Nurses), they (nurses) can communicate with as well..." During a telephone interview in the breakroom on [DATE] at 10:30 AM, Nurse #10 was asked what she communicated to the physician (on call for attending physician) on [DATE] regarding the observed blood on the toilet paper. Nurse #10 stated, "I did tell (Named Physician) that she was on [MEDICATION NAME] and I told him her last PT/INR that was done. That was not too far back. I was very concerned about that..." Nurse #10 was asked if she got a laboratory order for another PT/INR. Nurse #10 stated, "No, I did not get any from him (physician)..." Review of a physician order [REDACTED].>10.0 CH... PT... >100.0 H..." Resident #61 had no PT/INR's drawn from [DATE] until she went to the hospital on [DATE] at which time the INR results were critically high. During a telephone interview in the breakroom on [DATE] beginning at 3:00 PM, Resident #61's nursing home attending physician was asked about [MEDICATION NAME] management and the normal procedure when a resident is on [MEDICATION NAME]. Resident #61's attending physician stated, "INR, some are very stable, will check more often if unstable and then every month if stable..." Resident #61's attending physician was asked what he considered stable. Resident #61's attending physician stated, If the PT/INR was within therapeutic range for 3 times then start obtaining them monthly. Resident #61's attending physician was asked what was the usual starting dose for [MEDICATION NAME]. He stated, "Start [MEDICATION NAME] low, keep checking and manage level between 2 and 3..." He was asked about Resident #61's high PT/INR and the [MEDICATION NAME] was held several days then the level was drawn and it was below the therapeutic range. Resident #61's physician had signed an order for [REDACTED].#61's attending physician stated, "That's not me, never, never, is a mistake, have to check and see what is going on... did they put my name on that... I not going to start somebody on that (15 mg) then not draw PT/INR for 1 month... was I the attending, or was I covering?" Resident #61's attending physician was asked about the additional drugs that could potentiate the effects of [MEDICATION NAME] like Fluconazole, [MEDICATION NAME], or [MEDICATION NAME]. Resident #61's attending physician stated, "...they would need less [MEDICATION NAME]" Resident #61's attending physician was asked about how he monitors how much Tylenol residents are receiving. Resident #61's attending physician stated, "...only give 1 gram or 1.5 per day..." Resident #61's attending physician was informed that Resident #61 had orders for [MEDICATION NAME] ,[DATE] mg four times a day (QID) and Tylenol 650 mg total dose q 4 hours scheduled upon admission and Resident #61 received up to 6,500 mg of [MEDICATION NAME] on some days. Resident #61's attending physician stated, "...Oh Boy, oh boy, that's too much ([MEDICATION NAME]), may have caused more problems - good thought..." Resident #61's attending physician was asked if a resident is on Fluconazole and [MEDICATION NAME], would that change how often he would order a PT/INR. Resident #61's attending physician stated, "...I would draw (PT/INR) more often and make sure they are on the lowest dose possible..." Resident #61's attending physician was asked if [MEDICATION NAME] toxicity could cause bleeding in the head without a fall if the INR is greater than 10. Resident #61's attending physician stated, "Yes, if INR is so high, oh my, so sad..." During a telephone interview in the breakroom on [DATE] beginning at 3:30 PM, the Medical Director was asked if there was a system in place to monitor the performance of the health care practitioners. The Medical Director stated, "I don't think so, I am not aware of any." The Medical Director was asked what his expectations would be for [MEDICATION NAME] management if there was a problem. The Medical Director stated, "I am the default doctor to call... Everyone should know about interactions... If nurses call me I could help... with HIPAA (Health Insurance and Portability and Accountability Act) I cannot go and handle someone else's patient unless the nurse had called me." The Medical Director was asked about what he would do if a nurse called him about a resident on [MEDICATION NAME] and had bruising. The Medical Director stated, "If on [MEDICATION NAME], that's common sense, if put on antibiotics, it (PT/INR) should be done and repeat." The Medical Director was asked if he attends Quality Assurance (QA) meetings. The Medical Director stated, "I go to QA meetings monthly." The Medical Director was asked if there were specific discussions about residents on [MEDICATION NAME]. The Medical Director stated, "I understand one had a bad outcome, they were another provider's patient... not everyone is perfect for sure. I just gave my 2 cents worth after that occurred... this could have been caught..." During an interview in the breakroom on [DATE] at 10:15 AM, the Tennessee Regional Nurse Consultant stated, "I realized we didn't have a ([MEDICATION NAME] therapy) policy, so we wrote this one ([MEDICATION NAME] Therapy policy dated [DATE])..." During a telephone interview in the breakroom on [DATE] beginning at 11:10 AM, the Medical Director was asked how he would manage a new resident admitted on [MEDICATION NAME] and how often he would draw PT/INR's. The Medical Director stated, "...relatively soon within the next several days, then standard of care is once a month if stable... sometimes ,[DATE] weeks... depends on medications, if on antibiotics or Tylenol, check more commonly (frequently) ..." The Medical Director was then asked if that resident had rectal bleeding or abdominal bruising, what would he do. The Medical Director stated, "...Stop the [MEDICATION NAME] and stop anything else... especially aspirin, check blood, platelets, check INR, and get a GI consult if there is rectal bleeding..." The first PT/INR for Resident #61 was drawn one month after an admission date of [DATE] on [DATE] with a result of 11XXX,[DATE].1. This result was sub therapeutic according to the [MEDICATION NAME] package insert. MD was notified with no new orders given. The [MEDICATION NAME] was increased to 7.5 mg on [DATE] with orders to draw a PT/INR on [DATE]. The PT/INR on [DATE] was 72XXX,[DATE].67 which was critically high. The [MEDICATION NAME] was held for 3 days and recheck on PT/INR on [DATE] which was 64XXX,[DATE].92 and still high. Orders to hold [MEDICATION NAME] on [DATE] and [DATE] and recheck PT/INR on [DATE] which was 15XXX,[DATE].37 which was sub therapeutic. A signed physician telephone order dated [DATE] documented to give 7.5 mg tonight for a total of 15 mg, (the MAR indicated [REDACTED].mg on [DATE] and recheck PT/INR in 1 month on [DATE]. Resident #61 was sent to hospital #1 following an episode of weakness and vomiting on [DATE] at 10:00 AM. Resident was found unresponsive in the emergency room and a PT/INR was drawn at 21:40 with a PT/INR result of >100/>10 and was then transferred to hospital #2 and expired on [DATE] at hospital #2. The failure of the facility to educate the staff on [MEDICATION NAME], failure to obtain and monitor the PT/INR laboratory test used to determine therapeutic levels for a blood thinning medication as ordered by the physician, and failure of the pharmacy consultant to identify and notify the facility for potential drug interactions related to [MEDICATION NAME] resulted in IJ for Resident #61. 6. Medical record review for Resident #13 documented an admission date of [DATE], a readmission date of [DATE], and a discharge date of [DATE] with [DIAGNOSES REDACTED]. Review of the admission orders [REDACTED]"Problem... Potential for bleeding/bruise related to anticoagulant therapy... Obtain lab work as ordered by MD (Medical Doctor), PT INR..." Review of the physician's orders [REDACTED]. [REDACTED]. res pt/inr 2.6 and 30.3 and res is currently on [MEDICATION NAME] 7.5 mg daily... left voice mail with previous information with phone nurse (Resident #13's physician's nurse). 1530 (3:30 PM) phone nurse (Resident #13's physician's nurse) called with new orders. nurse stated that was in normal range and to recheck pt/inr in 2 weeks..." There was no new order written for PT/INR to be drawn in two weeks. Review of the "...(Named Hospital) PATIENT REPORT..." dated [DATE] documented, "...INR 2.6 H (HIGH)... PT WITH INR 30.3 H..." Review of the "...(Named Laboratory)... FINAL REPORT..." dated [DATE] documented, "[MEDICATION NAME] 116.4 CH (critical high)... CONFIRMED BY REPEAT ANALYSIS... INR 10.74 CH... CONFIRMED BY REPEAT ANALYSIS..." There were no laboratory results for the week of [DATE] as ordered. During an interview in the breakroom on [DATE] at 6:00 PM, the Director of Nursing (DON) was asked about the PT/INR result to be drawn the following week after [DATE]. The DON brought in the "Health Status Note" and stated, "...according to this, the nurse called with new orders, stated was in normal range, and to check in 2 weeks... think the order was written incorrectly..." The DON was asked what should be followed, the doctor orders or the nurses' notes. The DON stated, "You know the answer. The doctor orders..." During a telephone interview in the breakroom on [DATE] at 10:00 AM, Nurse #8 was asked about the order she wrote on [DATE] at 4:00 PM. Nurse #8 stated, "I'm assuming the doctor called, can't really remember... I know that was what I was told, if I wrote it, I was told it..." During a telephone interview in the breakroom on [DATE] at 10:25 AM, Resident #13's physician was asked about the [DATE] physician's orders [REDACTED]. Resident #13's physician stated, "...was in 1 week, should be in 1 week..." During a telephone interview in the breakroom on [DATE] at 2:05 PM, Nurse #9 was asked about the nurses' note written on [DATE] to recheck the PT/INR in 2 weeks. Nurse #9 stated, "I am so sorry, I really don't remember at all what I was told..." Review of the physician's orders [REDACTED].#13 received the last dose of [MEDICATION NAME] on [DATE]. Review of the "Monthly Consultant Pharmacist Report..." documented, "...This report includes consultant pharmacist activities between [DATE] and [DATE]... (Named Resident) is on [MEDICATION NAME] with orders on ,[DATE] for [MEDICATION NAME] The interaction between and the antibiotic listed above may be severe. Please... consider checking INR ASAP (as soon as possible) and alspo (also) every 3 to 5 days for several weeks until it can be concluded that INR is stable..." Review of the physician's orders [REDACTED]. PT WITH INR 23.9 H..." Review of the "...(Named Hospital) PATIENT REPORT..." dated [DATE] documented, "...INR 1.9 H... PT WITH INR 22.1 H..." There was no PT/INR performed after [DATE] until 13 days after the antibiotic was completed. During an interview in the breakroom on [DATE] at 8:48 AM, the DON handed the surveyor a pharmacy review, and stated, "...we did realize this resident did not have a PT/INR done for a few days after the antibiotic had been completed..." (The facility's policy states the PT/INRs should be drawn every three days or a minimum of twice weekly during antibiotics treatment and continue for one week after completion of the antibiotics). Review of the physician's orders [REDACTED].#13's PT/INR and there was no documentation of the parameters for the desired therapeutic range of the PT/INR with instructions on when to hold the dose as the facility's policy states. The failure of the facility to educate the staff on [MEDICATION NAME], failure to obtain a PT/INR laboratory result as ordered by the physician, failure to appropriately obtain and monitor the PT/INR laboratory test used to determine therapeutic levels for a blood thinning medication, and the failure to document the parameters of the desired therapeutic range of the PT/INR with instructions on when to hold the dose on the physician order [REDACTED].#13. 7. Medical record review for Resident #14 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the "Clinical Physician Orders" dated [DATE] documented, "...2 mg (milligrams) [MEDICATION NAME] po q day..." Review of the physician's orders [REDACTED]./INR and there was no documentation of the parameters for the desired therapeutic range of the PT/INR with instructions on when to hold the dose as the facility's policy states. The failure of the facility to educate the staff on [MEDICATION NAME], failure to document the parameters of the desired therapeutic range of the PT/INR with instructions on when to hold the dose on the physician order [REDACTED].#14 in IJ. 8. During an interview in the breakroom on [DATE] at 1:55 PM, Nurse #7 was asked if she has had any [MEDICATION NAME] training at this facility. Nurse #7 stated, "...After (Resident #61's) passing (death o

Based on policy review, review of the [MEDICATION NAME] package insert, review of Lippincott Nursing 2014 Drug Handbook, medical record review, pharmacy review, observation and interview, it was determined the facility failed to educate the staff on [MEDICATION NAME]; failed to document the parameters of the desired therapeutic range of the [MEDICATION NAME]/International Normalization Ratio (PT/INR) with instructions on when to hold the dose on the physician orders [REDACTED].#13, 14 and 61) sampled residents reviewed of the 3 residents receiving [MEDICATION NAME]. The facility failed to follow care plan interventions for sheep skin to chair arms for 1 of 2 (Resident #53) sampled residents reviewed of the 2 residents at risk for skin conditions. The failure of the facility to educate the staff on [MEDICATION NAME]; failure to obtain and monitor the PT/INR laboratory test used to determine therapeutic levels for a blood thinning medication, failure to obtain a PT/INR as ordered by the physician; the failure of the pharmacy consultant to identify and notify the facility for potential drug interactions related to [MEDICATION NAME]; and/or the failure to document the parameters of the desired therapeutic range of the PT/INR with instructions on when to hold the dose on the physician order [REDACTED].#13, 14, and 61. The Administrator, Director of Nursing, and the Regional Nurse Consultant were informed of the immediate jeopardy (IJ) on [DATE] at 12:40 PM in the break room. The IJ is ongoing. The immediate jeopardy for F309 "K" constitutes Substandard Quality of Care. The findings included: 1. Review of the facility's "[MEDICATION NAME] THERAPY" policy with an effective date of [DATE] documented, "...Policy: A process is in place to promote the safe and therapeutic administration of [MEDICATION NAME] Guidelines... PT/INR... The physician's orders [REDACTED]. When an antibiotic is ordered, the nurse should inform the physician if the resident is receiving [MEDICATION NAME] PT/INRs should be drawn every three days or a minimum of twice weekly during antibiotics treatment and continue for one week after completion of the antibiotics... Education Nurses should be trained on [MEDICATION NAME] and on the process in place for monitoring. The training should include side effects, adverse reactions, drug interactions, facility process, and the use of the [MEDICATION NAME] Flowsheet..." The facility was unable to provide documentation that staff were educated on the [MEDICATION NAME] Therapy policy that went into effect [DATE]. 2. Review of the facility's "New Admission Lab (laboratory) Guidelines" with a revised date of [DATE] documented, "[MEDICATION NAME] ([MEDICATION NAME])... ANY NEW ADMISSION REQUIRES PT/INR... PT/INR q (every) week for first month DAY 2 OF ADMIT FOR BASELINE... PT/INR q (every) month after first month... PT/INR recheck in 1 week after dosage change..." 3. Review of Lippincott Nursing 2014 Drug Handbook documented, "[MEDICATION NAME] INTERACTIONS Drug-drug. [MEDICATION NAME]: May increase bleeding with long-term therapy (more than 2 weeks) at high doses (more than 2 g (grams) / (per) day) of [MEDICATION NAME]. Monitor patient very carefully..." 4. Review of the [MEDICATION NAME] ([MEDICATION NAME]) package insert documented, "[MEDICAL CONDITION] Fibrillation In patients with non-valvular AF ([MEDICAL CONDITION] Fibrillation), anticoagulate with [MEDICATION NAME] ([MEDICATION NAME]) to target INR of 2.5 (range, 2XXX,[DATE].0)... 5 WARNINGS AND PRECAUTIONS 5.1 Hemorrhage [MEDICATION NAME] can cause major or fatal bleeding. Bleeding is more likely to occur within the first month. Risk factors for bleeding include high intensity of anticoagulation (INR (greater than) > 4.0)... 7 DRUG INTERACTIONS... 7.1... have the potential to increase the effect (increase INR) of [MEDICATION NAME] Closely monitor INR if a concomitant drug is... fluconazole... [MEDICATION NAME] 10 OVERDOSAGE... 10.1 Signs and Symptoms Bleeding (...appearance of blood in stools... excessive bruising...) is a manifestation of excessive anticoagulation... DRUG INTERACTIONS... Antibiotics and antifungals: Closely monitor INR when initiating or stopping an antibiotic or antifungal course of therapy..." 5. Medical record review for Resident #61 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a care plan dated [DATE] documented, "...Problem... potential for bleeding related to anticoagulant therapy... Approach... 2) Monitor for s/s (signs and symptoms) of bleeding (bruises, petechiae, tarry stools, blood in urine). Notify MD (Medical Doctor) if noted. 3) Obtain lab work as ordered by MD, PT/INR... 4.) Report labs to MD... Problem... Actual Resident on 9 or more medications... Approach... 1) Monitor resident closely for s/s of adverse medications reactions. 2) Notify MD of any problems noted... pharmacy consultant to review Prn (as needed)... [DATE]... Problem... Actual Infection: UTI (Urinary Tract Infection)... [MEDICATION NAME]([MEDICATION NAME]) 500 mg (milligrams) BID (twice per day) PO (by mouth) x (times) 10 days..." Review of the admission Minimum Data Set ((MDS) dated [DATE] documented Resident #61 received Anticoagulant ([MEDICATION NAME]) for 7 of 7 days during the look back period, and a Brief Interview Mental Status (BIMS) score of 13 which indicates the resident is cognitively intact. Review of the admission orders [REDACTED]" Based on the physician's orders [REDACTED]. Review of the physician's orders [REDACTED]." Review of the Medication Administration Record [REDACTED]. Review of the Medication Administration Record [REDACTED] Review of the Medication Administration Record [REDACTED]. Review of the Medication Administration Record [REDACTED]. The medications listed above ([MEDICATION NAME], Fluconazole and Cipro) can potentiate the effects of [MEDICATION NAME] and can increase the risk of bleeding. Resident #61 received these medications from admitted [DATE] through discharge date [DATE]. There were days during her stay when Resident #61 received up to a total dose of [MEDICATION NAME] of up to 6,500 mg (6.5 grams). Review of the Pharmacy recommendation dated [DATE] documented, "...(Resident #61)... No Recommendations..." Review of the Pharmacy recommendation dated [DATE] documented, "...Recommendation to Physician Services... (Resident #61) is currently receiving [MEDICATION NAME] therapy. Please make sure INR is drawn ASAP (as soon as possible) and repeated monthly if stable..." Review of the Pharmacy recommendation dated [DATE] documented, "...(Resident #61)... NEW MEDS/CHANGES?: [MEDICATION NAME] incr (increased)... RISK MEDS?: None... NOTE/RECOM (recommend): no med-related problems noted- No Recommendations..." The only recommendation from the Pharmacy Consultant during Resident #61's nursing home stay was to draw an INR ASAP and repeat monthly if stable. During a telephone interview in the breakroom on [DATE] at 3:00 PM, the Pharmacy Consultant was asked if he had any guidelines for PT/INR values for residents on [MEDICATION NAME] therapy. The Pharmacy Consultant stated, "...INR is recommended to stay within 2 to (-) 3 range. When asked would antibiotics affect the PT/INR, the Pharmacy Consultant stated, "...with antibiotics as well, they recommend a PT/INR every ,[DATE] days... With Cipro, INR's can shoot up, also Fluconazole can be a major offender..." When asked how long should the PT/INR be in the ,[DATE] range before considering it stable. The Pharmacy Consultant stated, "The physician has the big picture of the event. I come in and get a snapshot." During an interview in the breakroom on [DATE] beginning at 8:43 AM, the Director of Nursing (DON) was asked what her expectations were for pharmacy recommendations. The DON stated, "...If it is alerting, he needs to bring my attention to it. If no alarm, it will come in email. If it's an alert, I should be called..." Review of a "Health Status Note" dated [DATE] at 12:35 documented, "...rsdt (Resident) stating, "There is a little blood in my stool" Rsdt noted to have a small amount of bright red blood in stool at this time... PCP (Primary Care Physician) notified at this time..." Review of a physician's telephone order dated [DATE] documented, " ...Obtain GI (gastrointestinal) consult for... blood in stool..." Resident #61 was admitted to the hospital on [DATE] and returned to this facility on [DATE]. Review of the hospital Progress Note documented, "...ADM (admission) DATE: [DATE]... LABORATORY DATA... PT 85.1, INR 8.1... ASSESSMENT: 1. Acute lower [MEDICAL CONDITION], probably secondary to [MEDICATION NAME] toxicity..." Review of a physician's telephone order dated [DATE] documented, "...PT/INR in 2 days on Sunday [DATE]..." Review of the "...(Named Hospital) PATIENT REPORT..." dated [DATE] documented, "...PT WITH INR... INR 1.1... PT... 11.8..." Based on the [MEDICATION NAME] package insert this INR result is below the therapeutic range for patients with [MEDICAL CONDITION]. Review of a "Health Status Note" dated [DATE] at 16:40 documented, "...Lab results in via (Named Hospital) fax. Normal results at this time. MD notified. No new orders at this time (for a non therapeutic level)..." Review of a "Health Status Note" dated [DATE] documented, "...Rsdt states, "I have had some blood in my stools." No blood noted at this time. PCP aware..." Review of a physician's telephone order dated [DATE] documented, "...(symbol for increase) [MEDICATION NAME] to 7.5 mg q day... PT/INR per lab in 1 week on [DATE]..." This is the first physician's orders [REDACTED].#61's [MEDICATION NAME] dosage since the laboratory result dated [DATE] which was below therapeutic range. Review of the "...(Named Laboratory)... FINAL REPORT..." dated [DATE] documented, "[MEDICATION NAME] 72.7 C (critical) H (high)... CONFIRMED BY REPEAT ANALYSIS... INR 6.67 CH... CONFIRMED BY REPEAT ANALYSIS..." Review of a physician's telephone order dated [DATE] documented, "...Hold [MEDICATION NAME] 7.5 for 3 days Recheck PT/INR Friday [DATE]..." Review of a "Health Status Note" dated [DATE] at 16:33 documented, "...Hold [MEDICATION NAME] 7.5mg for 3 days. Recheck PT/INR Friday [DATE]..." and at 21:48 documented, "...Labs faxed to (Resident #61's physician's) office and contacted by phone on critical labs..." Review of the "...(Named Laboratory)... FINAL REPORT..." dated [DATE] documented, "[MEDICATION NAME] 64.6 H... INR 5.92 H..." Review of a physician's telephone order dated [DATE] documented, "...Hold [MEDICATION NAME] ,[DATE] + (and) ,[DATE]... Recheck PT INR on ,[DATE] & (and) Call MD c (with) results for further orders..." Review of the "...(Named Laboratory)... FINAL REPORT..." dated [DATE] documented, "[MEDICATION NAME] 15.2... INR 1.37..." Based on the [MEDICATION NAME] package insert this INR result is below the therapeutic range for patients with [MEDICAL CONDITION]. Review of a physician's orders [REDACTED]. Recheck PT/INR in 1 month [DATE]..." There was no documented physician's orders [REDACTED].#61's admission date of [DATE] through [DATE] (1 month with no baseline). Of the 4 PT/INR's that were obtained during Resident #61's entire nursing home stay ([DATE] through [DATE]), none were in the therapeutic range of 2XXX,[DATE].0 as stated in the [MEDICATION NAME] package insert. Review of a "Health Status Note" dated [DATE] documented, "...Res stated she was having rectal bleeding... Upon examining contents of toilet, observed toilet tissue with 2 quarter size spots of blood. Upon examining res. (resident) Observed 0.5 cm (centimeter) hemorrhoid. (Named Doctor) (on call for (Resident #61's physician) notified) N/O (new order) [MEDICATION NAME] HC ([MEDICATION NAME] Cream) suppository (treatment for [REDACTED]. Review of a "Health Status Note" dated [DATE] at 20:32 documented, "...Late Entry for [DATE], (Resident #61's physician) office was called, (Resident #61) wanted him (Resident #61's physician) to come and look at her stomach, (Resident #61) told them (staff) she was concerned about spots on stomach, these were not new areas but she still wanted him to look at them (spots), I (Nurse #6) asked to see if we needed to draw a pt/inr, (Resident #61's physician) showed up at facility and went in and assessed resident, (Resident #61's physician) stated that there was no need for a pt/inr at this time, but he (Resident #61's physician) did order a [MEDICATION NAME] shot for her hip, nurse (#6) drew up shot and,(Resident #61's physician) administered shot..." During an interview in the breakroom on [DATE] at 1:55 PM, Nurse #7 was asked if she ever saw blood in Resident #61's stool. Nurse #7 stated, "Yes, and I remember I contacted the GI doctor and I don't know what happened after that..." During an interview in the breakroom on [DATE] at 2:10 PM, Nurse #6 was asked about the late entry nurse note entered in the computer on [DATE] and those "spots" on Resident #61's abdomen. Nurse #6 stated, "...She (Resident #61) wanted to know if there were more than usual. I told her I did not know but would call the doctor. He (Resident #61's Physician) came and saw her..." Nurse #6 was asked what was his response when asked about drawing another PT/INR. Nurse #6 stated, "He said we didn't need to draw one..." Nurse #6 was asked if she notified the DON or anyone about her concern. Nurse #6 stated, "I did not go anywhere else with my concern." During an interview in the breakroom on [DATE] beginning at 8:43 AM, the DON was asked what was her expectation of the nurses when asking a physician regarding a concern they have and the physician doesn't validate the concern. The DON stated, "They should come to me and I'll call the Medical Director, or they could go directly to him. He is there for us. We also have RNs (Registered Nurses), they (nurses) can communicate with as well..." During a telephone interview in the breakroom on [DATE] at 10:30 AM, Nurse #10 was asked what she communicated to the physician (on call for attending physician) on [DATE] regarding the observed blood on the toilet paper. Nurse #10 stated, "I did tell (Named Physician) that she was on [MEDICATION NAME] and I told him her last PT/INR that was done. That was not too far back. I was very concerned about that..." Nurse #10 was asked if she got a laboratory order for another PT/INR. Nurse #10 stated, "No, I did not get any from him (physician)..." Review of a physician order [REDACTED].>10.0 CH... PT... >100.0 H..." Resident #61 had no PT/INR's drawn from [DATE] until she went to the hospital on [DATE] at which time the INR results were critically high. During a telephone interview in the breakroom on [DATE] beginning at 3:00 PM, Resident #61's nursing home attending physician was asked about [MEDICATION NAME] management and the normal procedure when a resident is on [MEDICATION NAME]. Resident #61's attending physician stated, "INR, some are very stable, will check more often if unstable and then every month if stable..." Resident #61's attending physician was asked what he considered stable. Resident #61's attending physician stated, If the PT/INR was within therapeutic range for 3 times then start obtaining them monthly. Resident #61's attending physician was asked what was the usual starting dose for [MEDICATION NAME]. He stated, "Start [MEDICATION NAME] low, keep checking and manage level between 2 and 3..." He was asked about Resident #61's high PT/INR and the [MEDICATION NAME] was held several days then the level was drawn and it was below the therapeutic range. Resident #61's physician had signed an order for [REDACTED].#61's attending physician stated, "That's not me, never, never, is a mistake, have to check and see what is going on... did they put my name on that... I not going to start somebody on that (15 mg) then not draw PT/INR for 1 month... was I the attending, or was I covering?" Resident #61's attending physician was asked about the additional drugs that could potentiate the effects of [MEDICATION NAME] like Fluconazole, [MEDICATION NAME], or [MEDICATION NAME]. Resident #61's attending physician stated, "...they would need less [MEDICATION NAME]" Resident #61's attending physician was asked about how he monitors how much Tylenol residents are receiving. Resident #61's attending physician stated, "...only give 1 gram or 1.5 per day..." Resident #61's attending physician was informed that Resident #61 had orders for [MEDICATION NAME] ,[DATE] mg four times a day (QID) and Tylenol 650 mg total dose q 4 hours scheduled upon admission and Resident #61 received up to 6,500 mg of [MEDICATION NAME] on some days. Resident #61's attending physician stated, "...Oh Boy, oh boy, that's too much ([MEDICATION NAME]), may have caused more problems - good thought..." Resident #61's attending physician was asked if a resident is on Fluconazole and [MEDICATION NAME], would that change how often he would order a PT/INR. Resident #61's attending physician stated, "...I would draw (PT/INR) more often and make sure they are on the lowest dose possible..." Resident #61's attending physician was asked if [MEDICATION NAME] toxicity could cause bleeding in the head without a fall if the INR is greater than 10. Resident #61's attending physician stated, "Yes, if INR is so high, oh my, so sad..." During a telephone interview in the breakroom on [DATE] beginning at 3:30 PM, the Medical Director was asked if there was a system in place to monitor the performance of the health care practitioners. The Medical Director stated, "I don't think so, I am not aware of any." The Medical Director was asked what his expectations would be for [MEDICATION NAME] management if there was a problem. The Medical Director stated, "I am the default doctor to call... Everyone should know about interactions... If nurses call me I could help... with HIPAA (Health Insurance and Portability and Accountability Act) I cannot go and handle someone else's patient unless the nurse had called me." The Medical Director was asked about what he would do if a nurse called him about a resident on [MEDICATION NAME] and had bruising. The Medical Director stated, "If on [MEDICATION NAME], that's common sense, if put on antibiotics, it (PT/INR) should be done and repeat." The Medical Director was asked if he attends Quality Assurance (QA) meetings. The Medical Director stated, "I go to QA meetings monthly." The Medical Director was asked if there were specific discussions about residents on [MEDICATION NAME]. The Medical Director stated, "I understand one had a bad outcome, they were another provider's patient... not everyone is perfect for sure. I just gave my 2 cents worth after that occurred... this could have been caught..." During an interview in the breakroom on [DATE] at 10:15 AM, the Tennessee Regional Nurse Consultant stated, "I realized we didn't have a ([MEDICATION NAME] therapy) policy, so we wrote this one ([MEDICATION NAME] Therapy policy dated [DATE])..." During a telephone interview in the breakroom on [DATE] beginning at 11:10 AM, the Medical Director was asked how he would manage a new resident admitted on [MEDICATION NAME] and how often he would draw PT/INR's. The Medical Director stated, "...relatively soon within the next several days, then standard of care is once a month if stable... sometimes ,[DATE] weeks... depends on medications, if on antibiotics or Tylenol, check more commonly (frequently) ..." The Medical Director was then asked if that resident had rectal bleeding or abdominal bruising, what would he do. The Medical Director stated, "...Stop the [MEDICATION NAME] and stop anything else... especially aspirin, check blood, platelets, check INR, and get a GI consult if there is rectal bleeding..." The first PT/INR for Resident #61 was drawn one month after an admission date of [DATE] on [DATE] with a result of 11XXX,[DATE].1. This result was sub therapeutic according to the [MEDICATION NAME] package insert. MD was notified with no new orders given. The [MEDICATION NAME] was increased to 7.5 mg on [DATE] with orders to draw a PT/INR on [DATE]. The PT/INR on [DATE] was 72XXX,[DATE].67 which was critically high. The [MEDICATION NAME] was held for 3 days and recheck on PT/INR on [DATE] which was 64XXX,[DATE].92 and still high. Orders to hold [MEDICATION NAME] on [DATE] and [DATE] and recheck PT/INR on [DATE] which was 15XXX,[DATE].37 which was sub therapeutic. A signed physician telephone order dated [DATE] documented to give 7.5 mg tonight for a total of 15 mg, (the MAR indicated [REDACTED].mg on [DATE] and recheck PT/INR in 1 month on [DATE]. Resident #61 was sent to hospital #1 following an episode of weakness and vomiting on [DATE] at 10:00 AM. Resident was found unresponsive in the emergency room and a PT/INR was drawn at 21:40 with a PT/INR result of >100/>10 and was then transferred to hospital #2 and expired on [DATE] at hospital #2. The failure of the facility to educate the staff on [MEDICATION NAME], failure to obtain and monitor the PT/INR laboratory test used to determine therapeutic levels for a blood thinning medication as ordered by the physician, and failure of the pharmacy consultant to identify and notify the facility for potential drug interactions related to [MEDICATION NAME] resulted in IJ for Resident #61. 6. Medical record review for Resident #13 documented an admission date of [DATE], a readmission date of [DATE], and a discharge date of [DATE] with [DIAGNOSES REDACTED]. Review of the admission orders [REDACTED]"Problem... Potential for bleeding/bruise related to anticoagulant therapy... Obtain lab work as ordered by MD (Medical Doctor), PT INR..." Review of the physician's orders [REDACTED]. [REDACTED]. res pt/inr 2.6 and 30.3 and res is currently on [MEDICATION NAME] 7.5 mg daily... left voice mail with previous information with phone nurse (Resident #13's physician's nurse). 1530 (3:30 PM) phone nurse (Resident #13's physician's nurse) called with new orders. nurse stated that was in normal range and to recheck pt/inr in 2 weeks..." There was no new order written for PT/INR to be drawn in two weeks. Review of the "...(Named Hospital) PATIENT REPORT..." dated [DATE] documented, "...INR 2.6 H (HIGH)... PT WITH INR 30.3 H..." Review of the "...(Named Laboratory)... FINAL REPORT..." dated [DATE] documented, "[MEDICATION NAME] 116.4 CH (critical high)... CONFIRMED BY REPEAT ANALYSIS... INR 10.74 CH... CONFIRMED BY REPEAT ANALYSIS..." There were no laboratory results for the week of [DATE] as ordered. During an interview in the breakroom on [DATE] at 6:00 PM, the Director of Nursing (DON) was asked about the PT/INR result to be drawn the following week after [DATE]. The DON brought in the "Health Status Note" and stated, "...according to this, the nurse called with new orders, stated was in normal range, and to check in 2 weeks... think the order was written incorrectly..." The DON was asked what should be followed, the doctor orders or the nurses' notes. The DON stated, "You know the answer. The doctor orders..." During a telephone interview in the breakroom on [DATE] at 10:00 AM, Nurse #8 was asked about the order she wrote on [DATE] at 4:00 PM. Nurse #8 stated, "I'm assuming the doctor called, can't really remember... I know that was what I was told, if I wrote it, I was told it..." During a telephone interview in the breakroom on [DATE] at 10:25 AM, Resident #13's physician was asked about the [DATE] physician's orders [REDACTED]. Resident #13's physician stated, "...was in 1 week, should be in 1 week..." During a telephone interview in the breakroom on [DATE] at 2:05 PM, Nurse #9 was asked about the nurses' note written on [DATE] to recheck the PT/INR in 2 weeks. Nurse #9 stated, "I am so sorry, I really don't remember at all what I was told..." Review of the physician's orders [REDACTED].#13 received the last dose of [MEDICATION NAME] on [DATE]. Review of the "Monthly Consultant Pharmacist Report..." documented, "...This report includes consultant pharmacist activities between [DATE] and [DATE]... (Named Resident) is on [MEDICATION NAME] with orders on ,[DATE] for [MEDICATION NAME] The interaction between and the antibiotic listed above may be severe. Please... consider checking INR ASAP (as soon as possible) and alspo (also) every 3 to 5 days for several weeks until it can be concluded that INR is stable..." Review of the physician's orders [REDACTED]. PT WITH INR 23.9 H..." Review of the "...(Named Hospital) PATIENT REPORT..." dated [DATE] documented, "...INR 1.9 H... PT WITH INR 22.1 H..." There was no PT/INR performed after [DATE] until 13 days after the antibiotic was completed. During an interview in the breakroom on [DATE] at 8:48 AM, the DON handed the surveyor a pharmacy review, and stated, "...we did realize this resident did not have a PT/INR done for a few days after the antibiotic had been completed..." (The facility's policy states the PT/INRs should be drawn every three days or a minimum of twice weekly during antibiotics treatment and continue for one week after completion of the antibiotics). Review of the physician's orders [REDACTED].#13's PT/INR and there was no documentation of the parameters for the desired therapeutic range of the PT/INR with instructions on when to hold the dose as the facility's policy states. The failure of the facility to educate the staff on [MEDICATION NAME], failure to obtain a PT/INR laboratory result as ordered by the physician, failure to appropriately obtain and monitor the PT/INR laboratory test used to determine therapeutic levels for a blood thinning medication, and the failure to document the parameters of the desired therapeutic range of the PT/INR with instructions on when to hold the dose on the physician order [REDACTED].#13. 7. Medical record review for Resident #14 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the "Clinical Physician Orders" dated [DATE] documented, "...2 mg (milligrams) [MEDICATION NAME] po q day..." Review of the physician's orders [REDACTED]./INR and there was no documentation of the parameters for the desired therapeutic range of the PT/INR with instructions on when to hold the dose as the facility's policy states. The failure of the facility to educate the staff on [MEDICATION NAME], failure to document the parameters of the desired therapeutic range of the PT/INR with instructions on when to hold the dose on the physician order [REDACTED].#14 in IJ. 8. During an interview in the breakroom on [DATE] at 1:55 PM, Nurse #7 was asked if she has had any [MEDICATION NAME] training at this facility. Nurse #7 stated, "...After (Resident #61's) passing (death on [DATE]) about antibiotics and [MEDICATION NAME]" During an interview in the breakroom on [DATE] at 2:10 PM, Nurse #6 was asked if she has had any [MEDICATION NAME] training at this facility. Nurse #6 stated, "I don't really remember before, but after this, (Resid

Based on policy review, review of a [MEDICATION NAME] package insert, review of the Lippincott Nursing Drug Handbook, review of the maintenance supervisor's log book, pharmacy review, observation and interview, it was determined the facility's Quality Assessment (QA) and Assurance committee failed to identify issues, develop and implement plans of action to correct quality deficiencies related to managing residents receiving anticoagulant therapy. The failure of the QA committee to identify and address concerns resulted in immediate jeopardy (a situation in which the provider's noncompliance has caused, or is likely to cause serious injury, harm, impairment, or death) for Resident #13, 14 and 61. The Administrator, the Director of Nursing (DON), the Regional Administrator and the Regional Nurse Consultant were informed of this immediate jeopardy (IJ) on 3/11/2014 at 5:15 PM in the breakroom. The IJ is ongoing. The findings included: During an interview in the breakroom on 3/11/14 at 1:29 PM, the Administrator stated, "...the QA committee is supposed to meet monthly... only met once since I have been here (started in January 2014)... did not meet in February... department heads attend... pharmacist does not attend... probably need to look at that and have come at least every 6 months... issues recently addressed were care plans, PAR (Patient at Risk) meetings, MDS (Minimum Data Set), PT/INRs ([MEDICATION NAME] / International Normalization Ratio), Infection Control, Medical Records..." The interventions put in place by the QA committee were not effective as evidenced by: a. The facility failed to follow care plan interventions for [MEDICATION NAME] therapy. Refer to F282. The facility failed to document the parameters of the desired therapeutic range of the [MEDICATION NAME] / International Normalization Ratio (PT/INR) with instructions on when to hold the dose on the physician order [REDACTED]. Refer to F309 and F428. b. The facility failed to ensure the pharmacy consultant identified and notified the facility for potential drug interactions related to [MEDICATION NAME] therapy. Refer to F428.

Based on policy review, review of a [MEDICATION NAME] package insert, medical record review and interview, it was determined the facility failed to ensure the physician monitored for changes in the medical condition of a resident by obtaining and monitoring the [MEDICATION NAME] / International Normalization Ratio (PT/INR) laboratory test used to determine therapeutic levels for a blood thinning medication for 1 of 3 (Resident #61) sampled residents reviewed of the 3 residents receiving [MEDICATION NAME]. The failure of the facility to ensure the physician monitored for changes in the medical condition of a resident by obtaining and monitoring the PT/INR laboratory test used to determine therapeutic levels according to the [MEDICATION NAME] package insert for a blood thinning medication resulted in immediate jeopardy (a situation in which the provider's noncompliance has caused, or is likely to cause serious injury, harm, impairment, or death) for Resident #61. The Administrator, the Director of Nursing (DON) and the Regional Nurse Consultant were informed of the immediate jeopardy (IJ) on [DATE] at 12:40 PM in the breakroom. The IJ is ongoing. The findings included: Review of the facility's "New Admission Lab (laboratory) Guidelines" with a revised date of [DATE] documented, "[MEDICATION NAME] ([MEDICATION NAME])... ANY NEW ADMISSION REQUIRES PT/INR... PT/INR q (every) week for first month DAY 2 OF ADMIT FOR BASELINE... PT/INR q (every) month after first month... PT/INR recheck in 1 week after dosage change..." Review of the [MEDICATION NAME] ([MEDICATION NAME]) package insert documented, "[MEDICAL CONDITION] Fibrillation In patients with non-valvular AF ([MEDICAL CONDITION] Fibrillation), anticoagulate with [MEDICATION NAME] ([MEDICATION NAME]) to target INR of 2.5 (range, 2XXX,[DATE].0)... 5 WARNINGS AND PRECAUTIONS 5.1 Hemorrhage [MEDICATION NAME] can cause major or fatal bleeding. Bleeding is more likely to occur within the first month. Risk factors for bleeding include high intensity of anticoagulation (INR > (greater than) 4.0... 10 OVERDOSAGE... 10.1 Signs and Symptoms Bleeding (...appearance of blood in stools... excessive bruising...) is a manifestation of excessive anticoagulation..." Medical record review for Resident #61 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a "Health Status Note" dated [DATE] at 12:35 documented, "...rsdt (Resident) stating, "There is a little blood in my stool" Rsdt noted to have a small amount of bright red blood in stool at this time... PCP (Primary Care Physician) notified at this time..." Review of a physician's telephone order dated [DATE] documented, "...Obtain GI (gastrointestinal) consult for... blood in stool..." Resident #61 was admitted to the hospital on [DATE] and returned to this facility on [DATE]. Review of the hospital Progress Note documented, "...ADM (admission) DATE: [DATE]... LABORATORY DATA... PT 85.1, INR 8.1... ASSESSMENT: 1. Acute lower [MEDICAL CONDITION], probably secondary to [MEDICATION NAME] toxicity..." Review of a physician's telephone order dated [DATE] documented, "...PT/INR in 2 days on Sunday [DATE]..." Review of the "...(Named Hospital) PATIENT REPORT..." dated [DATE] documented, "...PT WITH INR... INR 1.1... PT... 11.8..." Based on the [MEDICATION NAME] package insert this INR result is below the therapeutic range for patients with [MEDICAL CONDITION]. Review of a "Health Status Note" dated [DATE] at 16:40 documented, "...Lab results in via (Named Hospital) fax. Normal results at this time. MD (Medical Doctor) notified. No new orders at this time (for a non therapeutic level)..." Review of a "Health Status Note" dated [DATE] documented, "...Rsdt states, "I have had some blood in my stools." No blood noted at this time. PCP aware..." Review of a physician's telephone order dated [DATE] documented, "...(symbol for increase) [MEDICATION NAME] to 7.5 mg q day... PT/INR per lab in 1 week on [DATE]..." This is the first physician's orders [REDACTED].#61's [MEDICATION NAME] dosage since the laboratory result dated [DATE] which was below therapeutic range. Review of the "...(Named Laboratory)... FINAL REPORT..." dated [DATE] documented, "[MEDICATION NAME] 72.7 C (critical) H (high)... CONFIRMED BY REPEAT ANALYSIS... INR 6.67 CH... CONFIRMED BY REPEAT ANALYSIS..." Review of a physician's telephone order dated [DATE] documented, "...Hold [MEDICATION NAME] 7.5 for 3 days Recheck PT/INR Friday [DATE]..." Review of a "Health Status Note" dated [DATE] at 16:33 documented, "...Hold [MEDICATION NAME] 7.5mg for 3 days. Recheck PT/INR Friday [DATE]..." and at 21:48 documented, "...Labs faxed to (Resident #61's physician's) office and contacted by phone on critical labs..." Review of the "...(Named Laboratory)... FINAL REPORT..." dated [DATE] documented, "[MEDICATION NAME] 64.6 H... INR 5.92 H..." Review of a physician's telephone order dated [DATE] documented, "...Hold [MEDICATION NAME] ,[DATE] + (and) ,[DATE]... Recheck PT INR on ,[DATE] & (and) Call MD c (with) results for further orders..." Review of the "...(Named Laboratory)... FINAL REPORT..." dated [DATE] documented, "[MEDICATION NAME] 15.2... INR 1.37..." Based on the [MEDICATION NAME] package insert this INR result is below the therapeutic range for patients with [MEDICAL CONDITION]. Review of a physician's orders [REDACTED]. Recheck PT/INR in 1 month [DATE]..." There was no documented physician's orders [REDACTED].#61's admission date of [DATE] through [DATE] (1 month with no baseline). Of the 4 PT/INR's that were obtained during Resident #61's entire nursing home stay ([DATE] through [DATE]), none were in the therapeutic range of 2XXX,[DATE].0 as stated in the [MEDICATION NAME] package insert. Review of a "Health Status Note" dated [DATE] documented, "...Res stated she was having rectal bleeding... Upon examining contents of toilet, observed toilet tissue with 2 quarter size spots of blood. Upon examining res. (resident) Observed 0.5 cm (centimeter) hemorrhoid. (Named Doctor) (on call for (Resident #61's physician) notified) N/O (new order) [MEDICATION NAME] HC ([MEDICATION NAME] Cream) suppository (treatment for [REDACTED]. Review of a "Health Status Note" dated [DATE] at 20:32 documented, "...Late Entry for [DATE], (Resident #61's physician) office was called, (Resident #61) wanted him (Resident #61's physician) to come and look at her stomach, (Resident #61) told them (staff) she was concerned about spots on stomach, these were not new areas but she still wanted him to look at them (spots), I (Nurse #6) asked to see if we needed to draw a pt/inr, (Resident #61's physician) showed up at facility and went in and assessed resident, (Resident #61's physician) stated that there was no need for a pt/inr at this time, but he (Resident #61's physician) did order a [MEDICATION NAME] shot for her hip, nurse (#6) drew up shot and,(Resident #61's physician) administered shot..." During an interview in the breakroom on [DATE] at 1:55 PM, Nurse #7 was asked if she ever saw blood in Resident #61's stool. Nurse #7 stated, "Yes, and I remember I contacted the GI doctor and I don't know what happened after that..." During an interview in the breakroom on [DATE] at 2:10 PM, Nurse #6 was asked about the late entry nurse note entered in the computer on [DATE] and those "spots" on Resident #61's abdomen. Nurse #6 stated, "...She (Resident #61) wanted to know if there were more than usual. I told her I did not know but would call the doctor. He (Resident #61's Physician) came and saw her..." Nurse #6 was asked what was his response when asked about drawing another PT/INR. Nurse #6 stated, "He said we didn't need to draw one..." Nurse #6 was asked if she notified the DON or anyone about her concern. Nurse #6 stated, "I did not go anywhere else with my concern." During an interview in the breakroom on [DATE] beginning at 8:43 AM, the DON was asked what was her expectation of the nurses when asking a physician regarding a concern they have and the physician doesn't validate the concern. The DON stated, "They should come to me and I'll call the Medical Director, or they could go directly to him. He is there for us. We also have RNs (Registered Nurses), they (nurses) can communicate with as well..." During a telephone interview in the breakroom on [DATE] at 10:30 AM, Nurse #10 was asked what she communicated to the physician (on call for attending physician) on [DATE] regarding the observed blood on the toilet paper. Nurse #10 stated, "I did tell (Named Physician) that she was on [MEDICATION NAME] and I told him her last PT/INR that was done. That was not too far back. I was very concerned about that..." Nurse #10 was asked if she got a laboratory order for another PT/INR. Nurse #10 stated, "No, I did not get any from him (physician)..." Review of a physician order [REDACTED].>10.0 CH... PT... >100.0 H..." Resident #61 had no PT/INR's drawn from [DATE] until she went to the hospital on [DATE] at which time the INR results were critically high. During a telephone interview in the breakroom on [DATE] beginning at 3:00 PM, Resident #61's nursing home attending physician was asked about [MEDICATION NAME] management and the normal procedure when a resident is on [MEDICATION NAME]. Resident #61's attending physician stated, "INR, some are very stable, will check more often if unstable and then every month if stable..." Resident #61's attending physician was asked what he considered stable. Resident #61's attending physician stated, If the PT/INR was within therapeutic range for 3 times then start obtaining them monthly. Resident #61's attending physician was asked what was the usual starting dose for [MEDICATION NAME]. He stated, "Start [MEDICATION NAME] low, keep checking and manage level between 2 and 3..." He was asked about Resident #61's high PT/INR and the [MEDICATION NAME] was held several days then the level was drawn and it was below the therapeutic range. Resident #61's physician had signed an order for [REDACTED].#61's attending physician stated, "That's not me, never, never, is a mistake, have to check and see what is going on... did they put my name on that... I not going to start somebody on that (15 mg) then not draw PT/INR for 1 month... was I the attending, or was I covering?" Resident #61's attending physician was asked if [MEDICATION NAME] toxicity could cause a beeding in the head without a fall if the INR is greater than 10. Resident #61's attending physician stated, "Yes, if INR is so high, oh my, so sad..." During a telephone interview in the breakroom on [DATE] beginning at 3:30 PM, the Medical Director was asked if there was a system in place to monitor the performance of the health care practitioners. The Medical Director stated, "I don't think so, I am not aware of any." The Medical Director was asked what his expectations would be for [MEDICATION NAME] management if there was a problem. The Medical Director stated, "I am the default doctor to call... Everyone should know about interactions... If nurses call me I could help... with HIPAA (Health Insurance and Portability and Accountability Act) I cannot go and handle someone else's patient unless the nurse had called me." The Medical Director was asked about what he would do if a nurse called him about a resident on [MEDICATION NAME] and had bruising. The Medical Director stated, "If on [MEDICATION NAME], that's common sense, if put on antibiotics, it (PT/INR) should be done and repeat." The Medical Director was asked if he attends Quality Assurance (QA) meetings. The Medical Director stated, "I go to QA meetings monthly." The Medical Director was asked if there were specific discussions about residents on [MEDICATION NAME]. The Medical Director stated, "I understand one had a bad outcome, they were another provider's patient... not everyone is perfect for sure. I just gave my 2 cents worth after that occurred... this could have been caught..." During a telephone interview in the breakroom on [DATE] beginning at 11:10 AM, the Medical Director was asked how he would manage a new resident admitted on [MEDICATION NAME] and how often he would draw PT/INR's. The Medical Director stated, "...relatively soon within the next several days, then standard of care is once a month if stable... sometimes ,[DATE] weeks... depends on medications..." The Medical Director was then asked if that resident had rectal bleeding or abdominal bruising, what would he do. The Medical Director stated, "...Stop the [MEDICATION NAME] and stop anything else... especially aspirin, check blood, platelets, check INR, and get a GI consult if there is rectal bleeding..." The first PT/INR for Resident #61 was drawn one month after Resident #61's admission date of [DATE] on [DATE] with a result of 11XXX,[DATE].1. This result was sub therapeutic according to the [MEDICATION NAME] package insert. MD was notified with no new orders given. The [MEDICATION NAME] was increased to 7.5 mg on [DATE] with orders to draw a PT/INR on [DATE]. The PT/INR on [DATE] was 72XXX,[DATE].67 which was critically high. The [MEDICATION NAME] was held for 3 days and recheck on PT/INR on [DATE] which was 64XXX,[DATE].92 and still high. Orders to hold [MEDICATION NAME] on [DATE] and [DATE] and recheck PT/INR on [DATE] which was 15XXX,[DATE].37 which was sub therapeutic. A signed physician order [REDACTED].mg on [DATE] and recheck PT/INR in 1 month on [DATE]. Resident #61 was sent to hospital #1 following an episode of weakness and vomiting on [DATE] at 10:00 AM. Resident was found unresponsive in the emergency room and a PT/INR was drawn at 21:40 with a PT/INR result of >100/>10 and was then transferred to hospital #2 and expired on [DATE] at hospital #2. The failure of the facility to ensure the physician monitored for changes in the medical condition of a resident by obtaining and monitoring the PT/INR laboratory test used to determine therapeutic levels according to the [MEDICATION NAME] package insert for a blood thinning medication resulted in immediate jeopardy (IJ) for Resident #61.

Based on review of the [MEDICATION NAME] package insert, medical record review, observation and interview, it was determined the facility failed to follow care plan interventions for [MEDICATION NAME] therapy or sheep skin to chair arms for 2 of 18 (Residents #13 and 53) sampled residents of the 31 residents included in the stage 2 review. The failure of the facility to follow care plan interventions by not obtaining a [MEDICATION NAME] / International Normalization Ratio (PT/INR) laboratory test for monitoring a bleeding study as ordered placed Resident #13 at a high risk of serious bleeding which resulted in an immediate jeopardy (a situation in which the provider's noncompliance has caused, or is likely to cause serious injury, harm, impairment, or death). The Administrator, the Director of Nursing (DON) and the Regional Nurse Consultant were informed of the immediate jeopardy (IJ) in the breakroom on 3/11/14 at 12:40 PM. The IJ is ongoing. The findings included: 1. Review of the [MEDICATION NAME] ([MEDICATION NAME]) package insert documented, "[MEDICAL CONDITION] Fibrillation In patients with non-valvular AF ([MEDICAL CONDITION] Fibrillation), anticoagulate with [MEDICATION NAME] ([MEDICATION NAME]) to target INR of 2.5 (therapeutic range, 2.0 - (to) 3.0)... 5 WARNINGS AND PRECAUTIONS 5.1 Hemorrhage [MEDICATION NAME] can cause major or fatal bleeding. Bleeding is more likely to occur within the first month. Risk factors for bleeding include high intensity of anticoagulation (INR > greater than) 4.0)... OVERDOSAGE... 10.1 Signs and Symptoms Bleeding (... appearance of blood in stools... excessive bruising...) is a manifestation of excessive anticoagulation... DRUG INTERACTIONS... Antibiotics and antifungals: Closely monitor INR when initiating or stopping an antibiotic or antifungal course of therapy... " 2. Medical record review for Resident #13 documented an admission date of [DATE], a readmission date of [DATE], and a discharge date of [DATE] with [DIAGNOSES REDACTED]. Review of the admission orders [REDACTED]"Problem... Potential for bleeding / bruise related to anticoagulant therapy... Obtain lab (laboratory) work as ordered by MD (Medical Doctor), PT INR..." Review of the physician's orders [REDACTED]. [REDACTED]. res pt/inr 2.6 and 30.3 and res is currently on [MEDICATION NAME] 7.5 mg daily... left voice mail with previous information with phone nurse (Resident #13's physician's nurse). 1530 (3:30 PM) phone nurse (Resident #13's physician's nurse) called with new orders. nurse stated that was in normal range and to recheck pt/inr in 2 weeks..." There was no new order written to obtain the PT/INR in two weeks. Review of the "...(Named Hospital) PATIENT REPORT..." dated 9/27/13 documented, "...INR 2.6 H (HIGH)... PT WITH INR 30.3 H..." Review of the "...(Named Laboratory)... FINAL REPORT..." dated 10/10/13 documented, "[MEDICATION NAME] 116.4 CH (critical high)... CONFIRMED BY REPEAT ANALYSIS... INR 10.74 CH... CONFIRMED BY REPEAT ANALYSIS..." There were no laboratory results for the PT/INR to be drawn in one week (week of 10/4/13) as ordered. During an interview in the breakroom on 3/10/14 at 6:00 PM, the Director of Nursing (DON) was asked about the PT/INR result to be drawn the following week after 9/27/13. The DON brought in the "Health Status Note" and stated, "...according to this, the nurse called with new orders, stated was in normal range, and to check in 2 weeks... think the order was written incorrectly..." The DON was asked what should be followed, the doctor orders or the nurses' notes. The DON stated, "You know the answer, the doctor orders..." During a telephone interview in the breakroom on 3/11/14 at 10:00 AM, Nurse #8 was asked about the order (recheck PT/INR in 1 week) she wrote 9/27/14 at 4:00 PM. Nurse #8 stated, "I'm assuming the doctor called, can't really remember... I know that was what I was told, if I wrote it, I was told it..." During a telephone interview in the breakroom on 3/11/14 at 10:25 AM, Resident #13's physician was asked about the 9/27/13 physician's orders [REDACTED]. Resident #13's physician stated, "...was in 1 week, should be in 1 week..." During a telephone interview in the breakroom on 3/11/14 at 2:05 PM, Nurse #9 was asked about the nurses' note written on 9/27/13 to recheck the PT/INR in 2 weeks. Nurse #9 stated, "I am so sorry. I really don't remember at all what I was told." The failure of the facility to follow care plan interventions by not obtaining a PT/INR laboratory test for monitoring a bleeding study as ordered placed Resident #13 at a high risk of serious bleeding which resulted in an immediate jeopardy. 3. Medical record review for Resident #53 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the "SBAR (Situation Background Assessment Recommendation) Communication Form and Progress Note" dated 11/28/13 documented, "...Bruising R (right) wrist/arm... Hit arm on w/c (wheelchair)... w/c arms padded for protection..." Review of the care plan updated 11/28/13 documented, "...11/28 bruising... 11/28 sheep skin chair arms..." Observations in the dining room on 3/5/14 at 11:28 AM, on 3/6/14 at 11:45 AM and on 3/7/14 at 11:30 AM, revealed Resident #53 seated in a wheelchair (w/c), with no padding or sheep skin on the arms of the w/c as care planned. During an interview in the DON's office, on 3/10/14 at 1:37 PM, the DON was informed there was no padding or sheepskin observed on Resident #53's wheelchair arms, while the resident was sitting in the w/c. The DON stated the sheep skin had been applied and secured to Resident #53's w/c arms and maybe they took the sheepskin off when they cleaned the wheelchair.

Based on review of Lippincott Nursing 2014 Drug Handbook, review of the Coumadin package insert, medical record review, pharmacy review and interview, it was determined the facility failed to ensure the pharmacy consultant identified and notified the facility for potential drug interactions for 1 of 3 (Resident #61) sampled residents reviewed of the 3 residents receiving Coumadin. The failure of the facility to ensure the pharmacy consultant identified and notified the facility for potential drug interactions resulted in immediate jeopardy (a situation in which the provider's noncompliance has caused, or is likely to cause serious injury, harm, impairment, or death) for Resident #61. The Administrator, the Director of Nursing (DON) and the Regional Nurse Consultant were informed of the immediate jeopardy (IJ) on 3/11/2014 at 12:40 PM in the breakroom. The IJ is ongoing. The findings included: Review of Lippincott Nursing 2014 Drug Handbook documented, "...Coumadin... INTERACTIONS Drug-drug. Acetaminophen: May increase bleeding with long-term therapy (more than 2 weeks) at high doses (more than 2 g (grams) / (per) day) of acetaminophen. Monitor patient very carefully..." Review of the Coumadin (warfarin) package insert documented, "...[DIAGNOSES REDACTED]in patients with non-valvular AF (Atrial Fibrillation), anticoagulate with warfarin (Coumadin) to target INR (International Normalization Ratio) of 2.5 (range, 2.0-3.0)... 5 WARNINGS AND PRECAUTIONS 5.1 Hemorrhage COUMADIN can cause major or fatal bleeding. Bleeding is more likely to occur within the first month. Risk factors for bleeding include high intensity of anticoagulation (INR (international normalization ratio) > (greater than) 4.0... 7 DRUG INTERACTIONS... 7.1... have the potential to increase the effect (increase INR) of warfarin... Closely monitor INR if a concomitant drug is... fluconazole... ciprofloxacin... fluoxetine... 10 OVERDOSAGE... 10.1 Signs and Symptoms Bleeding (...appearance of blood in stools... excessive bruising...) is a manifestation of excessive anticoagulation...DRUG INTERACTIONS... Antibiotics and antifungals: Closely monitor INR when initiating or stopping an antibiotic or antifungal course of therapy..." Medical record review for Resident #61 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a care plan dated 6/20/13 documented, "...Problem... potential for bleeding related to anticoagulant therapy... Approach... 2) Monitor for s/s (signs and symptoms) of bleeding (bruises, petechiae, tarry stools, blood in urine). Notify MD (Medical Doctor) if noted. 3) Obtain lab work as ordered by MD, PT (Protime) /INR... 4.) Report labs to MD... Problem... Actual Resident on 9 or more medications... Approach... 1) Monitor resident closely for s/s of adverse medications reactions. 2) Notify MD of any problems noted... pharmacy consultant to review Prn (as needed)... 9/4/13... Problem... Actual Infection: UTI (Urinary Tract Infection)... Approaches... Cipro (ciprofloxacin) 500 mg (milligrams) BID (twice per day) PO (by mouth) x (times) 10 days..." Review of the admission Minimum Data Set ((MDS) dated [DATE] documented Resident #61 received Anticoagulant (warfarin...) for 7 of 7 days during the look back period, and a Brief Interview Mental Status (BIMS) score of 13 which indicates the resident is cognitively intact. Review of the admission orders [REDACTED]" Based on the physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of the Medication Administration Record [REDACTED] Review of the Medication Administration Record [REDACTED]. Review of the Medication Administration Record [REDACTED]. The medications listed above (Percocet, Acetaminophen, Prozac, Fluconazole and Cipro) can potentiate the effects of Coumadin and can increase the risk of bleeding. Resident #61 received these medications from admitted [DATE] through discharge date [DATE]. There were days during her stay when Resident #61 received up to a total dose of Acetaminophen of up to 6,500 mg (6.5 grams). Review of the Pharmacy recommendation dated 6/28/13 documented, "...(Resident #61)... No Recommendations..." Review of the Pharmacy recommendation dated 7/13/13 documented, "...Recommendation to Physician Services... (Resident #61) is currently receiving Coumadin therapy. Please make sure INR is drawn ASAP (as soon as possible) and repeated monthly if stable..." Review of the Pharmacy recommendation dated 8/30/13 documented, "...(Resident #61)... NEW MEDS/CHANGES?: Coumadin incr (increased)... RISK MEDS?: None... NOTE/RECOM: no med-related problems noted- No Recommendations..." The only recommendation from the Pharmacy Consultant during Resident #61's nursing home stay was to draw an INR ASAP and repeat monthly if stable. During a telephone interview in the breakroom on 3/6/14 at 3:00 PM, the Pharmacy Consultant was asked if he had any guidelines for PT/INR values for residents on Coumadin therapy. The Pharmacy Consultant stated, "...INR is recommended to stay within 2 to (-) 3 range. When asked would antibiotics affect the PT/INR, the Pharmacy Consultant stated, "...with antibiotics as well, they recommend a PT/INR every 3-5 days... With Cipro, INR's can shoot up, also Fluconazole can be a major offender..." When asked how long should the PT/INR be in the 2-3 range before considering it stable. The Pharmacy Consultant stated, "The physician has the big picture of the event. I come in and get a snapshot." During an interview in the breakroom on 3/11/14 beginning at 8:43 AM, the Director of Nursing (DON) was asked what her expectations were for pharmacy recommendations. The DON stated, "...If it is alerting, he needs to bring my attention to it. If no alarm, it will come in email. If it's an alert, I should be called..." The failure of the facility to ensure the pharmacy consultant identified and notified the facility for potential drug interactions resulted in immediate jeopardy (IJ) for Resident #61.

Based on policy review, review of a [MEDICATION NAME] package insert, medical record review and interview, it was determined the facility failed to ensure the physician monitored for changes in the medical condition of a resident by obtaining and monitoring the [MEDICATION NAME] / International Normalization Ratio (PT/INR) laboratory test used to determine therapeutic levels for a blood thinning medication for 1 of 3 (Resident #61) sampled residents reviewed of the 3 residents receiving [MEDICATION NAME]. The failure of the facility to ensure the physician monitored for changes in the medical condition of a resident by obtaining and monitoring the PT/INR laboratory test used to determine therapeutic levels according to the [MEDICATION NAME] package insert for a blood thinning medication resulted in immediate jeopardy (a situation in which the provider's noncompliance has caused, or is likely to cause serious injury, harm, impairment, or death) for Resident #61. The Administrator, the Director of Nursing (DON) and the Regional Nurse Consultant were informed of the immediate jeopardy (IJ) on [DATE] at 12:40 PM in the breakroom. The IJ was effective [DATE]. The facility provided an acceptable Allegation of Compliance on [DATE], and a revisit on [DATE], revealed corrective actions implemented on [DATE], removed the Immediate Jeopardy. Noncompliance for F 385 continues at a "D" level citation. The findings included: Review of the facility's "New Admission Lab (laboratory) Guidelines" with a revised date of [DATE] documented, "[MEDICATION NAME] ([MEDICATION NAME])... ANY NEW ADMISSION REQUIRES PT/INR... PT/INR q (every) week for first month DAY 2 OF ADMIT FOR BASELINE... PT/INR q (every) month after first month... PT/INR recheck in 1 week after dosage change..." Review of the [MEDICATION NAME] ([MEDICATION NAME]) package insert documented, "[MEDICAL CONDITION] Fibrillation In patients with non-valvular AF ([MEDICAL CONDITION] Fibrillation), anticoagulate with [MEDICATION NAME] ([MEDICATION NAME]) to target INR of 2.5 (range, 2XXX,[DATE].0)... 5 WARNINGS AND PRECAUTIONS 5.1 Hemorrhage [MEDICATION NAME] can cause major or fatal bleeding. Bleeding is more likely to occur within the first month. Risk factors for bleeding include high intensity of anticoagulation (INR > (greater than) 4.0... 10 OVERDOSAGE... 10.1 Signs and Symptoms Bleeding (...appearance of blood in stools... excessive bruising...) is a manifestation of excessive anticoagulation..." Medical record review for Resident #61 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a "Health Status Note" dated [DATE] at 12:35 documented, "...rsdt (Resident) stating, "There is a little blood in my stool" Rsdt noted to have a small amount of bright red blood in stool at this time... PCP (Primary Care Physician) notified at this time..." Review of a physician's telephone order dated [DATE] documented, "...Obtain GI (gastrointestinal) consult for... blood in stool..." Resident #61 was admitted to the hospital on [DATE] and returned to this facility on [DATE]. Review of the hospital Progress Note documented, "...ADM (admission) DATE: [DATE]... LABORATORY DATA... PT 85.1, INR 8.1... ASSESSMENT: 1. Acute lower [MEDICAL CONDITION], probably secondary to [MEDICATION NAME] toxicity..." Review of a physician's telephone order dated [DATE] documented, "...PT/INR in 2 days on Sunday [DATE]..." Review of the "...(Named Hospital) PATIENT REPORT..." dated [DATE] documented, "...PT WITH INR... INR 1.1... PT... 11.8..." Based on the [MEDICATION NAME] package insert this INR result is below the therapeutic range for patients with [MEDICAL CONDITION]. Review of a "Health Status Note" dated [DATE] at 16:40 documented, "...Lab results in via (Named Hospital) fax. Normal results at this time. MD (Medical Doctor) notified. No new orders at this time (for a non therapeutic level)..." Review of a "Health Status Note" dated [DATE] documented, "...Rsdt states, "I have had some blood in my stools." No blood noted at this time. PCP aware..." Review of a physician's telephone order dated [DATE] documented, "...(symbol for increase) [MEDICATION NAME] to 7.5 mg q day... PT/INR per lab in 1 week on [DATE]..." This is the first physician's orders [REDACTED].#61's [MEDICATION NAME] dosage since the laboratory result dated [DATE] which was below therapeutic range. Review of the "...(Named Laboratory)... FINAL REPORT..." dated [DATE] documented, "[MEDICATION NAME] 72.7 C (critical) H (high)... CONFIRMED BY REPEAT ANALYSIS... INR 6.67 CH... CONFIRMED BY REPEAT ANALYSIS..." Review of a physician's telephone order dated [DATE] documented, "...Hold [MEDICATION NAME] 7.5 for 3 days Recheck PT/INR Friday [DATE]..." Review of a "Health Status Note" dated [DATE] at 16:33 documented, "...Hold [MEDICATION NAME] 7.5mg for 3 days. Recheck PT/INR Friday [DATE]..." and at 21:48 documented, "...Labs faxed to (Resident #61's physician's) office and contacted by phone on critical labs..." Review of the "...(Named Laboratory)... FINAL REPORT..." dated [DATE] documented, "[MEDICATION NAME] 64.6 H... INR 5.92 H..." Review of a physician's telephone order dated [DATE] documented, "...Hold [MEDICATION NAME] ,[DATE] + (and) ,[DATE]... Recheck PT INR on ,[DATE] & (and) Call MD c (with) results for further orders..." Review of the "...(Named Laboratory)... FINAL REPORT..." dated [DATE] documented, "[MEDICATION NAME] 15.2... INR 1.37..." Based on the [MEDICATION NAME] package insert this INR result is below the therapeutic range for patients with [MEDICAL CONDITION]. Review of a physician's orders [REDACTED]. Recheck PT/INR in 1 month [DATE]..." There was no documented physician's orders [REDACTED].#61's admission date of [DATE] through [DATE] (1 month with no baseline). Of the 4 PT/INR's that were obtained during Resident #61's entire nursing home stay ([DATE] through [DATE]), none were in the therapeutic range of 2XXX,[DATE].0 as stated in the [MEDICATION NAME] package insert. Review of a "Health Status Note" dated [DATE] documented, "...Res stated she was having rectal bleeding... Upon examining contents of toilet, observed toilet tissue with 2 quarter size spots of blood. Upon examining res. (resident) Observed 0.5 cm (centimeter) hemorrhoid. (Named Doctor) (on call for (Resident #61's physician) notified) N/O (new order) [MEDICATION NAME] HC ([MEDICATION NAME] Cream) suppository (treatment for [REDACTED]. Review of a "Health Status Note" dated [DATE] at 20:32 documented, "...Late Entry for [DATE], (Resident #61's physician) office was called, (Resident #61) wanted him (Resident #61's physician) to come and look at her stomach, (Resident #61) told them (staff) she was concerned about spots on stomach, these were not new areas but she still wanted him to look at them (spots), I (Nurse #6) asked to see if we needed to draw a pt/inr, (Resident #61's physician) showed up at facility and went in and assessed resident, (Resident #61's physician) stated that there was no need for a pt/inr at this time, but he (Resident #61's physician) did order a [MEDICATION NAME] shot for her hip, nurse (#6) drew up shot and,(Resident #61's physician) administered shot..." During an interview in the breakroom on [DATE] at 1:55 PM, Nurse #7 was asked if she ever saw blood in Resident #61's stool. Nurse #7 stated, "Yes, and I remember I contacted the GI doctor and I don't know what happened after that..." During an interview in the breakroom on [DATE] at 2:10 PM, Nurse #6 was asked about the late entry nurse note entered in the computer on [DATE] and those "spots" on Resident #61's abdomen. Nurse #6 stated, "...She (Resident #61) wanted to know if there were more than usual. I told her I did not know but would call the doctor. He (Resident #61's Physician) came and saw her..." Nurse #6 was asked what was his response when asked about drawing another PT/INR. Nurse #6 stated, "He said we didn't need to draw one..." Nurse #6 was asked if she notified the DON or anyone about her concern. Nurse #6 stated, "I did not go anywhere else with my concern." During an interview in the breakroom on [DATE] beginning at 8:43 AM, the DON was asked what was her expectation of the nurses when asking a physician regarding a concern they have and the physician doesn't validate the concern. The DON stated, "They should come to me and I'll call the Medical Director, or they could go directly to him. He is there for us. We also have RNs (Registered Nurses), they (nurses) can communicate with as well..." During a telephone interview in the breakroom on [DATE] at 10:30 AM, Nurse #10 was asked what she communicated to the physician (on call for attending physician) on [DATE] regarding the observed blood on the toilet paper. Nurse #10 stated, "I did tell (Named Physician) that she was on [MEDICATION NAME] and I told him her last PT/INR that was done. That was not too far back. I was very concerned about that..." Nurse #10 was asked if she got a laboratory order for another PT/INR. Nurse #10 stated, "No, I did not get any from him (physician)..." Review of a physician order [REDACTED].>10.0 CH... PT... >100.0 H..." Resident #61 had no PT/INR's drawn from [DATE] until she went to the hospital on [DATE] at which time the INR results were critically high. During a telephone interview in the breakroom on [DATE] beginning at 3:00 PM, Resident #61's nursing home attending physician was asked about [MEDICATION NAME] management and the normal procedure when a resident is on [MEDICATION NAME]. Resident #61's attending physician stated, "INR, some are very stable, will check more often if unstable and then every month if stable..." Resident #61's attending physician was asked what he considered stable. Resident #61's attending physician stated, If the PT/INR was within therapeutic range for 3 times then start obtaining them monthly. Resident #61's attending physician was asked what was the usual starting dose for [MEDICATION NAME]. He stated, "Start [MEDICATION NAME] low, keep checking and manage level between 2 and 3..." He was asked about Resident #61's high PT/INR and the [MEDICATION NAME] was held several days then the level was drawn and it was below the therapeutic range. Resident #61's physician had signed an order for [REDACTED].#61's attending physician stated, "That's not me, never, never, is a mistake, have to check and see what is going on... did they put my name on that... I not going to start somebody on that (15 mg) then not draw PT/INR for 1 month... was I the attending, or was I covering?" Resident #61's attending physician was asked if [MEDICATION NAME] toxicity could cause a beeding in the head without a fall if the INR is greater than 10. Resident #61's attending physician stated, "Yes, if INR is so high, oh my, so sad..." During a telephone interview in the breakroom on [DATE] beginning at 3:30 PM, the Medical Director was asked if there was a system in place to monitor the performance of the health care practitioners. The Medical Director stated, "I don't think so, I am not aware of any." The Medical Director was asked what his expectations would be for [MEDICATION NAME] management if there was a problem. The Medical Director stated, "I am the default doctor to call... Everyone should know about interactions... If nurses call me I could help... with HIPAA (Health Insurance and Portability and Accountability Act) I cannot go and handle someone else's patient unless the nurse had called me." The Medical Director was asked about what he would do if a nurse called him about a resident on [MEDICATION NAME] and had bruising. The Medical Director stated, "If on [MEDICATION NAME], that's common sense, if put on antibiotics, it (PT/INR) should be done and repeat." The Medical Director was asked if he attends Quality Assurance (QA) meetings. The Medical Director stated, "I go to QA meetings monthly." The Medical Director was asked if there were specific discussions about residents on [MEDICATION NAME]. The Medical Director stated, "I understand one had a bad outcome, they were another provider's patient... not everyone is perfect for sure. I just gave my 2 cents worth after that occurred... this could have been caught..." During a telephone interview in the breakroom on [DATE] beginning at 11:10 AM, the Medical Director was asked how he would manage a new resident admitted on [MEDICATION NAME] and how often he would draw PT/INR's. The Medical Director stated, "...relatively soon within the next several days, then standard of care is once a month if stable... sometimes ,[DATE] weeks... depends on medications..." The Medical Director was then asked if that resident had rectal bleeding or abdominal bruising, what would he do. The Medical Director stated, "...Stop the [MEDICATION NAME] and stop anything else... especially aspirin, check blood, platelets, check INR, and get a GI consult if there is rectal bleeding..." The first PT/INR for Resident #61 was drawn one month after Resident #61's admission date of [DATE] on [DATE] with a result of 11XXX,[DATE].1. This result was sub therapeutic according to the [MEDICATION NAME] package insert. MD was notified with no new orders given. The [MEDICATION NAME] was increased to 7.5 mg on [DATE] with orders to draw a PT/INR on [DATE]. The PT/INR on [DATE] was 72XXX,[DATE].67 which was critically high. The [MEDICATION NAME] was held for 3 days and recheck on PT/INR on [DATE] which was 64XXX,[DATE].92 and still high. Orders to hold [MEDICATION NAME] on [DATE] and [DATE] and recheck PT/INR on [DATE] which was 15XXX,[DATE].37 which was sub therapeutic. A signed physician order [REDACTED].mg on [DATE] and recheck PT/INR in 1 month on [DATE]. Resident #61 was sent to hospital #1 following an episode of weakness and vomiting on [DATE] at 10:00 AM. Resident was found unresponsive in the emergency room and a PT/INR was drawn at 21:40 with a PT/INR result of >100/>10 and was then transferred to hospital #2 and expired on [DATE] at hospital #2. The failure of the facility to ensure the physician monitored for changes in the medical condition of a resident by obtaining and monitoring the PT/INR laboratory test used to determine therapeutic levels according to the [MEDICATION NAME] package insert for a blood thinning medication resulted in immediate jeopardy (IJ) for Resident #61. Validation of the Credible Allegation of Compliance was accomplished on-site [DATE], through medical record review, review of facility documents, observation, and interviews with nursing and administrative staff. The revised Physician order [REDACTED]. The facility provided evidence of in-service training with sign-in sheets for all licensed nursing staff. The in-service was related to [MEDICATION NAME] policy, [MEDICATION NAME] therapy, [MEDICATION NAME] Management alert, Physician orders [REDACTED]. Interviews with licensed nurses conducted [DATE] revealed nursing staff were knowledgeable of [MEDICATION NAME] Policy, physician orders [REDACTED]. The facility provided evidence of new auditing logs for [MEDICATION NAME], physician's orders [REDACTED]. The facility had one resident present and receiving [MEDICATION NAME], Resident # 14. Medical record review for Resident # 14 confirmed physician orders [REDACTED].# 14 was observed on [DATE] in bed with geri-sleeves in place. The facility provided documentation of the in-service [DATE] by the Regional Director of Operations with the consulting pharmacist including review of the Federal Regulations regarding Medication Regimen Review, expectations and responsibilities to the facility for [MEDICATION NAME] management including drug interactions, side effects, and medications that have the ability to potentiate the anticoagulant effect of [MEDICATION NAME]. The [MEDICATION NAME] drug monograph was reviewed. The facility provided documentation of the Medical Director's in-service by the Administrator [DATE], concerning [MEDICATION NAME] policy, [MEDICATION NAME] Therapy, physician orders [REDACTED]. The facility provided documentation the Medical Director reviewed these items on [DATE] and on [DATE] with each of the 6 attending physicians of residents in the facility, along with the importance of addressing condition changes such as bruising, petechiae, fever, and providing treatment and noting this in their physician progress notes [REDACTED]. Interviews with the Administrator, DON, Regional Nurse Consultants and Director of Operations confirmed the facility had Quality Assessment and Assurance meetings which discussed Survey results, [MEDICATION NAME] policy, [MEDICATION NAME] therapy, physician orders, notification of physicians, PT/INR tracking, Medical Director responsibilities, Pharmacy responsibilities, audits, care plan updates, and continued monitoring of residents on [MEDICATION NAME]. The facility will remain out of compliance at a Scope and Severity level "D" a pattern of deficient practice that constitutes no actual harm with potential for more than minimal harm, that is not Immediate Jeopardy, until it provides an acceptable plan of correction.

Based on review of the [MEDICATION NAME] package insert, medical record review, observation and interview, it was determined the facility failed to follow care plan interventions for [MEDICATION NAME] therapy or sheep skin to chair arms for 2 of 18 (Residents #13 and 53) sampled residents of the 31 residents included in the stage 2 review. The failure of the facility to follow care plan interventions by not obtaining a [MEDICATION NAME] / International Normalization Ratio (PT/INR) laboratory test for monitoring a bleeding study as ordered placed Resident #13 at a high risk of serious bleeding which resulted in an immediate jeopardy (a situation in which the provider's noncompliance has caused, or is likely to cause serious injury, harm, impairment, or death). The Administrator, the Director of Nursing (DON) and the Regional Nurse Consultant were informed of the immediate jeopardy (IJ) in the breakroom on 3/11/14 at 12:40 PM. The Immediate Jeopardy was effective 9/11/13. The facility provided an acceptable Allegation of Compliance on 3/26/14, and a revisit on 3/31/14, revealed the corrective actions implemented on 3/20/14, removed the Immediate Jeopardy. Noncompliance for F 282 continues at a "D" level citation. The findings included: 1. Review of the [MEDICATION NAME] ([MEDICATION NAME]) package insert documented, "[MEDICAL CONDITION] Fibrillation In patients with non-valvular AF ([MEDICAL CONDITION] Fibrillation), anticoagulate with [MEDICATION NAME] ([MEDICATION NAME]) to target INR of 2.5 (therapeutic range, 2.0 - (to) 3.0)... 5 WARNINGS AND PRECAUTIONS 5.1 Hemorrhage [MEDICATION NAME] can cause major or fatal bleeding. Bleeding is more likely to occur within the first month. Risk factors for bleeding include high intensity of anticoagulation (INR > greater than) 4.0)... OVERDOSAGE... 10.1 Signs and Symptoms Bleeding (... appearance of blood in stools... excessive bruising...) is a manifestation of excessive anticoagulation... DRUG INTERACTIONS... Antibiotics and antifungals: Closely monitor INR when initiating or stopping an antibiotic or antifungal course of therapy... " 2. Medical record review for Resident #13 documented an admission date of [DATE], a readmission date of [DATE], and a discharge date of [DATE] with [DIAGNOSES REDACTED]. Review of the admission orders [REDACTED]"Problem... Potential for bleeding / bruise related to anticoagulant therapy... Obtain lab (laboratory) work as ordered by MD (Medical Doctor), PT INR..." Review of the physician's orders [REDACTED]. [REDACTED]. res pt/inr 2.6 and 30.3 and res is currently on [MEDICATION NAME] 7.5 mg daily... left voice mail with previous information with phone nurse (Resident #13's physician's nurse). 1530 (3:30 PM) phone nurse (Resident #13's physician's nurse) called with new orders. nurse stated that was in normal range and to recheck pt/inr in 2 weeks..." There was no new order written to obtain the PT/INR in two weeks. Review of the "...(Named Hospital) PATIENT REPORT..." dated 9/27/13 documented, "...INR 2.6 H (HIGH)... PT WITH INR 30.3 H..." Review of the "...(Named Laboratory)... FINAL REPORT..." dated 10/10/13 documented, "[MEDICATION NAME] 116.4 CH (critical high)... CONFIRMED BY REPEAT ANALYSIS... INR 10.74 CH... CONFIRMED BY REPEAT ANALYSIS..." There were no laboratory results for the PT/INR to be drawn in one week (week of 10/4/13) as ordered. During an interview in the breakroom on 3/10/14 at 6:00 PM, the Director of Nursing (DON) was asked about the PT/INR result to be drawn the following week after 9/27/13. The DON brought in the "Health Status Note" and stated, "...according to this, the nurse called with new orders, stated was in normal range, and to check in 2 weeks... think the order was written incorrectly..." The DON was asked what should be followed, the doctor orders or the nurses' notes. The DON stated, "You know the answer, the doctor orders..." During a telephone interview in the breakroom on 3/11/14 at 10:00 AM, Nurse #8 was asked about the order (recheck PT/INR in 1 week) she wrote 9/27/14 at 4:00 PM. Nurse #8 stated, "I'm assuming the doctor called, can't really remember... I know that was what I was told, if I wrote it, I was told it..." During a telephone interview in the breakroom on 3/11/14 at 10:25 AM, Resident #13's physician was asked about the 9/27/13 physician's orders [REDACTED]. Resident #13's physician stated, "...was in 1 week, should be in 1 week..." During a telephone interview in the breakroom on 3/11/14 at 2:05 PM, Nurse #9 was asked about the nurses' note written on 9/27/13 to recheck the PT/INR in 2 weeks. Nurse #9 stated, "I am so sorry. I really don't remember at all what I was told." The failure of the facility to follow care plan interventions by not obtaining a PT/INR laboratory test for monitoring a bleeding study as ordered placed Resident #13 at a high risk of serious bleeding which resulted in an immediate jeopardy. 3. Medical record review for Resident #53 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the "SBAR (Situation Background Assessment Recommendation) Communication Form and Progress Note" dated 11/28/13 documented, "...Bruising R (right) wrist/arm... Hit arm on w/c (wheelchair)... w/c arms padded for protection..." Review of the care plan updated 11/28/13 documented, "...11/28 bruising... 11/28 sheep skin chair arms..." Observations in the dining room on 3/5/14 at 11:28 AM, on 3/6/14 at 11:45 AM and on 3/7/14 at 11:30 AM, revealed Resident #53 seated in a wheelchair (w/c), with no padding or sheep skin on the arms of the w/c as care planned. During an interview in the DON's office, on 3/10/14 at 1:37 PM, the DON was informed there was no padding or sheepskin observed on Resident #53's wheelchair arms, while the resident was sitting in the w/c. The DON stated the sheep skin had been applied and secured to Resident #53's w/c arms and maybe they took the sheepskin off when they cleaned the wheelchair. Validation of the Credible Allegation of Compliance was accomplished on-site 3/31/14, through medical record review, review of facility documents, observation, and interviews with nursing and administrative staff. The facility provided evidence of in-service training with sign-in sheets for all licensed nursing staff. The in-servicewas related to [MEDICATION NAME] policy, Labs: PT/INR, physician's orders [REDACTED]. The facility provided evidence the Interdisciplinary team was inserviced on proper procedure for updating care plans and keeping them current. The revised Physician order [REDACTED]. The facility provided evidence that all residents' care plans had been revised to reflect current interventions, medication and treatment orders. The facility provided evidence of weekly audit and observation of a sample of 5 residents by DON or designee to ensure implementation of care plan interventions. The facility provided evidence of new auditing logs for [MEDICATION NAME], physician's orders [REDACTED]. Interviews with licensed nurses conducted 3/31/14 revealed nursing staff were knowledgeable of [MEDICATION NAME] Policy, physician orders [REDACTED]. Facility had one resident receiving [MEDICATION NAME], Resident # 14. Medical record review for Resident # 14 confirmed care plan was updated for current interventions of anticoagulant therapy, including medication orders, frequency of PT/INR, placement of geri-sleeves to prevent bruising. Resident # 14 was observed on 3/31/14 in bed with geri-sleeves in place. Interviews with the Administrator, DON, and Regional Nurse Consultants confirmed the facility had Quality Assessment and Assurance meetings which discussed care plan audits, updates, and continued monitoring of care plans. The facility will remain out of compliance at a Scope and Severity level "D" a pattern of deficient practice that constitutes no actual harm with potential for more than minimal harm, that is not Immediate Jeopardy, until it provides an acceptable plan of correction.

Based on review of Lippincott Nursing 2014 Drug Handbook, review of the Coumadin package insert, medical record review, pharmacy review and interview, it was determined the facility failed to ensure the pharmacy consultant identified and notified the facility for potential drug interactions for 1 of 3 (Resident #61) sampled residents reviewed of the 3 residents receiving Coumadin. The failure of the facility to ensure the pharmacy consultant identified and notified the facility for potential drug interactions resulted in immediate jeopardy (a situation in which the provider's noncompliance has caused, or is likely to cause serious injury, harm, impairment, or death) for Resident #61. The Administrator, the Director of Nursing (DON) and the Regional Nurse Consultant were informed of the immediate jeopardy (IJ) on 3/11/2014 at 12:40 PM in the breakroom. The IJ was effective 9/11/13. The facility provided an acceptable Allegation of Compliance on 3/26/14, and a revisit on 3/31/14, revealed corrective actions implemented on 3/20/14, removed the Immediate Jeopardy. Noncompliance for F 428 continues at a "D" level citation. The findings included: Review of Lippincott Nursing 2014 Drug Handbook documented, "...Coumadin... INTERACTIONS Drug-drug. Acetaminophen: May increase bleeding with long-term therapy (more than 2 weeks) at high doses (more than 2 g (grams) / (per) day) of acetaminophen. Monitor patient very carefully..." Review of the Coumadin (warfarin) package insert documented, "...[DIAGNOSES REDACTED]in patients with non-valvular AF (Atrial Fibrillation), anticoagulate with warfarin (Coumadin) to target INR (International Normalization Ratio) of 2.5 (range, 2.0-3.0)... 5 WARNINGS AND PRECAUTIONS 5.1 Hemorrhage COUMADIN can cause major or fatal bleeding. Bleeding is more likely to occur within the first month. Risk factors for bleeding include high intensity of anticoagulation (INR (international normalization ratio) > (greater than) 4.0... 7 DRUG INTERACTIONS... 7.1... have the potential to increase the effect (increase INR) of warfarin... Closely monitor INR if a concomitant drug is... fluconazole... ciprofloxacin... fluoxetine... 10 OVERDOSAGE... 10.1 Signs and Symptoms Bleeding (...appearance of blood in stools... excessive bruising...) is a manifestation of excessive anticoagulation...DRUG INTERACTIONS... Antibiotics and antifungals: Closely monitor INR when initiating or stopping an antibiotic or antifungal course of therapy..." Medical record review for Resident #61 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a care plan dated 6/20/13 documented, "...Problem... potential for bleeding related to anticoagulant therapy... Approach... 2) Monitor for s/s (signs and symptoms) of bleeding (bruises, petechiae, tarry stools, blood in urine). Notify MD (Medical Doctor) if noted. 3) Obtain lab work as ordered by MD, PT (Protime) /INR... 4.) Report labs to MD... Problem... Actual Resident on 9 or more medications... Approach... 1) Monitor resident closely for s/s of adverse medications reactions. 2) Notify MD of any problems noted... pharmacy consultant to review Prn (as needed)... 9/4/13... Problem... Actual Infection: UTI (Urinary Tract Infection)... Approaches... Cipro (ciprofloxacin) 500 mg (milligrams) BID (twice per day) PO (by mouth) x (times) 10 days..." Review of the admission Minimum Data Set ((MDS) dated [DATE] documented Resident #61 received Anticoagulant (warfarin...) for 7 of 7 days during the look back period, and a Brief Interview Mental Status (BIMS) score of 13 which indicates the resident is cognitively intact. Review of the admission orders [REDACTED]" Based on the physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of the Medication Administration Record [REDACTED] Review of the Medication Administration Record [REDACTED]. Review of the Medication Administration Record [REDACTED]. The medications listed above (Percocet, Acetaminophen, Prozac, Fluconazole and Cipro) can potentiate the effects of Coumadin and can increase the risk of bleeding. Resident #61 received these medications from admitted [DATE] through discharge date [DATE]. There were days during her stay when Resident #61 received up to a total dose of Acetaminophen of up to 6,500 mg (6.5 grams). Review of the Pharmacy recommendation dated 6/28/13 documented, "...(Resident #61)... No Recommendations..." Review of the Pharmacy recommendation dated 7/13/13 documented, "...Recommendation to Physician Services... (Resident #61) is currently receiving Coumadin therapy. Please make sure INR is drawn ASAP (as soon as possible) and repeated monthly if stable..." Review of the Pharmacy recommendation dated 8/30/13 documented, "...(Resident #61)... NEW MEDS/CHANGES?: Coumadin incr (increased)... RISK MEDS?: None... NOTE/RECOM: no med-related problems noted- No Recommendations..." The only recommendation from the Pharmacy Consultant during Resident #61's nursing home stay was to draw an INR ASAP and repeat monthly if stable. During a telephone interview in the breakroom on 3/6/14 at 3:00 PM, the Pharmacy Consultant was asked if he had any guidelines for PT/INR values for residents on Coumadin therapy. The Pharmacy Consultant stated, "...INR is recommended to stay within 2 to (-) 3 range. When asked would antibiotics affect the PT/INR, the Pharmacy Consultant stated, "...with antibiotics as well, they recommend a PT/INR every 3-5 days... With Cipro, INR's can shoot up, also Fluconazole can be a major offender..." When asked how long should the PT/INR be in the 2-3 range before considering it stable. The Pharmacy Consultant stated, "The physician has the big picture of the event. I come in and get a snapshot." During an interview in the breakroom on 3/11/14 beginning at 8:43 AM, the Director of Nursing (DON) was asked what her expectations were for pharmacy recommendations. The DON stated, "...If it is alerting, he needs to bring my attention to it. If no alarm, it will come in email. If it's an alert, I should be called..." The failure of the facility to ensure the pharmacy consultant identified and notified the facility for potential drug interactions resulted in immediate jeopardy (IJ) for Resident #61. Validation of the Credible Allegation of Compliance was accomplished on-site 3/31/14, through medical record review, review of facility documents, observation, and interviews with nursing and administrative staff. The revised Physician' Order Policy, Coumadin policy, physician's orders [REDACTED]. The facility provided documentation of the in-service 3/15/14 by the Regional Director of of Operations with the consulting pharmacist including review of the Federal Regulations regarding Medication Regimen Review, expectations and responsibilities to the facility for Coumadin management including drug interactions, side effects, and medications that have the potential to potentiate the anticoagulant effect of Coumadin, monthly review of each resident's drug regimen review with reporting to attending physician of any irregularities. The Coumadin drug monograph was reviewed. The facility provided evidence of in-service training with sign-in sheets for all licensed nursing staff related to Coumadin policy, Coumadin therapy, Coumadin Management alert, significant drug interactions, in-service on Tylenol and limits with anticoagulant therapy, Physician orders [REDACTED]. Interviews with licensed nurses conducted 3/31/14 revealed nursing staff were able to verbalize knowledge of Coumadin Policy, physician orders [REDACTED]. The facility provided evidence of new auditing logs for Coumadin, physician's orders [REDACTED]. The facility had one resident present and receiving Coumadin, Resident # 14. Medical record review for Resident # 14 confirmed physician orders [REDACTED]. Medical record review documented physician order [REDACTED]. Resident # 14 was observed on 3/31/14 in bed with geri-sleeves in place. The facility provided evidence of consulting pharmacist review on 3/15/14 of Resident # 14's Coumadin use, documentation of potential drug interactions with Coumadin, without consequences, for Celexa, Pravastatin, metoprolol, review of INR results of 3/10/14 at 2.7, and documentation pharmacist would continue to monitor INR and report irregular findings to MD. Interviews with the Administrator, DON, Regional Nurse Consultants and Director of Operations confirmed the facility had Quality Assessment and Assurance meetings which discussed Survey results, Coumadin policy, Coumadin therapy, physician orders, PT/INR tracking, Pharmacy responsibilities, Pharmacy drug regimen reviews, audits, care plan updates, and continued monitoring of residents on Coumadin. The facility will remain out of compliance at a Scope and Severity level "D" a pattern of deficient practice that constitutes no actual harm with potential for more than minimal harm, that is not Immediate Jeopardy, until it provides an acceptable plan of correction.