Every finding on record at Palm Garden of Clearwater

Based on interviews and record review, the facility failed to honor the Advanced Directive for one resident (#1) out of three residents sampled. On 05/14/2026, facility staff initiated Cardio-Pulmonary Resuscitation (CPR), including cardiac compressions (use of hands to push down hard and fast to manually pump blood through the heart), when Resident #1 was found unresponsive. The resident had a physician order for Do Not Resuscitate (DNR), dated 06/13/2025. Cardiopulmonary Resuscitation was provided to Resident #1 for approximately nine minutes. Failure to honor the resident's wishes caused unnecessary physical and psychosocial harm and denied Resident #1 a peaceful death. The survey team verified the facility's corrective actions to correct the noncompliance for F578 and found the facility to be in compliance as of 5/18/26, prior to the survey visitFindings included: Review of Resident #1's admission Record revealed an admission date of 05/02/2025, with medical diagnoses to include: Type II Diabetes Mellitus with hypoglycemia without coma, and atherosclerotic heart disease of native coronary artery without angina pectoris. Review of Resident #1's orders revealed an order for Do Not Resuscitate (DNR), dated 06/13/2025 with no end date.Review of Resident #1's medical record documents revealed a paper Do Not Resuscitate Order (Form DH 1896), signed by Resident #1 and the Physician on 06/13/2025.Review of Resident #1's quarterly Minimum Data Set (MDS), dated [DATE], showed Resident #1 had a Brief Interview Mental Status of 15, indicating intact cognition.Review of Resident #1's progress notes revealed:05/14/2026 at 11:25 AM: At 9:00am [Resident #1] was observed in bed absent of vital, no pulse, no respirations. Code blue called and initiated. EMT [Emergency Medical Technician] arrived at 9:13am and took over. Medical Director 5 [sic] pronounced him deceased at 9:20am.Review of Resident #1's Care Plan revealed the following:Focus: Resident #1 had chosen Do Not Resuscitate (DNR), initiated 06/13/2025.Goal: Resident #1's heart stopped beating or if the resident stopped breathing, Cardiopulmonary Resuscitation (CPR), was not to be initiated in honor with Resident #1's wishes, initiated 06/13/2025.Interventions included: verify presence of Physician's order for DNR, initiated 06/13/2025. During an interview on 06/08/2026 at 09:53 AM, Staff A, Certified Nursing Assistant (CNA), stated she saw Resident #1, on 05/14/2026 at around 08:00 AM. Staff A stated Resident #1 mentioned not feeling well. Staff A stated she told Staff C Licensed Practical Nurse (LPN), Resident #1 wasn't feeling well around 08:45 AM. Staff A explained having checked on Resident #1 again at approximately 09:00 AM, and stated the resident appeared asleep. Staff A stated she called out to Resident #1 three times, with no response, and she began looking for the rise and fall of Resident #1's belly and stated it was not there. Staff A explained having called out to Staff C, and the nurse went in to Resident #1's room to assist Resident #1. Staff A explained that Resident #1's assigned nurse asked her to get another nurse for assistance. During an interview on 06/08/2026 at 10:11 AM, Staff B Registered Nurse (RN), stated she was told by Staff A that Staff C Licensed Practical Nurse (LPN), needed assistance with Resident #1. Staff B stated that upon reaching the room of Resident #1, CPR was being performed by staff. Staff B stated everyone was asking about a code status and stated there was a lot of yelling that Resident #1 was a full code. Staff B stated someone said Resident #1 was a DNR. Staff B stated she saw a paper DNR for Resident #1. Staff B stated she did not check Resident #1's code status, prior to going to the room. During an interview on 06/08/2026 at 10:34 AM, Staff D RN, Unit Manager (UM), stated she heard a code blue (an emergency announcement used in healthcare facilities to signal that someone is experiencing a life-threatening medical emergency), through the facility intercom system, on 05/14/2026. Staff D stated upon entry into Resident #1's room we were told he was a CPR. Staff D stated she saw Staff C performing CPR on Resident #1. Staff D stated once it was determined that Resident #1 had a DNR, she and other staff members took over to assist with CPR. Staff D stated the DNR status was being checked when we got there. Staff D stated CPR was performed on Resident #1, before Resident #1's code status of DNR status was confirmed. Staff D stated a nurse attempted to not honor Resident #1's wishes. During an interview on 06/08/2026 at 11:48 AM, the Nurse Practitioner (NP), stated that upon entering Resident #1's room, chest compressions were being performed on Resident #1, by Staff C LPN. The NP explained having assisted with chest compressions for Resident #1 and stated she found out later that Resident #1 had a code status of DNR. During an interview on 06/08/2026 at 01:00 PM with the Social Services Director (SSD), she stated that if a resident comes in with a DNR, Social Services will upload to the electronic health record (EHR) and nursing staff will put in a request for an order to the provider. She stated she updates the DNR book on a monthly basis and on an as needed basis if the resident is brought in before or after the audit period. If a resident is brought in during the weekend, it's the nursing staffs responsibility to obtain and upload to the EHR. During an interview on 06/08/2026 at 02:17 PM, Staff F Licensed Practical Nurse (LPN), stated she heard a code blue over the intercom to Resident #1's room. Staff F stated she went to check Resident #1's code status and saw that the resident had a DNR. Staff F stated she yelled down the hall that Resident #1 had a DNR.Staff F explained having checked Resident #1's code status, because that was the facility's process. During an interview on 06/08/2026 at 02:32 PM, Resident #1's Primary Care Physician (PCP) stated Resident #1's medical record included a DNR and stated the nurse didn't go back to the computer or chart before starting CPR. The PCP stated, if there was a DNR on the chart, then it should have been followed. During an interview on 06/08/2026 at 02:49 PM, the Medical Director (MD), stated the first action the staff should have taken for an unresponsive resident was to identify the resident's advanced directives. The MD stated should have known Resident #1's code status and how to honor it. The MD stated, they did not actually honor the resident's wishes. During an interview on 06/09/2026 at 12:32 PM, with the Nursing Home Administrator (NHA), Director of Nursing (DON), and the Director of Quality Assurance (DQA), they stated if a resident was found unresponsive, the staff was supposed to (if not a nurse), notify a nurse. They stated the nurse would then check the resident's vitals, breath sounds, pulse, and heart sounds. They stated another nurse would be delegated to check the resident's code status. They stated CPR would not be started until the code status of a resident was confirmed as full code. They stated CPR would continue until EMS arrived and took over. They stated if the resident had a DNR, once confirmed by a nurse or higher, the staff would contact the provider. During an interview on 06/09/2026 at 01:00 PM, with the NHA, DON, and the DQA, they stated between 08:00 AM and 09:00 AM, Staff A set up and left a food tray for Resident #1. They stated prior to 09:05 AM, Staff A went into Resident #1's room and spoke to the resident and tapped Resident #1's leg and received no response. They stated Staff A then left the room to notify the nurse. They stated Staff A and Resident #1's assigned nurse entered Resident #1's room at 09:03 AM. They stated Staff C, LPN, checked Resident #1's pulse and began CPR. They stated at 09:04 AM, Staff E NP, entered Resident #1's room. They stated the NP, said she saw Resident #1's assigned nurse performing chest compressions, and switched out with her to continue CPR. They stated after 09:05 AM, Staff D RN UM, began performing rescue breaths on Resident #1. They stated at 09:07 AM, EMS was contacted. They stated at 09:09 AM, Staff F confirmed Resident #1's code status as DNR. They stated EMS arrived at 09:11 AM. They stated EMS told the staff to stop CPR and respect Resident #1's wishes at 09:13 AM. They stated from 09:04 AM to 09:13 AM, CPR was being performed on Resident #1. They stated EMS confirmed Resident #1's DNR was valid. They stated upon admission to the facility, resident code statuses are confirmed. They stated facility staff did not follow the facility policy and stated no, Resident #1's wishes were not honored. Review of a policy titled: Advance Directives & Code Status, and revised 10/10/2024, revealed: 3. The code status order will be documented in the {Electronic Medical record (EMR)}and will serve as the primary source of validation of code status by a licensed nurse should a resident be found unresponsive. a. A licensed nurse will only initiate CPR once the code status has been verified in by a licensed nurse indicating the resident wants CPR. b. If has an order for DNR then CPR will not be initiated. c. If is down (internet outage, power failure) the code status must be verified by a licensed nurse using the back-up code status notebook. 7. If a resident is found unresponsive the EMR must be accessed to determine the code status order by a licensed nurse. For any resident without a physician's order for DNR, or without documented wishes to withhold CPR, EMS (911) is called, the attending physician notified, and emergency basic life support (CPR) is initiated by a licensed nurse. Facility immediate actions to remove the Immediate Jeopardy included: Resident's family was immediately notified of events, investigation and corrective measures implemented on 5/14/26.An immediate self-report was filed 5/14/26.The nurse who initiated compressions was questioned and verbally and in writing admitted she was aware of the P&P (Policy and Procedure) but did not follow it.All staff involved in the incident received immediate education regarding P&P and honoring resident wishes.An immediate audit was completed by medical records, and social services on 5/14/26 for all other residents that included code status order verification, care plan audit including advanced directive review, Do Not Resuscitate Order (DNRO) if applicable, and emergency code status back up binders, there were no concerns identified.The Human Resources (HR) director audited all licensed nurses CPR certification cards and all were in compliance on 5/14/26.The Director of quality assurance, director of education, and all Unit managers were present and initiated immediate re-education will licensed nurses to include the following; attestation of Advanced Directive Acknowledgement, Clinical Competency for CPR which included nurse to verify code status order before initiating CPR, and if a DNRO was identified CPR would be halted to honor resident wishes,Advanced Directive Code Status Quiz for competency, Abuse Neglect Exploitation(ANE) policy, and Resident Rights including honoring wishes all of these action items were completed by 5/18/26. Any new licensed nurses will be provided with the same re-education during orientation. The Director of Quality Assurance/designee immediately initiated on 5/14 Code Blue Drills to include after action review for opportunities with on-the-spot re-education this was done 3x daily for the first 15 days, on all three shifts with weekly ad hoc Quality Assurance and Performance Improvement (QAPI). All licensed nurses had completed a drill by 5/18/26. Verification of the facility's removal plan was conducted by the survey team on 06/08/2026: Ad Hoc meetings were performed on 05/14/2026, 05/21/2026, 05/28/2026, and 06/04/2026 with the Interdisciplinary team. Review of facility education and competencies revealed all nursing staff signed that they received: Advance Directive Acknowledgement, Palm Garden Clinical Competency, Exam: Advanced Directive Code Status. Interviews were conducted with 41 staff members: 19 licensed nurses, 19 CNAs, and 3 ancillary staff across all shifts. The staff members were able to state that they had been trained and were knowledgeable about the new policies. The facilities corrective actions plan included: 1. Resident #1 expired in the center on 5/14/26. No corrective measures could be implemented for resident #1. Resident's family was immediately notified of events, investigation and corrective measures implemented on 5/14/26. The nurse who initiated compressions was removed on 5/14/26 and subsequently terminated and reported to the Board of Nursing. An immediate self-report was filed 5/14/26. The nurse who initiated compressions was questioned and verbally and in writing admitted she was aware of the P&P but did not follow it.2. An immediate audit was completed by medical records, and social services on 5/14/26 for all other residents that included code status order verification, care plan audit including advanced directive review, DNRO if applicable, and emergency code status back up binders, there were no concerns identified. The HR director audited all licensed nurses CPR certification cards and all were in compliance on 5/14/26. 3. The Director of quality assurance, director of education, and all Unit managers were present and initiated immediate re-education will licensed nurses to include the following; attestation of Advanced Directive Acknowledgement, Clinical Competency for CPR which included nurse to verify code status order before initiating CPR, and if a DNRO was identified CPR would be halted to honor resident wishes, Advanced Directive Code Status Quiz for competency, ANE policy, and Resident Rights including honoring wishes all of these action items were completed by 5/18/26. Any new licensed nurses will be provided with the same re-education during orientation. The Director of Quality Assurance/designee immediately initiated on 5/14 Code Blue Drills to include after action review for opportunities with on-the-spot re-education this was done 3x daily for the first 15 days, on all three shifts with weekly ad hoc QAPI. All licensed nurses had completed a drill by 5/18/26. 4. The Director of Quality Assurance/designee will conduct ongoing competency audits utilizing code blue drills with after action reviews and questionnaires, a minimum of 3 x weekly on all shifts, including weekends and holidays a minimum of 30 days, then 3 x monthly ongoing with any concerns corrected on the spot. These drill audits will be presented weekly to the QAPI committee for a minimum of 30 days and then monthly ongoing for plan review and revision.

Based on interviews and record review, the facility failed to ensure nursing staff were competent in the identification of code status for one resident (#1) out of three residents sampled. On 05/14/2026, facility staff initiated Cardio-Pulmonary Resuscitation (CPR), including cardiac compressions (use of hands to push down hard and fast to manually pump blood through the heart), when Resident #1 was found unresponsive. The resident had a physician order for Do Not Resuscitate (DNR), dated 06/13/2025. Cardiopulmonary Resuscitation was provided to Resident #1 for approximately nine minutes. Failure to honor the resident's wishes caused unnecessary physical and psychosocial harm and denied Resident #1 a peaceful death. The survey team verified the facility's corrective actions to correct the noncompliance for F726 and found the facility to be in compliance as of 5/18/26, prior to the survey visitFindings Included: Review of Resident #1's admission Record revealed an admission date of 05/02/2025, with medical diagnoses to include: Type II Diabetes Mellitus with hypoglycemia without coma, and atherosclerotic heart disease of native coronary artery without angina pectoris. Review of Resident #1's orders revealed an order for Do Not Resuscitate (DNR), dated 06/13/2025 with no end date.Review of Resident #1's medical record documents revealed a paper Do Not Resuscitate Order (Form DH 1896), signed by Resident #1 and the Physician on 06/13/2025.Review of Resident #1's quarterly [NAME] Data Set (MDS), dated [DATE], showed Resident #1 had a Brief Interview Mental Status of 15, indicating intact cognition.Review of Resident #1's progress notes revealed:05/14/2026 at 11:25 AM: At 9:00am [Resident #1] was observed in bed absent of vital, no pulse, no respirations. Code blue called and initiated. EMT [Emergency Medical Technician] arrived at 9:13am and took over. Medical Director 5 [sic] pronounced him deceased at 9:20am.Review of Resident #1's Care Plan revealed the following:Focus: Resident #1 had chosen Do Not Resuscitate (DNR), initiated 06/13/2025.Goal: Resident #1's heart stopped beating or if the resident stopped breathing, Cardiopulmonary Resuscitation (CPR), was not to be initiated in honor with Resident #1's wishes, initiated 06/13/2025.Interventions included: verify presence of Physician's order for DNR, initiated 06/13/2025. During an interview on 06/08/2026 at 09:53 AM, Staff A, Certified Nursing Assistant (CNA) stated she saw Resident #1, on 05/14/2026 at around 08:00 AM. Staff A stated Resident #1 mentioned not feeling well. Staff A stated she saw Resident #1 again around breakfast time. Staff A stated Resident #1 said he did not feel well and did not feel like eating, and Staff A could leave the food tray. Staff A stated she told Staff C, Licensed Practical Nurse (LPN), Resident #1 was not feeling well around 08:45 AM. Staff A explained having checked on Resident #1 again at approximately 09:00 AM, and stated the resident appeared asleep. Staff A stated she called out to Resident #1 three times, with no response, and she began looking for the rise and fall of Resident #1's belly and stated it was not there. Staff A explained having called out to Staff C, and the nurse went into Resident #1's room to assist Resident #1. Staff A stated Staff C asked Staff G, CNA and herself, to get another nurse for assistance and to call a code blue (an emergency announcement used in healthcare facilities to signal that someone is experiencing a life-threatening medical emergency), over the intercom. Staff A stated she did not call a code blue, because she did not know how to call a code on the intercom. During an interview on 06/08/2026 at 10:11 AM, Staff B Registered Nurse (RN), stated she was told by Staff A that Staff C, LPN needed assistance with Resident #1. Staff B stated upon reaching the room of Resident #1, CPR was already being performed by staff. Staff B stated she observed CPR being performed on Resident #1's bed, without a backboard. Staff B stated she did not check Resident #1's code status, before going into the room. Staff B stated there was a lot of yelling in Resident #1's room with some staff members stating Resident #1's code status was full code. During an interview on 06/08/2026 at 10:28 AM, Staff G, CNA stated on 05/14/2026 Staff A, CNA ran down the hall and said there was an emergency in Resident #1's room. Staff G explained being asked by Staff C, LPN to call a code blue. Staff G stated she did not know how to page a code blue over the intercom. Staff G stated two or three minutes later, there was a code blue to a different room than Resident #1's room. During an interview on 06/08/2026 at 10:34 AM, Staff D, RN Unit Manager (UM) stated she heard a code blue through the facility intercom system, on 05/14/2026. Staff D stated upon entry into Resident #1's room We were told he was a CPR. Staff D stated she saw Staff C, LPN performing CPR on Resident #1. Staff D stated when residents are found unresponsive the process for staff call a code blue, grab a laptop, check the resident's code status, or use a binder at any nursing station for residents with DNRs. Staff D stated, I don't feel like she followed our process, checking the code status before starting CPR. Staff D stated, If she had checked the code status, she would not have started CPR. Staff D stated Staff C had received advanced directives training prior to 05/14/2026. During an interview on 06/08/2026 at 11:48 AM, the Nurse Practitioner (NP), explained chest compressions had been started by Staff C LPN, when she entered Resident #1's room on 05/14/2026. The NP stated she assisted with Resident #1's CPR and performed chest compressions. The NP stated, after she started CPR, she learned Resident #1 had a DNR. During an interview on 06/08/2026 at 12:28 PM, the Director of Quality Assurance (DQA), stated Staff C LPN told leadership staff she had checked Resident #1's code status prior to performing CPR. The DQA stated Staff C did not explain how she saw a different code status than DNR in Resident #1's Electronic Medical Record. During an interview on 06/08/2026 at 02:17 PM, Staff F Licensed Practical Nurse (LPN), stated she was responsible for education of staff at the facility. Staff F stated she responded to a code blue call on 05/14/2026. Staff F stated she first went to a med-cart to identify Resident #1's code status. Staff F stated, That's our procedure to check code status before we do anything. Staff F stated she yelled down the hall, that Resident #1 was a DNR. Staff F stated upon arrival to Resident #1's room, EMS was in the room. During an interview on 06/08/2026 at 02:32 PM, Resident #1's Primary Care Physician (PCP), stated Resident #1's had a DNR. The PCP stated, The nurse didn't go back to the computer or chart before starting CPR. The PCP stated, If there was a DNR on the chart, then it should have been followed. The PCP stated, It's on her unfortunately. During an interview on 06/08/2026 at 02:49 PM, the Medical Director (MD), stated the first action the staff should have taken for an unresponsive resident was to identify the residents' advanced directives. The MD stated the staff should have known Resident #1's code status and how to honor it. The MD stated for Resident #1's DNR, Unfortunately that was not handled properly. During an interview on 06/09/2026 at 12:32 PM, with the Nursing Home Administrator (NHA), Director of Nursing (DON), and the Director of Quality Assurance (DQA), they stated if a resident was found unresponsive, the staff was supposed to (if not a nurse), notify a nurse. They stated the nurse would then check the resident's vitals, breath sounds, pulse, and heart sounds. They stated another nurse would be delegated to check the resident's code status. They stated CPR would not be started until the code status of a resident was confirmed as full code. They stated CPR would continue until EMS arrived and took over. They stated if the resident had a DNR, once confirmed by a nurse or higher, the staff would contact the provider. During an interview on 06/09/2026 at 01:00 PM, with the NHA, DON, and the DQA, they stated for a resident who had a DNR, once the DNR was verified, someone was supposed to contact the provider, and then the staff was supposed to receive orders. They stated the NP, said she saw Resident #1's assigned nurse performing chest compressions, and switched out with her to continue CPR. They stated Staff D, RN UM, gave rescue breaths to Resident #1, during CPR. They stated no staff member stopped CPR until EMS arrived and told them to stop. They stated the facility had a policy in effect for over a year: if CPR was started on a resident who had a DNR, once the DNR was confirmed, CPR could be stopped without the need for a provider or EMS to give an order to stop. They stated on 05/14/2026 at 09:09 AM, Staff F LPN confirmed Resident #1's code status as DNR. They stated CPR was performed on Resident #1 on 05/14/2026 from 09:04 AM to 09:13 AM. They stated, They should have stopped and verified in [the Electronic Medical Record] the way she wastrained. They stated the competencies for the nurses who performed CPR were not demonstrated properly.Review of a document titled: Job Description revealed: Job title: Registered NurseEssential Function:-Works using the guidelines established from the Nurse Practice Act, company standards, policies and procedures and clinical judegement.-Implements the guest plan of care and evaluates the guest's response.Marginal Functions: Decisions are made that reflect knowledge and good judgment and demonstrate an awareness of guest/family/physician needs. Review of a document titled: Job Description revealed:Job Title: Licensed Practical NurseEssential Function:-Works under direct supervision using the Nurse Practice Act, policies and procedures and clinical judgement.-Implements the guest plan of care and evaluates the guest's response. A document titled: Clinical Competency and revised 08/2024, revealed standards to include:3. Delegates a licensed nurse to check {Electronic Medical record (EMR)}for code status order.9. Does not begin CPR if DNR order.12. Places resident on back, backboard or hard surface to begin CPR.16. Stop CPR if it was started and a DNR order was found/presented. Honor Resident wishes.Review of a policy titled: Advance Directives & Code Status, revised 10/10/2024, revealed:3. The code status order will be documented in the {Electronic Medical record (EMR)}and will serve as the primary source of validation of code status by a licensed nurse should a resident be found unresponsive.a. A licensed nurse will only initiate CPR once the code status has been verified in EMR by a licensed nurse indicating the resident wants CPR.b. If EMR has an order for DNR then CPR will not be initiated.c. If EMR is down (internet outage, power failure) the code status must be verified by a licensed nurse using the back-up code status notebook.7. If a resident is found unresponsive the EMR must be accessed to determine the code status order by a licensed nurse. For any resident without a physician's order for DNR, or without documented wishes to withhold CPR, EMS (911) is called, the attending physician notified, and emergency basic life support (CPR) is initiated by a licensed nurse.Facility immediate actions to remove the Immediate Jeopardy included: Resident's family was immediately notified of events, investigation and corrective measures implemented on 5/14/26.All staff involved in the incident received immediate education regarding Policies and Procedures (P&P) and honoring resident wishes.An immediate self-report was filed 5/14/26.The nurse who initiated compressions was questioned and verbally and in writing admitted she was aware of the P&P but did not follow it. An immediate audit was completed by medical records, and social services on 5/14/26 for all other residents that included code status order verification, care plan audit including advanced directive review, Do Not Resuscitate Order (DNRO) if applicable, and emergency code status back up binders, there were no concerns identified.The Human Resource (HR) director audited all licensed nurses CPR certification cards, and all were in compliance on 5/14/26.The Director of quality assurance, director of education, and all Unit managers were present and initiated immediate re-education will licensed nurses to include the following; attestation of Advanced Directive Acknowledgement, Clinical Competency for CPR which included nurse to verify code status order before initiating CPR, and if a DNRO was identified CPR would be halted to honor resident wishes,Advanced Directive Code Status Quiz for competency, ANE policy, and Resident Rights including honoring wishes all of these action items were completed by 5/18/26. Any new licensed nurses will be provided with the same re-education during orientation. The Director of Quality Assurance/designee immediately initiated on 5/14 Code Blue Drills to include after action review for opportunities with on-the-spot re-education this was done 3x daily for the first 15 days, on all three shifts with weekly ad hoc Quality Assurance and Performance Improvement (QAPI). All licensed nurses had completed a drill by 5/18/26. Verification of the facility's removal plan was conducted by the survey team on 06/08/2026:Ad Hoc meetings were performed on 05/14/2026, 05/18/2026, 05/28/2026, and 06/04/2026 with the Interdisciplinary team.Review of facility education and competencies revealed all nursing staff signed that they received: Advance Directive Acknowledgement, Palm Garden Clinical Competency, Exam: Advanced Directive Code Status.Interviews were conducted with 41 staff members: 19 licensed nurses, 19 CNAs, and 3 ancillary staff across all shifts. The staff members were able to state that they had been trained and were knowledgeable about the new policies. The facilities corrective actions plan included:1. Resident #1 expired in the center on 5/14/26. No corrective measures could be implemented for resident #1. Resident's family was immediately notified of events, investigation and corrective measures implemented on 5/14/26. The nurse who initiated compressions was removed on 5/14/26 and subsequently terminated and reported to the Board of Nursing. An immediate self-report was filed 5/14/26. The nurse who initiated compressions was questioned and verbally and in writing admitted she was aware of the P&P but did not follow it.2. An immediate audit was completed by medical records, and social services on 5/14/26 for all other residents that included code status order verification, care plan audit including advanced directive review, DNRO if applicable, and emergency code status back up binders, there were no concerns identified. The HR director audited all licensed nurses CPR certification cards, and all were in compliance on 5/14/26.3. The Director of quality assurance, director of education, and all Unit managers were present and initiated immediate re-education will licensed nurses to include the following; attestation of Advanced Directive Acknowledgement, Clinical Competency for CPR which included nurse to verify code status order before initiating CPR, and if a DNRO was identified CPR would be halted to honor resident wishes, Advanced Directive Code Status Quiz for competency, Abuse Neglect and Exploitation (ANE) policy, and Resident Rights including honoring wishes all of these action items were completed by 5/18/26. Any new licensed nurses will be provided with the same re-education during orientation. The Director of Quality Assurance/designee immediately initiated on 5/14 Code Blue Drills to include after action review for opportunities with on-the-spot re-education this was done 3x daily for the first 15 days, on all three shifts with weekly ad hoc QAPI. All licensed nurses had completed a drill by 5/18/26.4. The Director of Quality Assurance/designee will conduct ongoing competency audits utilizing code blue drills with after action reviews and questionnaires, a minimum of 3 x weekly on all shifts, including weekends and holidays a minimum of 30 days, then 3 x monthly ongoing with any concerns corrected on the spot. These drill audits will be presented weekly to the QAPI committee for a minimum of 30 days and then monthly ongoing for plan review and revision.

Based on observations, interviews, and record review, the facility failed to ensure staff followed care plan interventions and perform accurate assessments on residents related to bed mobility assistance for three residents (#5, #6, and #7) out of three residents sampled.On 07/25/2025 Staff A, Certified Nursing Assistant (CNA), independently rolled Resident #5 onto her side in bed to perform incontinence care. Staff A, CNA left Resident #5 unattended in bed to collect supplies. Resident #5 fell out of the bed while unattended and suffered a right hip fracture which required a transfer to a higher level of care and surgical repair.This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to residents and resulted in the determination of Immediate Jeopardy on 08/07/2025. The findings of Immediate Jeopardy were determined to be removed on 08/08/2025 and the scope and severity was reduced to an E after verification of removal of immediacy of harm.Findings Included: 1. During an interview on 08/06/2025 at 8:32 a.m., Resident #5 stated she had a fall a couple months after she was admitted to the facility. Resident #5 stated she was supposed to always have two people assisting her with care. She stated she requested a bigger bed. She stated, Sometimes they come in with two people and sometimes they just come in with one person. She stated, they set up a chair on the side of the bed for her to hold onto because they told her they could not use side rails. She stated, The chair slides while I'm holding onto it. She stated she requested a bigger bed a few times after a fall and was told they would order it, and it never came until after her most recent fall (07/25/2025). She stated, This last fall I broke my hip in two places and had to have surgery. The CNA came in to change me by herself, she rolled me onto my side, she put my legs with one on top of the other, the CNA went to grab something off of the dresser and I told her I was slipping, and she told me, You will be okay, I told her again that I was slipping and then I fell off of the bed. I only got the bigger bed now because I fell. The aides were upset that they were taking so long, to get me a bigger bed because they all knew I was at risk. Review of Resident #5's admission record revealed an initial admission date of 04/05/2025 and a re-admission date of 07/28/2025. Resident #5 was admitted to the facility with diagnoses to include: displaced apophyseal fracture of left femur (a break in the growth plate area of the large bone of the upper leg), initial encounter for closed fracture (08/04/2025), displaced fracture of greater trochanter (a bony prominence located on the upper part of the thigh bone) of right femur, initial encounter for closed fracture (07/28/2025), spondylolysis (a stress fracture in a vertebra), cervical (neck) region (09/21/2024), unspecified fall, subsequent encounter (09/21/2024), muscle weakness (generalized) (09/21/2024), other abnormalities of gait and mobility (09/21/2024), morbid (severe) obesity due to excess calories (09/21/2024), and repeated falls (09/21/2024). Review of Resident #5's Quarterly Minimum Data Set (MDS), dated [DATE] revealed in Section C-Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. Review of Section GG-Functional Abilities revealed Resident #5 had an impairment on one side to her upper and lower extremity. Resident #5 required substantial/maximal assistance revealing helpers do more than half the effort. Helpers lift or hold trunk or limbs and provides more than half the effort for rolling left and right. Sitting to lying (the ability to move from sitting on side of bed to lying flat on the bed, lying on side of bed), Resident #5 was dependent, meaning helper does all the effort. Residents do none of the effort to complete the activity. Or the assistance of two or more helpers is required for the resident to complete the activity. Review of Resident #5's care plan dated 08/03/2024 revealed: Focus: ADL Self-Care and/or mobility deficit. Needs assistance with ADL's Initiated on 09/23/2024.Interventions included: BED MOBILITY-Total ASSIST X 2 TRANSFERS-Total ASSIST with Hoyer X 2TOILETING-Total ASSIST X 2DRESSING-Total ASSIST X 2BATHING-Total ASSIST X 2 Review of Resident #5's Intervention/Task for July revealed one person assistance was provided for ADL-Bed Mobility on 07/26/2025 (day shift), 07/28/2025 (evening shift), 07/30/2025 (day shift), 07/31/2025 (evening shift), 08/01/2025 (day shift), 08/02/2025 (evening shift), 08/03/2025 (day shift and evening shift), 08/05/2025 (evening shift), 08/07/2025 day shift). A review of the physician order summary for Resident #5 revealed: Right hip Xray 2 views due to status post fall pain. Start Date 07/26/2025.Send to ER (emergency room) for further eval and treat. Start Date 07/27/2025. Review of Resident #5's progress notes revealed: -07/28/2025 at 7:47 p.m. Fall Risk Evaluation Fall Risk: History of falls (past 3 months): 1-2 falls in past 3 months. Level of consciousness / mental status: Alert (oriented x 3) OR comatose. Resident is chairbound / incontinent. Systolic blood pressure: No noted drop between lying and standing. Vision status: Adequate (with or without glasses). Predisposing disease: 1-2 present. Residents had a change in condition in the last 14 days. Recent hospitalization history in last 30 days: Yes. Notes: Post right hip surgery 7/27/25 Gait / balance: Requires use of assistive devices (i.e. cane, wheelchair, walker, furniture). Medication: Takes 3-4 these medications (or medication classes) currently and / or within last 7 days. Fall Risk Score: 15.0.-07/28/2025 6:05 p.m. Nursing Note Note Text: readmitted a [AGE] year-old female from [Acute Care Hospital] via stretcher accompanied by 2 Emergency Medical Services (EMS) staff.Surgical incision to right hip clean, dry with dressing intact, with PICO [a single-use, portable negative pressure wound therapy system designed to promote wound healing] dressing functioning well. Patient also has skin tear to right lower leg with sutures in place. Bruising noted to right knee/ right[sic] lower leg. Discoloration and flaking noted BIL [bilateral] feet.-07/27/2025 12:00 a.m. Nursing Note Late Entry:Note Text: Result of X ray[sic] right hip reported to ARNP [Advanced Practical Nurse Practitioner] with order received for resident to be sent to ER [Emergency Room] for further eval and treat. DON [Director of Nursing] notified. This writer called [Family Member] 2x [twice] left message, awaiting for call back. Facility protocol followed. Resident transported to ER via 911.-07/26/2025 07:38 a.m. Radiology Note Note Text: Patient complained of pain of 7 on right hip/pelvis area s/p [status post] fall last evening. Administered PRN [as needed] pain pill. Notified provider on call.received order for STAT (immediate) xray[sic] to right hip/pelvis area 2 views. [Mobile Radiology Company] services needed due to pt [patient] being bed bound.-07/26/2025 3:52 p.m. Nursing Note Note Text: Bariatric [bed] delivered to [room number], resident in new bed without difficulty. Resident[sic] says new bed is comfortable.-07/25/2025 4:56 p.m. Interdisciplinary (IDT) Note Late Entry:Note Text: Resident reviewed by IDT for s/p [status post] fall on 7/25. Resident found by the floor nurse lying on floor on her back next to bed. CNA reported she was providing incontinent care and stepped away to get a towel; during that time, resident rolled off the bed. Head-to-toe assessment completed; no visible injuries noted. Pt [patient] was complaining of left shoulder pain. Neuro checks initiated. NP [Nurse Practitioner] notified; new orders received for STAT [immediate] left shoulder x-ray and one-time dose of oxycodone for pain. Message left for [Family Member] return call regarding notification of family. Interventions: Wider bed ordered for resident. Staff re-educated on following Kardex instructions; emphasized requirement for two-person assist as documented. STAT x-ray of Left shoulder and one time dose of oxycodone was ordered.-7/25/2025 6:27 p.m. Nursing Note Note Text: Called to room by CNA. Observed resident lying on the floor on her back side next to bed. Resident states she rolled off of the side of the bed. Head to toe assessment completed. Complaints of left shoulder pain. No visible sign of injury. Neuro checks initiated. Returned to bed using [mechanical lift] with multiple staff present. [ARNP] notified. New order for STAT left shoulder xray[sic] and one time dose of oxycodone for pain. Message left for [Family Member] to return call to facility.-07/25/2025 7:15 p.m. Nursing Note Note Text: Spoke with [Employee of Bed Supplier]. Bariatric bed to be delivered 7/26 before 11:45am. Resident made aware. Review of Resident #5's Hospital Discharge Records dated 07/27/2025 revealed: Procedure History: Arthroplasty Hip Bipolar (a surgical procedure replaces the damaged femoral head with a prosthetic implant) (Right), (07/27/2025), Open Reduction Internal Fixation Hip (surgical procedure used to treat hip fractures by realigning the bone and securing it with internal hardware) (Right) (07/27/2025). During a phone interview on 08/06/2025 at 12:57 p.m., Staff A, CNA stated on 07/25/2025 she went to provide Resident #5 with care. She said, I rolled [Resident #5] onto her side in the bed, and I went to grab a towel from the dresser. While I was grabbing the towel [Resident #5] slipped off the bed. I usually take everything I need with me. She stated there was not a rail on the bed for the resident to hold onto. Staff A stated Resident #5 holds onto the top of the dresser for support, and It is difficult to roll her sometimes. She stated, I ran out and started screaming for the nurse. I grabbed her a pillow for her head while we were waiting for someone to come in the room. She stated Resident #5 said her hip was hurting after the fall. Staff A stated the nurse did an assessment and then they put Resident #5 back in bed. She said, I don't know if [Resident #5] went out to the hospital or not. I thought [Resident #5] was a one person assist. We look in the Kardex to tell you how many people a resident requires to provide care. She stated after the incident, the Director of Nursing (DON) did a one-on-one in-service. She said, It was something on falls being careful and being aware. During an interview on 08/06/2025 at 10:38 a.m., Staff B, Licensed Practical Nurse (LPN), stated on 07/25/2025 she did wound care in the morning and worked on the floor from 3:00 p.m.-11:00 p.m. She was called to Resident #5's room by Staff A, CNA, and Resident #5 was on the floor lying on her back between the two beds. Staff A, CNA told her she was in the middle of changing her when she walked to the dresser to grab towels and the resident fell. Staff B stated the aide told her, The weight of her body flipped her to the other side of the bed. [Staff A, CNA], was the only aide in the room. [Resident #5] was supposed to have two people assisting her. She did a head-to-toe assessment on Resident #5. Staff B stated, I did not move the right shoulder much because I know she has had long term pain in that shoulder. Her legs are big, and [Resident #5] cannot hold them up on her own. I lifted both of her legs, and she did not have any pain at that time. There was no redness, swelling or bruise at the time of the assessment. Resident #5 was only complaining of left shoulder pain. She stated she got orders for STAT (emergent) left shoulder Xray. She said Resident #5 never complained of hip pain on the shift. She stated she called the doctor and asked if the pain medication could be given early. She stated when she got back to work on Monday, she was told Resident #5 went out to the hospital for her hip. She stated at the time of the fall Resident #5 had a regular size standard bed. Staff B stated, We talked about getting her a bariatric bed a long time ago. Resident #5 was able to hold herself over by holding onto the nightstand next to the bed or the armoire on the other side. If she was in a bariatric bed she would not be able to reach the nightstand to hold herself up, so we did not get her the bariatric bed. She said Resident #5 does not use her right arm for anything anymore. She stated, The bed she had [at the time of the fall] did not have anything for her to hold onto. She said Resident #5 does not move; she can't reposition herself or anything. There was some room on each side of the bed, if she was a moveable person she would not be able to move much. Residents who need a bariatric bed just need to bring it up to the managers, and they would get them one. There really is not a system in place for determining when a resident needs a bariatric bed. The unit manager can call and request a bariatric bed if they feel a resident needs it. She said, If we need more room to turn the resident we would request for one. But usually, it is a customer service thing when a resident requests for it. During an interview on 08/06/2024 at 3:56 p.m., the Director of Nursing (DON) stated she did the reportable investigation for Resident #5's fall. On 07/25/2025 at 4:30 p.m. Staff A, CNA was providing incontinent care for Resident #5. Resident #5 was on her side in the bed. Staff A, CNA went to grab the towels off the dresser. Resident #5 legs began to slide down. Resident #5 told Staff A, CNA she was starting to slide and Staff A, CNA could not intercept her fast enough, resulting in Resident #5 falling to the floor. Resident#5 was assessed by the nurse and complained of left shoulder pain. They did an Xray of the left shoulder and it was negative for a fracture. The next day (07/26/2025), Resident #5 started complaining of right hip pain, they did an Xray, and it was positive for a hip fracture. The results came back close to midnight, and Resident #5 was sent to the hospital for further evaluation. Resident #5 was admitted to the hospital and underwent a right hip arthroplasty on 07/27/2025. The DON stated the resident returned back to the facility on [DATE]. During the investigation, she interviewed staff and other residents to see if there were any concerns with Staff A, CNA's care. No residents or other staff had concerns with Staff A, CNA's care. She provided education to all staff related to making sure they have all of their items in reach when providing care. If they need to grab something while providing care residents should be placed back on the bed. They ordered a wider bed for Resident #5, and it was delivered the next day (07/26/2025). They updated Resident #5's Kardex for her to be a two person assist with everything. The DON stated, There is not anything that is black or white to determine what type of assistance a resident needs while providing care. It can be determined by therapy; some people can do more than others. There are a lot of factors, there is not a guide. The DON stated Resident #5 had another event in October 2024. During this event Resident #5's legs were hanging over the side of the bed, they had to assist her down to the floor and then put her back in bed. She said, According to the 10/14/2024 interdisciplinary team (IDT) note it says Resident #5 is a two person assist with incontinence care. I thought this was referring to when Resident #5 was using the bathroom and holding onto the bar. She said bed mobility is how many people it takes to move people in bed. At the time her bed mobility was a one person assist, and her transfer status was two person assist. She stated, There was some confusion, because the two-person changing brief was not under the activities of daily living (ADL) part of the Kardex and her bed mobility in ADL's said Resident #5 was a one person assist. When the care plan was updated in October of 2024, it updated under a different part of the Kardex. She said Resident #5 needing to be a two-person assist for brief changing was only on the safety part of the Kardex. Staff A, CNA was following the ADL Kardex. Residents use different things to hold onto while care is being provided. They can use furniture, she said, Their chair would be up against their bed, or chairs that have handrails, or whatever is there for them to grab onto. If they have a scoop mattress they can hold onto that, it depends on the resident. We try to use trapezes; we try other interventions other than side rails. We don't like to utilize bed rails, she said, It is frowned upon to use them since the initiative for no bed rails. In our setting they don't want us to use the bed rails. If a resident uses bedrails, an evaluation is done for the adaptive rails, and we put them on. The CNA's document under tasks when they perform an activity for a resident. If the task is marked off as one person assist, then one person assists with that activity. We did not substantiate the allegation because everyone was under the impression she was a one person assist with the bed mobility. 2. During an interview on 08/06/2025 at 2:51 p.m., Resident #6 stated she thought she was supposed to have two people assisting her but usually it is only one person assisting. She stated she holds onto the mattress and sheets when she has to turn, especially when she turns on her right side because she has little to no movement on her left side and there has been several times where she feels like she is going to fall head first off of the bed. She stated when that happens the aide usually runs around and moves her upper body back into position, so she does not fall. She stated she wishes there was something sturdier to hold on to, so she was more comfortable with turning. Review of Resident #6's admission record revealed an admission date of 03/26/2024 and diagnoses to include hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side (03/26/2024), morbid (severe) obesity due to excess calories (03/26/2024), flaccid hemiplegia affecting left nondominant side (03/26/2024). Review of Resident #6's Quarterly MDS, dated [DATE], revealed a BIMS score of 15 out of 15, indicating intact cognition. Review of Section GG-Functional Abilities revealed, Resident #6 had an impairment to one side of her upper and lower extremity. Resident #6 required Substantial/maximal assistance, helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort for Roll left and right and sit to lying. Resident #6 was dependent helper who does all the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity for Lying to sitting on side of bed, sit to stand, chair/bed to chair transfer and tub/shower transfer. Review of Resident #6's Care Plan, dated 04/09/2025, revealed the following:Focus: ADL Self-Care and/or mobility deficit. Needs assistance with ADL's at risk of developing complications associated with decreased ADL self-performance related to: Cognitive impairment, disease process/condition, weakness. Date Initiated 08/06/2025 Revision Date 08/06/2025Interventions: Encourage and assist to turn and reposition, shifting weight to enhance circulation. Date Initiated: 08/06/2025Provide assistance/supervision as needed: Bed Mobility-Assist x2Transfers-Assist x2 mechanical liftToileting-Assist x 2Dressing-Assist x1Bathing-Assist x2Grooming-Assist x1Eating-SupervisionDate Initiated 08/06/2025 Revision on: 08/06/2025 Review of Resident #6's Visual/Bedside Kardex as of 08/06/2025 revealed: Safety: check for toileting needs; ensure proper footwear; give verbal cues as needed; observe for bleeding gums, nosebleeds, unusual bruising, tarry black stools, pink or discolored urine to nurse and/or MD.Resident care:Encourage residents to report any signs of bleeding or bruising; monitor for side effects IE: abdominal or stomach pain, bloody or cloudy urine; nail care; observed skin rash for increased spread or signs of infection; place items in easy reach and Orient to placement; place items used in easy reach IE water, telephone, call lights; report changes in visual status PRN; resident prefers to have: now male CNA's; splint: apply left [NAME] guard and AM. Remove left [NAME] guard at DHS. Where daily as tolerated. Two person assist with turning and repositioning. Bladder/bowel:assist with toileting and peri care as needed; never mind frequent checks for incontinence; incontinence care as needed; monitor BM's and document; the relocation would be preventative skin care as ordered; keep will be clean dry and odor free daily. Review of Resident #6's Interventions/Task log revealed: ADL-Bed Mobility was provided with a one person assist on 07/25/2025 (day and night shift), 07/26/2025 (day and night shift), 07/27/2025 (day, evening, and night shift), 07/28/2025 (day shift), 07/29/2025 (day and night shift), 07/30/2025 (day and night shift), 08/01/2025 (day and night shift), 08/02/2025 (night shift), 08/03/2025 (night shift), 08/04/2025 (night shift), 08/04/2025 (night shift), 08/05/2025 (evening and night shift), 08/06/2025 (day and night shift). 3. During an interview on 08/06/2025 at 2:59 p.m., Resident #7 stated he usually has only one person but occasionally, there's a second person to assist him. He stated when they turn him he tries to reach down and hold the metal bar underneath the mattress but due to his Multiple Sclerosis (MS) he has very little strength in his hands and often is very uncomfortable and makes him nervous about falling. The resident stated he has asked multiple people about getting some siderails but has been told by everyone he does not qualify. Review of Resident #7's admission record revealed an admission date of 07/26/2023. Resident #7 was admitted to the facility with diagnoses to include: Multiple Sclerosis (07/26/2023), Muscle wasting and atrophy (07/27/2023), Muscle weakness (07/27/2023), Unspecified lack of coordination (07/27/2023), Functional quadriplegia (07/26/2023), and need for assistance with personal care (07/26/2023). Review of Resident #7's Quarterly MDS, dated [DATE], revealed in Section C-Cognitive Patterns a BIMS of 15 out 15 indicating intact cognition. Review of Section GG-Functional Abilities revealed Resident #7 had an impairment to both sides of his upper and lower extremities. Resident #7 was dependent; helper does all the effort. Residents does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity for Roll left and right, sit to lying, lying to sitting on side of bed, chair/bed to chair transfer, and tub shower transfer. Review of Resident #7's Care Plan, dated 07/26/2023, revealed the following: Focus: Resident's ADL needs include assist with bed mobility; transfers; locomotion/walking; dressing; toileting; personal hygiene; bathing. Date Initiated: 07/27/2023Interventions: The resident cannot transfer without help. The resident will need total mechanical lift with 2 persons assist for transfers. Date Initiated: 07/27/2023The resident needs help to move and reposition in the bed. Will need one or two person assistance to change position or scoot up in bed. This may involve some lifting of the legs or boosts. Date Initiated: 07/27/2023Provide assistance/supervision as needed: Bed Mobility-Assist x1Transfers-Assist x2 mechanical liftToileting-Assist x 1Dressing-Assist x2Bathing-Assist x1Grooming-Assist x1Eating-Setup AssistDate Initiated 08/07/2025 Revision on: 08/07/2025 Review of Resident #7's Visual/Bedside Kardex as of 08/06/2025 revealed: Safety: Check for toileting needs; encourage appropriate footwear; keep adaptive equipment within reach; scoop mattress.Resident Care: CPAP as ordered; nail care; O2 as ordered for OSA/SOB; place items used in easy reach i.e. water, telephone, call lights; use Broda chair.Bladder/Bowel:assessed with toileting and peri care as needed; document bowel movements daily; frequent checks for incontinence; incontinence care as needed; monitor BM's and document; preventative skin care is ordered; will be clean dry and odor free daily.Bed Mobility:ADL-Bed Mobility; The resident needs help to move and reposition in the bed. Will need one or two person assistance to change position or scoot up in bed. This may involve some lifting of the legs or boosts. Turn and reposition frequently as needed.Bathing:ADL-bathing type showers Wednesday and Saturday 7:00 a.m. to 3:00 p.m.; The residents needs help getting in and out of the shower and may be able to wash their face or upper body but need assistance washing the rest, including their feet. During an interview on 08/06/2025 at 8:50 a.m., Staff E, CNA stated she knows a resident requires a one or two person assist when they are heavy or aggressive. During an interview on 08/06/2025 at 8:58 a.m., Staff F, CNA stated she looks in the computer, Kardex under resident care to tell her if a Resident is a one or two person assist. During an interview on 08/07/2025 at 3:46 p.m., Staff G, CNA, stated the facility provided education recently. The education reminded them to look at the Kardex under resident care to know if a resident needs one or two person assistance with ADL care. During an interview on 08/07/2025 at 3:47 p.m., Staff C, Certified Nursing Assistant (CNA), stated she had received education about the Kardex, specifically where to look for one or two person assist for her residents. She goes into the Kardex under Resident Care, and she can find one or two person assist. She said they provided this education to her yesterday and during her orientation in the beginning of July when she was hired. During an interview on 08/07/2025 at 3:51 p.m., Staff D, CNA stated she did receive education two weeks ago on where to look for resident care needs like how many aides are needed to assist with bed mobility, she looks at the Kardex under Resident Care and if she cannot find what she needs she will go ask the nurse. During an interview on 08/07/2025 at 3:52 p.m., Staff H, CNA stated they provided education last week and taught us how to get into the electronic record. She said if they need to know if a resident is a one or two person assist they look under patient care on the Kardex. During an interview on 08/07/2025 at 10:29 a.m., the Director of Rehab (DOR) stated when a resident is admitted to the facility they get an evaluation and a screening completed by therapy. For residents in Long Term Care, they screen them to determine their bed mobility. They review the residents records, speak with the resident and family to determine their prior level of care. We observe them to see if they can perform the action we are evaluating. After the evaluation we tell the nurse. Therapy does not update or document on the care plan. Resident #5 was seen by therapy most recently on 02/27/2025 thru 06/27/2025. She required a max assistance, she really needed a lot of assistance with everything. She has been dependent since 09/21/2024. Resident #7 has MS, and he does not like to participate in therapy. We have picked him up several times. He was last seen in May of 2025. Resident #7 is dependent for bed mobility since his admission in 2023. He is a big guy if the CNA's feel like they need a two person they could use two people. Resident #6 has been dependent since her admission in 2024. The DOR stated when they do the quarterly or annual assessments they use the Task report to show what type of assistance the CNA's have been using for care. If a resident is all over the board we will do an evaluation to determine what their current level of care assistance is. If we determine a different level of care, we communicate it to the CNA and the nurse. It is up to the CNA to determine if they can provide the care for the residents by using one person or two and what is safe for them and the residents. Review of the facilities policy dated October 2022 titled person-centered comprehensive care plan revealed,Guideline:It is the practice of the center to develop and implement a person-centered comprehensive care plan that includes measurable objectives and time frames to meet their preferences and goals, and address the guest/residents nursing, medical, physical, mental, and psychosocial needs. The comprehensive care plan will be developed within seven days after completion of the comprehensive assessment and no more than 21 days after admission. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each assessment, including both comprehensive and quarterly review assessments and with significant changes in the guest/resident's condition. The interdisciplinary team will work collaboratively with the guest/resident, responsible party and/or family members to develop a comprehensive person-centered care plan that encompasses each guest/resident personal preferences, goals, and objectives. The comprehensive person-centered care plan will be developed based on the minimum data set (MDS) to assess the guest/residence clinical condition, cognitive and functional status, and use of services. The comprehensive care plan will address the following: services to be furnished to attain or maintain the guest/residents highest practicable physical, mental, and psychosocial well-being. PASARR recommendations (if applicable) Guest/resident goals for admission and desired outcomes Guest/resident preferences for future discharge referrals to local community resources needs and strengths of the guest/resident culturally competent care and services/preferences trauma informed care/interventions potential triggers guest/residents refusal of care or services and centers action to provide education to guest/resident and or representative Facility immediate actions to remove the Immediate Jeopardy included: -Resident #5 had a comparison review of their most recent completed MDS section GG, which included input from the multidisciplinary team with their current ADL care plan/Kardex interventions, and her plan of care was updated to accurately reflect the amount of ADL assistance and type of support for bed mobility and toileting/incontinence care on 7/29/2025. -The care plan specialist/designee reviewed all residents ADL care plan/Kardex utilizing input from the resident's medical record, gg evaluations, staff interviews including therapy documentation as applicable, on 8/6/25 and 8/7/25, which included 1- or 2-person support to clarify the minimum number of people required to safely perform the task. These process changes included guidance for the safest level of ADL support. 13 residents had the level of support assistance revised. For the remainder of the residents the care plan specialist/designee revised the Kardex to place the ADL level of assistance and number of staff support under one section resident care to create a uniform view for nursing assistants to decrease opportunities for error on 8/6/2025. -Director of education/designee educated all nursing staff (CNAs and nurses) on pulling up the care plan and Kardex interventions to identify the correct ADL level assistance and type of support required with a return demonstration. This education was initiated on 7/25/25 on-going for new employees -The DON/designee on 8/8/25 conducted an observational audit of nursing staff providing ADL care at the bedside or completed an ADL documentation review of 15 (10 %) nursing staff providing resident ADL care to ensure appropriate support and safety measures were followed according to the resident's care plan or Kardex. Any identified concerns were corrected immediately with staff utilizing corrective education. Verification of the facility's removal plan was conducted by the survey team on 08/08/2025.On 08/08/2025 interviews with facility staff was conducted for 4 RN's, 9 CNA's, and 2 LPN's to verify education and training had been completed related to topics to include:-Reviewing Kardex before caring for Resident, Safety and Resident Care, prior to providing any care and document accordingly. All staff were able to voice understanding of the policies and processes required to provide competent care to residents. The staff interviewed have worked across all shifts. -A review of the sign in sheets was conducted to verify education and training was completed as outlined in the IJ removal plans. Based on verification

Based on observations, interviews, and record review, the facility failed to prevent a fall with serious injury for one resident (#5) out of three residents sampled for accidents. On 07/25/2025 Staff A, Certified Nursing Assistant (CNA), independently rolled Resident #5 onto her side in bed to perform incontinence care. Staff A, CNA left Resident #5 unattended in bed to collect supplies. Resident #5 fell out of the bed while unattended and suffered a right hip fracture which required a transfer to a higher level of care and surgical repair.This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to residents and resulted in the determination of Immediate Jeopardy on 08/07/2025. The findings of Immediate Jeopardy were determined to be removed on 08/08/2025 and the scope and severity was reduced to an E after verification of removal of immediacy of harm.Findings included: During an interview on 08/06/2025 at 8:32 a.m., Resident #5 stated she had a fall a couple months after she was admitted to the facility. Resident #5 stated she was supposed to always have two people assisting her with care. She stated she requested a bigger bed. She stated, Sometimes they come in with two people and sometimes they just come in with one person. She stated, they set up a chair on the side of the bed for her to hold onto because they told her they could not use side rails. She stated, The chair slides while I'm holding onto it. She stated she requested a bigger bed a few times after a fall and was told they would order it, and it never came until after her most recent fall (07/25/2025). She stated, This last fall I broke my hip in two places and had to have surgery. The CNA came in to change me by herself, she rolled me onto my side, she put my legs with one on top of the other, the CNA went to grab something off of the dresser and I told her I was slipping, and she told me, You will be okay, I told her again that I was slipping and then I fell off of the bed. I only got the bigger bed now because I fell. The aides were upset that they were taking so long, to get me a bigger bed because they all knew I was at risk. Review of Resident #5's admission record revealed an initial admission date of 04/05/2025 and a re-admission date of 07/28/2025. Resident #5 was admitted to the facility with diagnoses to include: displaced apophyseal fracture of left femur (a break in the growth plate area of the large bone of the upper leg), initial encounter for closed fracture (08/04/2025), displaced fracture of greater trochanter (a bony prominence located on the upper part of the thigh bone) of right femur, initial encounter for closed fracture (07/28/2025), spondylolysis (a stress fracture in a vertebra), cervical (neck) region (09/21/2024), unspecified fall, subsequent encounter (09/21/2024), muscle weakness (generalized) (09/21/2024), other abnormalities of gait and mobility (09/21/2024), morbid (severe) obesity due to excess calories (09/21/2024), and repeated falls (09/21/2024). Review of Resident #5's Quarterly Minimum Data Set (MDS), dated [DATE] revealed in Section C-Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. Review of Section GG-Functional Abilities revealed Resident #5 had an impairment on one side to her upper and lower extremity. Resident #5 required substantial/maximal assistance revealing helpers do more than half the effort. Helpers lift or hold trunk or limbs and provides more than half the effort for rolling left and right. Sitting to lying (the ability to move from sitting on side of bed to lying flat on the bed, lying on side of bed), Resident #5 was dependent, meaning helper does all the effort. Residents do none of the effort to complete the activity. Or the assistance of two or more helpers is required for the resident to complete the activity. Review of Resident #5's care plan dated 08/03/2024 revealed: Focus: ADL Self-Care and/or mobility deficit. Needs assistance with ADL's Initiated on 09/23/2024.Interventions included: BED MOBILITY-Total ASSIST X 2 TRANSFERS-Total ASSIST with Hoyer X 2TOILETING-Total ASSIST X 2DRESSING-Total ASSIST X 2BATHING-Total ASSIST X 2 Review of Resident #5's Intervention/Task for July revealed one person assistance was provided for ADL-Bed Mobility on 07/26/2025 (day shift), 07/28/2025 (evening shift), 07/30/2025 (day shift), 07/31/2025 (evening shift), 08/01/2025 (day shift), 08/02/2025 (evening shift), 08/03/2025 (day shift and evening shift), 08/05/2025 (evening shift), 08/07/2025 day shift). A review of the physician order summary for Resident #5 revealed: Right hip Xray 2 views due to status post fall pain. Start Date 07/26/2025.Send to ER (emergency room) for further eval and treat. Start Date 07/27/2025. A review of Resident #5's right hip Xray, radiology report, dated 07/26/2025 revealed:Reason for Study: Acute Pain Due To TraumaFINDINGS: There is deformity of the femoral neck concerning for a fracture. There is joint space narrowing of the right hip with bony productive change. There is diffuse osteopenia.Conclusion: Deformity of the right femoral neck concerning for a fracture. A follow-up CT (computed tomography) scan of the hip is suggested. Review of Resident #5's progress notes revealed: -07/28/2025 at 7:47 p.m. Fall Risk Evaluation Fall Risk: History of falls (past 3 months): 1-2 falls in past 3 months. Level of consciousness / mental status: Alert (oriented x 3) OR comatose. Resident is chairbound / incontinent. Systolic blood pressure: No noted drop between lying and standing. Vision status: Adequate (with or without glasses). Predisposing disease: 1-2 present. Residents had a change in condition in the last 14 days. Recent hospitalization history in last 30 days: Yes. Notes: Post right hip surgery 7/27/25 Gait / balance: Requires use of assistive devices (i.e. cane, wheelchair, walker, furniture). Medication: Takes 3-4 these medications (or medication classes) currently and / or within last 7 days. Fall Risk Score: 15.0.-07/28/2025 6:05 p.m. Nursing Note Note Text: readmitted a [AGE] year-old female from [Acute Care Hospital] via stretcher accompanied by 2 Emergency Medical Services (EMS) staff.Surgical incision to right hip clean, dry with dressing intact, with PICO [a single-use, portable negative pressure wound therapy system designed to promote wound healing] dressing functioning well. Patient also has skin tear to right lower leg with sutures in place. Bruising noted to right knee/ right[sic] lower leg. Discoloration and flaking noted BIL [bilateral] feet.-07/27/2025 12:00 a.m. Nursing Note Late Entry:Note Text: Result of X ray[sic] right hip reported to ARNP [Advanced Practical Nurse Practitioner] with order received for resident to be sent to ER [Emergency Room] for further eval and treat. DON [Director of Nursing] notified. This writer called [Family Member] 2x [twice] left message, awaiting for call back. Facility protocol followed. Resident transported to ER via 911.-07/26/2025 07:38 a.m. Radiology Note Note Text: Patient complained of pain of 7 on right hip/pelvis area s/p [status post] fall last evening. Administered PRN [as needed] pain pill. Notified provider on call.received order for STAT (immediate) xray[sic] to right hip/pelvis area 2 views. [Mobile Radiology Company] services needed due to pt [patient] being bed bound.-07/26/2025 3:52 p.m. Nursing Note Note Text: Bariatric [bed] delivered to [room number], resident in new bed without difficulty. Resident[sic] says new bed is comfortable.-07/25/2025 4:56 p.m. Interdisciplinary (IDT) Note Late Entry:Note Text: Resident reviewed by IDT for s/p [status post] fall on 7/25. Resident found by the floor nurse lying on floor on her back next to bed. CNA reported she was providing incontinent care and stepped away to get a towel; during that time, resident rolled off the bed. Head-to-toe assessment completed; no visible injuries noted. Pt [patient] was complaining of left shoulder pain. Neuro checks initiated. NP [Nurse Practitioner] notified; new orders received for STAT [immediate] left shoulder x-ray and one-time dose of oxycodone for pain. Message left for [Family Member] return call regarding notification of family. Interventions: Wider bed ordered for resident. Staff re-educated on following Kardex instructions; emphasized requirement for two-person assist as documented. STAT x-ray of Left shoulder and one time dose of oxycodone was ordered.-7/25/2025 6:27 p.m. Nursing Note Note Text: Called to room by CNA. Observed resident lying on the floor on her back side next to bed. Resident states she rolled off of the side of the bed. Head to toe assessment completed. Complaints of left shoulder pain. No visible sign of injury. Neuro checks initiated. Returned to bed using [mechanical lift] with multiple staff present. [ARNP] notified. New order for STAT left shoulder xray[sic] and one time dose of oxycodone for pain. Message left for [Family Member] to return call to facility.-07/25/2025 7:15 p.m. Nursing Note Note Text: Spoke with [Employee of Bed Supplier]. Bariatric bed to be delivered 7/26 before 11:45am. Resident made aware. Review of Resident #5's Hospital Discharge Records dated 07/27/2025 revealed: Procedure History: Arthroplasty Hip Bipolar (a surgical procedure replaces the damaged femoral head with a prosthetic implant) (Right), (07/27/2025), Open Reduction Internal Fixation Hip (surgical procedure used to treat hip fractures by realigning the bone and securing it with internal hardware) (Right) (07/27/2025). During a phone interview on 08/06/2025 at 12:57 p.m., Staff A, CNA stated on 07/25/2025 she went to provide Resident #5 with care. She said, I rolled [Resident #5] onto her side in the bed, and I went to grab a towel from the dresser. While I was grabbing the towel [Resident #5] slipped off the bed. I usually take everything I need with me. She stated there was not a rail on the bed for the resident to hold onto. Staff A stated Resident #5 holds onto the top of the dresser for support, and It is difficult to roll her sometimes. She stated, I ran out and started screaming for the nurse. I grabbed her a pillow for her head while we were waiting for someone to come in the room. She stated Resident #5 said her hip was hurting after the fall. Staff A stated the nurse did an assessment and then they put Resident #5 back in bed. She said, I don't know if [Resident #5] went out to the hospital or not. I thought [Resident #5] was a one person assist. We look in the Kardex to tell you how many people a resident requires to provide care. She stated after the incident, the Director of Nursing (DON) did a one-on-one in-service. She said, It was something on falls being careful and being aware. During an interview on 08/06/2025 at 10:38 a.m., Staff B, Licensed Practical Nurse (LPN), stated on 07/25/2025 she did wound care in the morning and worked on the floor from 3:00 p.m.-11:00 p.m. She was called to Resident #5's room by Staff A, CNA, and Resident #5 was on the floor lying on her back between the two beds. Staff A, CNA told her she was in the middle of changing her when she walked to the dresser to grab towels and the resident fell. Staff B stated the aide told her, The weight of her body flipped her to the other side of the bed. [Staff A, CNA], was the only aide in the room. [Resident #5] was supposed to have two people assisting her. She did a head-to-toe assessment on Resident #5. Staff B stated, I did not move the right shoulder much because I know she has had long term pain in that shoulder. Her legs are big, and [Resident #5] cannot hold them up on her own. I lifted both of her legs, and she did not have any pain at that time. There was no redness, swelling or bruise at the time of the assessment. Resident #5 was only complaining of left shoulder pain. She stated she got orders for STAT (emergent) left shoulder Xray. She said Resident #5 never complained of hip pain on the shift. She stated she called the doctor and asked if the pain medication could be given early. She stated when she got back to work on Monday, she was told Resident #5 went out to the hospital for her hip. She stated at the time of the fall Resident #5 had a regular size standard bed. Staff B stated, We talked about getting her a bariatric bed a long time ago. Resident #5 was able to hold herself over by holding onto the nightstand next to the bed or the armoire on the other side. If she was in a bariatric bed she would not be able to reach the nightstand to hold herself up, so we did not get her the bariatric bed. She said Resident #5 does not use her right arm for anything anymore. She stated, The bed she had [at the time of the fall] did not have anything for her to hold onto. She said Resident #5 does not move; she can't reposition herself or anything. There was some room on each side of the bed, if she was a moveable person she would not be able to move much. Residents who need a bariatric bed just need to bring it up to the managers, and they would get them one. There really is not a system in place for determining when a resident needs a bariatric bed. The unit manager can call and request a bariatric bed if they feel a resident needs it. She said, If we need more room to turn the resident we would request for one. But usually, it is a customer service thing when a resident requests for it. During an interview on 08/06/2024 at 3:56 p.m., the Director of Nursing (DON) stated she did the reportable investigation for Resident #5's fall. On 07/25/2025 at 4:30 p.m. Staff A, CNA was providing incontinent care for Resident #5. Resident #5 was on her side in the bed. Staff A, CNA went to grab the towels off the dresser. Resident #5 legs began to slide down. Resident #5 told Staff A, CNA she was starting to slide and Staff A, CNA could not intercept her fast enough, resulting in Resident #5 falling to the floor. Resident#5 was assessed by the nurse and complained of left shoulder pain. They did an Xray of the left shoulder and it was negative for a fracture. The next day (07/26/2025), Resident #5 started complaining of right hip pain, they did an Xray, and it was positive for a hip fracture. The results came back close to midnight, and Resident #5 was sent to the hospital for further evaluation. Resident #5 was admitted to the hospital and underwent a right hip arthroplasty on 07/27/2025. The DON stated the resident returned back to the facility on [DATE]. During the investigation, she interviewed staff and other residents to see if there were any concerns with Staff A, CNA's care. No residents or other staff had concerns with Staff A, CNA's care. She provided education to all staff related to making sure they have all of their items in reach when providing care. If they need to grab something while providing care residents should be placed back on the bed. They ordered a wider bed for Resident #5, and it was delivered the next day (07/26/2025). They updated Resident #5's Kardex for her to be a two person assist with everything. The DON stated, There is not anything that is black or white to determine what type of assistance a resident needs while providing care. It can be determined by therapy; some people can do more than others. There are a lot of factors, there is not a guide. The DON stated Resident #5 had another event in October 2024. During this event Resident #5's legs were hanging over the side of the bed, they had to assist her down to the floor and then put her back in bed. She said, According to the 10/14/2024 interdisciplinary team (IDT) note it says Resident #5 is a two person assist with incontinence care. I thought this was referring to when Resident #5 was using the bathroom and holding onto the bar. She said bed mobility is how many people it takes to move people in bed. At the time her bed mobility was a one person assist, and her transfer status was two person assist. She stated, There was some confusion, because the two-person changing brief was not under the activities of daily living (ADL) part of the Kardex and her bed mobility in ADL's said Resident #5 was a one person assist. When the care plan was updated in October of 2024, it updated under a different part of the Kardex. She said Resident #5 needing to be a two-person assist for brief changing was only on the safety part of the Kardex. Staff A, CNA was following the ADL Kardex. Residents use different things to hold onto while care is being provided. They can use furniture, she said, Their chair would be up against their bed, or chairs that have handrails, or whatever is there for them to grab onto. If they have a scoop mattress they can hold onto that, it depends on the resident. We try to use trapezes; we try other interventions other than side rails. We don't like to utilize bed rails, she said, It is frowned upon to use them since the initiative for no bed rails. In our setting they don't want us to use the bed rails. If a resident uses bedrails, an evaluation is done for the adaptive rails, and we put them on. The CNA's document under tasks when they perform an activity for a resident. If the task is marked off as one person assist, then one person assists with that activity. We did not substantiate the allegation because everyone was under the impression she was a one person assist with the bed mobility. Review of the facility's policy, dated October 2014, revision date November 2018 revealed the following:PALM Program(Preventing Accidental Level Change Mishaps)Purposethe PALM program is designed to identify those residents who are at risk for repeated falls and serves to alert team members to provide interventions designed to reduce fall risk.ProcedureNew Admissions1. During the admission process, residents will be evaluated using the evaluation of risk for falls form.2. A therapy screen will be completed during the admission process, if no therapy is ordered on admission.3. Residents identified at risk for falls will have an interim plan of care developed to address identified risk factors.4. Residents who are identified as being at risk for falls and have fallen within the past 30 days or have had significant injury from a fall prior to admission may be placed in the PALM program.Current Residents1. following a fall, the resident will be reevaluated using the evaluation of risk for falls form. No, this evaluation will also be completed upon hospital return, quarterly and with significant change.2. The care plan will be updated following each fall with modification of interventions based on interdisciplinary team review and resident need.3. All residents experiencing a fall(s) will be reviewed at the next standards of care meeting following the fall(s).4. The interdisciplinary team will determine which residents are to be included in the PALM program. The program may include but is not limited to residents who are at risk for falls and have had one of the following: repeat falls within a 30 day periodProgram Overview1. once a resident has been selected by the interdisciplinary team to participate in the PALM program, a palm symbol will be placed in the following places as applicable: outside the residence room beside the residence name plate/door.2. The residents care plan will be updated to reflect participation in the PALM program.3. Team interventions which may apply to PALM program participants include the following suggested interventions:o Ambulation programo Family/resident educationo therapy processo bowel and bladder evaluation programo increase activities in the evening after dinner; scheduled individual activity, determine resident preferenceso pet therapyo exercise programo assist resident outdoors for fresh airo change nap or bedtimeo soothing music at bedtimeo Dim lights at night, provide quiet environmento lavender hand massageo pain management programo nonskid shoes, slipper socks; evaluate for proper footwearo medication review by pharmacy and or by physician/ARNP/[NAME] labs; chemical panel(s), urinalysiso orthostatic blood pressure checks, vital signso every 15 minute checks, 1 to 1 supervision or two to one supervisiono in view of staff when out of [NAME] encourage family visitso psychiatric consulto neurology consulto ophthalmology or audiology consulto keep glasses cleano heat brakes locked on wheelchair/[NAME] anti tipper device for wheelchairso automatic wheelchair brakeso Dycem chair [NAME] wheelchairs lock during transferso bad adjusted to accommodate resident height (hips at 90 degree angle when feet flat on floor)o specialty mattresso wheelchair cushions as appropriateo adequate lighting, Night Lightso remove clutter and barriers from floorso stop signso raised toilet seatso hipsterso low bed with mats, bed in lowest positiono evaluate resident ability to utilize bathroom assisted/unassisted according to their cognitive status or ability4. interventions to reduce risk of falls unique to each resident should be included in the residence care plan and on Kardex.5. Education regarding the PALM program will be provided to all team members upon hire annually and as needed. Facility immediate actions to remove the Immediate Jeopardy included: --The IDT team completed a root cause analysis 7/28/25 and medical record review for resident #5 to identify gaps in the level of supervision, ADL assistance and general safe practices to reduce resident injury. --The care plan specialist team/designee completed a resident review of ADL care plan/ Kardex interventions 8/6/25 and 8/7/25 to ensure there were no discrepancies in the number of staff support needed to complete task toileting/incontinence care or bed mobility. Those 13 residents identified had their care plan/Kardex corrected. The Kardex format was streamlined so all ADL support guidance is contained under the resident care tile to decrease staff error. --The Director of Education/designee provided education to nursing staff to (98.4% 62/63 of CNAs and 100% 29/29 Nurses) on pulling up the care plan/Kardex to identify the level of assistance and supervision required. The Director of Education/designee educated staff on general safety interventions identified based on the root cause analysis such as having required supplies gathered and within reach to provide care, utilize call bell when needed additional support, and to ensure resident is in a safe position prior to leaving the bedside, review care plan/Kardex prior to providing care to ensure level of assistance and support needed. This was initiated on 7/25/25 and is ongoing for new employees. Additionally, the one CNA left for education will return tomorrow and will be educated prior to working her shift. Completed 8/8/25. --The DON/designee on 8/8/25 conducted an observational audit of nursing staff providing ADL care at the bedside or completed an ADL documentation review of 15 (10 %) nursing staff providing resident ADL care to ensure appropriate support and safety measures were followed according to the resident's care plan or Kardex. Any identified concerns were corrected immediately with staff utilizing corrective education. Verification of the facility's removal plan was conducted by the survey team on 08/08/2025. On 08/08/2025 interviews with facility staff was conducted for 4 RN's, 9 CNA's, and 2 LPN's to verify education and training had been completed related to topics to include:-Reviewing Kardex before caring for Resident, Safety and Resident Care, prior to providing any care and document accordingly. All staff were able to voice understanding of the policies and processes required to provide competent care to residents. The staff interviewed have worked across all shifts. -A review of the sign in sheets was conducted to verify education and training was completed as outlined in the IJ removal plans. Based on verification of the facility's Immediate Jeopardy removal plan the immediate jeopardy was determined to be removed on 08/08/2025 and the non-compliance was reduced to a scope and severity of E.

Based on interview and record reviews, the facility failed to ensure Preadmission Screening and Resident Review (PASRR) assessments were accurate for twelve residents (#1, #126, #44, #97, #71, #119, #116, #60, #90, and #39) out of 32 residents sampled. Findings included: 1. Review of Resident #1's Admission Record showed Resident #1 was admitted to the facility on [DATE] with a primary diagnosis of unspecified dementia. Other diagnoses include major depressive disorder and anxiety disorder. Review of the Level I PASRR dated 11/2/2024 showed in Section II: Other Indications for PASRR Screen Decision-Making, 5. Does the individual have a primary diagnosis of dementia, was marked No. A Level II PASRR evaluation must be completed if the individual has a primary or secondary diagnosis of dementia or related neurocognitive disorder (including Alzheimer's disease), and a suspicion or diagnosis of a Serious Mental Illness. Review of Section IV: PASRR Screen Completion revealed: Individual may be admitted to a Nursing Facility (check one of the following): No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required, was marked. 2. Review of resident #126's Admission Record showed Resident #126 was admitted to the facility on [DATE] with diagnoses of generalized anxiety disorder, major depressive disorder, and unspecified dementia. Review of the Level I PASRR dated 9/24/2024 showed in Section I: PASRR Screen Decision-Making, section A. MI (Mental Illness) or Suspected MI (check all that apply): Depressive Disorder, was checked. Anxiety Disorder was not checked. Section II: Other Indications for PASRR Screen Decision-Making revealed a Level II PASRR evaluation must be completed if the individual has a primary or secondary diagnosis of dementia or related neurocognitive disorder (including Alzheimer's disease), and a suspicion or diagnosis of a Serious Mental Illness. Under Section IV: PASRR Screen Completion, Individual may be admitted to a Nursing Facility (check one of the following): No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required, was marked. 3. Review of Resident #44's Admission Record showed Resident #44 was admitted to the facility on [DATE] with diagnoses of major depressive disorder, unspecified dementia, and generalized anxiety disorder. Review of the Level I PASRR dated 7/30/2023 showed in Section I: PASRR Screen Decision-Making, section A. MI (Mental Illness) or Suspected MI (check all that apply): Anxiety Disorder, Depressive Disorder, and Psychotic Disorder, were checked. Section II: Other Indications for PASRR Screen Decision-Making revealed a Level II PASRR evaluation must be completed if the individual has a primary or secondary diagnosis of dementia or related neurocognitive disorder (including Alzheimer's disease), and a suspicion or diagnosis of a Serious Mental Illness. Under Section IV: PASRR Screen Completion, Individual may be admitted to a Nursing Facility (check one of the following): No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required, was marked. 4. Review of Resident #97's Admission Record showed Resident #97 was admitted to the facility on [DATE] with a primary diagnosis of unspecified dementia with a date of 4/10/2023. Other diagnoses include major depressive disorder. Review of the Level I PASRR, dated 4/5/2023 showed in Section I: PASRR Screen Decision-Making, section A. MI (Mental Illness) or Suspected MI (check all that apply): No diagnoses were checked. Section II: Other Indications for PASRR Screen Decision-Making revealed under question 6. Does the individual have a secondary diagnosis of dementia, related neurocognitive disorder (including Alzheimer's disease) and the primary diagnosis of a Serious Mental Illness or Intellectual Disability?, Yes was marked. Section II also revealed a Level II PASRR evaluation must be completed if the individual has a primary or secondary diagnosis of dementia or related neurocognitive disorder (including Alzheimer's disease), and a suspicion or diagnosis of a Serious Mental Illness. Under Section IV: PASRR Screen Completion, Individual may be admitted to a Nursing Facility (check one of the following): No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required, was marked. 5. Review of Resident #71's Admission Record showed Resident #71 was admitted to the facility on [DATE] with a diagnosis of major depressive disorder. Other diagnoses include dementia with a date of 6/4/2021, and anxiety disorder with a date of 7/15/2023. Review of the Level I PASRR, dated 07/17/2023 showed in Section II: Other Indications for PASRR Screen Decision-Making revealed under question 6. Does the individual have a secondary diagnosis of dementia, related neurocognitive disorder (including Alzheimer's disease) and the primary diagnosis of a Serious Mental Illness or Intellectual Disability?, Yes was marked. Section II also revealed under question 7. Does the individual have validating documentation to support the dementia or related neurocognitive disorder (including Alzheimer's disease)?, Yes was marked. Section II revealed a Level II PASRR evaluation must be completed if the individual has a primary or secondary diagnosis of dementia or related neurocognitive disorder (including Alzheimer's disease), and a suspicion or diagnosis of a Serious Mental Illness. Under Section IV: PASRR Screen Completion, Individual may be admitted to a Nursing Facility (check one of the following): No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required, was marked. 6. Review of Resident #119's Admission Record showed Resident #119 was admitted to the facility on [DATE] with a diagnosis of unspecified dementia. Other diagnoses include major depressive disorder with a date of 12/24/2024, and anxiety disorder with a date of 1/23/2025. Review of the Level I PASRR, dated 12/5/2024 showed in Section I: PASRR Screen Decision-Making, section A. MI (Mental Illness) or Suspected MI (check all that apply): Depressive Disorder was checked, but Anxiety Disorder was not checked. Section II: Other Indications for PASRR Screen Decision-Making revealed a Level II PASRR evaluation must be completed if the individual has a primary or secondary diagnosis of dementia or related neurocognitive disorder (including Alzheimer's disease), and a suspicion or diagnosis of a Serious Mental Illness. Under Section IV: PASRR Screen Completion, Individual may be admitted to a Nursing Facility (check one of the following): No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required, was marked. 20536 7. Review of Resident #116's medical record revealed he was admitted to the facility on [DATE] and readmitted from the hospital on 4/23/2024. Review of the diagnosis sheet revealed diagnoses to include but not limited to: Anxiety (onset 10/7/2023), Adjustment disorder with depressed mood (onset 3/7/2023). Review of a Level I PASRR screen was completed on 1/31/2023 revealed under Section I: PASRR Screen Decision-Making, section A. MI (Mental Illness) or Suspected MI (check all that apply): Anxiety Disorder was checked, but Depressive Disorder was not checked. On 2/6/2025 at 9:00 a.m., an interview with the Director of Nursing (DON) was conducted. The DON confirmed there were no other current Level I PASRR screens that reflected Resident #116 having a diagnosis of depression. She confirmed Resident #116 had an onset diagnosis of depression as of 3/7/2023. She revealed she would now update the Level I PASRR screen to reflect the diagnosis. 8. Review of Resident #60's medical record revealed she was admitted to the facility on [DATE] and readmitted from the hospital on 10/14/2024. Review of the diagnosis sheet revealed diagnoses to include but not limited to: anxiety (onset date 7/29/2024) and major depression (onset date 7/29/2024). Review of a Level I PASRR screen completed on 10/8/2024 revealed under Section I: PASRR Screen Decision-Making, section A. MI (Mental Illness) or Suspected MI (check all that apply): Depressive Disorder was checked, but Anxiety Disorder was not checked. On 2/6/2025 at 9:00 am., an interview with the DON confirmed there were no other Level I PASRR screens reflecting Resident #60 having a diagnosis of Anxiety. She confirmed Resident #60 had an onset diagnosis of Anxiety as of 7/29/2024. She revealed she would now update the Level I PASRR screen to reflect the diagnosis. 49227 9. Review of the admission record showed Resident #90 initial admission to the facility was on 9/22/2024 and readmitted on [DATE] with diagnoses to include anxiety disorder, mood affective disorder, psychosis, and depression. Review of a Level I PASRR for Resident #90 dated 12/26/2024 revealed under Section I: PASRR Screen Decision-Making, section A. MI (Mental Illness) or Suspected MI (check all that apply): Anxiety Disorder, Depressive Disorder, and Other (specify): Mood Disorder were checked, but Psychotic Disorder was not checked. Under Section IV: PASRR Screen Completion, Individual may be admitted to a Nursing Facility (check one of the following): No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required, was marked. 48223 10. Review of the Admission Record showed Resident #39 was admitted on [DATE] with a diagnosis of major depressive disorder. Review of Resident #39's PASRR Level I screen dated 10/29/2024 revealed under Section I: PASRR Screen Decision-Making, section A. MI (Mental Illness) or Suspected MI (check all that apply): Depressive Disorder was not checked. Under Section IV: PASRR Screen Completion, Individual may be admitted to a Nursing Facility (check one of the following): No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required, was marked. During an interview on 2/6/2025 at 12:30 p.m., the Nursing Home Administrator stated the facility does not have a policy and procedures for PASRR.

Based on interviews, observations, and record review, the facility failed to ensure sufficient staffing in order to provide timely meal service to residents on two units (B & D units) of four units in the facility. Findings included: During an interview on 2/3/2025 at 8:00 a.m., Resident #268 stated concerns regarding the food temperature, stating it was always cold. During an interview on 2/3/2025 at 9:55 a.m., Resident #266 stated having concerns regarding the temperature of the food when served. During an interview on 2/3/2025 at 10:17 a.m., Resident #269 stated having concerns regarding the temperature of the food when it is received. During an interview on 2/3/2025 at 10:30 a.m., Resident #270 stated having concerns regarding the food temperatures, everything is always cold. On 2/3/2025 at 12:34 p.m., the first meal cart arrived at B unit and at 12:42 p.m., the staff started to serve the trays from the cart. At 1:07 p.m., the last tray was passed for the first cart. The staff observed for meal service was three Certified Nursing Assistants (CNAs) and one nurse. On 2/3/2025 at 12:38 p.m., the second meal cart arrived at B unit and at 12:45 p.m., the cart was taken to D unit. At 12:55 p.m., the cart was taken back to B unit for rooms 240-260. At 1:01 p.m., the staff started passing the trays and the last tray was removed at 1:15 p.m. The staff observed for meal service was three CNAs and two nurses. On 2/3/2025 at 1:18 p.m., a third meal cart arrived at B unit abd the staff took the cart to D unit. At 1:25 p.m., the staff started to serve trays and at 2:00 p.m., the last tray was removed and served. Two CNAs and one nurse were available to pass the trays. During an interview on 2/4/2025 at 2:40 p.m., Resident #266 stated the food was still cold, especially breakfast, but all meals have been so far. During an interview on 2/4/2025 at 2:44 p.m., Resident #39 stated the meals have been ice cold. During an interview on 2/4/2025 at 2:48 p.m., Resident #268 stated the food was better than usual, but still not warm. During an interview on 2/4/2025 at 2:52 p.m., Resident #269 stated the food has remained cold. On 2/5/2025 at 8:40 a.m., a test tray was requested for D unit. The meal to be served was baked egg casserole, toast, oatmeal, and two links of sausage. The facility utilized top and bottom insulated domes and plate warmer. At 8:55 a.m., the eggs were plated at 146 F; the sausage 160 F, with the toast. The oatmeal was placed in an insulated bowl and temperature was 164 F. At 8:57 a.m., the tray was placed on an open cart with five other trays as the insulated meal delivery cart did not have enough room for those six trays. At 8:59 a.m., the trays arrived on to D unit. The staff available to assist with meals was the Nursing Home Administrator (NHA), the Director of Nursing (DON), the Infection Control Nurse (ICN), and two CNAs. The last tray was served at 9:00 a.m. The egg casserole's temperature was 164 F, sausage temperature was 172 F, and the oatmeal's temperature was 86 F. Two state surveyors tasted the meal; egg casserole was warm and oatmeal was lukewarm. During an interview on 2/5/2025 at 8:03 a.m., the Dietary Manager (DM) stated not being aware of cold food issues and the facility would be happy to heat up anyone's meal who needed it. During an interview on 2/6/2025 at 11:15 a.m., Staff Q, CNA stated they were responsible for 10-13 residents. Staff Q, CNA stated anything over 10 makes it difficult to give good patient care. During an interview on 2/6/2025 at 10:45 a.m., Staff R, CNA stated they were responsible for 11 residents. Staff R, CNA also stated being able to accomplish her tasks most of the time, but not always. Staff R, CNA stated they have been requested to stay late for hours on a regular basis and the administration does not ask about staffing. During an interview on 2/6/2025 at 8:55 a.m., Staff P, CNA stated they were responsible for 13 residents and the facility does not ask the staff for opinions in staffing, to her knowledge everything is based on numbers. During an interview on 2/6/2025 at 8:50 a.m., Staff O, Registered Nurse (RN) stated documentation sometimes does not occur as patient care is the priority. During an interview on 2/6/2025 at 8:39 a.m., Staff U, CNA/Staffing Coordinator (SC) stated they were responsible for staffing the building. The facility bases everything off of the census. The facility tries to have more staff on the rehab side of the facility, as these units have more visitors coming and going. Staff U, CNA SC stated they review the census daily to ensure they are staffing appropriately and they don't change the number of staff from the week to the weekend unless the census changes. During an interview on 2/6/2025 at 9:20 a.m. with the NHA and DON, the NHA stated the facility staffs the building on acuity and needs of the residents. There is no difference in the staffing from the weekends to the weekdays for direct patient care. The facility does have four unit managers (32 hours/day) throughout the week and on the weekends they go to a 12 hour/day supervisor. The facility has a staffing coordinator in the facility seven days per week to ensure coverage and assist if there happens to be a call off. A nurse manager is on call to ensure coverage. A policy and procedure for staffing was requested from the NHA. The NHA stated she was not certain if the facility had a policy and procedure or if they just followed the regulations. The facility did not provide a staffing policy and procedure.

Based on observations, record review, and interviews, the facility did not follow professional standards for food service safety in the kitchen and one of four nourishment rooms. Findings included: On 2/3/25 at 8:26 a.m., a tour of the kitchen was conducted with the Certified Dietary Manager (CDM). Upon entrance to the kitchen, an observation of three staff revealed they were on the tray line for breakfast. An observation of Staff D, [NAME] revealed he was wearing a restraint not fully covering his hair and more than a quarter of an inch was exposed. The same concerns were observed at 8:40 a.m. On 2/3/25 at 8:45 a.m., observations of the walk-in fridge were conducted with the CDM. A clear container containing boiled eggs, without the shell, was observed. An observation of the container of boiled eggs revealed they were not labeled. An interview with the CDM revealed the container of boiled eggs should have been labeled. She was observed labeling the container with a date of 2/2/25. Further observations of the walk-in fridge revealed a box of green and red whole peppers that had wrinkles across the surface, noticeable softness, and dark brown/black spots, which appeared not good for use. The CDM was observed removing the box of peppers. Further observations of the walk-in fridge revealed a sheet pan rack with trays of dessert. The CDM confirmed the desserts were going to be used for meal service that day. Observations of the top tray of desserts, which were in individual clear containers, had no label or date. The CDM was observed labeling the top tray of desserts with a date of 2/3/25. On 2/3/25 at 8:49 a.m., observations of the walk-in freezer revealed frozen vegetables were scattered on the floor along with other food particles/debris. Further observations revealed unidentifiable frozen food and debris toward the back of the freezer, underneath a metal rack where French fried potatoes were placed on top. (Photographic Evidence Obtained) On 2/3/25 at 9:05 a.m., a tour of the four facility nourishment rooms was conducted with the CDM. An observation of the inside of the A wing microwave revealed food particles were stuck to the sides and top. Splatters of food were observed that appeared to be dried. The CDM stated it should be clean and was observed calling a staff member to clean the microwave. She confirmed resident food is re-heated in the microwaves in the nourishment rooms. On 2/4/25 at 9:20 a.m., an observation of the dish machine in use revealed Staff A, Culinary Assistant was using her cell phone while putting clean kitchen items on the drying rack. An interview with the CDM revealed Staff A, Culinary Assistant's role is considered, Catcher, as they are responsible for placing clean kitchenware to dry or putting away as needed. Further observation of the dish machine in use revealed Staff C, Culinary Assistant's hair restraint was not fully covering her hair. The hair restraint appeared to be coming off, towards the back of her head. On 2/5/25 at 11:12 a.m., an observation of the lunch meal service revealed Staff D, [NAME] was taking temperatures of the hot food items. Staff D, [NAME] was observed touching his pants with his hands before he started taking food temperatures. He was not observed performing hand hygiene after touching his pants. At approximately 11:13 a.m., Staff D, [NAME] was observed removing a wipe from the wrapper to wipe down the probe of the digital thermometer. A piece of the wrapper was observed on a clean plate in front of him. Staff D, [NAME] was observed removing the piece of wrapper from the clean plate with his un-gloved hand. He was not observed performing hand hygiene before or after this task. During the observation of lunch meal temperatures, Staff D, [NAME] did not wipe the thermometer probe between mashed sweet potato and whole sweet potato. Further observation of the lunch meal temperatures revealed the ribs had an internal temperature of 129 degrees Fahrenheit ( F). Staff D, [NAME] stated he completed and recorded the temperatures about 10-15 minutes before this observation and the temperature was 147 F. He stated the ribs needed to go back into the oven as he expected a temperature of 145 F. On 2/5/25 at 11:20 a.m., an observation of Staff A, Culinary Assistant revealed she was taking the temperatures of the cold food/beverage items to include cake, pudding and milk. Observations of Staff A, Culinary Assistant revealed she did not perform hand hygiene before taking the temperatures of the cold food/beverage items. An observation of the temperature of the cake revealed it was 46 F and the pudding was 42 F. Staff A, Culinary Assistant stated the pudding and cake were taken out of the fridge and placed on the sheet pan rack around 11:12 a.m. Further observations of Staff A, Culinary Assistant revealed she did not wipe down the thermometer probe between taking the temperatures of the cake and pudding. Both food items were not observed being discarded and remained on the rack. On 2/5/25 at 11:25 a.m., an observation of the kitchen hood, over the stove, revealed the vents and sides had a brown rusted color. Further observation of the hood revealed areas of oxidation as evidenced by a white color/residue. An interview with the CDM revealed when the vents are removed every Friday, they are oily and have some residue. She stated the dietary staff do a deep clean of the hood every month. The Director of Maintenance (DOM) provided an invoice of the last time the hood was cleaned by [Vendor name], which revealed a date of 9/25/24. (Photographic Evidence Obtained) On 2/6/25 at 11:07 a.m., a review of the meal temperature log for 2/3/25 to 2/9/25 was conducted with the CDM. A review of Wednesday's log revealed the entree for lunch had a temperature of 170 F. The CDM stated the cook took the final cooking temperature, but they are not expected to document it. She could not confirm why the cook documented 170 F, however, during the lunch meal observation on 2/5/25 he stated the entree was 147 F when he tested it. The CDM stated she educated the cook on keeping the food covered, as she noticed it was not covered while on the tray line and thinks that's what contributed to the low temperature. The CDM stated the temperature of the ribs on 2/5/25 was not appropriate, as they are looking for a minimum of 135 F. She stated she tried to observe the cooks on the tray line monthly. On 2/6/25 at 11:10 a.m., an interview with the CDM revealed her expectation is the thermometer probe should be wiped with probe wipes between each food when taking and recording meal temperatures. She stated she's not sure if staff were educated on this task prior to her starting as CDM in August 2024. An interview with the CDM regarding hand hygiene revealed she expected staff to wash their hands before and after they complete meal temperatures. Regarding cold food temperatures, she stated cold food and beverages should be 41 F or below. On 2/6/25 at 11:16 a.m., the CDM stated if staff have a quarter inch of hair or longer, they need to wear a hair restraint. She stated it's the same rule for beards. An interview with the CDM related to labeling/dating revealed she tries to complete rounds every morning. She stated there is a poster on the walk-in fridge and freezer door for staff to refer to regarding labeling/dating expectations. She stated she's provided multiple in-service trainings related to labeling/dating and how long food and beverage items are good for. She stated herself, the assistant food service manager, and/or cook are expected to review the labels/dates. On 2/6/25 at 11:23 a.m., an interview with the CDM revealed the whole dietary team is responsible for cleanliness of the kitchen. She stated floors are cleaned after lunch and at night. The CDM stated staff clean between meals, as needed. She stated the green beans that were observed on the floor on 2/3/25 should have been cleaned up. On 2/6/25 at 11:32 a.m., an interview with the CDM revealed dietary aides are responsible for cleaning the nourishment rooms. She stated, I should be the second set of eyes. She stated the dietary aide goes to the nourishment rooms every night as it's an evening shift task. An interview with the CDM regarding cell phone use revealed staff, Shouldn't be using cellphones at all. She stated she's educated staff multiple times regarding cell phone use in the kitchen. A review of the facility's policy titled, Personal Hygiene, with an effective date of April 15, 2024, revealed the following: Purpose: Guidelines for personal hygiene to promote a safe and sanitary department must be followed. Procedure: . 2. Clean Hands and Fingernails: a. Hands must be washed prior to beginning work. 3. Head Covering Worn: .b. Hair must be appropriately restrained or completely covered. 4. Conduct: .e. Team members' personal items are to be stored in designated areas away from the food preparation area. A review of the facility's policy titled, Food Labeling & Dating - Refrigeration, with no effective date, revealed the following: Purpose: The center adheres to a labeling and dating system to ensure the safety of ready-to-eat, time/temperature control for food safety. Policy Explanation and Compliance Guidelines for Staffing: . 2. The food shall be stored, covered, marked for contents, and dated when placed in the refrigerator or freezer. 4. The individual opening or preparing a food shall be responsible for covering, labeling, dating and storying the food at the time of production or end of the meal service. 7. The Head Cook, or designee, shall be responsible for checking the refrigerator daily for food items that are expiring, and shall discard accordingly. 8. The Culinary Manger, or designee, shall spot check refrigerators for compliance, and document accordingly. Corrective action shall be taken as needed. A review of the facility's policy titled, Record of Food Temperatures, with an effective date of April 15, 2024, revealed the following: Purpose: It is the policy of this center to record food temperatures daily to ensure food is at the proper serving temperature(s) before trays are assembled. Policy Explanation and Compliance Guidelines: .2. Hot foods will be held at 135 degrees Fahrenheit or greater. 4. Potentially hazardous cold food temperatures will be kept at or below 41 degrees Fahrenheit . 8. If the food temperature falls into an unsafe range, immediately follow procedures for reheating previously cooked food . 14. Food temperatures will be verified using a thermometer which is both clean, sanitized and calibrated to ensure accuracy. A review of the facility's policy titled, Handwashing - Culinary and Glove Use, with an effective date of April 15, 2024, revealed the following: Compliance Guidelines: 1. Culinary team members shall keep their hands and exposed portions of their arms clean. 6. Frequency of Handwashing: a. Culinary team member shall clean their hands and exposed portions of their arm immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single service and single use articles and also in the following situations: . ii. After hands have touched anything unsanitary i.e., garbage, soiled utensils/equipment, dirty dishes, etc. iii. After hands have touched bare human body parts other than clean hands (such as face, nose, hair etc.)

Based on observations, record review, and interviews, the facility failed to maintain resident dignity related to 1.) wearing of plastic informational bands for ten residents (#30, #50, #72, #33, #90, #121, #45, #34, #123, and #81) of sixty-seven sampled residents and 2.) failed to ensure a urinary catheter bag with contents was positioned in a private manner during two of four days observed (2/3/2025 and 2/4/2025), for one resident (#123) of fourteen residents who utilized indwelling catheters. Findings included: 1. On 2/3/2025 at 8:40 a.m., 11:00 a.m., and 1:00 p.m.; 2/4/2025 at 7:50 a.m. and 1:30 p.m.; 2/5/2025 at 8:00 a.m. and 1:45 p.m.; and 2/6/2025 at 7:50 a.m. and 10:00 a.m., the following residents were observed either in the hallways or in their rooms wearing white plastic and/or pink plastic wrist bands on their wrists. The white plastic wrist bands had photos of the face of the resident, numbers, and an electronic bar code. Resident #30 was observed with the white plastic wrist band on her right wrist. Resident #30 was interviewed during the observation and stated she did not know why she was wearing the wrist band and also stated, I would rather not wear it. A review of Resident #30's medical record revealed she was admitted to the facility on [DATE]. Review of the most current Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed under Section C - Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score 11 of 15, which indicated the resident had moderate cognitive impairment. Resident #50 was observed with a white plastic wrist band on his right wrist. Resident #50 was interviewed during the observation and stated, I don't want this on, it's filled with bacteria, gross. A review of Resident #50's medical record revealed she was admitted to the facility on [DATE]. Review of the most current Annual MDS assessment dated [DATE] revealed under Section C - Cognitive Patterns, a BIMS score of 15 of 15, indicating the resident was cognitively intact. Resident #72 was not observed with a wrist bands on, but when interviewed stated, I take them off, don't like them on my wrist when discussing the wrist bands. She further revealed when she takes the bands off, she is supplied with more and keeps telling staff she does not want to wear it. A review of Resident #72's medical record revealed she was admitted to the facility on [DATE]. Review of the most current Quarterly MDS assessment dated [DATE] revealed under Section C - Cognitive Patterns, a BIMS score of 15 of 15, indicating the resident was cognitively intact. Resident #33 was observed with no wrist band on, but when interviewed stated, I don't have one on now, they are supposed to get me another and I would rather not have one if that is ok when discussing the wrist bands. A review of Resident #33's medical record revealed she was admitted to the facility on [DATE]. A review of the most current Quarterly MDS assessment dated [DATE] revealed under Section C - Cognitive Patterns, a BIMS score of 15 of 15, indicating the resident was cognitively intact. Resident #90 was observed with a white and pink plastic wrist band on his right wrist. Interview with Resident #90 revealed he did not like the feel of the bands and did not want to wear them. He revealed the facility asked him to wear the bands and he does not know why. He preferred to not wear them as they are not comfortable. A review of Resident #90's medical record revealed he was admitted to the facility on [DATE]. The most current Quarterly MDS assessment dated [DATE] revealed under Section C - Cognitive Patterns, a BIMS score of 15 of 15, indicating the resident was cognitively intact. Resident #121 was observed with a white plastic wrist band on her right wrist. An interview was conducted with the resident following the observation. She revealed she did not like the band on and did not know why she had to wear it. A medical record review revealed Resident #121 was admitted to the facility on [DATE]. A review of the most current Quarterly MDS assessment dated [DATE] revealed under Section C - Cognitive Patterns, a BIMS score of 9 of 15, which indicated the resident had moderate cognitive impairment. Resident #45 was observed with a white plastic wrist band on her right wrist. An interview was conducted with the resident following the observation. She revealed she did not know what the band was for and she would rather not wear it. She further revealed the band gets caught on things and she does not like the feeling of wearing it. A brief record review revealed Resident #45 was admitted to the facility on [DATE]. A review of the most current Quarterly MDS assessment dated [DATE] revealed under Section C - Cognitive Patterns, a BIMS score of 8 of 15, which indicated the resident had moderate cognitive impairment. Resident #34 was observed with a white plastic band on her right wrist. An interview was conducted with the resident following the observation. Resident #34 revealed she would rather not wear the band and was not told why she had to wear it. A review of the medical record revealed Resident #34 was admitted to the facility on [DATE]. Review of the current Quarterly MDS assessment dated [DATE] revealed under Section C - Cognitive Patterns, a BIMS score of 7 of 15, which indicated the resident had severe cognitive impairment. Resident #123 was observed wearing a white plastic band and a pink plastic band on his right wrist. Interview with the resident revealed he was not aware of why he had to wear the bands and did not know what they were for. Most of the photo and bar code on the white plastic band were worn away and was no longer in a readable state. Resident #123 revealed he did not feel comfortable wearing the bands and would rather not wear them. A brief review of the medical record revealed Resident #123 was admitted to the facility on [DATE] and recently readmitted from the hospital on 1/28/2025. Review of the most current 5 day MDS assessment, dated 12/9/2024 revealed under Section C - Cognitive Patterns, a BIMS score of 15 of 15, indicating the resident was cognitively intact. Resident #81 was observed wearing a white plastic band on his right wrist. An interview with the resident revealed he did not know why he was wearing it and they just put it on. He also revealed he does not like wearing the band. A brief review of the medical record revealed the resident was admitted to the facility on [DATE]. Review of the most current Quarterly MDS assessment dated [DATE] revealed under Section C - Cognitive Patterns, a BIMS score of 15 of 15, indicating the resident was cognitively intact. On 2/6/2025 at 10:00 a.m., an interview with Staff J, Registered Nurse/Unit Manager (RN UM) and the Director of Nursing (DON), confirmed the facility implemented the use of wrist bands about three to four months ago. Staff J, RN UM and the DON also confirmed the bands were to identify the resident with first and last name and with a photo of them. The DON further explained the bar code on the band was for staff to obtain medical information from the resident's medical record. Staff J, RN UM and the DON were not able to provide consent forms for the above mentioned residents or any other resident in the facility who were wearing wrist bands. The DON explained the wrist bands were used to ensure staff had the right resident they were providing care and service to. She also explained they would accommodate residents who did not want to wear the wrist band by not placing them on, but was unaware of any residents who did not want to wear them. The DON was also unaware there were so many residents who were not understanding of the purpose of the wrist bands. 2. On 2/3/2025 at 10:00 a.m. and 2:10 p.m., and on 2/4/2025 at 7:50 a.m., 8:50 a.m., and 10:18 a.m., Resident #123's room was observed with the door open. An indwelling catheter bag was observed hanging from the left side of the resident's bed, visible from the hallway and nurses station. The catheter bag was not placed in a privacy bag. (Photographic Evidence Obtained) On 2/4/2025 at 1:50 p.m., Resident #123 was observed in his room seated upright in bed with his over the bed table and lunch meal tray positioned in front of him. An indwelling catheter bag was observed hanging from the left side of the resident's bed, visible from the hallway and nurses station. The catheter bag was not placed in a privacy bag and was approximately 1/2 full of yellow liquid. On 2/5/2025 at 7:29 a.m., Resident #123 was observed resting in bed. An indwelling catheter bag was observed hanging from the left side of the resident's bed, visible from the hallway. The catheter bag was not placed in a privacy bag and was approximately 1/2 full of yellow liquid. On 2/5/2025 at 7:56 a.m. Resident #123 was observed in his room lying in bed and had just received his breakfast meal tray from staff. The room light was on the indwelling catheter bag was lying on the floor. At 7:59 a.m., Staff R, Certified Nursing Assistant (CNA) was observed walking in the room and assisted the resident with setting up the breakfast tray. She left the room and came back in the room with another breakfast tray at 8:03 a.m. for the resident's roommate. She left the room and did not see or attempt to reposition the catheter bag. (Photographic Evidence Obtained) At 8:19 a.m., Staff J, RN UM was observed walking by the room and looked in the room. Staff J, RN UM repositioned the catheter bag to the side of the bed, below the mattress. The catheter bag and contents were visible from the hallway and nurses station. At 9:10 a.m., an interview was conducted with Staff J, RN UM. Staff J, RN UM confirmed she walked by Resident 123's room earlier and saw the catheter bag was lying on the floor. She revealed she went inside and immediately repositioned it on the side and bottom of the bed frame, ensuring the bag was up off the floor. Staff J, RN UM revealed she left the room to retrieve a privacy bag to place the catheter bag in. She could not remember if the bag was without a privacy bag the last two days. Staff J, RN UM stated the resident's catheter bag should have been placed in a privacy bag so the contents were not visible from the hallway. A review of the current Care Plans with a next review date 3/12/2025, revealed the following areas: Risk for complications related to use of indwelling catheter, with interventions in place to include: Anchor to thigh to decrease trauma, Change [indwelling] catheter and bag [as needed], Keep bag below level of bladder, and Privacy bag. On 2/6/2025 at 3:00 p.m., the Nursing Home Administrator (NHA) provided the Admission Packet, which is provided to newly admitted residents and/or their representatives. Within the Admission Packet was a booklet related to Resident Rights, with a last amended date of 3/8/2022, which revealed: (a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with access to persons and services inside and outside the facility, including those specified in this section. (1) A facility must treat with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. (c ) Planning and Implementing Care. (4) The right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care. (6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimented research, and to formulate an advance directive. (d) Respect and dignity. The resident has the right to be treated with respect and dignity, including: (3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. (h) Privacy and Confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal and medical records. (1) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident. Further interview with the NHA revealed the facility did not have a specific policy and procedure related to Privacy and Dignity. She revealed they follow the guidelines which is referenced in the Resident Rights section of the admission packet. The NHA further confirmed she did not have consent forms to show residents have consented to wearing plastic wrist bands on their wrists. On 2/6/2025 at 11:00 a.m., the Nursing Home Administrator provided the facility's Catheter Care policy and procedure with a date of 7/2023 for review. Review of the Purpose revealed; To provide safe and proper care of a guest/resident with an indwelling catheter by evaluating elimination status, minimizing risk of bladder infection, and maintaining skin integrity. The Equipment section of the policy revealed to utilize a Privacy Bag.

Based on observations, record review, and interviews, the facility failed to follow physician orders and provide wound care in accordance with professional standards of practice for three residents (#5, #138, and #266) of five residents reviewed for surgical and non-surgical wound care. Findings included: 1. Review of the Admission Record for Resident #5 showed initial admitted to the facility was on 3/29/22 with diagnoses to include need for assistance with personal care and disorders of the bone density and structure. Review of Resident #5's care plan revealed the following: Focus initiated 1/18/23 and revision on: 8/20/24: [Resident #5] is at risk for alteration in skin integrity related to: weakness .terminal prognosis. Goal: Skin will remain intact through the next review, revised on 12/3/24. Interventions: Left forehead abrasion cleanse with N/S (normal saline,) pat dry, apply xeroform and cover with dry dressing every other day (QOD) and as needed (PRN) until healed, date initiated 1/24/25. During an observation on 2/3/25 at 8:16 a.m., Resident #5 was lying in bed with a light pink wound dressing with borders secured to the skin on the left side of her forehead dated 2/1/25. During an observation on 2/4/25 at 11:19 a.m., Resident #5 was lying in bed with a light pink wound dressing with borders secured to the skin on the left side of her forehead dated 2/1/25. During an interview, record review, and observation on 2/4/25 at 11:24 a.m., Staff I, Registered Nurse (RN) confirmed the dressing on Resident #5's left forehead was dated 2/1/25. Staff I, RN reviewed Resident #5's Treatment Administration Record (TAR), which showed the wound dressing was completed on 2/3/25 at 10:10 p.m. During an interview on 2/4/25 at 11:30 a.m., Staff J, RN, Unit Manager (UM) said she would check into the date and time the dressing change was documented and the date on Resident #5's current dressing. During an interview on 2/4/25 at 1:56 p.m., Staff J, RN UM said Staff K, Licensed Practical Nurse (LPN) told her on 2/3/24 she documented Resident #5's dressing was changed and did not change the dressing. During a telephone interview on 2/4/25 at 2:18 p.m., Staff K, LPN said on 2/3/25 Resident #5's wound care was documented as completed and the wound care was not completed. Review of Resident #5's February 2025 TAR revealed an order dated 1/23/25 and discontinued on 2/4/25 at 11:42 a.m., showed left forehead wound: Cleanse with normal saline, pat dry. Apply xeroform and cover with a dry dressing every other day and PRN (as needed) if loose or soiled. Review of Resident #5's nursing progress note dated 2/4/25 at 11:52 a.m. showed . forehead treatment, scheduled for yesterday evening, was not performed. 50570 2. On 2/3/25 at 12:37 p.m., an observation of Resident #138 revealed she was ambulating herself in a wheelchair down the B unit hall. Further observations revealed her left pant leg was raised up and exposed an undated bandage on her shin. On 2/4/25 at 10:45 a.m., an observation of Resident #138 revealed she was in bed with the head of bed at approximately a 45-degree angle. An observation of the resident's left shin revealed an undated bandage. A review of Resident #138's Admission Record revealed an original admitted [DATE] and re-admitted [DATE]. Further review of the resident's Admission Record revealed diagnoses including type 2 diabetes mellitus without complications, unspecified protein-calorie malnutrition, unspecified dementia, moderate, with agitation, weakness, and history of falling. A review of Resident #138's Active Orders revealed the following, Left shin: Cleanse skin tear with normal saline, pat dry. Apply xeroform and cover with a foam dressing every three days and PRN [as needed] if loose or soiled. as needed for loose or soiled dressing, with an order/start date of 2/4/25. Further review of Active Orders revealed the following, Left shin: Cleanse skin tear with normal saline, pat dry. Apply xeroform and cover with a foam dressing every three days and PRN if loose or soiled. every day shift every 3 day(s) for reopened skin tear, with an order/start date of 2/4/25. A review of Resident #138's January 2025 TAR revealed the following, Left shin skin tear: Cleanse with NS [normal saline], pat dry, apply xeroform and DCD [dry clean dressing] q [every] 3 days and PRN until resolved. every evening shift every 3 day(s), with an order date of 1/16/25 and a discontinued date of 1/31/25. A review of Resident #138's wound care notes revealed documentation by Staff G, LPN Wound Care on 1/31/25 and 2/5/25. The note on 2/5/25 by Staff G, LPN Wound Care revealed the following, Previously healed skin tear now noted with weakened most skin to superior aspect of original site . New order received and initiated. No other documentation related to Resident #138's left shin skin tear was observed in the resident's electronic health record from 1/31/25 to 2/4/25. On 2/5/25 at 10:33 a.m., an interview was conducted with Staff F, RN. She stated Resident #138 has orders for the left shin skin tear and received xeroform and a dry dressing. She stated the resident's bandage was changed by the wound care nurse. Staff F, RN stated the orders are for wound care every three days, or as needed. She stated Resident #138 is seen by the wound care nurse weekly. Staff F, RN stated floor nurses follow wound orders, and she monitors Resident #138's bandage daily. She stated the wound care nurse dates the resident's bandage. On 2/5/25 at 10:37 a.m., an observation of Resident #138's left shin was conducted with Staff F, RN. An observation of the bandage revealed a date of 2/4/25. She stated the initials on the bandage was the wound care nurse. On 2/5/25 at 10:51 a.m., an interview with Staff P, LPN/Unit Manager (UM) revealed whoever is changing the wound dressing should be documenting and labeling the bandage. She stated the wound care nurse wouldn't be treating a skin tear. Staff P, LPN/UM stated the floor nurse is supposed to treat the skin tear. She confirmed the expectations for wound care is to date the bandage. Staff P, LPN/UM stated, If you see a dressing with no date, who's to say how long it's been there? On 2/5/25 at 4:38 p.m., an interview with the Director of Nursing (DON) and Staff G, LPN Wound Care revealed Staff G, LPN Wound Care put Resident #138's dressing on 2/4/25. She stated she resolved treatment and discontinued orders on 1/31/25. Staff G, LPN Wound Care stated she received a call from the floor nurse stating Resident #138 had a dressing on with no date or physician's orders. The DON and Staff G, LPN Wound Care stated they don't know who put the dressing on. Staff G, LPN Wound Care stated, Staff aren't supposed to put anything on without dating it. The DON stated they shouldn't be putting a dressing on without orders. 48223 3. Review of the Admission Record revealed Resident #266 was admitted to the facility on [DATE] with diagnoses including infection and inflammatory reaction due to internal left knee prosthesis and bacteremia. On 2/4/25 at 10:20 a.m., Resident #266 was observed sitting up in a chair and had a dressing on the left knee dated 2/1. Review of Resident #266's Clinical Admission evaluation dated 1/31/25 at 10:26 p.m. revealed the resident was admitted with a surgical wound to the left knee. Review of Resident #266's hospital discharge summary dated 1/31/25 revealed dressing to remain until post op day #7 unless it becomes saturated, then change. The incision must remain covered until postop day #14. Review of Resident #266's February 2025 Order Summary Report showed no orders for treatment to the left knee until 2/4/25. During an interview on 2/5/25 at 2:33 p.m., Staff O, RN stated if a dressing is removed or replaced there should be a physician's order and if a resident is admitted with orders to leave a dressing intact then this order should be transcribed, so other nurses don't have to search for the information at a later date. During an interview on 2/5/25 at 4:17 p.m., the DON confirmed there was not an active order for Resident #266's left knee surgical incision until 2/4/25. Her expectation is the facility follow physician orders and call the physician for orders if needed. Review of the facility's policy and procedure titled Clean Dressing Change (Wound/Surgical Site) Clean, dated 7/23 revealed the following Procedure: 1. Verify physician's order for dressing change and pain medication. 15. Follow treatment order for application of topical medication, if ordered. 18. Document date, time dressing changed, and initials on a piece of tape and place on dressing. 23. Document the following in the electronic medical record: - Date and time of dressing change. 25. Change dressings according to treatment protocols and/or physician orders. 26. Notify the physician of any changes or concerns with wound or surrounding skin. 27. Review and revise treatment plan, as indicated and per physician order.

Based on interviews, and record review, the facility failed to offer a nourishing snack at bedtime for five (#268, #266, #269, #39, and #270) out of six residents sampled for dining. Findings included: During an interview on 2/3/2025 at 8:00 a.m., Resident #268 voiced concerns regarding the food. A follow-up interview occurred on 2/5/2025 at 12:19 p.m. Resident #268 stated not being offered an evening snack and they (the facility staff) said I needed to request a snack from the kitchen, although the kitchen is closed when I call. During an interview on 2/3/2025 at 9:55 a.m., Resident #266 voiced concerns regarding the food. A follow-up interview occurred on 2/5/2025 at 12:23 p.m. Resident #266 stated when requesting a snack, the evening of 2/3/2025, the staff stated they did not have snacks available. The evening of 2/4/2025 the staff member stated they did not usually have snacks, but would see what could be found, and they brought back a moon pie. During an interview on 2/3/2025 at 10:17 a.m., Resident #269 voiced concerns regarding the food. A follow-up interview occurred on 2/5/2025 at 12:15 p.m. Resident #269 stated the staff do not offer snacks after dinner and it would be nice if the facility did offer snacks after dinner. Resident #269 stated enjoying something sweet before going to bed when at home. During an interview on 2/5/2025 at 12:37 p.m., Resident #39 stated not being offered evening snack, although they would like a snack. During an interview on 2/5/2025 at 12:30 p.m., Resident #270 stated the staff did not offer an evening snack, although that would be wonderful. During an interview on 2/5/2025 at 2:46 p.m., the Dietary Manager (DM) stated snacks are sent to the units each evening for residents' that have requested one. The snacks are sent to the unit with the resident's name so the staff know who they are for. We also send a variety of other snacks (i.e., graham crackers, saltines, oatmeal cream pie, applesauce, pudding, and peanut butter crackers) in case a resident requests one. During an interview on 2/5/2025 at 4:17 p.m., the Registered Dietitian (RD) reviewed the facility Meal Delivery Schedule and stated there was at least 15 hours between dinner and breakfast. The RD continued to state not having reviewed this as the facility and corporate choose the times for the meals. Review of the facility's Meal Delivery Schedule, not dated, revealed the following: - Dinner: 1A Wing - 4:30 p.m. for Rooms: 100-200; 2C Wing - 4:40 p.m. for Rooms: 300; 3A Wing - 4:50 p.m. for Rooms: 20/40/60; 4C Wing - 5:00 p.m. Rooms: 300 Assist; Main DR (Dining Room) - 5:10 p.m. for Main; 5A Wing - -5:30 p.m. for Rooms: 40/60 Assist; 6B Wing - 5:40 p.m. for Rooms: Rooms #1; 7B Wing - 5:50 p.m. for Rooms: #2; 8D Wing - 6:00 p.m. for Rooms: All. - Breakfast: 1A Wing - 7:30 a.m. for Rooms: 100-200; 2C Wing - 7:40 a.m. for Rooms: 300; 3A Wing - 7:50 a.m. for Rooms: 20/40/60; 4C Wing - 8:00 a.m. for Rooms: 300 Assist; 5A Wing - 8:10 a.m. for Rooms: 40/60 Assist; 6B Wing - 8:20 a.m. for Rooms: #1; 7B Wing - 8:30 a.m. for Rooms: #2; 8D Wing - 8:40 a.m. for Rooms: All. Review of the Meal Delivery Schedule revealed 15 hours between dinner and breakfast for 1A, 2C, 3A, and 4C and 14 hours and 40 minutes for 5A, 6B, 7B, and 8D. Review of the facility's policy and procedure titled Frequency of Meals dated April 15, 2024, revealed: Purpose: The center will ensure that each resident/guest receives at least three meals daily without extensive time lapses between meals. Policy Explanation and Compliance Guidelines: 1. The center has scheduled three regular mealtimes, comparable to normal mealtimes in the community, per day and bedtime snack. 3. There will be no more than 14 hours between an evening meal and breakfast the following day, unless a nourishing snack is served at bedtime; then, up to 16 hours may elapse between an evening meal and breakfast the following day if the resident/guest council agrees to this meal time span. Review of the facility's policy and procedure titled Snacks, HS Snacks and Nourishments dated April 15,2024 revealed: Purpose: Snacks are provided in accordance with the prescribed diet and in accordance with state law and according to residents'/guests' preferences and requests. Individual and/or bulk snacks are available at the nurses' station or other designated locations, i.e., Pantry or Nourishment Rooms. Procedure: . 2. At least one (1) snack is offered at bedtime daily and is included in the menu nutritional analysis. Additional snacks should be available throughout the day per residents'/guests' preferences and requests. 3. Bulk snacks may also be available in the Pantry/Nourishment Room as part of a par level stocking program. 4. A minimum of two (2) of the following four food components is offered to all residents for the bedtime snack and is considered nutritionally complete snack: a. Fruit or Fruit Juice b. Whole grain or enriched variety crackers c. Variety of cookies; 5. Bedtime snacks for restrictive therapeutic diets, i.e., Renal, Liberal House Renal, Gluten Restricted, etc should be outlined on the menu. Diabetics on insulin should also receive a labeled bedtime snack. Snacks should be: a. Labeled with resident's/guest's name, room number, and date. b. Delivered to each nursing unit by the Culinary department. c. Offered to the residents/guests by the Nursing department d. Delivered on ice or placed directly into the Pantry/ Nourishment Room refrigerator or freezer and held at appropriate temperatures (</= 41 degrees or </= 0 degrees).

Based on observations, interviews, and record review, the facility did not ensure prompt efforts were made to resolve grievance for two residents (#109 and #268) out of three residents sampled for grievances. Findings included: During an interview and observation on 2/3/2025 at 12:29 p.m., Resident #109 stated repeated concerns regarding meals and care and the facility does not listen to her. During an interview on 2/4/2025 at 11:13 a.m., Resident #109 stated continued concern regarding meals and care. A review of the Grievance Logs from November 2024 to February 5, 2025, did not reveal grievance concern for Resident #109. Review of the grievance log for June 2024 revealed a grievance written for Resident #109 on 6/21/2024. During an interview on 2/5/2025 at 9:23 a.m., the Dietary Manager (DM) stated they spoke with Resident #109 on 2/3/2025 regarding meal concerns and updated the meal ticket. The DM continued to state I receive concerns from residents. I will meet with the resident and discuss, I do not document the concerns. I am trying to get better at that. During an interview on 2/5/2025 at 10:19 a.m., the DM presented Resident #109's meal ticket dated 2/5/2025, showing for breakfast the resident prefers cornflakes. The DM said on 2/3/2025, the meal ticket was updated but the update was not reflected until 2/5/2025 and prior to the update the resident's breakfast preference was oatmeal. During an interview on 2/6/2025 at 10:19 a.m., with Staff M, Licensed Practical Nurse and Care Plan Specialist (LPN/CPS) stated Resident #109 had a care plan meeting on 2/3/2025 during which time Resident #109 did have care and food concerns. Staff M, LPN/CPS stated referred Resident #109's concerns to the Unit Manager (UM). During an interview on 2/6/2025 at 10:35 a.m., Staff J, Registered Nurse/Unit Mansager (RN/UM) stated they spoke with Resident #109 regarding the concerns and stated anyone can file a grievance. Staff J, RN/UM stated upon receipt of a grievance, staff will document and send the grievance to the appropriate department for resolution. Once these steps are completed and the resolution occurs, the grievance is given to the Social Service Director. During an interview on 2/3/2025 at 9:55 a.m., Resident #268 stated having concerns about care and food temperatures since admission on 1/28/2025. Resident #268 also stated he reported the concerns to everyone, certified nursing assistants (CNAs), nurses, and unit manager and nothing has changed. A Review of the Grievance Log from January 2025 to February 5, 2025, did not reveal grievance concerns for Resident #268. During an interview on 2/5/2025 at 2:00 p.m., Staff N, CNA confirmed Resident #268 complained about the temperature of the food and some other things. Staff N, CNA also stated they don't really have time to complete the grievance, that is for something really big. During an interview on 2/5/2025 at 2:33 p.m., Staff O, RN stated anyone can fill out a grievance and they place the completed form in the Unit Manager's office for follow-up. During an interview on 2/5/2025 at 8:00 a.m., the DM stated they did not know of a consistent problem with cold food. The DM also stated there have been concerns with food temperatures but very sporadic and nothing that would need a grievance for. During an interview on 2/5/2025 at 2:25 p.m., the Social Services Director (SSD) confirmed being responsible for the grievance process. The SSD explained grievances can be completed by anyone (i.e. staff, family, resident) for the facility to work on. The grievance is filled out and given to her or kept by the manager who filled it out. The grievance is then brought to the morning meeting for discussion and logging. The grievance is given to the appropriate department for follow up and resolution with the resident. Once the department manager resolves the grievance with the resident, the completed form is turned in to the SSD for filing and tracking. The SSD stated they try to resolve the grievances quickly, 3-5 days but she doesn't follow up with any of the residents regarding issues unless they were related to Social Services. The SSD stated they will summarize the areas of concern, weekly and monthly, for the Quality Assurance Committee and they have noticed some trends in call lights and food temperatures, but they were not sure if anything has happened with those trends. During an interview on 2/6/2025 at 10:08 a.m., the Nursing Home Administrator (NHA) stated the grievance process is coordinated by the SSD and anyone can complete a grievance. The grievance is received and logged by the SSD, then taken to the next manager meeting, which is held twice daily, in the morning and at the end of the day, for discussion and assignment for investigation/resolution. Discussion occurs regarding the grievance at the meetings daily until resolved, usually 3-5 days. The SSD tracks and trends the data for discussion at the Quality Assurance Committee. Review of the facility's policy and procedures titled Grievances with revision date of March 2024 revealed the following: Purpose: F585 - The center recognizes the guest/resident/legal representative/family has the right to voice grievances to the center without discrimination and without fear of reprisal. The center team members are responsible for making prompt efforts to resolve a grievance and to keep the guest/resident appropriately updated on the progress being made toward resolution. Definitions: Prompt effort to resolve includes the center's acknowledgment of a grievance and to actively work toward a documented resolution of that grievance. Policy: The Grievance Official and Social Services personnel will serve as guest/resident liaisons/advocates in the concern grievance procedure. 4. The guest/resident has the right to file a grievance orally or in written format. 5. The center will make a prompt effort to resolve any grievance received. Grievances will be reviewed, investigated, resolved and documented in five days. 7. The center will review with the guest/resident/legal representative/family the final resolution of the grievance. Procedure: The Grievance Official and Social Services personnel will serve as resident liaisons/advocates in the concern grievance procedure. 1. A grievance is defined as any formal expression (verbally or in writing) of interest regarding the well-being of a guest/resident. 4. The center will designate a Grievance Official with whom the grievance can be filed and will post his or her name, business address (mailing and email) and business phone number. Any team member can write or assist in the writing of a grievance. 5. The Grievance Official is the Social Service Director/designee. a. The Grievance Official is responsible for the following items: 1. Overseeing the grievance process to include receiving and tracking grievances through to their conclusions to include the investigation, documentation of the summary and the follow up. 5. The Grievance Official will close the grievance and reflect the conclusion/outcome of the grievance investigation or abuse investigation. 6. The Grievance Official will provide the guest/resident/legal representative with a written decision about the filed grievance upon request. 7. The grievances will be brought to the morning stand up meeting daily. They will be reviewed out loud with all the leadership team members. The grievance forms will come to the stand up meeting daily until resolved. 9. Below is a list of items that the investigating team member will include on the grievance form and the Grievance Official will be responsible to assure is completed when a written decision is requested. A written decision will only be provided by the Grievance Official/designee. a. The date the grievance was received. b. The guest/resident name that is involved in the grievance. c. A summary of the guest/resident/legal representative/family grievance. (What is the grievance)? d. The steps that were taken to investigate the grievance. e. A summary of the pertinent findings or conclusions of the investigation regarding the grievance. f. A statement as to whether the grievance was confirmed or not confirmed. g. Documentation of any corrective action taken or to be taken by the center. 10. Upon receipt of the grievance, documentation on the grievance form will be initiated by the Grievance Official/designee or whichever professional team member receives the concern. Instructions for completion are outlined on the Addendum. a. The Grievance Official/designee will document the date the grievance is received on the Grievance Log and copies are made and distributed to the Executive Director and the referenced department representative.

Based on observations, interviews, and record reviews, the facility failed to ensure care to prevent pressure ulcers was received in accordance with professional standards of practice for one resident (#30) of five residents sampled for skin conditions. Findings included: Review of the medical record revealed Resident #30 was admitted to the facility on [DATE]. Review of the diagnosis sheet revealed diagnoses to include but not limited to palliative care, weakness, muscle weakness/atrophy, reduced mobility, need for assistance with personal care, and risk for pressure ulcers. Review of Resident #30's February 2025 Order Summary Report revealed the following orders: - Resident to wear right offloading boot when in bed as tolerated; remove for care and skin checks. Re: right heel DTI (deep tissue injury) every shift, order date 11/22/2024. - Offload bilateral heels while in bed as tolerated every shift for preventative, order dated 11/13/2024. On 2/3/2025 at 8:50 a.m., Resident #30 was observed noted in her room and lying upright. Resident #30's feet were observed sticking out from the bed covers at the end of the bed. Resident #30 was not wearing any splint or boot orthotics during the time of the observation. Staff R, CNA was observed going in the room and assisted with breakfast meal/tray set up. Staff R, CNA was interview following the observation and stated she was not sure if Resident #30 had any weakness or contractures in her upper or lower extremities. Staff R, CNA confirmed she had Resident #30 on her assignment regularly during the 7 a.m. to 3 p.m. shift. On 2/5/2025 at 7:40 a.m., Resident #30 was observed in her room lying in bed with both feet observed sticking out from the bed linen. Both feet were bare and were without any type of splint/orthotics. At 7:55 a.m., an interview with Resident #30's assigned CNA Staff CC, CNA, who revealed she knows the resident and her daily care needs. She also revealed she did not know if Resident #30 had any upper or lower extremity weakness or has any contractures and confirmed she was unaware if the resident utilizes any splints or orthotics, to include use of a soft resting/offloading boot. On 2/5/2025 at 11:00 a.m. and 12:43 p.m., Resident #30 was observed in her room and lying in bed and was not wearing any type of foot splint/orthotic offloading boot during times of the observations. On 2/5/2025 at 1:10 p.m., Resident #30 was observed in her room and was. The resident was asked if she wears any type of splints or boots and she said, bunny boots, but could not remember the last time she wore them. She could not remember a time when she refused to wear them. Following the interview, resident's assigned CNA Staff AA, CNA, was interviewed. Staff AA, CNA confirmed she had Resident #30 on her assignment regularly and revealed the resident is dependent on staff for all her ADLs. Staff AA, CNA was not able to state if the resident wore any splints or boots on her feet. Staff AA, CNA entered Resident #30's room and asked the resident if she could open her stand up closet door. After obtaining permission from the resident, Staff AA, CNA opened the door and at the bottom of the closet was a light blue colored soft boot, right footed. Staff AA, CNA revealed she was not aware of the boot before. The resident saw the boot and said, yes I have worn that before. She continued to say she did not want it anymore because it hurt her foot. She confirmed staff did not offer her to wear it for a while and did not know it was part of a doctor's order. Review of the current Quarterly MDS assessment dated [DATE], revealed; Cognition/BIMS score - 11 of 15, which revealed the resident had mild cognitive impairment. It was evident through review of the nurse progress notes and interviews with the assigned CNA, the resident was not offered to wear the right side offloading boot for at least three days observed 2/3/25, 2/4/25, 2/5/25. Review of Resident #30's Care Plans with a next review date 3/6/2025 did not reveal problem areas/interventions related to Resident #30's right heel, as indicated in the current Order Summary Report. On 2/6/2025 at 7:55 a.m., Resident #30 was observed in her room seated upright in her bed and under the bed sheets/covers. Both of her feet were sticking out from the sheets and were noted with no orthotic or splint/soft boot on her right foot. On 2/6/2025 at 10:00 a.m., an interview with Staff J, RN UM revealed she was knowledgeable of Resident #30 with relation to her daily medical care and services. Staff J, RN UM revealed Resident #30 usually stays in her room throughout the day and does not wish to participate in group activities or eat in the community dining room. Staff J, RN UM confirmed Resident #30 usually does not like to get out from bed to a chair and has right side weakness and skin integrity with risk for pressure ulcers. Staff J, RN UM confirmed the resident was ordered a right foot boot to wear use daily and as tolerated. Staff J, RN UM was not sure if the resident had behaviors of refusing to wear the boot, but revealed staff are to assist with the boot daily, per the order, and to document if used or refused. Staff J, RN UM reviewed Resident #30's medical record and could not find any documentation or care planning behavior problem areas relating to Resident #30 refusing to wear the boot on her right foot. Review of the February 2025 MAR revealed documentation on the 7 a.m. to 3 p.m. shift on 2/3/2025, 2/4/2025, and 2/5/2025 indicating Resident #30 was offered and assisted with the right foot offloading boot. Observations during the 7 a.m. to 3 p.m. shift and interview with the resident and Staff AA, CNA and Staff CC, CNA during the same days observed, revealed Resident #30 was not offered or wearing the boot. On 2/6/2025 at 11:00 a.m., an interview with the Rehabilitation Director confirmed the Rehabilitation Department both Physical Therapy and Occupational Therapy were not currently seeing Resident #30 on their caseload. The Rehabilitation Director revealed the offloading boot would not come recommended or ordered from their department as this boot was that was ordered from the physician was for pressure ulcer reducing risk.

Based on observations, interviews, and record review, the facility failed to follow contracture maintenance programs for one resident (#81) of sixty-seven sampled residents. It was found the resident was not assisted with donning and doffing of their splint device during four of four days observed (2/3/2025, 2/4/2025, 2/5/2025, and 2/6/2025). Findings included: On 2/4/2025 at 2:30 p.m., Resident #81 was noted in his room and lying in bed and under the covers. Resident #81's right hand appeared contracted and he was not wearing any splints or orthotics. There was no evidence in the room of a splint or orthotic. During an interview with the Resident's assigned Certified Nursing Assistants (CNAs) Staff R, CNA and AA, CNA, both revealed they know the resident and have him on their routine assignments. Staff R, CNA and AA, CNA were unaware Resident #81 had any right hand weakness or contracture and were unaware if he utilized any splints or orthotics on that hand. On 2/5/2025 at 7:23 a.m., 8:43 a.m., and 1:40 p.m., Resident #81 was noted in his room and in bed with the room lights off. Resident #81's right hand was observed without any splint or orthotic on. There was no evidence in the room of any hand splints or orthotic for use. On 2/5/2025 at 8:43 a.m., Resident #81 was observed awake and alert. It was found he was hard of hearing, could speak, but interview questions needed to be written on a pad of paper for him to read. He permitted an interview and it was communicated via pen and paper. The following questions were written for Resident #81 to read, and he communicated back verbally: 1. Are you in any physical pain, to include your ear? Resident #81 responded, Not in any pain, but I am supposed to see an ear doctor. 2. Which hand do you eat with? Resident #81 responded, I eat with my left hand and try with my right hand. 3. Are you in any pain in your right hand? Resident #81 responded, No pain, but I can't use it much. 4. Are you seeing Therapy for your right hand weakness/contracture? Resident #81 responded, I did before but not recently. 5. Do you wear a splint or orthotic on your right hand? Resident #81 responded, No, but I have a splint hanging in my closet. 6. Do you or do staff assist you with wearing of the splint on your right hand? Resident #81 responded, Staff are supposed to help put it on, I can't get it or put it on myself. It was observed the splint was in a yellow bag and hanging on the door. 7. When was the last time staff assisted with putting the splint on your right hand? Resident #81 responded, I can't even remember, it has been awhile and I actually forgot about it. 8. Would you wear it if staff assisted placing it on your right hand? Resident #81 responded, Yes, I would, I know it helps with my weakness. 9. In the past, did you wear the splint on your right hand during the day or during the night? Resident #81 responded, I believe I was helped with it at night, but it's been awhile since I have had it on, and the night staff have not helped put it on. Review of Resident #81's February 2025 Order Summary Report revealed the following order: - Patient to wear R (right) resting hand splint at tolerated, don R hand splint status post p.m. care, doff R hand splint status post a.m. care with frequent checks for redness, edema, or pressure areas. If so, immediately contact Occupational therapy. Order date 3/20/2023. Review of the 1/2025 and 2/2025 Medication Administration Record (MAR)/Treatment Administration Record (TAR) did not reveal documentation related to the right hand splint order or documentation to support the order was followed. Review of the current care plans, with next review date 4/20/2025, revealed the following: - At risk for falls related to: weakness, possible medication side effects, impaired vision. Interventions in place to include: Pressure relieving cushion, right resting hand splint as ordered and tolerated, and keep adaptive equipment within reach. - Resident has self-care deficit related to CVA (cerebrovascular accident) with right sided weakness, functional quadriplegic, requires extensive assistance with ADL's (activities of daily living) and requires mechanical lift and assist of two for transfers. Interventions include: Resident to wear right resting hand splint as tolerated, put on right hand splint after P.M. care, take off right hand splint after A.M. care with frequent skin checks for redness, edema, or pressure areas. On 2/5/2025 at 10:10 a.m., an interview with the Rehabilitation Director revealed she was familiar with Resident #81 and both Physical Therapy (PT) and Occupational Therapy (OT) completed therapy with him but she was going to have OT re-evaluate him for his splint use very soon. The Rehabilitation Director revealed the Rehabilitation Therapy department send the plan and direction out for nursing to follow and usually it is the responsibility of the aide on shift at nights to position the right hand splint, and then to remove during care and also during the days. The Rehabilitation Director was not aware staff were not placing the right hand splint on Resident #81 per the order and plan of care. She also was not aware the Medication Administration Record (MAR), and Treatment Administration Record (TAR) did not have the order to show this splint was offered/placed/removed on a daily basis. Staff BB was aware this Right hand splint was care planned with interventions for nursing staff to place on daily and as tolerated. On 2/6/2025 at 7:30 a.m., Resident #81 was noted in his room and lying flat in bed. The resident was not wearing a splint or orthotic on his right hand. On 2/6/2025 at 7:36 a.m., an interview with Staff W, Licensed Practical Nurse (LPN) revealed she was knowledgeable of Resident #81 and she has him on her routine daily assignment. She confirmed Resident #81 is hard of hearing and communicates by way of writing on a note pad with a pen. Staff W, LPN revealed Resident #81 can verbalize, he just cannot hear. She further confirmed he has right side upper extremity/hand weakness and he wears an orthotic/splint at night. She stated she believes he refuses the orthotic/splint but verified there was no documentation in the resident's chart to support that. She also confirmed he did not have any Behavior care plans to support refusal of care and treatment. Staff W, LPN revealed the order shows Resident #81 is to wear a right hand splint during the nights and by the time she gets to work for the 7 a.m. to 3 p.m. shift, the splint should already be removed, so she would not know if he wore it in the evenings or not. Staff W, LPN also confirmed the MAR did not support any information to document if the splint was offered, worn, or refused on a daily basis. On 2/6/2025 at 10:00 a.m., an interview with Staff J, RN Unit Manager (UM) confirmed she was knowledgeable of Resident #81 and his care. She revealed he stays in his room by choice most of the day and receives assistance from staff with most of his ADLs. She revealed he has right sided weakness, to include his upper extremity and right hand. Staff J, RN UM further revealed the resident was on a splinting program, which was ordered by the physician, based on education and recommendation by the OT department. She revealed Resident #81 was to wear a resting hand splint on his right hand in the evenings and as tolerated. She also revealed nursing staff, to include CNAs, are responsible for applying and removing of the splint daily. Staff J, RN UM also revealed Resident #81 will refuse the splint at times but was not able to confirm this through the resident's record documentation. Staff J, RN UM confirmed there was no documented evidence to support Resident #81 refuses to wear the right hand splint. Staff J, RN UM revealed Resident #81 is able to make his daily decisions and was interviewable with knowledge of his medical care and services. Review of the medical record revealed Resident #81 was admitted to the facility on [DATE]. Review of the advance directives revealed he was his own responsible party. Review of the diagnosis sheet revealed diagnoses to include but not limited to hemiplegia, muscle spasms, and repeated falls. Review of the current Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed; Cognition/Brief Interview Mental Status (BIMS) score 15 of 15, which indicated the resident was cognitively intact. ADL - Upper extremity impairment one side. Active Diagnoses - Hemiplegia and Paraplegia. Review of Resident #81's medical record revealed the following: - Admission/Preadmission Nursing Evaluation dated 10/14/2020 revealed; Section Q under Mobility, resident very limited and makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. Notes revealed resident has right sided weakness. - Occupational Therapy Evaluation and Plan of Treatment for certification period of 9/11/2023 to 12/9/2023 revealed primary diagnoses of hemiplegia affecting right dominant side and abnormal posture. The Assessment further revealed objectives and goals to re-establish hand/wrist splint wear to prevent further skin and or joint breakdown. Right wrist 30 degree flex contraction with note slight radial deviation. Patient recently was on OT caseload for splinting and states has not been wearing splint. Target: 9/24/2023. The baseline 9/11/2023 revealed patient reports has been wearing right hand splint. Goal #2 revealed to educate staff/patient on proper splint wear and wheelchair management to prevent further joint and or skin breakdown with target date of 12/9/2023. - Review of the Occupational Therapy Discharge Summary dated 9/21/2023 revealed the reason for discharge from therapy was the resident's maximum potential achieved. Comments on 9/21/2023 revealed the resident states he has not been wearing the splint. Further notes revealed; Patient/staff claims to have continue to be wearing right resting splint, Therapist noted decreased tone in RUE (right upper extremity) from last encounters. Patient has been observed wearing splint early mornings. Staff educated on wear, care, and frequent skin checks with good understanding. The summary note revealed; Patient and Caregiver Training: Patient/Staff/caregivers have been provided with therex (therapeutic exercises), theract (therapeutic activities), NMR (neuromuscular reeducation), and ADL prothesis training/education with facility, PROM (passive range of motion)/stretch. The discharge status and recommendation section of the discharge summary revealed; OT recommending PT/Staff continue right hand/wrist resting hand splint to prevent further tone/contracture and ROM (range of motion) of BUE HEP (home exercise program) (specific to RUE) while perform ADL, and encouragement to participate in OOB (out of bed) activities to maintain current level of function. - Review of Nurse Progress Notes dated from 11/5/2024 - 2/5/2025 did not reveal any documentation to support Resident #81 refusing to wear the right hand splint at nights or documentation to support use of the right hand splint. The Rehabilitation Director provided a Rehab to Nursing Communication Form, dated 3/13/2023 for review. The form revealed a topic of: Splint wearing schedule. The remarks revealed; Pt (patient) to wear right resting hand splint as tolerated splint to be put on during p.m. care and removed with a.m. care. Monitor for changes in skin integrity and perform hand and nail hygiene as needed. The form was signed and dated by a therapist on 3/13/2023, nurse on 3/13/2023, Rehabilitation Director on 3/14/2023, and a Unit Manager, not dated. Review of a Splinting and Wheelchair Positioning Program sheet identified precautions and instructions for use of the right hand splint. The sheet revealed precautions to include frequent skin checks and instructions and adaptive equipment to include: Resting hand splint as tolerated, Pt able to don (apply) independently, requires assistance to doff (remove). The notes revealed: Pt to utilize right resting hand splint as tolerates recommended on with p.m. care and doff with a.m. care, receive frequent skin checks; Pt able to doff independently. On 2/6/2025 at 1:00 p.m., the Nursing Home Administrator (NHA) provided the SPLINT and BRACE Program procedure for review. The document did not have a last review date. The procedure revealed; Splints to be worn according to the schedule outlined in the Referral from therapy that then placed in Tasks and the Kardex. Therapy will train the CNAs and nursing team members how to put the device on and off with the specifics on the SPLINTING PROGRAM form. Each guest or resident with a splint will have a SPLINT BOX or designated splint storage container when it is not in use. It should be labeled with the resident/guest's name and located in their room. The SPLINTING PROGRAM form will be stored in the top of the splint box for reference and any other place deemed appropriate by the center [Interdisciplinary Team]. Cleaning of the splint should be done according to manufacturer's guidelines. Examples of Typical splints seen in our centers are: The Resting Hand Splint, The Ankle-Foot Orthosis (AFO).

Based on interview and record review, the facility failed to ensure the documentation was accurate in the medical record for three of three sampled residents (#1, #2, #3). Findings included: Resident #1 was admitted on [DATE] and discharged on [DATE] to the hospital according to the face sheet. Review of the Admissions Report showed diagnoses included but were not limited to pneumonia, Urinary Tract Infection, severe protein-calorie malnutrition, hemiplegia following a Cerebral Vascular Accident, hypotension, polyneuropathy, muscle weakness, history of falls, dysphagia, neuromuscular dysfunction of bladder, gastrostomy, spinal stenosis, anemia, recurrent severe depressive disorder, stage 3 chronic kidney disease, other specified interstitial pulmonary diseases, and bronchiectasis. Review of the 5-day Minimum Data Set (MDS) dated [DATE] showed Section C Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact). Section GG showed the ability to eat was not applicable, he required partial to moderate assistance for toileting and bathing. The resident used a wheelchair. Section K, Swallowing Disorder showed the resident used a feeding tube for nutrition. Review of the physician orders showed a full code; NPO (nothing by mouth) diet Review of the Clinical Admission on 03/19/2024 showed under 11. Nutrition section 3. He was receiving nutrition orally. 4. Taking nutrition and hydration orally. No complaints of thirst. No signs and symptoms of swallowing disorder. Mucous membranes moist. 5. Intake, NPO was not checked. Education does not address Gastrostomy tube. Review of the nursing progress notes showed: -On 03/20/2024 at 1557, resident continues on antibiotic po (by mouth) for pneumonia with no adverse effect. Resident has a productive cough with moderate secretions, denies SOB (shortness of breath). No active fever, fluids encouraged. Staff E, Licensed Practical Nurse (LPN) -On 03/20/2024 at 19:02 (7:02 p.m.) showed no signs of difficulty breathing. No SOB noted. Head of bed elevated. Head elevated at 30 degrees. Cough present. Moist/loose productive cough noted. Moderate amount of secretions. Secretions are moderate in consistency. Secretion clear. Cough with effective airway. Cough with retained secretions. No pain related to cough. Taking nutrition and hydration orally. No complaints of thirst. No signs / symptoms of swallowing disorder. Staff E, LPN -On 03/21/2024 at 15:52 (3:52 p.m.), HOB (Head of Bed) elevated at 30 degrees. Cough present. Moist/loose productive cough noted. Moderate amount of secretions. Secretions are moderate in consistency. Secretions clear. cough with effective airway. Taking nutrition and hydration orally. No complaints of thirst. No signs / symptoms of a swallowing disorder. Currently on antibiotics (ABT) for pneumonia. Staff E, LPN -On 03/21/2024 at 15:59 (3:59 p.m.), resident continues on ABT po for pneumonia with no adverse effects presents with productive cough with moderate clear secretions. Resident denies SOB or pain with coughing. No current fever. Staff E, LPN -On 03/22/2024 at 15:34 (3:34 p.m.) no signs of difficulty breathing. No SOB noted. HOB elevated at 30 degrees. Cough present. Moist/loose productive cough noted. Moderate amount of secretions. Secretions are moderate in consistency. Secretions clear. cough with effective airway. Taking nutrition and hydration orally. No complaints of thirst. No signs / symptoms of a swallowing disorder. Currently on antibiotics. Staff E, LPN -On 03/23/2024 at 17:46 (5:46 p.m.), pt (patient) had several opened back dated g-tube syringes on dresser in room, pt used an opened syringe and bolus self with Boost which was located in drawer. Old open g-tube syringes removed from room. Pt approached this writer and stated he bolus self with Boost for years and he wants g-tube syringes to remain at bedside for his own personal use. PCP (primary care physician) will follow up with pt. LPN -On 03/24/2024 at 15:09 (3:09 p.m.) HOB elevated at 30 degrees. No signs of difficulty breathing. No SOB noted. No cough. Nutrition was blank. Staff B, Registered Nurse, weekend supervisor (RN, WE supervisor) -On 03/25/2024 at 16:50 (4:50 p.m.) No signs of difficulty breathing. No SOB noted. HOB elevated 30 degrees. Cough present. Cough present. Moist/loose productive cough noted. Moderate amount of secretions. Secretions are moderate in consistency. Secretions yellow. cough with effective airway. Taking nutrition and hydration orally. No complaint of thirst. No s/s of a swallowing disorder. Currently on Abt for pneumonia. Staff E, LPN -On 03/26/2024 at 20:31 (8:31 p.m.) No signs of difficulty breathing. No SOB noted. HOB elevated 30 degrees. Cough present. Cough present. Moist/loose productive cough noted. Moderate amount of secretions. Secretions are moderate in consistency. Secretions clear. cough with effective airway. Taking nutrition and hydration orally. No complaint of thirst. No s/s of a swallowing disorder. Currently on Abt for pneumonia. Staff E, LPN -On 03/28/2024 at 15:22 (3:52 p.m.) No signs of difficulty breathing. No SOB noted. HOB elevated 30 degrees. Cough present. Moist/loose productive cough noted. Moderate amount of secretions. Secretions are moderate in consistency. Cough with effective airway. Taking nutrition and hydration orally. No complaint of thirst. No s/s of a swallowing disorder. Currently on Abt for pneumonia. Staff E, LPN -On 03/29/2024 at 15:17 (3:17 p.m.) pulse ox at 94%. Alert and oriented x 3. No signs of difficulty breathing. No SOB noted. HOB elevated 30 degrees. Cough present. Moist/loose productive cough noted. Moderate amount of secretions. Secretions are moderate in consistency. Cough with effective airway. Taking nutrition and hydration orally. No complaint of thirst. No s/s of a swallowing disorder. Currently on Abt for pneumonia. Staff E, LPN Review of the Aide Tasks showed: What percentage of the meal was eaten? -03/20/24: 08:00 x (times) 25-50%; 12:30 x 51-75%; 17:31 x 51-75% -03/26/24: 17:42 x 51-75% -03/28/24: 17:22 x 51-75% -03/29/24: 20:59 x 0-25% Number of times fluid offered: -03/19/24: 21:33 x 100 -03/20/24: 14:59 x 3; 1733 x 3 -03/21/24: 02:04 x 1; 1309 x 2; 2259 x 3 -03/22/24: 02:46 x 1 -03/24/24: 03:12 x 1; 1452 x 2 -03/25/24: 14:38 x 2 -03/26/24: 01:47 x 1; 14:59 x 2; 17:40 x 3 -03/27/24: 06:59 x 1; 22:34 x 3 -03/28/24: 17:24 x 3 -03/29/24: 11:30 x 2; 21:02 x 3 -03/30/24: 09:08 x 4 Does resident take snack? -03/20/24: 10:00 x yes; 14:00 x yes -03/21/24: 22:59 x yes -03/24/24: 21:00 x yes -03/26/24: 22:24 x yes During an interview on 04/11/2024 at 11:16 a.m. Staff E, LPN stated it was a mistake on her documentation that he (Resident #1) was nothing by mouth for medications. He was getting everything by his g-tube. Staff E, LPN reviewed the skilled notes she had documented and stated it was incorrect documentation. He was taking his meds and nutrition via g-tube. Staff E, LPN stated, It was careless charting. She stated she never saw him take anything orally. He (Resident #1) had stated he had a g-tube for [AGE] years. During an interview on 04/11/2024 at 11:33 a.m. the Director of Nursing (DON) stated the documentation was an error, referring to the nursing notes and aide task notes. The DON stated she would have to call these staff members and ask them about their documentation. She stated she did not look at the documentation in the ADL (activities of daily living ) tasks after the incident. The DON stated, I truly feel they were just checking it off. We will look into that and start education today. It is very concerning to me. 22481 A review of Resident #2's clinical chart, the face sheet, documented an admission of 03/01/2024 with a readmission of 03/25/2024. His diagnoses information included Pneumonitis due to inhalation of food and vomit. A review of Resident #2's physician orders reflected he was ordered a NPO (Nothing by mouth) diet. A review of Resident #2's snack provision, as documented by the certified nursing assistants for the period of 03/28/2024 through 04/09/2024, reflected the resident had been documented to have been provided a snack on 03/28, 03/29, 03/30, 04/01, 04/02, 04/03, 04/04, 04/05, 04/06, 04/07,04/08, and 04/09. An observation was conducted on 04/10/2024 of Resident #2 in his room. Resident #2's eyes were open, alert, but he did not verbally answer questions. He nodded acknowledgment, and nodded when asked if he was comfortable. A review of Resident #3's clinical chart, the face sheet, documented an admission of 02/23/2021 with a readmission of 03/15/2024. His diagnoses information included Pleural effusion and dysphagia. A review of Resident #3's physician orders reflected he was ordered a NPO diet. A review of Resident #3's snack provision, as documented by the certified nursing assistants for the period of 03/28/2024 through 04/09/2024, reflected the resident had been documented to have been provided a snack on 04/05/2024. An observation was conducted on 04/10/2024 at 11:15 a.m. of Resident #3, in his room. He was observed in bed, the television was on. Resident #3 did not answer when spoken to.

Based on interview and record review, the facility failed to report an event that led to transfer to a higher level of care within the specified timeframe of the allegation for one of one sampled residents (#1). Findings included: Review of the facility's policy, Abuse, Neglect, Exploitation and Misappropriation, revised September 2023 showed the center recognizes each resident's right to be free from abuse, neglect, and exploitation (ANE), misappropriation of resident property. Neglect: Neglect as defined in statute 483.5 is the failure of the center, its team members or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. This occurs when the center was aware of or should have been aware of, goods, or services that the resident (s) required but the center failed to provide them resulting in or may result in physical harm, pain, mental anguish, or emotional distress. 6. Reporting: All team members are required to report suspected maltreatment to their immediate Supervisor or Director of Quality Assurance / designee or Executive Director. Notifications can take place in person or via telephone. The employee must report to department manager or supervisor in the center so that the resident may immediately be protected from further maltreatment. The Executive Director or The Director of Quality Assurance are to be informed immediately of the situation. In the absence of the Executive Director and the Director of Quality Assurance the Director of Clinical Services and / or the Social Service Director are to be informed of the situation immediately. The center also must report all alleged violations of any type of abuse or any event that led to significant bodily injury immediately but no later than 2 hours from the time of the allegation. The center must report all alleged violations of neglect, exploitation, or misappropriation immediately but no later than 24 hours from the time of the allegation. If any of these resulted in serious bodily injury, then you must report within 2 hours of the time of the allegation. Incidents of ANE or Misappropriation requires notification to outside agencies. These include the State Survey Agency (Agency for Healthcare Administration), Adult Protective Services / Department of Children and Families and if there is suspicion that a crime is involved then notification to local law enforcement. The Director of Clinical Services / designee shall notify the physician and the resident's representative concerning the suspected maltreatment and the findings of the assessment. The Director of Clinical Services / designee shall reassure the resident's representative that an investigation has been initiated, that the resident is being protected and that appropriate action has been taken. All verbal contact with the resident's representative shall be documented accordingly. The Director of Quality Assurance / designee will file the Immediate Federal report with AHCA, and then submit the summary and findings of the investigation with the 5-Day Federal Report. Resident #1 was admitted on [DATE] and discharged on [DATE] to the hospital according to the face sheet. Review of the Admissions Report showed diagnoses included but were not limited to pneumonia, Urinary Tract Infection, severe protein-calorie malnutrition, hemiplegia following a Cerebral Vascular Accident, hypotension, polyneuropathy, muscle weakness, history of falls, dysphagia, neuromuscular dysfunction of bladder, gastrostomy, spinal stenosis, anemia, recurrent severe depressive disorder, stage 3 chronic kidney disease, other specified interstitial pulmonary diseases, and bronchiectasis. Review of the 5-day Minimum Data Set (MDS) dated [DATE] showed Section C Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact). Section GG showed the ability to eat was not applicable, he required partial to moderate assistance for toileting and bathing. The resident used a wheelchair. Section K, Swallowing Disorder showed the resident used a feeding tube for nutrition. Review of the physician orders showed a full code and revealed; NPO diet. Enteral Feeding of Boost Very High Calorie, 237 ml [milliliter] bolus four times a day, family to provide as of 03/29/2024. Enteral feeding at bedtime, Jevity 1.5 237 ml every evening, flush with 120 ml water before and after as of 3/29/2024. Flush feeding tube with 120 ml of water before and after each feeding 5 times a day and four times a day for hydration as of 3/29/2024. Send to ER [emergency room ] on 3/30/2024. Review of the nursing progress notes showed: On 03/30/2024 at 15:42 (3:42 p.m.) the patient was in the ice cream social and began to become hypoxia and de-sating. Brought back to his room and placed in his bed. O2 (oxygen) sats (saturation) in the 40s. Placed on portable oxygen. Put on 15 Liter rebreather mask which only improved to the 70s. Still pallor in color. Order to send out was made. 911 called. Pt [patient] sent out around 2 p.m. family aware. Staff C, Registered Nurse (RN) Review of SNF/NF [skilled nursing facility/nursing facility] to Hospital Transfer Form dated 03/30/2024 at 14:20 (12:20 p.m.) showed SOB [short of breath], oxygen saturation in the 60's. Enteral feeding via peg tube. Staff B, RN During an interview on 04/10/2024 at 1:47 p.m. with the Nursing Home Administrator (NHA), the Director of Nursing (DON) and the Director of Quality Assurance / Risk Manager (DOQA/RM), the DOQA / RM stated during the investigative process, Resident #1 was self-propelling in the facility. Resident #1 self-propelled from his room on the D wing to the C wing to the main dining room where a group activity was occurring. This was normal for him. Resident #1 was alert and oriented. Resident #1 performed his own transferring. Resident #1 socialized and was into mingling. DOQA / RM stated that Staff C, RN was his nurse and stated she last observed Resident #1 at 1 p.m. for his bolus feeding and medications. Resident #1's Certified Nursing Assistant (CNA) stated she observed him in his room at 1:30 p.m. for personal care. DOQA / RM stated he was independent at baseline. DOQA / RM stated Resident #1 has had the peg tube for greater than a year according to the family. Resident #1 managed the peg tube at home and gave his own bolus feedings at home. DOQA / RM stated that day (03/30/2024) at 3:30 p.m. he ate ice cream. The activity was an ice cream social. DOQA / RM stated, Originally, I was told he grabbed the ice cream. During the reenactment, Staff A, Activity Aide (AA) showed that she stands in front of the congregated group (20 residents), and she said she asks who wants ice cream and then she gives them ice cream. The NHA stated they have a rolling cart / cooler for activities only. It was scooped ice cream into cones. The DOQA / RM stated there were no other staff members in the ice cream social. There were other residents there but no staff. The DOQA / RM stated through the investigation it was determined Resident #1 had asked for the ice cream and Staff A, AA handed it to him. The NHA stated that the story changed a couple of times. The DOQA / RM stated the investigation was started on 04/01/2024, after DOQA / RM reenacted the scene with Staff A, AA. The DOQA / RM stated that Staff A, AA admitted she had the Dietary List. The Dietary List included all the residents and included all the residents' dietary types, NPO [nothing by mouth], thickened liquids, etc. The DOQA / RM stated the Dietary Tool was 11 pages long that day, it was a list of the whole house. The DOQA / RM stated Resident #1 was transferred to the hospital on 03/30/2024. The DOQA / RM stated Staff A. AA was removed from the schedule on 04/01/2024 after full knowledge of the incident. The DOQA / RM stated she was first informed he grabbed the ice cream. DOQA / RM found out it was given to him, and it was on a cone, not just a cup. On 04/04/2024, Staff A, AA was terminated from service with closure of the investigation. The DOQA / RM stated the Federal Report went in on 04/01/2024 for 1-day at 8:50 p.m., the 5-day on 04/05/2024 at 4:50 p.m. The DOQA / RM called DCF (Stated Agency: Department of Children and Families) on 04/01/2024 at 19:58 (7:58 p.m.) and Law Enforcement was called on 04/01/2024 at 18:56 (6:56 p.m.) The DOQA / RM stated she got the call of the incident on 03/30/2024 from the Staff B, RN, weekend supervisor, that Resident #1 had gotten ahold of ice cream and was being sent out to the hospital at 2:38 p.m. (on 03/30/2024). The DOQA / RM asked Staff A, AA to call her and with the initial call from Staff A, AA, and what was communicated to me, was he grabbed the ice cream, He got ice cream, he grabbed it. The DOQA / RM stated, Had I known the details I would have reported immediately. We did not follow MD [medical doctor] orders and a higher level of care was necessary. The NHA stated she was not notified about the incident until 04/01/2024.

Based on interview and record review, the facility failed to ensure the Comprehensive Patient-Centered Care Plan was developed and accurate related to NPO (nothing by mouth) status and behaviors for one of three sampled residents (#1). Findings included: Resident #1 was admitted on [DATE] and discharged on [DATE] to the hospital. Review of the Admissions Report showed diagnoses included but were not limited to pneumonia, Urinary Tract Infection, severe protein-calorie malnutrition, hemiplegia following a Cerebral Vascular Accident, hypotension, polyneuropathy, muscle weakness, history of falls, dysphagia, neuromuscular dysfunction of bladder, gastrostomy, spinal stenosis, anemia, recurrent severe depressive disorder, stage 3 chronic kidney disease, other specified interstitial pulmonary diseases, and bronchiectasis. Review of the 5-day Minimum Data Set (MDS) dated [DATE] showed Section C Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact). Section GG showed the ability to eat was not applicable, he required partial to moderate assistance for toileting and bathing. The resident used a wheelchair. Section K, Swallowing Disorder showed the resident used a feeding tube for nutrition. Review of the physician orders showed a full code and revealed: -NPO diet; -Enteral Feeding of Boost Very High Calorie, 237 ml (milliliters) bolus four times a day, family to provide as of 03/29/2024; -Enteral feeding at bedtime, Jevity 1.5 237 ml every evening, flush with 120 ml water before and after as of 3/29/2024; -Flush feeding tube with 120 ml of water before and after each feeding 5 times a day and four times a day for hydration as of 3/29/2024. Review of the Baseline Care Pla) showed admitted from hospital with pneumonia, community acquired, with aspiration; acute hypoxia, respiratory failure, UTI [urinary tract infection], CVA [cerbral vascular accident] with right hemiparesis dysphagia g-tube. Nutrition / Hydration: diet order. Review of Resident #1's care plans showed: The resident was dependent on GT [gastric tube] for nutrition and hydration as of 03/29/2024. Interventions included but not limited to administer tube feeding as ordered, family to provide product as of 3/29/2024; advance to oral intake per ST [speech therapy] as of 3/29/2024; flush tube with water as ordered as of 3/29/2024; keep head of bed elevated during feed tubing administration as of 3/29/2024; monitor as as available as of 3/29/2024; monitor tolerance of tube feeding via nursing documentation and / or discussion with resident; verify tube placement prior to administering feeding; weight per protocol all as of 3/29/2024. Resident #1 has behavior problems related to non-compliance with diet. He has chronic dysphagia, g-tube dependent, and is aware of risk involved, as evidenced by (drinking tap water from the bathroom sink, eating cookies, cheese found in room that he grabs off tray at nurses' station). As of 03/20/2024. Interventions included to explain care in advance, in terms resident understands as of 3/20/2024; observe behavior episodes and attempt to determine underlying cause as of 3/20/2024; re-approach later if becomes agitated as of 3/20/2024; report changes in behavior status to physician / nurse as of 3/20/2024; and strive to anticipate care needs and provide them before resident becomes overly stressed as of 3/20/2024. During an interview on 04/11/2024 at 10:04 a.m. the MDS coordinator confirmed the behavior care plan focus area did not indicate the resident was NPO (nothing by mouth). She stated the interventions were a checked box area, but she did have the option to personalize the interventions for the resident. During an interview on 04/11/2024 at 10:57 a.m. the Director of Quality Assurance / Risk Manager (DOQA / RM) stated, I became aware of the behaviors during the investigation, not before. She stated she found an unopened package of cheez-its snacks in the resident's room; however, no-one saw him eating or drinking. During an interview on 04/11/2024 at 11:33 a.m. the Director of Nursing (DON) stated that at morning meeting, DOQA / RM stated she had spoken with the significant other the significant other had stated he tried to get cookies from her. The DON stated she spoke with the MDS Director and reviewed Resident #1's behavior care plan with the DOQA / RM. The DON stated we were discussing the in the morning meeting. We wanted to make sure something was in the care plan that he may get something on his own based on the significant other's interview. The DON verified the behavior care plan looked like the facility knew about the non-compliant behaviors as of the admission and were occurring at the facility. The DON agreed the interventions were very basic for a behavior care plan and needed to be more focused on his behaviors and specific to him. The Regional Nurse stated on 04/11/2024 at 12:00 p.m. they use the MDS 3.0 RAI User's Manual as the care plan policy. Review of the facility's policy, Baseline Care Plan, effective October 2022 showed it is the practice of the center to develop and implement a baseline care plan for each guest/resident within 48 hours of the admission. The baseline care plan will include instructions needed to provide effective and person-centered care to the guest / resident that meet professional standards of quality care .will include specific health and safety concerns. The baseline care plan will address at a minimum: Dietary orders.

Based on observations, interviews, and policy reviews, the facility failed to secure medications properly for four (Residents #37, #127, and # 43) of 46 sampled residents , in one of two medication storage rooms, and in two of four medication carts. Findings included: 1. On 12/14/22 at 9:04 a.m., an observation was made in the room of Resident #127. There was a medicine cup with 10-12 medication tablets inside the cup. (Photographic evidence obtained.) A review of admission records indicated Resident #127 was admitted on [DATE] with diagnoses including dementia, Alzheimer disease, major depressive disorder, type 2 diabetes mellitus, coagulation factor deficiency, and heart disease. A review of the Medication Administration Record (MAR) indicated the following orders signed off on the morning of 12/14/22: Omega 3 fatty acid capsule 1000 mg. Signed off as given at 8:37 a.m. Spironolactone tablet 50 mg x 2 tablets. Signed off as given at 8:37 a.m. Jardiance tablet 10 mg. Signed off as given at 8:40 a.m. Allopurinol tablet 100 mg. Signed off as given at 8:40 a.m. Divalproex sodium ER tablet 500 mg. Signed off as given at 8:40 a.m. Risperidone tablet 0.25 mg. Signed off as given at 8:40 a.m. Gemfibrozil tablet 600mg. Signed off as given at 8:40 a.m. Pepcid tablet 20 mg. Signed off as given at 8:40 a.m. Metoprolol tartrate tablet 50 mg. Signed off as given at 8:40 a.m. Apixaban tablet 2.5 mg. Signed off as given at 8:40 a.m. Bumetanide tablet 2 mg. Signed off as given at 8:40 a.m. All medications were signed off by Staff B, Licensed Practical Nurse (LPN.) He was currently assigned as the nurse for Resident #127 An interview was conducted with Staff B, LPN, on 12/14/22 at 9:06 a.m. Staff B walked into the room and observed Resident #127 sleeping and a medication cup full of tablets in front of the resident on the overbed table. Staff B said, That's my fault. I should not have left the medications unattended. He usually swallows them right away. He must have fallen asleep. I should have stayed with him. Staff B said the resident did not normally have problems taking his medications; he swallowed them right away. He stated it must have been an off morning. Staff B said, It was my mistake. The expectation is to stay with resident when they are taking their medications. Stay and make sure they swallow. Staff B removed the medications and stepped out of the room, went to the med cart, and then asked the resident if he wanted to take the medications now or later. The resident did not respond. The LPN stated he would give him 15 minutes and attempt to re-administer. On 12/14/22 at 5:40 p.m., an interview was conducted with the Director of Nursing (DON.) The DON stated she was notified of the medications left at bedside for Resident #127. She stated the nurse informed her the resident had brought the medication cup to his mouth and he left to get the roommate's medication. The DON stated the nurse did not stay to confirm the resident had swallowed the tablets. The DON stated the nurse should have stayed to ensure the resident swallowed the medication. The DON stated they have started education. On 12/14/22 at 5:55 p.m., an observation was made of a bottle of Calcium Carbonate 500 mg on the bedside table of Resident #37. This bottle had been observed on the bedside table on 12/12, 12/13, and 12/14/22. (Photographic evidence obtained.) The DON was shown a photograph of the Calcium Carbonate at the bedside of Resident #37. She stated the resident should not be keeping medications at bedside. She confirmed all medications must be locked up and administered by the nurse unless the resident had been approved for self-administration. A follow-up interview was conducted with the DON on 12/15/22 at 1:56 p.m. The DON confirmed Resident #37 has not been assessed for self-administration of medication. She stated she will speak with the resident, assess her if needed, and provide a lock box if she is approved to self-administering medication. On 12/15/22 at 12:22 p.m. an observation was completed of the 200 hall medication storage room with Staff E, Unit Manager (UM.) In the cabinet, there was a box of eyedrops that had been opened. Staff E opened a new box to see what kind of seal should be on the bottle. The unopened bottle was observed to have a blue safety seal around the lid. The open bottle had no seal and was not labeled or dated. The UM stated she could not imagine someone used eye drops and put them back in the cabinet. She confirmed they should not be in the cabinet like they were. She said she would throw them away because there was no way to know if they had been used on a resident on not. (Photographic evidence obtained.) On 12/15/22 at 12:30 p.m. an observation was completed on medication cart 1B with Staff D, LPN. Two loose medication tablets were found in the drawer of the medication cart. The bottom drawer had a sticky substance spilled in the bottom. Staff D stated there should not be loose medication in the cart. She said the sticky substance appears to be from a bottle of medication waste that was leaking. Staff D said nurses checked their own carts and they were cleaned more in-depth on the 3:00 p.m.-11:00 p.m. shift. She stated she had not had time to check her cart yet today, 12/15/22. (Photographic evidence obtained.) On 12/15/22 at 1:00 p.m. an observation was completed on medication cart 2A with Staff C, UM. She stated the medication cart was being used on the current shift by Staff B, LPN. Four half tablets were found loose in the drawers of the medication cart. The UM stated there should not be any loose medication in the carts. She stated she personally cleaned the carts weekly and nurses should be checking their medication carts every shift. (Photographic evidence obtained.) An interview was conducted with the DON on 12/15/22 at 1:10 p.m. The DON was made aware of the loose tablets in the medication carts and the open eye drops in the medication storage room. She confirmed there should be no loose medication in any medication cart. She also stated there should not be any opened eye drops or unlabeled medications in the medication storage rooms. She said she would ensure the issues were taken care of. Resident Council minutes from a meeting on 10/12/22 were reviewed. The residents indicated they were concerned about medications being left at the bedside during the 3:00 p.m.-11:00 p.m. and 11:00 p.m.-7:00 a.m. shifts. A facility policy titled Storage and Expiration Dating of Medications, Biologicals, dated 7/21/22, was reviewed. The policy stated the following: 3.3. Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. 5.1. Facility staff may record the calculated expiration date based on date opened on the primary medication container. 5.4 When an ophthalmic solution or suspension has a manufacturers shortened beyond use date once opened, the facility staff should record the date opened and the date to expire on the container. 5.4.1. Facility staff should evaluate the continued sterility of the product based on clinical judgement or contamination of the dispenser after contact with eye, eyelid, lashes or finger. 13.2. Facility should store bedside medications or biologicals in a locked compartment within the resident's room. 17. Facility personnel should inspect nursing station storage areas for proper storage compliance on a regular scheduled basis. A facility policy titled, General Dose Preparation and Medication Administration, dated January 2022. The policy stated the following: 3.10. Facility staff should not leave medications or chemicals unattended. 5.10. Observe the resident's consumption of the medication(s). 37999 2. On 12/13/22 at 10:56 a.m., an observation was made of Resident #43 which identified a clear plastic bag sitting on the bed next to the resident. The bag contained two bottles of over-the counter (OTC) medications, one was Cal-Mag (Calcium/Magnesium) and the other had a handwritten label indicating that it contained Body Gold Ginsana Energy Brain, the bottles manufacturer label identified it as a bottle of Vitamin B2. The resident stated staff did not know about the medications and they were taken daily because of not getting any vitamins at the facility. Photographic evidence was obtained. A review of Resident #43's Admission Record indicated the resident was admitted on [DATE]. The record included diagnoses not limited to cellulitis of left lower limb, Methicillin resistant Staphylococcus aureus infection as the cause of diseases classified elsewhere, and type 2 Diabetes mellitus with diabetic polyneuropathy. The 5-day Minimum Data Set (MDS) revealed a Brief Interview of Mental Status (BIMS) score of 14 out of 15, indicating an intact cognition. A review of the Order Summary Report did not include a physician order for either Cal-Mag (Calcium/Magnesium) or Body Gold Ginsana Energy Brain or that the resident was able to self-administer medication. An observation and interview were conducted, on 12/14/22 at 8:58 a.m., with Staff F, agency LPN for Resident #43. The residents' OTC bottles were not observed and the resident reported throwing away the OTC medications yesterday as if they were given to the facility they would not be given back. The Director of Nursing was interviewed, at 5:48 p.m. on 12/14/22, regarding the observation of the OTC medication that had been in Resident #43's possession and had reported throwing away the two bottles. She stated, which means she still has them.

Based on observations, interview, and policy review, the facility failed to label and date opened food and maintain a clean, sanitary kitchen in accordance with professional standards for food service safety. Findings: Observation on 12/12/2022 at 10:44 a.m. , revealed packets of food, trash, and a wash rag underneath the shelves on the food pantry room floor. A molded pan of gravy was found underneath the shelf with food stored on the shelf inside the refrigerator on the floor. Observation on 12/14/2022 at 10:00 a.m., was conducted in the nourishment room on the C and D nursing wings. Inside the nourishment room on the D wing was an opened, unlabeled, and undated [brand name] meatball bag left inside the freezer. Inside the nourishment room on the C wing was two boxes of ice cream and two frozen dinner boxes unlabeled and undated. On 12/18/2022 at 10:00 a.m., an interview was conducted with Staff L, the Certified Dietary Manager, CDM. The CDM said the nourishment rooms are cleaned, stocked, and maintained by designated culinary aids every day of the week. The CDM said the dietary staff made sure the food inside the refrigerator and freezers were dated and labeled correctly. Food that is not labeled and dated should not be left inside the freezer or refrigerator. The CDM said he could see there was undated and unlabeled food, but he would not throw it out because he hated to waste food. On 12/14/2022 at 4:21 p.m., an interview was conducted with the Nursing Home Administrator, NHA. The NHA said her expectation for food stored inside the nourishment rooms freezer and refrigerators should be labeled and dated and only used for the residents not the staff. The NHA said the dietary staff restocked the refrigerator every afternoon and should check to see if there were any food items unlabeled and undated; they should throw out any items they found inside the freezer or refrigerator not dated our labeled. Record review of the facility's policy titled, Food Storage, dated October 2014, showed that food storage areas shall be maintained in a clean manner at all times. Procedure 2. Shelves, racks, dollies, or other surfaces used for food storage should facilitate thorough cleaning. Record review of the facility's policy titles, Resident Personal Food, dated October 2014, showed items brought into the facility will be stored unsanitary conditions. Procedure 2. Labeled and dated perishable items may be stored under refrigeration in thee nursing unit consistent with standards of food storage.

Based on observations, record reviews, and interviews, the facility failed to implement an effective Infection Control program related to the unsanitary environment of the laundry room related to personal food items and belongings sitting on same folding counter as resident linen, failed to ensure two (Staff H and J) direct care staff members had fingernails that were per Centers of Disease Control and Prevention guidelines were of an appropriate length, and failed to ensure Seven (Residents #86, #119, #23, #112, #37, #58, and #42) out of eight residents receiving oxygen therapies. Findings included: 1. During an interview with the Infection Preventionist (IP) on 12/14/22 at 11:05 a.m., she stated the facility followed the Center of Disease Control and Prevention (CDC) recommendations/guidelines. She stated she had been to the laundry area earlier that day. An observation was conducted on 12/14/22 at 12:28 p.m., with the IP of the facility's laundry processing area. Staff K, Laundry Aide, was standing against the laundry folding counter and stated she had just returned from lunch. In the corner of the laundry counter, which had folded linen and hospital gowns on top of it, was a plate of cookies, an opened bag of cheesy puffed treats, a cell phone, and a key ring with keys. Immediately following the observation of the laundry processing are, the IP confirmed food items should not be on the folding counter. The policy - Handling Linens to Prevent and Control Infection, effective December 2020, identified that written policies and procedures are needed and should include training for staff who will handle linens and laundry. The policy provided by the facility did not address keeping personal items stored with facility linens. The CDC guideline, Appendix D - Linen and laundry management: Best Practices for Environmental Cleaning in Healthcare Facilities: in RLS, reviewed: March 27, 2020, (https://www.cdc.gov/hai/prevent/resource-limited/laundry.html), identified that Best practices for management of clean linen: Sort, package, transport, and store clean linens in a manner that prevents risk of contamination by dust, debris, soiled linens or other soiled items. An observation was made on 12/13/22 at 11:40 a.m., of Staff H's, Certified Nursing Assistant (CNA), fingernails which extended approximately 1/2 - 3/4 inches past the fingertip. The fingernails were painted white and black, the fourth finger on right hand was white with black raised jewels and the fourth finger on left hand was painted black with white raised jewels. The staff member stated I lost one indicating a shorter nail on the middle finger of left hand. She stated she used double gloves so not to break through. On 12/14/22 at 8:44 a.m., Staff H was observed, on the 400 hall, with the continued long fingernails. On 12/13/22 at 11:59 a.m., Staff J, CNA, was observed propelling a resident in a wheelchair from the residents room. The Staff J's fingernails were thick, painted pink, and extended approximately 1/4-1/2 above the fingertip. Staff J stated, they're long. The Infection Preventionist (IP) reported, on 12/14/22 at 11:05 p.m., that fingernails for direct care staff should not be more than 1/4 past fingertip and if looking at back of hand should be barely seen. She stated that rhinestones could cause a problem and would have to check the protocol for fake and painted fingernails. The facilty policy - Dress Code Policy, effective October 1, 2014 and revised September 2, 2021, indicated that the purpose was to provided the very best service and care possible to out resident/patients. Our manners of dress, grooming, and personal cleanliness speak for us at Palm Garden when we are in contact with residents, family members, guests, and co-workers. The detail #8 identified that Hair and nails should be clean and groomed. Nail length should not be so long as to interfere with work duties. The CDC guideline - Water, Sanitation, and Environmentally Related Hygiene (WASH), last reviewed on June 15, 2022, (https://www.cdc.gov/hygiene/index.html), indicated that Appropriate hand hygiene includes diligently cleaning and trimming fingernails, which may harbor dirt and germs and can contribute to the spread of some infections, such as pinworms. Fingernails should be kept short, and the undersides should be cleaned frequently with soap and water. Because of their length, longer fingernails can harbor more dirt and bacteria than short nails, thus potentially contributing to the spread of infection. The CDC guideline - Hand Hygiene in Healthcare Settings, last reviewed on January 8, 2021, included the following: - Germs can live under artificial fingernails both before and after using an alcohol-based hand sanitizer and handwashing; - It is recommended that healthcare providers do not wear artificial fingernails or extensions when having direct contact with patients at high risk (e.g., those in intensive-care units or operating rooms); - Keep natural nail tips less than 1/4 inch long. On 12/14/22 at 9:06 a.m., an observation was made of Resident #86 wearing a nebulizer mask while lying in bed, the nebulizer machine could be heard from the hallway. The observation revealed, on 12/14/22 at 9:08 a.m., a steady amount of aerosol coming from the residents' nebulizer mask, the resident stated it was just a nebulizer. The nebulizer machine could be heard stopping, as this writer left the residents' room at 9:08 a.m. on 12/14/22 and from the hallway an observation identified that the resident had removed the nebulizer mask. On 12/14/22 at 9:15 a.m., Staff I, Licensed Practical Nurse (LPN), stated a nebulizer treatment could take between 10-15 minutes depending on the (nebulizer) machines' compressor. Staff I stated, what did she do, take it off? The LPN entered Resident #86's room, on 12/14/22 at 9:21 a.m., and picked up the nebulizer mask from the top of the bedside dresser, looked at it, and placed it into the plastic bag hanging from the bedside dresser. The nurse removed the mask and identified a clear liquid remained in the nebulizer medication cup. The nurse left the residents' room on 12/14/22 a short time later and stated that the nebulizer had been rinsed and dried. During an interview on 12/14/22 at 11:05 a.m., the Infection Preventionist (IP) stated that nebulizer/oxygen/continuous positive airway pressure (cpap) equipment should be cleaned, dried, then put in a bag. The oxygen equipment was changed weekly, stay in plastic bag, and not on (resident) dresser. The facility policy - Cleaning and Disinfecting Nebulizer, effective December 2020, indicated that Cleaning and disinfecting of nebulizer machine will be completed based on the manufacturer's recommendations. The procedure portion of policy included the following instructions: - 1. Follow manufacturer's guidelines for cleaning and disinfecting of machine and equipment. Specific instructions may vary with the manufacturer. - 2. Consult with the manufacturer to determine which cleaning procedures. - 3. Apply clean gloves. - 4. Disassemble the nebulizer by removing the cup and mask or mouthpiece. - 5. Thoroughly clean all visible soil or organic material from the cup, mask or mouthpiece before cleaning and disinfection. - 6. Follow manufacturer's recommendations for cleaning instructions, frequency, disinfection, and replacement (i.e. Use warm water and a mild dish detergent to wash the nebulizer parts. Rinse them thoroughly to remove all soap and residue. Allow the parts to air-dry on a clean surface). - 7. Shake off any excess water and allow the cup to air dry on a clean surface. Do not place the nebulizer parts directly on a contaminated surface. 2. On 12/12/22 at 09:59 a.m. Resident #58 was observed in her room sitting in her wheelchair. An oxygen concentrator was noted behind her chair. The resident's oxygen nasal cannula was observed on top of her nightstand, laying above magazines and other objects. The tubing was noted not bagged and exposed to the elements. A clear storage bag was noted by the side of the nightstand, dated 12/6/22. Photographic evidence was obtained. Review of the Electronic Medical Record (EMR), showed Resident #58 was admitted to the facility on [DATE] with a diagnosis to include shortness of breath. The resident's active physician orders dated 12/15/22, showed to use oxygen PRN (as needed) to keep O2 Saturation above 90% every shift, order date 2/7/22 and to change and date all oxygen tubing every week when in use, order date 1/27/22. On 12/12/22 at 10:13 a.m., Resident #42's CPAP (Continuous Positive Airway Pressure) machine was observed on the resident's bedside table. The mask was laying on top of a container full of personal care items. The tubing and mask were not bagged. Photographic evidence was obtained. A review of the EMR showed Resident #42 was admitted to the facility on [DATE] with a diagnosis to include obstructive sleep apnea. The resident's active physician orders dated 12/15/22 showed CPAP settings for every evening and night shift, order date 8/26/22. The orders did not indicate how the mask or tubing should be stored, or how often they should be cleaned or changed. On 12/12/22 at 10:24 a.m., 12/13/22 at 12:06 p.m., and 12/14/22 at 9:19 a.m., Resident #37's nebulizer machine was observed on her nightstand. The mask was positioned on top of the machine, which was also opened to the elements. Resident #37 confirmed she used it for her nebulizer treatment. The nebulizer mask and machine were exposed to the elements during 3 of 3 days of survey. A review of active physician orders for Resident #37 showed Albuterol sulfate nebulization solution 2.5 MG (milligram)/3 ML(milliliters) 0.083% 3 ml inhale orally via nebulizer every 4 hours as needed for SOB (shortness of breath). The orders did not indicate how the machine, mask or tubing should be stored, or how often they should be cleaned or changed. On 12/14/22 at 5:40 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated respiratory equipment should be stored in a bag and dated. It should not be left out for sanitary reasons. She stated the concern was brought to her attention earlier, and they have started in-services. The DON stated their expectation is to ensure equipment is stored appropriately. On 12/15/22 at 3:24 p.m. an interview was conducted with the Regional Clinical and the DON. They stated they had already started education, which included to follow the policy related to cleaning, and maintaining equipment in a sanitary manner. The DON said, the policy might not specifically state bagging it does address appropriate storage though. 3. An observation was made on 12/12/22 at 1:18 p.m. in the room of Resident #112. The resident's nebulizer mask was sitting on her bedside table uncovered. On 12/13/22 at 11:44 a.m. Resident #112's nebulizer mask remained uncovered on the table. (Photographic evidence obtained.) A review of admission records indicated Resident #112 was admitted on [DATE] with diagnoses including chronic respiratory failure and chronic obstructive pulmonary disease (COPD.) A review of Resident #112's orders revealed an order for Ipratropium-Albuterol Solution 0.5-2.5 mg/3 ml. 3 ml two times a day for shortness of breath. An observation was made on 12/13/22 at 10:09 a.m., in the room of Resident #119. The resident's nebulizer mask was sitting on the bedside table uncovered. The resident stated the mask stayed that way and did not get put in a bag. (Photograph unable to be obtained due to location of the resident.) A review of admission records indicated Resident #119 was admitted on [DATE] with diagnoses including COPD and chronic diastolic heart failure. A review of orders revealed an order for Albuterol Sulfate Nebulization Solution 2.5mg/3 ml. 3 ml inhale orally every six hours as needed for shortness of breath/wheezing. An observation was made on 12/13/22 at 11:44 a.m., in the room of Resident #23. The resident's nebulizer mask was sitting on the bedside table uncovered. An additional observation was made on 12/14/22 at 10:43 a.m., in the room of Resident #23. The resident's nebulizer mask remained uncovered. The resident stated it was kept that way. She said she wondered because at home her nebulizer went in a box, but this one never was. A review of admission records indicated Resident #23 was admitted on [DATE] with diagnoses including COPD. A review of orders revealed an order for Ipratropium-Albuterol Solution 0.5-2.5 mg/3 ml. 3 ml four times a day for COPD. 43453 46234

Based on observations, record reviews, and interviews, the facility failed to ensure two (Residents #43 and #86) of 46 sampled residents were assessed for self-administration of medications. Findings included: 1. During an interview with Resident #43 on 12/13/22 at 10:56 a.m., an observation was made of a clear bag sitting on the bed next to the resident. The bag contained 2 bottles of over-the counter (OTC) medications: Cal-Mag and a relabeled Vitamin B2 bottle, Body Gold Ginsana Energy Brain. The resident stated staff did not know of the OTC medications, and she took them daily because of not getting any vitamins at the facility. The resident stated the Vitamin B2 was relabeled. Photographic evidence was obtained. The Admission Record identified Resident #43 was admitted on [DATE] and included diagnoses not limited to cellulitis of left lower limb, Methicillin resistant Staphylococcus Aureus infection as the cause of diseases classified elsewhere, and type 2 Diabetes mellitus with diabetic polyneuropathy. The 5-day Minimum Data Set (MDS) revealed a Brief Interview of Mental Status (BIMS) score of 14 out of 15, indicating an intact cognition. A review of the Order Summary Report did not include a physician order for either Cal-Mag (Calcium/Magnesium) or Body Gold Ginsana Energy Brain or that the resident was able to self-administer medication. On 12/14/22 at 8:58 a.m., an observation and interview were conducted with Staff F, agency Licensed Practical Nurse (LPN) of Resident #43. The residents' OTC bottles were not observed. The resident reported throwing away the OTC medications yesterday as if they were given to the facility they would not be given back. On 12/14/22 at 5:48 p.m., the Director of Nursing was interviewed regarding the observation of the OTC medication that had been in Resident #43 possession and had reported throwing away the two bottles. She stated, which means she still has them. 2. An observation was made, on 12/14/22 at 9:06 a.m., of Resident #86 lying in bed, wearing a nebulizer mask, the nebulizer machine could be heard from the hallway. On 12/14/22 at 9:08 a.m., the observation revealed a steady amount of aerosol was coming from the residents' nebulizer mask, the resident stated it was just a nebulizer. This writer left the residents' room and when reaching the opposite side of the hallway, on 12/14/22 at 9:08 a.m., the nebulizer machine stopped. An observation, on 12/14/22 at 9:09 a.m., indicated the resident had removed the nebulizer mask. On 12/14/22 beginning at 9:17 a.m., during an observation of Resident #86 and an interview with Staff I, Licensed Practical Nurse (LPN), Staff I stated, a nebulizer treatment had been given to Resident #86. Staff I reported nebulizer treatments could take about 10 - 15 minutes depending on the machine's compressor. Staff I reviewed Resident #86's physician orders and stated it did not look like the resident had an order to allow for the self-administration of the nebulizer medication. Staff I entered Resident #86's room, picked up the nebulizer mask from top of the bedside dresser, looked at it, then placed it into the plastic bag hanging from the bedside dresser under the nebulizer machine. When asked, the nurse removed the mask and indicated the nebulizer's medication cup still held a clear liquid. Staff I informed the resident the treatment would have to continue and placed the mask on the resident. The nurse stated, have to stay and watch [the treatment]. Staff I sat in the bedside chair next to Resident #86's bed. Staff I stated the procedure [for administration of nebulizer medication] was they (nurses) generally check back in on them [the residents]. On 12/14/22 at 5:48 p.m., the Director of Nursing (DON) stated she knew about the incident with Resident #86. She said she was there, and heard what the nurse (Staff I) had told this writer. She stated her expectation would be that staff stay with the resident during the treatment. A review of Resident #86's Admission Record revealed the resident was admitted on [DATE]. The record included a diagnosis not limited to unspecified chronic obstructive pulmonary disease. The 5-day Minimum Data Set (MDS) revealed a Brief Interview of Mental Status (BIMS) score of 10 out of 15, indicating a moderate cognition impairment. The review of Resident #86's Order Summary Report, active as of 12/14/22 at 9:47 a.m., did not include a physician order for the self-administration of any medication. The consent form for Self-Administration of Medication (undated) indicated It is the policy of this facility that the resident has the right to self-administer his or her own mediation if the interdisciplinary team has determined that the practice is safe. The form included but was not limited to the following criteria be met: 1. Physician's orders for administration of medication must be on file at the facility (may be all or a specific drug). 2. The resident has signed a document stating his/her desire to self-medicate. 3. The level of ability to identify medication, dosage, time, and to store properly has been determined as sage by the interdisciplinary team.

Based on interviews with facility nursing staff, the medical director, and facility administration, and clinical record review for Resident #95 and Resident #280 along with a review of job descriptions for the Licensed Practical Nurse, Registered Nurse, Clinical Services Coordinator and Director of Clinical Services and review of the facility's policy and procedure related to general medication administration, the facility failed to provide the necessary care and services in accordance with acceptable standards of nursing practice for two (#95 & #280) of seven sampled residents. Based on a review of five open records and two closed records of residents who received [MEDICATION NAME], one (Resident #95) received [MEDICATION NAME] in error and did not receive monitoring of the blood values of PT/INR ([MEDICATION NAME] time/International Normalizing Ratio; a measure of blood clotting time) that were consistent with recognized monitoring standards for [MEDICATION NAME] therapy. Facility staff failed to transcribe an order for [REDACTED].#280 showed an order to increase [MEDICATION NAME] as part of their therapy. This order was never placed in Resident #280's chart due to being transcribed into Resident #95's chart in error. As a result, Resident #95 developed a significant [MEDICAL CONDITION] and severe anticoagulation. The actions of the medical and nursing staff who failed to order the necessary laboratory test to monitor the clotting times and identify the transcription error subsequently resulted in Resident #95 expiring from a major stroke caused by [MEDICATION NAME] toxicity. Past noncompliance at the Immediate Jeopardy level was identified on [DATE] as occurring on [DATE]. The administrative team was notified on [DATE] at 4:53 p.m. the Immediate Jeopardy was determined to be corrected on [DATE], prior to the facility visit. Findings included: 1. Florida Nurse Practice Act Section 464.003 Definitions: (16)?Licensed practical nurse means any person licensed in this state to practice practical nursing. (19)?Practice of practical nursing means the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirm; the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist; and the teaching of general principles of health and wellness to the public and to students other than nursing students. A practical nurse is responsible and accountable for making decisions that are based upon the individual's educational preparation and experience in nursing. (20)?Practice of professional nursing means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: (a)?The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others. (b)?The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments. A professional nurse is responsible and accountable for making decisions that are based upon the individual's educational preparation and experience in nursing. 2. A review of the job description Licensed Practical Nurse (LPN) dated ,[DATE] provided that the basic function of this position was to deliver care to residents of this facility. The essential functions listed included works under direct supervision using the Nurse Practice Act, policies and procedures and nursing judgement. Makes observations and reports pertinent information related to the care of the resident. Implements the resident plan of care and evaluates the resident response, provides resident/family/caregiver education as directed and conducts self in a professional manner in compliance with unit and facility policies. Requirements listed under marginal functions includes participates in the identification of staff educational needs. The LPN contributes to the formulation/review of nursing care plans of assigned residents by identifying pertinent nursing problems and suggest appropriate nursing orders. The LPN evaluates the care of residents by conducting observations related to the effectiveness of nursing interventions, medications, etc., and reports as appropriate and documents in the progress notes. The section titled general patient/resident care the job description included that interventions are performed in a timely manner. Active participation in resident care management is evident as part of resident education and discharge planning. Listed under adherence to facility procedures states that the LPN will utilize facility procedure manuals or reference materials. Medications are charted correctly with name, dose, route, site, time and initials of nurse administering. The LPN participates in the coordination of care by relaying information to other members of the health care team. The leadership role of the LPN requires that problems be identified, data gathered, and solutions are suggested and communicated regarding the problem. The transcription of all orders is checked. The LPN role in communication during change of shift report is complete, accurate and concise. The LPN displays professionalism as evidenced by decisions that are made that reflect knowledge and good judgement and demonstrate an awareness of patient/resident/family/physician needs. The specific requirements for an LPN per the job description are the LPN possesses the ability to make independent decisions when necessary and must be able to relate information concerning a resident's condition. The LPN must be able to function independently, have personal integrity, flexibility, and the ability to work effectively with residents, personnel and support agencies. 3. Review of the job description titled Registered Nurse (RN) with no date listed revealed the basic function is to plan and deliver nursing care to patients/residents requiring long-term or rehabilitative care. The essential functions of the job listed for the RN included works using the guidelines established from the Nurse Practice Act, Company Standards, Polices and Procedures and nursing judgement. Assesses plans and evaluates nursing care delivered to patients/residents requiring long-term or rehabilitation care. The RN implements the patient/resident plan of care and evaluates the patient/resident response. Directs and supervises care given by other nursing personnel. The RN provides input in the formulation and evaluation of standards of care. Maintains knowledge of necessary documentation requirements. In addition, the RN provides patient/residents/family/caregiver education as directed and conducts self in a professional manner in compliance with unit and facility policies. The RN participates in the identification of staff educational needs. The minimum performance standards for the RN listed under assessment revealed admission and routine resident observation/transfer notes are complete and accurately reflect the resident status. Documentation of observations is complete and reflects knowledge of unit documentation policies and procedures. The assessments identifies changes in the resident's physical or psychological condition. Nursing care plans are initiated/reviewed/individualized on assigned residents monthly and PRN (as needed) that indicate pertinent nursing problems are identified, goals are stated, and appropriate nursing orders are formulated. The RN evaluates the effectiveness of nursing interventions, medications, etc., and the evaluations are documented in the progress notes. Under the medication administration section, it notes medications are charted correctly with name, dose, route, site, time and initials of nurse administrating. In the section coordination of care, it documented co-workers are informed of changes in patient/resident condition or of any other changes occurring on the unit and information is relayed to other members of the healthcare team. Documented under the leadership tab it states assistance, direction and education are provided to unit personnel and families. Problems are identified, data is gathered, solutions are suggested and communication regarding the problem are appropriate. Transcription of all orders is checked. The RN responsibilities for communication included that change of shift report is complete, accurate and concise. Listed under professionalism is decisions are made that reflect knowledge and good judgement and demonstrate an awareness of patient/resident/family/physician needs. Specific requirements for the RN consist of possessing the ability to make independent decisions when necessary and must be able to relate information concerning a patient/resident. Finally, the RN must be able to function independently, have personnel integrity, flexibility, and the ability to work effectively with patients/residents, personnel and support agencies. 4. Review of the job description Clinical Services Coordinator (CSC) dated ,[DATE] revealed this position will be responsible for collaboration in developing, implementing, evaluating and revising unit policies and procedures in accordance with current applicable federal, state and local guidelines and regulations that govern the center to ensure that clinical staff are adequately trained and competent to provide the highest degree of quality care to our residents and guest. The essential functions include the evaluation and professional development of unit personnel. The CSC assist with clinical assessments and evaluations of residents/guest. The CSC assist with provision of medications and treatments and monitors the delivery of appropriate resident/guest care through daily rounds. The CSC will exercise administration and functional supervision over unit personnel and contracted services personnel on the unit. The specific requirements listed for the CSC state that the CSC must possess the ability to plan, organize, develop, implement and interpret clinical programs, goals, objectives, policies and procedures. 5. A review was conducted of the job description Director of Clinical Services (DCS) with no date listed that revealed the basic function was the responsibility for effective overall management of the Nursing Department and coordination with other disciplines to provide quality care to all patients/residents. The essential function of the DCS states that the DCS supports and practices the philosophy, objectives and standards of the Department of Nursing and participates in the revision of these as necessary to ensure quality care to all patients/residents. The DCS monitors the outcomes of nursing services actively by evaluating the performance of nursing staff, ensuring compliance with all facility and regulatory agency standards, and policies and procedures. The DCS exercises administrative and functional supervision over nursing personnel. The DCS ensures implementation of resident care planning format to comply with patients/resident's needs and various regulatory agency requirements. The DCS visits nursing units on a daily basis and observes the care the patients/residents are receiving to ensure compliance with accepted facility nursing standards. Periodically visit all nursing shifts to monitor performance of nursing unit staff and to ensure that quality care is being provided to patients/residents. 6. Review of Potter and Perry's Fundamentals of Nursing 6th Ed. Chapter 15, Nursing Assessment page 292 revealed, Diagnostic and Laboratory Data. The results of diagnostic and laboratory test can identify or verify alterations questioned or identified during the nursing health history or physical examination . The nurse identifies variations from normal and interprets findings according to the disease process and treatments. In addition, the nurse uses laboratory data to evaluate the success or failure or nursing and medical interventions .Observation and recording of client (resident) assessment is a legal and professional responsibility . The American Nurse Association Policy Statement (2003) and Standards of Clinical Nursing Practice (1998) mandate accurate data collection and recording as independent functions essential to the role of the professional nurse. 7. A review of a local hospital emergency room History and Physical, dated [DATE], revealed Resident #95 was admitted to the hospital emergency room unresponsive to verbal and tactile stimuli (sound or touch). Computerized Tomography scan (CT scan) showed a significant [MEDICAL CONDITION] (abnormal bleeding in the brain) with [DIAGNOSES REDACTED] (water on the brain). The emergency physician spoke with Resident #95's family who were unsure of the CODE STATUS but stated that she would not likely want intubation or other mechanical means of sustaining life. Resident #95's family was present and were informed by the emergency physician that she would not likely survive. Resident #95 had recently been admitted to the local hospital for an upper [MEDICAL CONDITION]. In addition, apparently when resident arrived to the rehabilitation facility she was put on [MEDICATION NAME]. The onset is unknown. The course and duration of symptoms is constant. [DIAGNOSES REDACTED]. Resident received a dose of vitamin K (reversal for blood thinning medications) in the emergency room . The emergency physician spoke with family again who reiterated that they did not want heroic measures performed such as intubation or surgery. Further review of hospital records revealed Resident #95's PT on [DATE] was >170.0 second(s) and the INR was >13. The therapeutic range for PT time is ,[DATE] seconds (fda.gov) and a therapeutic INR is between 0XXX,[DATE].2 (fda.gov). An interview was conducted on [DATE] at 2:26 p.m. with the emergency room (ER) physician who cared for Resident #95 on [DATE]. The ER physician stated that Resident #95 arrived in the ER in bad shape. Resident #95 had a severe [MEDICAL CONDITION] that was not survivable. The ER physician stated that he was in contact with the hospitalist who contacted the nursing home and primary care physician regarding recent lab work. The ER physician stated that the significance of coagulation numbers showed Resident #95 was severely anticoagulated, which led to the hemorrhage. The ER physician would expect someone who was receiving [MEDICATION NAME] to receive monitoring for dosage adjustments. The ER physician also mentioned that Resident #95 recently left the hospital with an upper [MEDICAL CONDITION] (on [DATE]) and blood thinners is the worst thing the resident could be put on. 8. A review of the facility policy titled, Medication Administration General Guidelines dated ,[DATE] revealed that medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. The policy also revealed under the medication preparation section that prior to administration, review and confirm MEDICATION ORDERS FOR [REDACTED]. Under the medication administration tab: medications are administered in accordance with written orders of the prescribers. If a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current [DIAGNOSES REDACTED]. If necessary, the nurse contacts the prescriber for clarification. This interaction with the pharmacy and the resulting order clarification are documented in nursing notes and elsewhere in the medical record as appropriate. 9. An interview was conducted on [DATE] at 09:41 a.m. with Resident #95's son. The son stated that recently, Resident #95 had been hospitalized for [REDACTED]. Resident #95's son stated that he was unsure of the timeframe the resident was expected to be at the skilled nursing facility. The staff at the facility had informed him that Resident #95 was being uncooperative with treatment and expected to be staying at the facility long term prior to the resident expiring. Resident #95's son stated that the day after Resident #95's passing; his brother went to the facility to collect her belongings. The nursing home administrator (NHA) informed that brother that the QA (quality assurance) discovered Resident #95 was receiving [MEDICATION NAME] without an order. Resident #95's son stated that the emergency physician called the medical examiner's office based on the condition, issues with the brain, and blood chemistry. The son stated that the medical examiner ruled the death accidental due to a major stroke caused by [MEDICATION NAME] toxicity. 10. A review of Resident #95's clinical record revealed she was admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. The state form 3008 showed the resident was transferred to the facility for physical therapy. A review of Resident #95's Admission Minimum Data Set (MDS), dated [DATE], revealed the resident scored a ,[DATE] on her Brief Interview for Mental Status indicating no cognitive impairment. Review of current medications revealed the resident received an anticoagulant three times during the look back period. A review of Physician's progress notes on [DATE] revealed patient presents after admission to local hospital due to abdominal pain. Patient has a history of hiatal hernia and gastritis noted on multiple EGDs (esophagogastroduodenoscopy; a scope with light and camera is used to look at digestive tract). Patient was evaluated by [MEDICATION NAME] and urology. Patient reports feeling tired and is resting comfortably. Also, complaint of cough and sore throat with sinus pressure. Resident is in no acute distress, lethargic and anxiousness. Cardiovascular assessment revealed regular heart rate and rhythm. Normal S1/S2 (heart sounds). The plan included medications and lab work. [MEDICATION NAME]/[MEDICATION NAME] was not on the list of medications in the plan and anticoagulant monitoring was also not on the plan. The physician orders, dated [DATE] at 22:22 p.m., reflected an order for [REDACTED].#95 was never diagnosed with [REDACTED]. The order sheet did not contain a signature from the physician on the form. A review of the 24-hour chart check showed that the Employee #G, RN, initialed orders that were placed on [DATE]. The instructions contained on the 24 hour chart check form provided that The designated nurse will review all physician orders for the previous 24-hours for verification that orders have been noted, transcribed as noted, materials/supplies/medications have been ordered, labs and diagnostics have been ordered and appropriate departments notified. The nurse signature for each day noted below indicates verification and follow-through for all physician orders. A review of the Care Plan, dated [DATE], revealed a focus of being at risk for abnormal bleeding, hemorrhage, and bruising related to anticoagulant use for A fib ([MEDICAL CONDITION]; an abnormal heart rhythm) with a goal that the resident will be free from signs and symptoms of abnormal bleeding through next review. Interventions included: encourage resident to report any signs of bleeding or bruising, lab work as ordered, medication as ordered, observed for bleeding gums, nose bleeds, unusual bruising, tarry black stools, pink or discolored urine to nurse and/or MD, report to physician and s/s of abnormal bleeding, hemorrhage and bruising, and skin checks per facility protocol. A review of the clinical record revealed no history or basis for a [DIAGNOSES REDACTED].#95's care plan. A review of the admission nursing note from [DATE] at 6:30 p.m. revealed Resident #95 was alert and oriented. Vitals were within normal limits. No complaint, signs, or symptoms of distress. Skin intact and able to voice needs. MD (Medical doctor) notified of orders and verified. Review of nurse notes on [DATE] at 05:00 a.m. revealed Resident noted with cough and SOB (shortness of breath); [MEDICATION NAME] (aerosaled inhaled medication) given as ordered; writer noted blood in mucus when resident coughed; ESNF (telemedicine) notified of resident condition and new order received for CXR (chest x-ray) x 2 view writer notified resident of new order; call light within reach. A nurse note, dated [DATE] at 6:45 a.m., revealed writer notified that resident noted with red and dark area in diaper with urine; writer notified ESNF; new order received for CBC with diff (complete blood count with differential), CMP (complete metabolic panel), and U/A and C&S (urine analysis with culture and sensitivity); resident notified. A review of a nursing note, dated [DATE] at 9:00 p.m. revealed, All labs, x-ray, and urine called in to ARNP (Advanced Registered Nurse Practitioner) n/o (new order) received and noted. Resident had no discomfort present this p.m. No bloody sputum. Fluids encouraged and offered. A nursing note on [DATE] at 9:30 a.m. revealed, patient refused meds, patient able to open eyes, patient O2 saturation (oxygen level) 93% on 2L/min via NC (nasal cannula), pulse 72, respirations 18, blood pressure ,[DATE]. Reported patient refused meds, called to MD in a.m., refused ABT (antibiotic). A nursing note, dated [DATE] at 12:00 p.m., revealed spoke with ARNP for Medical Director, reported patient did not received ABT (antibiotic) in a.m., pupils equal and reactive in a.m. when assessed and vitals taken at 9:30 a.m. and 10:00 a.m. A nursing note on [DATE] at 1:00 p.m. revealed, patient's C.N.A. (certified nursing assistant) got attention of nurse at 12:15 p.m. Went to assess patient. Patient displayed labored breathing, O2 saturation 85% (,[DATE]% normal), patient not responding to voice, touch. Call to MD. Administered [MEDICATION NAME] to patient, O2 sat increased to 93% on 2L/min (oxygen). Received order to send patient to ER for evaluation and treatment. Blood sugar 191, blood pressure ,[DATE], pulse 68, O2 93%. EMS arrived within 5 minutes. During assessment, patient's pupils became enlarged and patient's arms became stiff. Patient sent to ER with all paperwork. Family notified. A review of ESNF PROGRESS NOTE/ORDERS dated [DATE] at 05:05 a.m. revealed; reason for call is cough and SOB with phlegm (mucus). Ordered placed for CXR - 2 view (SOB, cough with sputum) and notify attending physician of eCare SNF orders in the morning. An eCare SNF PROGRESS NOTE/ORDER dated [DATE] at 06:50 a.m. revealed a chief complaint of blood urine, history of [MEDICAL CONDITION]. Orders UA/C&S, CBC, and CMP, notify attending physician of eCare SNF orders in the morning. A review of the Transfer Form dated [DATE] revealed the reason for the transfer was AMS (altered mental status) and decreased O2 saturation (low oxygen level). A review of a physician progress notes [REDACTED].#95 toER on [DATE] secondary to AMS. Expired same day. Contact with hospitalist, revealed bleeding (illegible). ARNP performed chart review the same day. Rounds indicate medication error, which placed patient on medications not ordered for her. Discussion with facility staff has indicated immediate attention to error along with corrective action plan. A review of the electronic Medication Administration Record [REDACTED]. The EMAR did not include a lab box to enter appropriate lab values. The nurses who administered the [MEDICATION NAME] at bedtime were Employees #D Licensed Practical Nurse (LPN), #E Registered Nurse (RN), #H (LPN), #I (LPN), #J (LPN), #K (LPN), and #L (LPN). Review of the consultant pharmacist's, physician recommendations for Resident #95, dated [DATE], found no recommendations were made related to the [MEDICATION NAME]. In addition, no recommendation for lab monitoring was noted. The only recommendation in place for Resident #95 related to discontinuing of an antidepressant which was followed through. 11. An interview was conducted on [DATE] at 12:25 p.m. with the facility's consultant pharmacist regarding Resident #95. The consultant pharmacist was asked how he confirmed that [MEDICAL CONDITION] [REDACTED].#95 as noted on the physician order entered in the eMAR for [MEDICATION NAME] 6 mg dated [DATE]. The consultant pharmacist stated that once a [DIAGNOSES REDACTED]. The consultant pharmacist stated that, eventually, he would expect to see an order for [REDACTED]. The consultant pharmacist was asked if they had logs before and he responded yes, but had not seen them in a while and he did not want to comment any further on it. 12. A review of Wittkowsky, Ann, The American Society of Health System Pharmacists, Chapter 24 [MEDICATION NAME], page 358 revealed: The intensity of [MEDICATION NAME] therapy is monitored by evaluation of the [MEDICATION NAME] time (PT), expressed as the INR . Table 24.7 summarizes the Frequency of INR monitoring and Patient Assessment. If the initiation method, then after administration of the first dose of [MEDICATION NAME]/[MEDICATION NAME], monitor the INR daily through day four of administration. If utilizing the average daily dosing method, monitor the INR every ,[DATE] days until the INR is greater than the lower limit of the desired therapeutic range then within 1 week. After hospital discharge: if the patient is stable, monitor the INR within ,[DATE] days, if the patient is unstable monitor the INR within ,[DATE] days. During the first month of treatment, monitor the INR at least weekly. The routine follow up for an INR of a medically unstable is every ,[DATE] weeks. 13. A review of the Geriatric Dosage Handbook 12th Edition 2007, pg. 1179, Initiation of Oral Anticoagulation with [MEDICATION NAME] revealed: Dosing of [MEDICATION NAME] ([MEDICATION NAME]) must be individualized according to patient response to the drug as indicated by the INR. Step 1. Obtain baseline INR. Begin therapy with [MEDICATION NAME] with a dose ,[DATE]mg per day with dosage adjustments based on results of INR determinations. Step 2. Day that INR is stabilized in the therapeutic range: Check INR daily. Adjust [MEDICATION NAME] dose based on the results of INR determinations. Patients stabilized in the therapeutic range: Intervals between subsequent INR determinations should be based upon the physician's judgement of the patient's reliability and response to [MEDICATION NAME] in order to maintain the individual within therapeutic range. Acceptable intervals for INR determinations are normally within the range ,[DATE] weeks after a stable dosage has been determined. Most patients are satisfactorily maintained on [MEDICATION NAME] at a dose of ,[DATE]mg. 14. During a phone interview with the medical director/attending physician on [DATE] at 10:45 a.m., the physician stated that another physician working with him might have seen Resident #95 while he was in the facility as we have someone in the building almost every day. I know that the orders related to [MEDICATION NAME] ([MEDICATION NAME]) and other items were not signed off and if they were in our box, would have been signed off by either the physician or the ARNP (advanced registered nurse practitioner). When a telephone order is given, the nurse would put it in the computer, print off the order, and put it in the physician box for a review and signature. Then the physician signs the stack in the box or the ARNP based on the order and the medication. An alert for [MEDICATION NAME] should have been made and we never received that either. No one in our staff ever signed off on the order. If you look at the order in both residents' charts, you will see that another resident's orders went to Resident #95 instead of Resident #280. I reviewed the charts and the staff did contact the ESNF (telemedicine) for Resident #95's possible hematuria. The practitioner is available when they call and speak to someone and they do record all the calls. The ESNF has verbal, face time and televisual services available. I know the facility has been in-serviced on the process but I am not sure if they are using more than the telephone. I would think the physician would ask about the medications the resident was receiving. I reviewed this case and there should have been pertinent information conveyed from a SBAR (Situation, Background, Assessment and Recommendation). Supposedly, there was a glitch in the communication. The file for Resident #95 went to the medical examiner, they took over the case, and the hospitalist and hospital physician were spoken too. The death was recorded at the medical examiner as accidental death. The resident did have a variety of cardiovascular diseases, with anticoagulants they don't cause the bleeding but if you start bleeding, they can't stop the bleeding. This resident most likely would have bled in the brain but we would never know if or when and how bad the bleed would have been. 15. An interview was conducted with Employee BB, LPN, an employee of 7 years, on [DATE] at 1:23 p.m. regarding [MEDICATION NAME] monitoring. Employee #BB, LPN, responded that the facility used to log PT/INR in the treatment book, but once they began using a computer system roughly four (4) months ago we stopped monitoring it in the treatment book. Employee #BB, LPN, was asked what the process was for monitoring PT/INR in January. Employee #BB, LPN, responded she was unaware of the process for monitoring PT/INR because it was taken care of on the ,[DATE] shift. Employee #BB, LPN, did not know where they charted the labs and if the physician was aware of the labs. Employee #BB, LPN, stated that recently we started doing it the old way again, which is much more efficient. We check the date, there is a place to sign that says the doctor was notified, place to document if the order was changed and next order date for labs unless they are ordered routinely. Employee #BB, LPN, responded that the system works much better now. An interview was conducted on [DATE] at 1:49 p.m. with the Director of Quality Assurance (DQA) regarding Resident #95. The DQA responded that, on [DATE], the nurses reported to her that an ER physician called and asked for the current INR for Resident #95 and they did not see an INR in the chart. The ER physician notified Resident #95's primary care physician (PCP) and the PCP called the facility inquiring why the resident was on [MEDICATION NAME]. At that time, we started an immediate investigation. The DQA stated that the resident died due to [MEDICATION NAME] toxicity. There was an order in Resident #95's chart for [MEDICATION NAME] that should not have been there. The medical di(TRUNCATED)

Based on observation, interview, and record review, the facility failed to follow the plan of care for two (#95 and #280) out of seven sampled residents receiving anticoagulant medications. Resident #280 did not receive the correct physician ordered dose of [MEDICATION NAME] in accordance with the plan of care due to a transcription error in the electronic Medication Administration Record [REDACTED]. Resident #95 had a physician order for [REDACTED].#95 had a care plan added to her clinical record for the use of this medication. The approaches contained in the care plan were not implemented and monitored to ensure Resident #95 did not display signs of decline or adverse effects from the anticoagulant medication. Resident #95 developed an [MEDICAL CONDITION], severe anticoagulation, and [MEDICATION NAME] toxicity that lead to her death after receiving 19 doses of medication not meant to be prescribed for her. Past noncompliance at the Immediate Jeopardy level was identified on [DATE] as occurring on [DATE]. The administrative team was notified on [DATE] at 4:53 p.m. The Immediate Jeopardy was determined to be corrected on [DATE], prior to the facility visit. Findings included: 1. A review of Resident #280's clinical record revealed she was admitted to the facility on [DATE] with relevant [DIAGNOSES REDACTED]. A review of the admission physician progress notes [REDACTED]. A review of the physician orders revealed Resident #280 received titrated doses of [MEDICATION NAME] for a [DIAGNOSES REDACTED]. The resident had labs ordered for PT/INR on night shift every Sunday and Wednesday from [DATE] - [DATE] and PT/INR on the night shift every Monday and Thursday from [DATE] - [DATE]. On [DATE], a hand written physician order was placed to increase [MEDICATION NAME] from 5 mg to 6 mg by mouth daily. This order was never placed in the facility's EMAR system for Resident #280. A review of Resident #280's [DATE] Medication Administration Record [REDACTED]. 2. A review of Resident #95's clinical record revealed she was admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. The state form 3008 reflected the resident was transferred to the facility for physical therapy. A review of the admission nursing note from [DATE] at 6:30 p.m. revealed Resident #95 was alert and oriented. Vitals were within normal limits. No complaint, signs, or symptoms of distress. Skin intact and able to voice needs. MD (Medical doctor) notified of orders and verified. There was no record of the resident receiving anticoagulant therapy at the time of admission. A review of Physician's progress notes on [DATE] revealed this patient presented after admission to a local hospital due to abdominal pain. Patient has a history of hiatal hernia and gastritis noted on multiple EGDs (esophagogastroduodenoscopy; a scope with light and camera is used to look at digestive tract). Patient was evaluated by [MEDICATION NAME] and urology. Patient reports feeling tired and is resting comfortably. Also, complaint of cough and sore throat with sinus pressure. Resident is in no acute distress, lethargic and anxious. Cardiovascular assessment revealed regular heart rate and rhythm. Normal S1/S2 (heart sounds). The plan included medications and lab work. [MEDICATION NAME]/[MEDICATION NAME] was not on the list of medications in the plan and anticoagulant monitoring was also not on the plan. A review of the electronic physician orders, dated [DATE] at 22:22 p.m., showed an order for [REDACTED].#95's record revealed no prior history of [DIAGNOSES REDACTED]. The order was entered into the electronic Medication Administration Record [REDACTED]. The order sheet did not contain a signature from the physician on the form. A review of the 24-hour chart check showed that the Employee #G, RN, initialed off orders that were placed on [DATE]. The instructions contained on the 24 hour chart check form state that The designated nurse will review all physician orders for the previous 24-hours for verification that orders have been noted, transcribed as noted, materials/supplies/medications have been ordered, labs and diagnostics have been ordered and appropriate departments notified. The nurse signature for each day noted below indicates verification and follow-through for all physician orders. A review of Resident #95's Admission Minimum Data Set (MDS), dated [DATE], revealed the resident scored a ,[DATE] on her Brief Interview for Mental Status indicating no cognitive impairment. Review of current medications revealed the resident received an anticoagulant three times during the look back period. A review of the Care Plan, dated [DATE], revealed a focus of being at risk for abnormal bleeding, hemorrhage, and bruising related to anticoagulant use for A fib ([MEDICAL CONDITION]; an abnormal heart rhythm) with a goal that the resident will be free from signs and symptoms of abnormal bleeding through next review. Interventions included: encourage resident to report any signs of bleeding or bruising, lab work as ordered, medication as ordered, observed for bleeding gums, nose bleeds, unusual bruising, tarry black stools, pink or discolored urine to nurse and/or MD, report to physician and s/s of abnormal bleeding, hemorrhage and bruising, and skin checks per facility protocol. A review of the clinical record found no history or basis for a [DIAGNOSES REDACTED].#95's care plan. A review of the electronic Medication Administration Record [REDACTED]. The EMAR did not include a lab box to enter appropriate lab values. The nurses who administered the [MEDICATION NAME] at bedtime were Employees #D (LPN), #E Registered Nurse (RN), #H (LPN), #I (LPN), #J (LPN), #K (LPN), and #L (LPN). Review of nurse notes on [DATE] at 05:00 a.m. revealed Resident noted with cough and SOB (shortness of breath); [MEDICATION NAME] (aerosaled inhaled medication) given as ordered; writer noted blood in mucus when resident coughed; ESNF (telemedicine) notified of resident condition and new order received for CXR (chest x-ray) x 2 view writer notified resident of new order; call light within reach. A nurse note dated [DATE] at 6:45 a.m. depicted writer notified that resident noted with red and dark area in diaper with urine; writer notified ESNF; new order received for CBC with diff (complete blood count with differential), CMP (complete metabolic panel), and U/A and C&S (urine analysis with culture and sensitivity); resident notified. A review of a nursing note dated [DATE] at 9:00 p.m. revealed, All labs, x-ray, and urine called in to ARNP (Advanced Registered Nurse Practitioner) n/o (new order) received and noted. Resident had no discomfort present this p.m. No bloody sputum. Fluids encouraged and offered. A nursing note on [DATE] at 9:30 a.m. revealed, patient refused meds, patient able to open eyes, patient O2 saturation (oxygen level) 93% on 2L/min via NC (nasal cannula), pulse 72, respirations 18, blood pressure ,[DATE]. Reported patient refused meds, called to MD in a.m., refused ABT (antibiotic). A nursing note dated [DATE] at 12:00 p.m. revealed, spoke with ARNP for Medical Director, reported patient did not receive ABT in a.m., pupils equal and reactive in a.m. when assessed and vitals taken at 9:30 a.m. and 10:00 a.m. A nursing note on [DATE] at 1:00 p.m. revealed, patient's C.N.A. (certified nursing assistant) got attention of nurse at 12:15 p.m. Went to assess patient. Patient displayed labored breathing, O2 saturation 85% (,[DATE]% normal), patient not responding to voice, touch. Call to MD. Administered [MEDICATION NAME] to patient, O2 sat increased to 93% on 2L/min (oxygen). Received order to send patient to ER for evaluation and treatment. Blood sugar 191, blood pressure ,[DATE], pulse 68, O2 93%. EMS arrived within 5 minutes. During assessment, patient's pupils became enlarged and patient's arms became stiff. Patient sent to ER with all paperwork. Family notified. A review of ESNF PROGRESS NOTE/ORDERS dated [DATE] at 05:05 a.m. revealed; reason for call is cough and SOB with phlegm (mucus). Ordered placed for CXR - 2 view (SOB, cough with sputum) and notify attending physician of eCare SNF orders in the morning. An eCare SNF PROGRESS NOTE/ORDER dated [DATE] at 06:50 a.m. revealed a chief complaint of blood urine, history of [MEDICAL CONDITION]. Orders UA/C&S, CBC, and CMP, notify attending physician of eCare SNF orders in the morning. A review of the Transfer Form, dated [DATE], revealed the reason for the transfer was AMS (altered mental status) and decreased O2 saturation (low oxygen level). A review of a physician progress notes [REDACTED].#95 toER on [DATE] secondary to AMS. Expired same day. Contact with hospitalist, revealed bleeding (illegible). ARNP performed chart review the same day. Rounds indicate medication error, which placed patient on medications not ordered for her. Discussion with facility staff has indicated immediate attention to error along with corrective action plan. A review of a local hospital emergency room History and Physical, dated [DATE], noted that Resident #95 was admitted to the hospital emergency room unresponsive to verbal and tactile stimuli (sound or touch). Computerized Tomography scan (CT scan) showed a significant [MEDICAL CONDITION] (abnormal bleeding in the brain) with [DIAGNOSES REDACTED] (water on the brain). The emergency physician spoke with Resident #95's family who were unsure of the CODE STATUS but stated that she would not likely want intubation or other mechanical means of sustaining life. Resident #95's family was present and informed by the emergency physician that she would not likely survive. Resident #95 had recently been admitted to the local hospital for an upper [MEDICAL CONDITION]. In addition, apparently when resident arrived to the rehabilitation facility she was put on [MEDICATION NAME]. The onset is unknown. The course and duration of symptoms is constant. [DIAGNOSES REDACTED]. Resident received a dose of vitamin K (reversal for blood thinning medications) in the emergency room . The emergency physician spoke with family again who reiterated that they did not want heroic measures performed such as intubation or surgery. Further review of hospital records revealed Resident #95's PT on [DATE] was >170.0 second(s) and the INR was >13. The therapeutic range for PT time is ,[DATE] seconds (fda.gov) and a therapeutic INR is between 0XXX,[DATE].2 (fda.gov). 3. A review of the Geriatric Dosage Handbook 12th Edition 2007, pg. 1179, Initiation of Oral Anticoagulation with [MEDICATION NAME] revealed: Dosing of [MEDICATION NAME] ([MEDICATION NAME]) must be individualized according to patient response to the drug as indicated by the INR. Step 1. Obtain baseline INR. Begin therapy with [MEDICATION NAME] with a dose ,[DATE]mg per day with dosage adjustments based on results of INR determinations. Step 2. Day that INR is stabilized in the therapeutic range: Check INR daily. Adjust [MEDICATION NAME] dose based on the results of INR determinations. Patients stabilized in the therapeutic range: Intervals between subsequent INR determinations should be based upon the physician's judgement of the patient's reliability and response to [MEDICATION NAME] in order to maintain the individual within therapeutic range. Acceptable intervals for INR determinations are normally within the range ,[DATE] weeks after a stable dosage has been determined. Most patients are satisfactorily maintained on [MEDICATION NAME] at a dose of ,[DATE]mg. A review of Wittkowsky, Ann, The American Society of Health System Pharmacists, Chapter 24 [MEDICATION NAME], page 358 revealed: The intensity of [MEDICATION NAME] therapy is monitored by evaluation of the [MEDICATION NAME] time (PT), expressed as the INR . Table 24.7 summarizes the Frequency of INR monitoring and Patient Assessment. If the initiation method, then after administration of the first dose of [MEDICATION NAME]/[MEDICATION NAME], monitor the INR daily through day four of administration. If utilizing the average daily dosing method, monitor the INR every ,[DATE] days until the INR is greater than the lower limit of the desired therapeutic range then within 1 week. After hospital discharge: if the patient is stable, monitor the INR within ,[DATE] days, if the patient is unstable monitor the INR within ,[DATE] days. During the first month of treatment, monitor the INR at least weekly. The routine follow up for an INR of a medically unstable is every ,[DATE] weeks. A review of the facility policy titled, Medication Administration General Guidelines dated ,[DATE] revealed that medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. The policy also revealed under the medication preparation section that prior to administration, review and confirm MEDICATION ORDERS FOR [REDACTED]. Under the medication administration tab: medications are administered in accordance with written orders of the prescriber. If a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current [DIAGNOSES REDACTED]. If necessary, the nurse contacts the prescriber for clarification. This interaction with the pharmacy and the resulting order clarification are documented in nursing notes and elsewhere in the medical record as appropriate. 4. A review of the consultant pharmacist's, physician recommendations for Resident #95, dated [DATE], revealed no recommendations were made related to the [MEDICATION NAME]. In addition, no recommendation for lab monitoring was noted. The only recommendation in place for Resident #95 related to discontinuing of an antidepressant, which was followed through. An interview was conducted on [DATE] at 12:25 p.m. with the facility's consultant pharmacist regarding Resident #95. The consultant pharmacist was asked how he confirmed that [MEDICAL CONDITION] [REDACTED].#95 as noted on the physician order entered in the EMAR for [MEDICATION NAME] 6 mg dated [DATE]. The consultant pharmacist stated that once a [DIAGNOSES REDACTED]. The consultant pharmacist stated that, eventually, he would expect to see an order for [REDACTED]. The consultant pharmacist was asked if they had logs before and he responded yes, but had not seen them in a while and he did not want to comment any further on it. 5. An interview was conducted on [DATE] at 12:38 p.m. with Employee #DD, MDS, regarding Resident #95. Employee #DD created the care plan for Resident #95 and confirmed the care plan [DIAGNOSES REDACTED]. Employee #DD did not know where the [DIAGNOSES REDACTED].#DD remembered that the order for the [MEDICATION NAME] read [MEDICAL CONDITION]. Employee #DD was asked what the process was for creating a new care plan for a resident. Employee #DD responded that we look at orders daily but do not study them. The focus was on the ones that require a care plan. We investigate the chart for the care plan and chart categories of medications. During a phone interview with the medical director/attending physician on [DATE] at 10:45 a.m., the physician stated that another physician working with him might have seen Resident #95 while he was in the facility as we have someone in the building almost every day. I know that the orders related to [MEDICATION NAME] ([MEDICATION NAME]) and other items were not signed off and if they were in our box, would have been signed off by either the physician or the ARNP (advanced registered nurse practitioner). When a telephone order is given, the nurse would put it in the computer, print off the order, and put it in the physician box for a review and signature. Then the physician signs the stack in the box or the ARNP based on the order and the medication. An alert for [MEDICATION NAME] should have been made and we never received that either. No one in our staff ever signed off on the order. If you look at the order in both residents' charts, you will see that another resident's orders went to Resident #95 instead of Resident #280. I reviewed the charts and the staff did contact the ESNF (telemedicine) for Resident #95's possible hematuria. The practitioner is available when they call and speak to someone and they do record all the calls. The ESNF has verbal, face time and televisual services available. I know the facility has been in-serviced on the process but I am not sure if they are using more than the telephone. I would think the physician would ask about the medications the resident was receiving. I reviewed this case and there should have been pertinent information conveyed from a SBAR (Situation, Background, Assessment and Recommendation). Supposedly, there was a glitch in the communication. The file for Resident #95 went to the medical examiner, they took over the case, and the hospitalist and hospital physician were spoken to. The death was recorded at the medical examiner as accidental death. The resident did have a variety of cardiovascular diseases, with anticoagulants, they don't cause the bleeding but if you start bleeding, they can't stop the bleeding. This resident most likely would have bled in the brain but we would never know if or when and how bad the bleed would have been. An interview was conducted on [DATE] at 2:26 p.m. with the emergency room (ER) physician who cared for Resident #95 on [DATE]. The ER physician stated that Resident #95 arrived in the ER in bad shape. Resident #95 had a severe [MEDICAL CONDITION] that was not survivable. The ER physician stated that he was in contact with the hospitalist who contacted the nursing home and primary care physician regarding recent lab work. The ER physician stated that the significance of coagulation numbers showed Resident #95 was severely anticoagulated, which led to the hemorrhage. The ER physician would expect someone who was receiving [MEDICATION NAME] to receive monitoring for dosage adjustments. The ER physician also mentioned that Resident #95 recently left the hospital with an upper [MEDICAL CONDITION] (on [DATE]) and blood thinners is the worst thing the resident could be put on. An interview was conducted on [DATE] at 09:41 a.m. with Resident #95's son. The son stated that recently, Resident #95 had been hospitalized for [REDACTED]. Resident #95's son stated that he was unsure of the timeframe the resident was expected to be at the skilled nursing facility. The staff at the facility had informed him that Resident #95 was being uncooperative with treatment and expected to be staying at the facility long term prior to the resident expiring. Resident #95's son stated that the day after Resident #95's passing; his brother went to the facility to collect her belongings. The nursing home administrator (NHA) informed that brother that the QA (quality assurance) discovered Resident #95 was receiving [MEDICATION NAME] without an order. Resident #95's son stated that the emergency physician called the medical examiner's office based on the condition, issues with the brain, and blood chemistry. The son stated that the medical examiner ruled the death accidental due to a major stroke caused by [MEDICATION NAME] toxicity. An interview was conducted on [DATE] at 1:49 p.m. with the Director of Quality Assurance (DQA) regarding Resident #95. The DQA responded that on [DATE] the nurses reported to her that an ER physician called and asked for the current INR for Resident #95 and they did not see an INR in the chart. The ER physician notified Resident #95's primary care physician (PCP) and the PCP called the facility inquiring why the resident was on [MEDICATION NAME]. At that time, we started an immediate investigation. The DQA stated that the resident died due to [MEDICATION NAME] toxicity. There was an order in Resident #95's chart for [MEDICATION NAME] that should not have been there. The medical director came in on the following day for an ad hoc QAPI (quality assurance performance improvement) meeting on [DATE] with the Executive Director (ED), Director of Clinical Services (DCS), Regional Director of Clinical Services (RDCS), and Regional Director of Operations (RDO). An interview was conducted with the nurse (Employee H, LPN) who entered the [MEDICATION NAME] order for Resident #95. The nurse remembered entering the order for Resident #95. The Nurse responded that there was a physician order for [REDACTED].#280 was not harmed due to the medication error of missing increased [MEDICATION NAME] from 5mg to 6mg for approximately 6 days. PT and INR tests revealed Resident #280 had therapeutic [MEDICATION NAME] levels per MD during chart review. The nurse who entered the orders incorrectly was suspended pending investigation and was then terminated. All residents receiving [MEDICATION NAME] were audited for current diagnosis. A [MEDICATION NAME] log was initiated and additional documentation added for INR lab. Nurses have to enter an INR into the EMAR (electronic medication administration record) prior to administering [MEDICATION NAME]. The ,[DATE] nurse (Employee G) who was responsible for doing the 24-hour chart check was suspended and then terminated for not following process. Each nurse who administered the [MEDICATION NAME] received a first and final write up for not verifying the INR prior to medication administration. The first and final write up means if they make another error they will be terminated. The DQA was asked what process was in place prior to being informed of the error. The DQA stated that basically nurses would get an order for [REDACTED]. The DQA has been employed for four years as the DQA. The surveyor informed the DQA that there was a log for [MEDICATION NAME] in the past; the DQA was unaware of what happened to it. An in house audit was completed on all residents to ensure all were receiving the correct medications. Audits were also completed for residents receiving [MEDICATION NAME] and anticoagulants. The audits for [MEDICATION NAME] and anticoagulants are now audited daily. The DQA ran a report listing all orders for the last 24 hours and they go through all new orders. The DQA stated that Resident #95 would have shown up due to a new order being entered for [MEDICATION NAME]. An interview was conducted on [DATE] at 2:43 p.m. with the regional director of clinical services (RDCS) regarding Resident #95. The RDCS stated that the IDT team (interdisciplinary team) met on [DATE] to go over orders from the weekend. The IDT team reviewed the order but no one questioned the order or verified it. The RDCS was asked to explain the care plan that was created for Resident #95 for anticoagulant use. The RDCS stated we reviewed that and do not know where the [DIAGNOSES REDACTED]. The RDCS was informed the medication was ordered on [DATE] and a care plan was not created until [DATE] and the RDCS responded we know. The RDCS stated that the first system failure was the 24-hour chart check. The nurse signed off that both charts were reviewed but had the nurse actually looked at the charts, he would have caught the error. The RDCS stated, We dropped the ball. An interview was conducted with Employee BB, LPN, an employee of 7 years, on [DATE] at 1:23 p.m. regarding [MEDICATION NAME] monitoring. Employee #BB, LPN, responded that the facility used to log PT/INR in the treatment book, but once they began using a computer system roughly four (4) months ago we stopped monitoring it in the treatment book. Employee #BB, LPN, was asked what the process was for monitoring PT/INR in January. Employee #BB, LPN, responded she was unaware of the process for monitoring PT/INR because it was taken care of on the ,[DATE] shift. Employee #BB, LPN, did not know where they charted the labs and if the physician was aware of the labs. Employee #BB, LPN, stated that recently we started doing it the old way again, which is much more efficient. We check the date, there is a place to sign that says the doctor was notified, place to document if the order was changed and next order date for labs unless they are ordered routinely. Employee #BB, LPN, responded that the system works much better now. An interview on [DATE] at 2:11 p.m. was conducted with the Director of Clinical Services (DCS) regarding current audits. The DCS responded that the staff received education and were in-serviced. [MEDICATION NAME] logs were initiated and are checked daily. We are also checking orders daily specifically, orders for [MEDICATION NAME] (blood thinner) and medications requiring special orders like prescriptions that need to be faxed to the pharmacy. The DCS responded that all the orders were checked for the last 3 months once we were notified of the issue from the hospital. The DCS stated that the ,[DATE] nurse (Employee G, RN) was in charge of the 24-hour chart checks and failed to notice the error. The DCS responded that nothing was in place after the ,[DATE] nurse checked to recheck or identify any issues. It is the expectation of the DCS, that staff check the orders and notify the physician/supervisor of issues. The DCS would expect the staff to alert someone regarding this error. During this same interview, the DCS was asked to describe the process for entering orders into the computer for a resident arriving from the hospital. The DCS responded that a nurse would enter the orders from the hospital records. At this time, a second nurse would check off that each medication was added. A call would then be placed to the MD and orders would be verified. The physician can discontinue or start a new order. When entering a telephone order the ,[DATE] nurse checks the order. The unit manager and DCS check the orders as well now. That intervention previously was not in place. The DCS stated that all nurses who administered [MEDICATION NAME] to Resident #95 received a first and final write up. All nurses were provided with training and we will continue to give training. An interview was conducted on [DATE] at 11:57 a.m. with Employee #L, LPN, who has been employed by the facility for close to [AGE] years. When administering medications she verifies the five rights of medication administration. Employee #L, LPN, stated that the process for medications that require monitoring are followed per physician orders related to the medication. A resident who was receiving [MEDICATION NAME] now goes on a log. We verify that the PT/INR has been completed and physician has been notified. Employee #L, LPN, stated that at one point, the checkpoints were not there and staff have recently installed it back into use. Employee #L, LPN, stated that she remembered Resident #95 and had worked with her a few times because she was a float nurse. Employee #L, LPN, remembered administering medications to Resident #95. Employee #L, LPN, responded that she was aware of the incident involving Resident #95 and did not know she was administering the wrong medication to the resident. Employee #L, LPN, stated that as far as she knew she administered medications correctly to Resident #95. She stated that she administered what was on her computer screen to give. Employee #L, LPN, stated that she was informed through meetings and actions that Resident #95 was given [MEDICATION NAME] and they had to send her to the hospital. The nursing staff informed her that Resident #95 passed away. Employee #L, LPN, responded that the facility reeducated the nursing staff and had to complete in-services regarding [MEDICATION NAME]. Employee #L, LPN, stated that the DCS gave her a paper to sign in regarding giving medications correctly and received a write up. Employee #L, LPN, stated that now we have to make sure they monitor the PT/INR, ensure that it was put into the flow record in the task book and in the computer when administering [MEDICATION NAME]. An interview was conducted on [DATE] at 5:00 p.m. with Employee #D, LPN, who works all three shifts. Employee #D, LPN, responded that when administering medications she checks the five rights every time. Employee #D, LPN, stated that she follows physician's orders for medications that require monitoring. Employee #D, LPN responded that if a resident is on [MEDICATION NAME] you check the PT/INR prior to administering as part of the five rights and that has been in place now since March. Prior to March, Employee #D, LPN, stated that she just gave the medications as scheduled and monitored the labs as ordered. If no labs were ordered, Employee #D, LPN, stated that she should have questioned it. Employee #D, LPN, remembers Resident #95's name but was not very familiar with her. Employee #D, LPN, does remember administering medications to Resident #95 including [MEDICATION NAME]. Employee #D, LPN, was not aware of any incidents involving Resident #95 while she was a resident in the facility but was aware of what happened once the resident was transferred to the hospital. Employee #D, LPN, revealed that she did receive a write up for the error. Employee #D, LPN, was able to verify and convey that she had received in-service training on the new [MEDICATION NAME] process and the logs for monitoring medications. An interview was conducted on [DATE] at 8:24 a.m. with Employee #K, LPN. Employee #K, LPN, was asked when administering medications are there any verifications that need to be done prior to administering the medication. Employee #K, LPN stated that if parameters were ordered I would follow them. If the resident was on [MEDICATION NAME] she would check the log for lab work (now), before the incident she would check the lab work in the morning, would document the PT/INR numbers. Now this information is put in the treatment book. Employee #K, LPN, was asked what the process was for medications that required monitoring. Employee #K, LPN, responded that they are monitored per physician orders. It is now in the computer, which alerts staff to do the ordered monitoring. Employee #K, LPN, was asked if someone was on [MEDICATION NAME] was there a special process. Employee #K, LPN, responded watch for bruising or bleeding, if they had a fall and on [MEDICATION NAME], would call the MD and make MD aware that the resident had a fall and was on [MEDICATION NAME]. She reported that she would also check lab results for the PT/INR results. Would also check the five rights. Employee #K, LPN, also stated that the lab would call if the labs(TRUNCAT

Based on resident record review for Residents #95 and #280, interviews with facility staff, medical director, facility administration, and review of the facility's policy and procedure general medication administration, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being, consistent with the resident's comprehensive care plan and provide care in accordance with professional standards of practice. Based on a review of five open and two closed records of residents (#95 AND #280) who received [MEDICATION NAME], Resident #95 did not receive monitoring of PT/INR ([MEDICATION NAME] time/International Normalizing Ratio; a measure of blood clotting) indicated for [MEDICATION NAME] therapy and received the [MEDICATION NAME] in error. an order for [REDACTED].#280 showed an order to increase [MEDICATION NAME] as part of their therapy. This order was never placed in Resident #280's chart due to being transcribed into Resident #95's chart in error. The processes in place to correct the error failed. The inattention by facility staff to identify the wrong order placed in Resident #95's chart and failure to suggest monitoring resulted in Resident #95 developing an [MEDICAL CONDITION], severe anticoagulation, and [MEDICATION NAME] toxicity that lead to Resident #95's death. Past noncompliance at the Immediate Jeopardy level was identified on [DATE] as occurring on ,[DATE]/ 2017. The administrative team was notified on [DATE] at 4:53 p.m. The Immediate Jeopardy was determined to be corrected on [DATE], prior to the facility visit. Findings Included: 1. A review of Resident #95's clinical record revealed she was admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. The state form 3008 reflected the resident was transferred to the facility for physical therapy. A review of Resident #95's Admission Minimum Data Set (MDS), dated [DATE], revealed the resident scored a ,[DATE] on her Brief Interview for Mental Status indicating no cognitive impairment. Review of current medications revealed the resident received an anticoagulant three times during the look back period. A review of Physician's progress notes on [DATE] portrayed patient presents after admission to local hospital due to abdominal pain. Patient has a history of hiatal hernia and gastritis noted on multiple EGDs (esophagogastroduodenoscopy; a scope with light and camera is used to look at digestive tract). Patient was evaluated by [MEDICATION NAME] and urology. Patient reports feeling tired and is resting comfortably. Also, complaint of cough and sore throat with sinus pressure. Resident is in no acute distress, lethargic and anxious. Cardiovascular assessment revealed regular heart rate and rhythm. Normal S1/S2 (heart sounds). The plan included medications and lab work. [MEDICATION NAME]/[MEDICATION NAME] was not on the list of medications in the plan and anticoagulant monitoring was also not on the plan. A review of the physician orders, dated [DATE] at 22:22 p.m., showed an order for [REDACTED].#95 was never diagnosed with [REDACTED]. The order sheet did not contain a signature from the physician on the form. A review of the 24-hour chart check showed that the Employee #G, RN, initialed off orders that were placed on [DATE]. The instructions contained on the 24 hour chart check form state that The designated nurse will review all physician orders for the previous 24-hours for verification that orders have been noted, transcribed as noted, materials/supplies/medications have been ordered, labs and diagnostics have been ordered and appropriate departments notified. The nurse signature for each day noted below indicates verification and follow-through for all physician orders. A review of Wittkowsky, Ann, The American Society of Health System Pharmacists, Chapter 24 [MEDICATION NAME], page 358 revealed: The intensity of [MEDICATION NAME] therapy is monitored by evaluation of the [MEDICATION NAME] time (PT), expressed as the INR . Table 24.7 summarizes the Frequency of INR monitoring and Patient Assessment. If the initiation method, then after administration of the first dose of [MEDICATION NAME]/[MEDICATION NAME], monitor the INR daily through day four of administration. If utilizing the average daily dosing method, monitor the INR every ,[DATE] days until the INR is greater than the lower limit of the desired therapeutic range then within 1 week. After hospital discharge: if the patient is stable, monitor the INR within ,[DATE] days, if the patient is unstable monitor the INR within ,[DATE] days. During the first month of treatment, monitor the INR at least weekly. The routine follow up for an INR of a medically unstable is every ,[DATE] weeks. A review of the Geriatric Dosage Handbook 12th Edition 2007, pg. 1179, Initiation of Oral Anticoagulation with [MEDICATION NAME] revealed: Dosing of [MEDICATION NAME] ([MEDICATION NAME]) must be individualized according to patient response to the drug as indicated by the INR. Step 1. Obtain baseline INR. Begin therapy with [MEDICATION NAME] with a dose ,[DATE]mg per day with dosage adjustments based on results of INR determinations. Step 2. Day that INR is stabilized in the therapeutic range: Check INR daily. Adjust [MEDICATION NAME] dose based on the results of INR determinations. Patients stabilized in the therapeutic range: Intervals between subsequent INR determinations should be based upon the physician's judgement of the patient's reliability and response to [MEDICATION NAME] in order to maintain the individual within therapeutic range. Acceptable intervals for INR determinations are normally within the range ,[DATE] weeks after a stable dosage has been determined. Most patients are satisfactorily maintained on [MEDICATION NAME] at a dose of ,[DATE]mg. A review of the electronic Medication Administration Record [REDACTED]. The EMAR did not include a lab box to enter appropriate lab values. The nurses who administered the [MEDICATION NAME] at bedtime were Employees #D Licensed Practical Nurse (LPN), #E Registered Nurse (RN), #H (LPN), #I (LPN), #J (LPN), #K (LPN), and #L (LPN). A review of the facility policy titled, Medication Administration General Guidelines dated ,[DATE] revealed that medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. The policy also revealed under the medication preparation section that prior to administration, review and confirm MEDICATION ORDERS FOR [REDACTED]. Under the medication administration tab: medications are administered in accordance with written orders of the prescriber. If a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current [DIAGNOSES REDACTED]. If necessary, the nurse contacts the prescriber for clarification. This interaction with the pharmacy and the resulting order clarification are documented in nursing notes and elsewhere in the medical record as appropriate. A review of the Care Plan, dated [DATE], revealed a focus of being at risk for abnormal bleeding, hemorrhage, and bruising related to anticoagulant use for A fib ([MEDICAL CONDITION]; an abnormal heart rhythm) with a goal that the resident will be free from signs and symptoms of abnormal bleeding through next review. Interventions included: encourage resident to report any signs of bleeding or bruising, lab work as ordered, medication as ordered, observed for bleeding gums, nose bleeds, unusual bruising, tarry black stools, pink or discolored urine to nurse and/or MD, report to physician and s/s of abnormal bleeding, hemorrhage and bruising, and skin checks per facility protocol. A review of the clinical record found no history or basis for a [DIAGNOSES REDACTED].#95's care plan. A review of the consultant pharmacist's, physician recommendations for Resident #95, dated [DATE], revealed no recommendations were made related to the [MEDICATION NAME]. In addition, no recommendation for lab monitoring was noted. The only recommendation in place for Resident #95 related to discontinuing of an antidepressant, which was followed through. An interview was conducted on [DATE] at 12:25 p.m. with the facility's consultant pharmacist regarding Resident #95. The consultant pharmacist was asked how he confirmed that [MEDICAL CONDITION] [REDACTED].#95 as noted on the physician order entered in the EMAR for [MEDICATION NAME] 6 mg dated [DATE]. The consultant pharmacist stated that once a [DIAGNOSES REDACTED]. The consultant pharmacist stated that, eventually, he would expect to see an order for [REDACTED]. The consultant pharmacist was asked if they had logs before and he responded yes, but had not seen them in a while and he did not want to comment any further on it. A review of the admission nursing note from [DATE] at 6:30 p.m. revealed Resident #95 was alert and oriented. Vitals were within normal limits. No complaint, signs, or symptoms of distress. Skin intact and able to voice needs. MD (Medical doctor) notified of orders and verified. Review of nurse notes on [DATE] at 05:00 a.m. revealed Resident noted with cough and SOB (shortness of breath); [MEDICATION NAME] (aerosaled inhaled medication) given as ordered; writer noted blood in mucus when resident coughed; ESNF (telemedicine) notified of resident condition and new order received for CXR (chest x-ray) x 2 view writer notified resident of new order; call light within reach. A nurse note dated [DATE] at 6:45 a.m. depicted writer notified that resident noted with red and dark area in diaper with urine; writer notified ESNF; new order received for CBC with diff (complete blood count with differential), CMP (complete metabolic panel), and U/A and C&S (urine analysis with culture and sensitivity); resident notified. A review of a nursing note dated [DATE] at 9:00 p.m. revealed, All labs, x-ray, and urine called in to ARNP (Advanced Registered Nurse Practitioner) n/o (new order) received and noted. Resident had no discomfort present this p.m. No bloody sputum. Fluids encouraged and offered. A nursing note on [DATE] at 9:30 a.m. revealed, patient refused meds, patient able to open eyes, patient O2 saturation (oxygen level) 93% on 2L/min via NC (nasal cannula), pulse 72, respirations 18, blood pressure ,[DATE]. Reported patient refused meds, called to MD in a.m., refused ABT (antibiotic). A nursing note dated [DATE] at 12:00 p.m. revealed, spoke with ARNP for Medical Director, reported patient did not receive ABT in a.m., pupils equal and reactive in a.m. when assessed and vitals taken at 9:30 a.m. and 10:00 a.m. A nursing note on [DATE] at 1:00 p.m. revealed, patient's C.N.A. (certified nursing assistant) got attention of nurse at 12:15 p.m. Went to assess patient. Patient displayed labored breathing, O2 saturation 85% (,[DATE]% normal), patient not responding to voice, touch. Call to MD. Administered [MEDICATION NAME] to patient, O2 sat increased to 93% on 2L/min (oxygen). Received order to send patient to ER for evaluation and treatment. Blood sugar 191, blood pressure ,[DATE], pulse 68, O2 93%. EMS arrived within 5 minutes. During assessment, patient's pupils became enlarged and patient's arms became stiff. Patient sent to ER with all paperwork. Family notified. A review of ESNF PROGRESS NOTE/ORDERS dated [DATE] at 05:05 a.m. revealed; reason for call is cough and SOB with phlegm (mucus). Ordered placed for CXR - 2 view (SOB, cough with sputum) and notify attending physician of eCare SNF orders in the morning. An eCare SNF PROGRESS NOTE/ORDER dated [DATE] at 06:50 a.m. revealed a chief complaint of blood urine, history of [MEDICAL CONDITION]. Orders UA/C&S, CBC, and CMP, notify attending physician of eCare SNF orders in the morning. A review of the Transfer Form, dated [DATE], revealed the reason for the transfer was AMS (altered mental status) and decreased O2 saturation (low oxygen level). Review of a local hospital emergency room History and Physical, dated [DATE], noted that Resident #95 was admitted to the hospital emergency room unresponsive to verbal and tactile stimuli (sound or touch). Computerized Tomography scan (CT scan) showed a significant [MEDICAL CONDITION] (abnormal bleeding in the brain) with [DIAGNOSES REDACTED] (water on the brain). The emergency physician spoke with Resident #95's family who were unsure of the CODE STATUS but stated that she would not likely want intubation or other mechanical means of sustaining life. Resident #95's family was present and informed by the emergency physician that she would not likely survive. Resident #95 had recently been admitted to the local hospital for an upper [MEDICAL CONDITION]. In addition, apparently when resident arrived to the rehabilitation facility she was put on [MEDICATION NAME]. The onset is unknown. The course and duration of symptoms is constant. [DIAGNOSES REDACTED]. Resident received a dose of vitamin K (reversal for blood thinning medications) in the emergency room . The emergency physician spoke with family again who reiterated that they did not want heroic measures performed such as intubation or surgery. Further review of hospital records revealed Resident #95's PT on [DATE] was >170.0 second(s) and the INR was >13. The therapeutic range for PT time is ,[DATE] seconds (fda.gov) and a therapeutic INR is between 0XXX,[DATE].2 (fda.gov). An interview was conducted on [DATE] at 2:26 p.m. with the emergency room (ER) physician who cared for Resident #95 on [DATE]. The ER physician stated that Resident #95 arrived in the ER in bad shape. Resident #95 had a severe [MEDICAL CONDITION] that was not survivable. The ER physician stated that he was in contact with the hospitalist who contacted the nursing home and primary care physician regarding recent lab work. The ER physician stated that the significance of coagulation numbers showed Resident #95 was severely anticoagulated, which led to the hemorrhage. The ER physician would expect someone who was receiving [MEDICATION NAME] to receive monitoring for dosage adjustments. The ER physician also mentioned that Resident #95 recently left the hospital with an upper [MEDICAL CONDITION] (on [DATE]) and blood thinners is the worst thing the resident could be put on. A review of a physician progress notes [REDACTED].#95 toER on [DATE] secondary to AMS. Expired same day. Contact with hospitalist, revealed bleeding (illegible). ARNP performed chart review the same day. Rounds indicate medication error, which placed patient on medications not ordered for her. Discussion with facility staff has indicated immediate attention to error along with corrective action plan. During a phone interview with the medical director/attending physician on [DATE] at 10:45 a.m., the physician stated that another physician working with him might have seen Resident #95 while he was in the facility as we have someone in the building almost every day. I know that the orders related to [MEDICATION NAME] ([MEDICATION NAME]) and other items were not signed off and if they were in our box, would have been signed off by either the physician or the ARNP (advanced registered nurse practitioner). When a telephone order is given, the nurse would put it in the computer and print off the order and put it in the physician box for a review and signature. Then the physician signs the stack in the box or the ARNP based on the order and the medication. An alert for [MEDICATION NAME] should have been made and we never received that either. No one in our staff ever signed off on the order. If you look at the order in both residents' charts, you will see that another resident's orders went to Resident #95 instead of Resident #280. I reviewed the charts and the staff did contact the ESNF (telemedicine) for Resident #95's possible hematuria. The practitioner is available when they call and speak to someone and they do record all the calls. The ESNF has verbal, face time and televisual services available. I know the facility has been in-serviced on the process but I am not sure if they are using more than the telephone. I would think the physician would ask about the medications the resident was receiving. I reviewed this case and there should have been pertinent information conveyed from a SBAR (Situation, Background, Assessment and Recommendation). Supposedly, there was a glitch in the communication. The file for Resident #95 went to the medical examiner, they took over the case, and the hospitalist and hospital physician were spoken to. The death was recorded at the medical examiner as accidental death. The resident did have a variety of cardiovascular diseases, with anticoagulants, they don't cause the bleeding but if you start bleeding, they can't stop the bleeding. This resident most likely would have bled in the brain but we would never know if or when and how bad the bleed would have been. An interview was conducted on [DATE] at 09:41 a.m. with Resident #95's son. The son stated that recently, Resident #95 had been hospitalized for [REDACTED]. Resident #95's son stated that he was unsure of the timeframe the resident was expected to be at the skilled nursing facility. The staff at the facility had informed him that Resident #95 was being uncooperative with treatment and expected to be staying at the facility long term prior to the resident expiring. Resident #95's son stated that the day after Resident #95's passing; his brother went to the facility to collect her belongings. The nursing home administrator (NHA) informed that brother that the QA (quality assurance) discovered Resident #95 was receiving [MEDICATION NAME] without an order. Resident #95's son stated that the emergency physician called the medical examiner's office based on the condition, issues with the brain, and blood chemistry. The son stated that the medical examiner ruled the death accidental due to a major stroke caused by [MEDICATION NAME] toxicity. An interview was conducted on [DATE] at 1:49 p.m. with the Director of Quality Assurance (DQA) regarding Resident #95. The DQA responded that on [DATE] the nurses reported to her that an ER physician called and asked for the current INR for Resident #95 and they did not see an INR in the chart. The ER physician notified Resident #95's primary care physician (PCP) and the PCP called the facility inquiring why the resident was on [MEDICATION NAME]. At that time, we started an immediate investigation. The DQA stated that the resident died due to [MEDICATION NAME] toxicity. There was an order in Resident #95's chart for [MEDICATION NAME] that should not have been there. The medical director came in on the following day for an ad hoc QAPI (quality assurance performance improvement) meeting on [DATE] with the Executive Director (ED), , Director of Clinical Services (DCS), Regional Director of Clinical Services (RDCS), and Regional Director of Operations (RDO). An interview was conducted with the nurse (Employee H, LPN) who entered the [MEDICATION NAME] order for Resident #95. The nurse remembered entering the order for Resident #95. The Nurse responded that there was a physician order for [REDACTED].#280 was not harmed due to the medication error of missing increased [MEDICATION NAME] from 5mg to 6mg for approximately 6 days. PT and INR tests revealed Resident #280 had therapeutic [MEDICATION NAME] levels per MD during chart review. The nurse who entered the orders incorrectly was suspended pending investigation and was then terminated. All residents receiving [MEDICATION NAME] were audited for current diagnosis. A [MEDICATION NAME] log was initiated and additional documentation added for INR lab. Nurses have to enter an INR into the EMAR (electronic medication administration record) prior to administering [MEDICATION NAME]. The ,[DATE] nurse (Employee G) who was responsible for doing the 24-hour chart check was suspended and then terminated for not following process. Each nurse who administered the [MEDICATION NAME] received a first and final write up for not verifying the INR prior to medication administration. The first and final write up means if they make another error they will be terminated. The DQA was asked what process was in place prior to being informed of the error. The DQA stated that basically nurses would get an order for [REDACTED]. The DQA has been employed for four years as the DQA. The surveyor informed the DQA that there was a log for [MEDICATION NAME] in the past; the DQA was unaware of what happened to it. An in house audit was completed on all residents to ensure all were receiving the correct medications. Audits were also completed for residents receiving [MEDICATION NAME] and anticoagulants. The audits for [MEDICATION NAME] and anticoagulants are now audited daily. The DQA ran a report listing all orders for the last 24 hours and they go through all new orders. The DQA stated that Resident #95 would have shown up due to a new order being entered for [MEDICATION NAME]. 2. A review of Resident #280's clinical record revealed she was admitted to the facility on [DATE] with relevant [DIAGNOSES REDACTED]. A review of the admission physician progress notes [REDACTED]. A review of the physician orders revealed Resident #280 received titrated doses of [MEDICATION NAME] for a [DIAGNOSES REDACTED]. The resident had labs ordered for PT/INR on night shift every Sunday and Wednesday from [DATE] - [DATE] and PT/INR on the night shift every Monday and Thursday from [DATE] - [DATE]. On [DATE], a hand written physician order was placed to increase [MEDICATION NAME] from 5 mg to 6 mg by mouth daily. This order was never placed in the facility's EMAR system for Resident #280 and according to interviews and record review was incorrectly placed in the EMAR system for Resident #95. 3. An interview on [DATE] at 2:11 p.m. was conducted with the Director of Clinical Services (DCS) regarding current audits. The DCS responded that the staff received education and were in-serviced. [MEDICATION NAME] logs were initiated and are checked daily. We are also checking orders daily specifically, orders for [MEDICATION NAME] (blood thinner) and medications requiring special orders like prescriptions that need to be faxed to the pharmacy. The DCS responded that all the orders were checked for the last 3 months once we were notified of the issue from the hospital. The DCS stated that the ,[DATE] nurse (Employee G, RN) was in charge of the 24-hour chart checks and failed to notice the error. The DCS responded that nothing was in place after the ,[DATE] nurse checked to recheck or identify any issues. It is the expectation of the DCS, that staff check the orders and notify the physician/supervisor of issues. The DCS would expect the staff to alert someone regarding this error. During this same interview, the DCS was asked to describe the process for entering orders into the computer for a resident arriving from the hospital. The DCS responded that a nurse would enter the orders from the hospital records. At this time, a second nurse would check off that each medication was added. A call would then be placed to the MD and orders would be verified. The physician can discontinue or start a new order. When entering a telephone order the ,[DATE] nurse checks the order. The unit manager and DCS check the orders as well now. That intervention previously was not in place. The DCS stated that all nurses who administered [MEDICATION NAME] to Resident #95 received a first and final write up. All nurses were provided with training and we will continue to give training. An interview was conducted on [DATE] at 2:43 p.m. with the regional director of clinical services (RDCS) regarding Resident #95. The RDCS stated that the IDT team (interdisciplinary team) met on [DATE] to go over orders from the weekend. The IDT team reviewed the order but no one questioned the order or verified it. The RDCS was asked to explain the care plan that was created for Resident #95 for anticoagulant use. The RDCS stated we reviewed that and do not know where the [DIAGNOSES REDACTED]. The RDCS was informed the medication was ordered on [DATE] and a care plan was not created until [DATE] and the RDCS responded we know. The RDCS stated that the first system failure was the 24-hour chart check. The nurse signed off that both charts were reviewed but had the nurse actually looked at the charts, he would have caught the error. The RDCS stated, We dropped the ball. An interview was conducted with Employee BB, LPN, an employee of 7 years, on [DATE] at 1:23 p.m. regarding [MEDICATION NAME] monitoring. Employee #BB, LPN, responded that the facility used to log PT/INR in the treatment book, but once they began using a computer system roughly four (4) months ago we stopped monitoring it in the treatment book. Employee #BB, LPN, was asked what the process was for monitoring PT/INR in January. Employee #BB, LPN, responded she was unaware of the process for monitoring PT/INR because it was taken care of on the ,[DATE] shift. Employee #BB, LPN, did not know where they charted the labs and if the physician was aware of the labs. Employee #BB, LPN, stated that recently we started doing it the old way again, which is much more efficient. We check the date, there is a place to sign that says the doctor was notified, place to document if the order was changed and next order date for labs unless they are ordered routinely. Employee #BB, LPN, responded that the system works much better now. An interview was conducted on [DATE] at 12:38 p.m. with Employee #DD, MDS, regarding Resident #95. Employee #DD created the care plan for Resident #95 and confirmed the care plan [DIAGNOSES REDACTED]. Employee #DD does not know where the [DIAGNOSES REDACTED].#DD remembers that the order for the [MEDICATION NAME] read [MEDICAL CONDITION]. Employee #DD was asked what the process was for creating a new care plan for a resident. Employee #DD responded that we look at orders daily but do not study them. The focus was on the ones that require a care plan. We investigate the chart for the care plan and chart categories of medications. An interview was conducted on [DATE] at 5:00 p.m. with Employee #D, LPN, who works all three shifts. Employee #D, LPN, responded that when administering medications she checks the five rights every time. Employee #D, LPN, stated that she follows physician's orders for medications that require monitoring. Employee #D, LPN responded that if a resident is on [MEDICATION NAME] you check the PT/INR prior to administering as part of the five rights and that has been in place now since March. Prior to March, Employee #D, LPN, stated that she just gave the medications as scheduled and monitored the labs as ordered. If no labs were ordered, Employee #D, LPN, stated that she should have questioned it. Employee #D, LPN, remembers Resident #95's name but was not very familiar with her. Employee #D, LPN, does remember administering medications to Resident #95 including [MEDICATION NAME]. Employee #D, LPN, was not aware of any incidents involving Resident #95 while she was a resident in the facility but was aware of what happened once the resident was transferred to the hospital. Employee #D, LPN, revealed that she did receive a write up for the error. Employee #D, LPN, was able to verify and convey that she had received in-service training on the new [MEDICATION NAME] process and the logs for monitoring medications. On [DATE] at 5:16 p.m., an interview was conducted with Employee #E, RN, who works the ,[DATE] shift and has been employed for only 1 month at the facility. Employee #E, RN, stated that prior to administering medications that she checks the five rights of medication administration every time. Employee #E, RN, responded she monitors medications based off physician orders. For a resident who is receiving [MEDICATION NAME] we check the PT/INR and labs as well as the five rights. If no labs were ordered for PT/INR, it should be questioned and calling the doctor is required. Employee #E, RN, remembers Resident #95, she worked with Resident #95 while she was being trained by Employee #H, LPN. Employee #E, RN, remembered administering medications to Resident #95 including [MEDICATION NAME]. Employee #E, RN, does not recall any incidents involving Resident #95 while the resident was in the facility but was made aware after the resident was transferred to the hospital. To her knowledge, Employee #E, RN, administered medications to Resident #95 without error. Employee #E, RN, responded that Resident #95 should not have received [MEDICATION NAME] and that was why she passed away. Employee #E, RN, received a write up for the error. Employee #E, RN, also received training regarding PT/INR labs, calling the doctor every time you get the results. Will call the doctor if no labs are ordered. Employee #E, RN, stated that [MEDICATION NAME] cannot be given without PT/INR results. An interview was conducted on [DATE] at 8:24 a.m. with Employee #K, LPN. Employee #K, LPN, was asked when administering medications are there any verifications that need to be done prior to administering the medication. Employee #K, LPN stated that if parameters were ordered I would follow them. If the resident was on [MEDICATION NAME] she would check the log for lab work (now), before the incident she would check the lab work in the morning, would document the PT/INR numbers. Now this information is put in the treatment book. Employee #K, LPN, was asked what the process was for medications that required monitoring. Employee #K, LPN, responded that they are monitored per physician orders. It is now in the computer, which alerts staff to do the ordered monitoring. Employee #K, LPN, was asked if someone was on [MEDICATION NAME] was there a special process. Employee #K, LPN, responded watch for bruising or bleeding, if they had a fall and on [MEDICATION NAME], would call the MD and make MD aware that the resident had a fall and was on [MEDICATION NAME]. She reported that she would also check lab results for the PT/INR results. Would also check the five rights. Employee #K, LPN, also stated that the lab would call if the labs were abnormal. Employee #K, LPN, remembers Resident #95. Employee #K, LPN, remembers administering medication to Resident #95 but does not remember administering [MEDICATION NAME]. The DCS informed her that she did give [MEDICATION NAME]. Employee #K, LPN, reported she had been written up for giving [MEDICATION NAME] without checking the INR and for not checking for ble

Based on resident record review, interviews with facility staff, medical director, facility administration and review of the policy and procedure for general medication administration, the facility failed to ensure each resident's drug regimen was free of unnecessary drugs. An unnecessary drug is any drug that is used without adequate monitoring. Based on a review of five open records and two closed records of residents receiving [MEDICATION NAME] (a blood thinner), one resident (Resident #95) of seven sampled residents did not receive adequate monitoring of PT/INR ([MEDICATION NAME] Time/International Normalizing Ratio); a measure of blood clotting time as indicated for [MEDICATION NAME] therapy. Resident #95 had an order placed in her chart in error for [MEDICATION NAME] for a [DIAGNOSES REDACTED]. Resident #95 was receiving [MEDICATION NAME] without monitoring of this high-risk medication. Resident #95 developed a significant [MEDICAL CONDITION] (bleeding in the brain) per local hospital records and was severely anticoagulated (process hindering the clotting of blood) per emergency physician interview. The actions of the medical and nursing staff who failed to order the necessary laboratory tests to monitor the clotting times and identify the transcription error subsequently resulted in Resident #95 developing a significant intracranial bleed, anticoagulation, and [MEDICATION NAME] toxicity resulting in the residents' death. Past noncompliance at the Immediate Jeopardy level was identified on [DATE] as occurring on ,[DATE]/ 2017. The administrative team was notified on [DATE] at 4:53 p.m. The Immediate Jeopardy was determined to be corrected on [DATE], prior to the facility visit. Findings Included: A review of a local hospital History and Physical, dated [DATE], revealed Resident #95 was admitted to the hospital emergency room unresponsive to verbal and tactile stimuli (sound or touch). Computerized Tomography scan (CT scan) showed a significant [MEDICAL CONDITION] with [DIAGNOSES REDACTED] (water on the brain). The emergency physician spoke with Resident #95's family who were unsure of the CODE STATUS but stated that she would not likely want intubation or other mechanical means of sustaining life. Resident #95's family was present and informed by the emergency physician that she would not likely survive. Resident #95 had recently been admitted to the local hospital for an upper [MEDICAL CONDITION]. In addition, apparently when resident arrived to the rehabilitation facility she was put on [MEDICATION NAME]. The onset is unknown. The course and duration of symptoms is constant. [DIAGNOSES REDACTED]. Resident received a dose of vitamin K (reversal for blood thinning medications) in the emergency room . The emergency physician spoke with family again who reiterated that they did not want heroic measures performed such as intubation or surgery. Further review of hospital records revealed Resident #95's PT on [DATE] was >170.0 second(s) and the INR was >13. The therapeutic range for PT time is ,[DATE] seconds (fda.gov) and a therapeutic INR is between 0XXX,[DATE].2 (fda.gov). An interview was conducted on [DATE] at 09:41 a.m. with Resident #95's son. The son stated that recently, Resident #95 had been hospitalized for [REDACTED]. Resident #95's son stated that he was unsure of the timeframe the resident was expected to be at the skilled nursing facility. The staff at the facility had informed him that Resident #95 was being uncooperative with treatment and expected to be staying at the facility long term prior to the resident expiring. Resident #95's son stated that the day after Resident #95's passing; his brother went to the facility to collect her belongings. The nursing home administrator (NHA) informed that brother that the quality assurance discovered Resident #95 was receiving [MEDICATION NAME] without an order. Resident #95's son stated that the emergency physician called the medical examiner's office based on the condition, issues with the brain, and blood chemistry. The son stated that the medical examiner ruled the death accidental due to a major stroke caused by [MEDICATION NAME] toxicity. During a phone interview with the medical director/attending physician on [DATE] at 10:45 a.m., the physician stated that another physician working with him might have seen Resident #95 while he was in the facility as we have someone in the building almost every day. I know that the orders related to [MEDICATION NAME] ([MEDICATION NAME]) and other items were not signed off and if they were in our box, would have been signed off by either the physician or the ARNP (advanced registered nurse practitioner). When a telephone order is given, the nurse would put it in the computer and print off the order and put it in the physician box for a review and signature. Then the physician signs the stack in the box or the ARNP based on the order and the medication. An alert for [MEDICATION NAME] should have been made and we never received that either. No one in our staff ever signed off on the order. If you look at the order in both residents' charts, you will see that another resident's orders went to Resident #95 instead of Resident #280. I reviewed the charts and the staff did contact the ESNF (telemedicine) for Resident #95's possible hematuria. The practitioner is available when they call and speak to someone and they do record all the calls. The ESNF has verbal, face time and televisual services available. I know the facility has been in-serviced on the process but I am not sure if they are using more than the telephone. I would think the physician would ask about the medications the resident was receiving. I reviewed this case and there should have been pertinent information conveyed from a SBAR (Situation, Background, Assessment and Recommendation). Supposedly, there was a glitch in the communication. The file for Resident #95 went to the medical examiner, they took over the case, and the hospitalist and hospital physician were spoken too. The death was recorded at the medical examiner as accidental death. The resident did have a variety of cardiovascular diseases, with anticoagulants they don't cause the bleeding but if you start bleeding, they can't stop the bleeding. This resident most likely would have bled in the brain but we would never know if or when and how bad the bleed would have been. An interview was conducted on [DATE] at 2:26 p.m. with the emergency room (ER) physician who cared for Resident #95 on [DATE]. The ER physician stated that Resident #95 arrived in the ER in bad shape. Resident #95 had a severe [MEDICAL CONDITION] that was not survivable. The ER physician stated that he was in contact with the hospitalist who contacted the nursing home and primary care physician regarding recent lab work. The ER physician stated that the significance of coagulation numbers showed Resident #95 was severely anticoagulated, which led to the hemorrhage. The ER physician would expect someone who was receiving [MEDICATION NAME] to receive monitoring for dosage adjustments. The ER physician also mentioned that Resident #95 recently left the hospital with an upper [MEDICAL CONDITION] and blood thinners is the worst thing the resident could be put on. A review of Resident #95's clinical record revealed she was admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. The state form 3008 showed the resident was transferred to the facility for physical therapy. A review of Wittkowsky, Ann, The American Society of Health System Pharmacists, Chapter 24 [MEDICATION NAME], page 358 revealed: The intensity of [MEDICATION NAME] therapy is monitored by evaluation of the [MEDICATION NAME] time (PT), expressed as the INR . Table 24.7 summarizes the Frequency of INR monitoring and Patient Assessment. If the initiation method, then after administration of the first dose of [MEDICATION NAME]/[MEDICATION NAME], monitor the INR daily through day four of administration. If utilizing the average daily dosing method, monitor the INR every ,[DATE] days until the INR is greater than the lower limit of the desired therapeutic range then within 1 week. After hospital discharge: if the patient is stable, monitor the INR within ,[DATE] days, if the patient is unstable monitor the INR within ,[DATE] days. During the first month of treatment, monitor the INR at least weekly. The routine follow up for an INR of a medically unstable is every ,[DATE] weeks. A review of the Geriatric Dosage Handbook 12th Edition 2007, pg. 1179, Initiation of Oral Anticoagulation with [MEDICATION NAME] revealed: Dosing of [MEDICATION NAME] ([MEDICATION NAME]) must be individualized according to patient response to the drug as indicated by the INR. Step 1. Obtain baseline INR. Begin therapy with [MEDICATION NAME] with a dose ,[DATE]mg per day with dosage adjustments based on results of INR determinations. Step 2. Day that INR is stabilized in the therapeutic range: Check INR daily. Adjust [MEDICATION NAME] dose based on the results of INR determinations. Patients stabilized in the therapeutic range: Intervals between subsequent INR determinations should be based upon the physician's judgement of the patient's reliability and response to [MEDICATION NAME] in order to maintain the individual within therapeutic range. Acceptable intervals for INR determinations are normally within the range ,[DATE] weeks after a stable dosage has been determined. Most patients are satisfactorily maintained on [MEDICATION NAME] at a dose of ,[DATE]mg. A review of Resident #95's Admission Minimum Data Set (MDS), dated [DATE], revealed the resident scored a ,[DATE] on her Brief Interview for Mental Status indicating no cognitive impairment. Review of current medications revealed the resident received an anticoagulant three times during the look back period. A review of a policy titled Medication Administration General Guidelines dated ,[DATE] revealed that medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. The policy also revealed under the medication preparation section that prior to administration, review and confirmed MEDICATION ORDERS FOR [REDACTED]. Under the medication administration tab: medications are administered in accordance with written orders of the prescribers. If a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current [DIAGNOSES REDACTED]. If necessary, the nurse contact the prescriber for clarification. This interaction with the pharmacy and the resulting order clarification are documented in nursing notes and elsewhere in the medical record as appropriate. A review of the Care Plan dated [DATE] revealed a focus of being at risk for abnormal bleeding, hemorrhage, and bruising related to anticoagulant use for A fib ([MEDICAL CONDITION]; an abnormal heart rhythm) with a goal that the resident will be free from signs and symptoms of abnormal bleeding through next review. Interventions included: encourage resident to report any signs of bleeding or bruising, lab work as ordered, medication as ordered, observed for bleeding gums, nose bleeds, unusual bruising, tarry black stools, pink or discolored urine to nurse and/or MD, report to physician and s/s of abnormal bleeding, hemorrhage and bruising, and skin checks per facility protocol. A review of the admission nursing note from [DATE] at 6:30 p.m. revealed Resident #95 was alert and oriented. Vitals are within normal limits. No complaint, signs, or symptoms of distress. Skin intact and able to voice needs. MD (Medical doctor) notified of orders and verified. Review of nurse notes on [DATE] at 05:00 a.m. revealed Resident noted with cough and SOB (shortness of breath); [MEDICATION NAME] (aerosaled inhaled medication) given as ordered; writer noted blood in mucus when resident coughed; ESNF (telemedicine) notified of resident condition and new order received for CXR (chest x-ray) x 2 view writer notified resident of new order; call light within reach. A nurse note dated [DATE] at 6:45 a.m. revealed writer notified that resident noted with red and dark area in diaper with urine; writer notified ESNF; new order received for CBC with diff (complete blood count with differential), CMP (complete metabolic panel), and U/A and C&S (urine analysis with culture and sensitivity); resident notified. A review of nursing note dated [DATE] at 9:00 p.m. revealed, All labs, x-ray, and urine called in to ARNP (Advanced Registered Nurse Practitioner) n/o (new order) received and noted. Resident had no discomfort present with p.m. No bloody sputum. Fluids encouraged and offered. A nursing note on [DATE] at 9:30 a.m. revealed, patient refused meds, patient able to open eyes, patient O2 saturation (oxygen level) 93% on 2L/min via NC (nasal cannula), pulse 72, respirations 18, blood pressure ,[DATE]. Reported patient refused meds, called to MD in a.m., refused ABT (antibiotic). A nursing note dated [DATE] at 12:00 p.m. revealed, spoke with ARNP for Medical Director, reported patient did not received ABT in a.m., pupils equal and reactive in a.m. when assessed and vitals taken at 9:30 a.m. and 10:00 a.m. A nursing note on [DATE] at 1:00 p.m. revealed, patients C.N.A. (certified nursing assistant) got attention of nurse at 12:15 p.m. Went to assess patient. Patient displayed labored breathing, O2 saturation 85% (,[DATE]% normal), patient not responding to voice, touch. Call to MD. Administered [MEDICATION NAME] to patient, O2 sat increased to 93% on 2L/min (oxygen). Received order to send patient to ER for evaluation and treatment. Blood sugar 191, blood pressure ,[DATE], pulse 68, O2 93%. EMS arrived within 5 minutes. During assessment, patient's pupils became enlarged and patient's arms became stiff. Patient sent to ER with all paperwork. Family notified. A review of ESNF PROGRESS NOTE/ORDERS dated [DATE] at 05:05 a.m. revealed; reason for call is cough and SOB with phlegm (mucus). Ordered placed for CXR - 2 view (SOB, cough with sputum) and notify attending physician of eCare SNF orders in the morning. An eCare SNF PROGRESS NOTE/ORDER dated [DATE] at 06:50 a.m. revealed a chief complaint of blood urine, history of [MEDICAL CONDITION]. Orders UA/C&S, CBC, and CMP, notify attending physician of eCare SNF orders in the morning. A review of the Transfer Form dated [DATE] revealed the reason for the transfer was AMS (altered mental status) and decreased O2 saturation (low oxygen level). A review of the electronic Medication Administration Record [REDACTED]. The EMAR did not include a lab box to enter appropriate lab values. The nurses who administered the [MEDICATION NAME] at bedtime were Employees #D Licensed Practical Nurse (LPN), #E Registered Nurse (RN), #H (LPN), #I (LPN), #J (LPN), #K (LPN), and #L (LPN). A review of the physician orders [REDACTED].#95 was never diagnosed with [REDACTED]. A review of the physician's orders [REDACTED]. [MEDICATION NAME] one tablet BID for five days for [DIAGNOSES REDACTED]. A review of the 24-hour chart check showed that the Employee #G, RN, checked off orders that were placed on [DATE]. The 24-hour chart check revealed that the designated nurse will review all physician orders [REDACTED]. Materials/supplies/medications have been ordered, labs and diagnostics have been ordered and appropriate departments notified. The nurse signature for each day noted below indicates verification and follow-through for all physician orders. A review of Physician's progress notes on [DATE] revealed; patient presents after admission to local hospital due to abdominal pain. Patient has a history of hiatal hernia and gastritis noted on multiple EGDs (esophagogastroduodenoscopy; a scope with light and camera is used to look at digestive tract). Patient was evaluated by [MEDICATION NAME] and urology. Patient reports feeling tired and is resting comfortably. Also, complaint of cough and sore throat with sinus pressure. Resident is in no acute distress, lethargic and anxiousness. Cardiovascular assessment revealed regular heart rate and rhythm. Normal S1/S2 (heart sounds). The plan included medications and lab work. [MEDICATION NAME]/[MEDICATION NAME] was not on the list of medications in the plan and anticoagulant monitoring was also not on the plan. A review of a physician progress notes [REDACTED].#95 toER on [DATE] secondary to AMS. Expired same day. Contact with hospitalist, revealed bleeding (illegible). ARNP performed chart review the same day. Rounds indicate medication error, which placed patient on medications not ordered for her. Discussion with facility staff has indicated immediate attention to error along with corrective action plan. A review of the consultant pharmacist's, physician recommendations for Resident #95 dated [DATE] revealed no mention of the [MEDICATION NAME] usage. A recommendation for the discontinuing of an antidepressant was noted and followed through on. An interview was conducted on [DATE] at 12:25 p.m. with the facility's consultant pharmacist regarding Resident #95. The consultant pharmacist was asked how he confirmed that [MEDICAL CONDITION] [REDACTED].#95. The consultant pharmacist stated that once a [DIAGNOSES REDACTED]. The consultant pharmacist stated that eventually he would expect to see an order for [REDACTED]. The consultant pharmacist was asked if they had logs before and he responded yes, but had not seen them in a while and he did not want to comment any further on it. An interview was conducted with Employee BB, LPN, an employee of 7 years, on [DATE] at 1:23 p.m. regarding [MEDICATION NAME] monitoring. Employee #BB, LPN, responded that the facility used to log PT/INR in the treatment book, but once they began using a computer system roughly four (4) months ago we stopped monitoring it in the treatment book. Employee #BB, LPN, was asked what the process was for monitoring PT/INR in January. Employee #BB, LPN, responded she was unaware of the process for monitoring PT/INR because it was taken care of on the ,[DATE] shift. Employee #BB, LPN, did not know where they charted the labs and if the physician was aware of the labs. Employee #BB, LPN, stated that recently we started doing it the old way again, which is much more efficient. We check the date, there is a place to sign that says the doctor was notified, place to document if the order was changed and next order date for labs unless they are ordered routinely. Employee #BB, LPN, responded that the system works much better now. An interview was conducted on [DATE] at 1:49 p.m. with the Director of Quality Assurance (DQA) regarding Resident #95. The DQA responded that on [DATE] the nurses reported to her that an ER physician called and asked for the current INR for Resident #95 and they did not see an INR in the chart. The ER physician notified Resident #95's primary care physician (PCP) and the PCP called the facility inquiring why the resident was on [MEDICATION NAME]. At that time, we started an immediate investigation. The DQA stated that the resident died due to [MEDICATION NAME] toxicity. There was an order in Resident #95's chart for [MEDICATION NAME] that should not have been there. The medical director came in on the following day for an ad hoc QAPI (quality assurance performance improvement) meeting on [DATE] with the Executive Director (ED), , Director of Clinical Services (DCS), Regional Director of Clinical Services (RDCS), and Regional Director of Operations (RDO). An interview was conducted with the nurse (Employee H, LPN) who entered the [MEDICATION NAME] order for Resident #95. The nurse remembered entering the order for Resident #95. The Nurse responded that there was a physician order [REDACTED].#280 was not harmed due to the medication error of missing increased [MEDICATION NAME] from 5mg to 6mg for approximately 6 days. PT and INR tests revealed Resident #280 had therapeutic [MEDICATION NAME] levels per MD during chart review. The nurse who entered the orders incorrectly was suspended pending investigation and was then terminated. All residents receiving [MEDICATION NAME] were audited for current diagnosis. A [MEDICATION NAME] log was initiated and additional documentation added for INR lab. Nurses have to enter an INR into the EMAR (electronic medication administration record) prior to administering [MEDICATION NAME]. The ,[DATE] nurse (Employee G) who was responsible for doing the 24-hour chart check was suspended and then terminated for not following process. Each nurse who administered the [MEDICATION NAME] received a first and final write up for not verifying the INR prior to medication administration. The first and final write up means if they make another error they will be terminated. The DQA was asked what process was in place prior to being informed of the error. The DQA stated that basically nurses would get an order for [REDACTED]. The DQA has been employed for four years as the DQA. The surveyor informed the DQA that there was a log for [MEDICATION NAME] in the past; the DQA was unaware of what happened to it. An in house audit was completed on all residents to ensure all were receiving the correct medications. Audits were also completed for residents receiving [MEDICATION NAME] and anticoagulants. The audits for [MEDICATION NAME] and anticoagulants are now audited daily. The DQA ran a report listing all orders for the last 24 hours and they go through all new orders. The DQA stated that Resident #95 would have shown up due to a new order being entered for [MEDICATION NAME]. An interview on [DATE] at 2:11 p.m. was conducted with the Director of Clinical Services (DCS) regarding current audits. The DCS responded that the staff received education and were in-serviced. [MEDICATION NAME] logs were initiated and are checked daily. We are also checking orders daily specifically, orders for [MEDICATION NAME] and medications requiring special orders like prescriptions that need to be faxed to the pharmacy. The DCS responded that all the orders were checked for the last 3 months once we were notified of the issue from the hospital. The DCS stated that the ,[DATE] nurse (Employee G, RN) was in charge of the 24-hour chart checks and failed to notice the error. The DCS responded that nothing was in place after the ,[DATE] nurse checked to recheck or identify any issues. It is the expectation of the DCS, that staff check the orders and notify the physician/supervisor of issues. The DCS would expect the staff to alert someone regarding this error. During this same interview, the DCS was asked to describe the process for entering orders into the computer for a resident arriving from the hospital. The DCS responded that a nurse would enter the orders from the hospital records. At this time, a second nurse would check off that each medication was added. A call would then be placed to the MD and orders would be verified. The physician can discontinue or start a new order. When entering a telephone order the ,[DATE] nurse checks the order. The unit manager and DCS check the orders as well now. That intervention previously was not in place. The DCS stated that all nurses who administered [MEDICATION NAME] to Resident #95 received a first and final write up. All nurses were provided with training and we will continue to give training. An interview was conducted on [DATE] at 2:43 p.m. with the regional director of clinical services (RDCS) regarding Resident #95. The RDCS stated that the IDT team (interdisciplinary team) met on [DATE] to go over orders from the weekend. The IDT team reviewed the order but no one questioned the order or verified it. The RDCS was asked to explain the care plan that was created for Resident #95 for anticoagulant use. The RDCS stated we reviewed that and do not know where the [DIAGNOSES REDACTED]. The RDCS was informed the medication was ordered on [DATE] and a care plan was not created until [DATE] and the RDCS responded we know. The RDCS stated that the first system failure was the 24-hour chart check. The nurse signed off that both charts were reviewed but had the nurse actually looked at the charts, he would have caught the error. The RDCS stated, We dropped the ball. An interview was conducted on [DATE] at 12:38 p.m. with Employee #DD, MDS, regarding Resident #95. Employee #DD created the care plan for Resident #95 and confirmed the care plan [DIAGNOSES REDACTED]. Employee #DD does not know where the [DIAGNOSES REDACTED].#DD remembers that the order for the [MEDICATION NAME] read [MEDICAL CONDITION]. Employee #DD was asked what the process was for creating a new care plan for a resident. Employee #DD responded that we look at orders daily but do not study them. The focus was on the ones that require a care plan. We investigate the chart for the care plan and chart categories of medications. An interview was conducted on [DATE] at 5:00 p.m. with Employee #D, LPN, who works all three shifts. Employee #D, LPN, responded that when administering medications she checks the five rights every time. Employee #D, LPN, stated that she follows physician's orders [REDACTED]. Employee #D, LPN responded that if a resident is on [MEDICATION NAME] you check the PT/INR prior to administering as part of the five rights and that has been in place now since March. Prior to March, Employee #D, LPN, stated that she just gave the medications as scheduled and monitored the labs as ordered. If no labs were ordered, Employee #D, LPN, stated that she should have questioned it. Employee #D, LPN, remembers Resident #95's name but was not very familiar with her. Employee #D, LPN, does remember administering medications to Resident #95 including [MEDICATION NAME]. Employee #D, LPN, was not aware of any incidents involving Resident #95 while she was a resident in the facility but was aware of what happened once the resident was transferred to the hospital. Employee #D, LPN, revealed that she did receive a write up for the error. Employee #D, LPN, was able to verify and convey that she had received in-service training on the new [MEDICATION NAME] process and the logs for monitoring medications. On [DATE] at 5:16 p.m., an interview was conducted with Employee #E, RN, who works the ,[DATE] shift and has been employed for only 1 month at the facility. Employee #E, RN, stated that prior to administering medications that she checks the five rights of medication administration every time. Employee #E, RN, responded she monitors medications based off physician orders. For a resident who is receiving [MEDICATION NAME] we check the PT/INR and labs as well as the five rights. If no labs were ordered for PT/INR it should be questioned and calling the doctor is required. Employee #E, RN, remembers Resident #95, she worked with Resident #95 while she was being trained by Employee #H, LPN. Employee #E, RN, remembered administering medications to Resident #95 including [MEDICATION NAME]. Employee #E, RN, does not recall any incidents involving Resident #95 while the resident was in the facility but was made aware after the resident was transferred to the hospital. To her knowledge, Employee #E, RN, administered medications to Resident #95 without error. Employee #E, RN, responded that Resident #95 should not have received [MEDICATION NAME] and that was why she passed away. Employee #E, RN, received a write up for the error. Employee #E, RN, also received training regarding PT/INR labs, calling the doctor every time you get the results. Will call the doctor if no labs are ordered. Employee #E, RN, stated that [MEDICATION NAME] cannot be given without PT/INR results. An interview was conducted on [DATE] at 8:24 a.m. with Employee #K, LPN. Employee #K, LPN, was asked when administering medications are there any verifications that need to be done prior to administering the medication. Employee #K, LPN stated that if parameters were ordered I would follow them. If the resident was on [MEDICATION NAME] she would check the log for lab work (now), before the incident she would check the lab work in the morning, would document the PT/INR numbers. Now this information is put in the treatment book. Employee #K, LPN, was asked what the process was for medications that required monitoring. Employee #K, LPN, responded that they are monitored per physician orders. It is now in the computer, which alerts staff to do the ordered monitoring. Employee #K, LPN, was asked if someone was on [MEDICATION NAME] was there a special process. Employee #K, LPN, responded watch for bruising or bleeding, if they had a fall and on [MEDICATION NAME], would call the MD and make MD aware that the resident had a fall and was on [MEDICATION NAME]. She reported that she would also check lab results for the PT/INR results. Would also check the five rights. Employee #K, LPN, also stated that the lab would call if the labs were abnormal. Employee #K, LPN, remembers Resident #95. Employee #K, LPN, remembers administering medication to Resident #95 but does not remember administering [MEDICATION NAME]. The DCS informed her that she did give [MEDICATION NAME]. Employee #K, LPN, reported she had been written up for giving [MEDICATION NAME] without checking the INR and for not checking for bleeding, or verifying the order and not checking the five rights of medication administration. Employee #K, LPN, was not aware at the time that she administered the wrong medications but was told of the error during her counseling. Employee #K, LPN, responded that she was aware that Resident #95 had expired. Employee #K, LPN, stated that she was not suspended, but did receive a write up and had to sign that she was aware of what she did wrong. Employee #K, LPN, reports she received an in-service on the new [MEDICATION NAME] process and the use of logs monitoring the meds, PT/INR, checking lab work, before giving, check the MD order, and check for right order. Employee #K, LPN, would write on [MEDICATION NAME] log during medication pass. If no orders were there she would call the MD for stat labs. An interview was conducted on [DATE] at 11:57 a.m. with Employee #L, LPN, who has been employed by the facility for close to [AGE] years. When administering medications she verifies the five rights of medication administration. Employee #L, LPN, stated that the process for medications that require monitoring are followed per physician order's related to the medication. A resident who was receiving [MEDICATION NAME] now goes on a log. We verif

Based on resident record reviews for Resident #95 and #280, interviews with Consultant Pharmacist, facility nursing staff, and review of the facility policy and procedure related to consultant pharmacist provider requirements and medication administration general guidelines, the facility failed to provide pharmaceutical services to meet the needs of two (Resident #95 & #280) of seven sampled residents reviewed for Coumadin usage. Resident #95 had an order for [REDACTED].#280's chart due to being transcribed into Resident #95's chart in error. Resident #95 received this high-risk medication nineteen (19) times without staff identifying the error or suggesting adequate monitoring of PT/INR (Prothrombin time/International Normalizing Ratio; a measure of blood clotting) resulting in Resident #95 developing a severe intracranial hemorrhage, severe anticoagulation, Coumadin toxicity and causing Resident #95's death. Past noncompliance at the Immediate Jeopardy level was identified on 4/13/2017 as occurring on 3/06/2017. The administrative team was notified on 4/13/2017 at 4:53 p.m. The Immediate Jeopardy was determined to be corrected on 4/06/2017, prior to the facility visit. Findings included: 1. A record review of the facility policy titled Organizational Aspects - Consultant Pharmacist Services Provider Requirements, dated 11/2016, found that regular and reliable consultant pharmacist services are to be provided to residents. The consultant pharmacist written agreement stipulated financial agreements and the terms of the services provided to the nursing care center. The policy provided that the consultant pharmacist agrees to render the required services in accordance with local, state, and federal Laws, regulations, and guidelines, nursing care center policies and procedures, community standards of practice, and professional standards of practice. The consultant pharmacist, or designee, provides pharmaceutical care services, including but not limited to the following: Review and follow up to previous month's pharmacy recommendations with the nursing care center staff. Medication regimen reviews for each skilled nursing resident at least monthly, or more frequently under certain conditions, incorporating the federally mandated standards of care in addition to other applicable professional standards. Communicate to the responsible prescriber, the facility's medical director and the director of nursing potential or actual problems detected and other findings related to medication therapy orders at least monthly. Communicate recommendations for changes in medication therapy in the monitoring of medication therapy. The policy also stated that the consultant pharmacist would assist in identification and evaluation of medication-related issues, including prevention and reporting of medication errors as well as suspected adverse medication consequences. In addition, the consultant pharmacist will participate and provide a report to the nursing care center's Quality Assessment and Assurance Committee's quarterly meeting. Assist the administrator and or other nursing care center representatives in setting standards in developing, implementing, and monitoring policies and procedures for the safe and effective distribution, control and use of medications and related equipment and services in the nursing care center. As requested, provide recommendations to the nursing care center administration and the pharmaceutical services committee or quality assessment and assurance committee such as: Recommend quality assurance and committee quality improvement (CQI) activities regarding the medication used process; in the prescribing, dispensing, storing, administration and monitoring of medications in the nursing care center; Compile required CQI data and provide analysis and feedback to the medical and nursing staffs of the nursing care center; for each quality assurance/CQI study, prepare a written report summarizing appropriate medication therapy statistics for the nursing care center; review medication incident reports; Identify one or more current medication references to assist in the identification of medications and information on indication/diagnosis/precautions/contraindications, possible adverse effects, and recommended dosages. An interview was conducted on 4/13/2017 at 09:41 a.m. with Resident #95's son. The son stated that recently, Resident #95 had been hospitalized for [REDACTED]. Resident #95's son stated that he was unsure of the timeframe the resident was expected to be at the skilled nursing facility. The staff at the facility had informed him that Resident #95 was being uncooperative with treatment and expected to be staying at the facility long term prior to the resident expiring. Resident #95's son stated that the day after Resident #95's passing; his brother went to the facility to collect her belongings. The nursing home administrator (NHA) informed that brother that the quality assurance discovered Resident #95 was receiving Coumadin without an order. Resident #95's son stated that the emergency physician called the medical examiner's office based on the condition, issues with the brain, and blood chemistry. The son stated that the medical examiner ruled the death accidental due to a major stroke caused by Coumadin toxicity. A review of the consultant pharmacist's physician recommendations for Resident #95 revealed the pharmacist had reviewed the resident's drug regimen on 3/10/2017. At the time of the review, Resident #95 was receiving Coumadin 6 mg at bedtime with no orders for PT/INR lab monitoring. No notation or physician recommendations were made related to the Coumadin usage or lab monitoring. The only recommendation made for Resident #95 on 3/10/2017 related to discontinuing of an antidepressant, which was followed through. An interview was conducted on 4/12/2017 at 12:25 p.m. with the facility's consultant pharmacist regarding Resident #95. The consultant pharmacist was asked how he confirmed that the cerebrovascular accident (CVA) [DIAGNOSES REDACTED].#95 which was contained on the 3/6/2017 order for Coumadin 6 mg. The consultant pharmacist stated that once a [DIAGNOSES REDACTED]. The consultant pharmacist stated that eventually he would expect to see an order for [REDACTED]. The consultant pharmacist was asked if they had logs before and he responded yes, but he had not seen them in a while and he did not want to comment any further on it. A review of Wittkowsky, Ann, The American Society of Health System Pharmacists, Chapter 24 Warfarin, page 358 revealed: The intensity of warfarin therapy is monitored by evaluation of the Prothrombin time (PT), expressed as the INR . Table 24.7 summarizes the Frequency of INR monitoring and Patient Assessment. If the initiation method, then after administration of the first dose of Warfarin/Coumadin, monitor the INR daily through day four of administration. If utilizing the average daily dosing method, monitor the INR every 3-5 days until the INR is greater than the lower limit of the desired therapeutic range then within 1 week. After hospital discharge: if the patient is stable, monitor the INR within 3-5 days, if the patient is unstable monitor the INR within 1-3 days. During the first month of treatment, monitor the INR at least weekly. The routine follow up for an INR of a medically unstable patient is every 1-2 weeks. A review of the Geriatric Dosage Handbook 12th Edition 2007, pg. 1179, Initiation of Oral Anticoagulation with Warfarin revealed: Dosing of warfarin (Coumadin) must be individualized according to patient response to the drug as indicated by the INR. Step 1. Obtain baseline INR. Begin therapy with warfarin with a dose 2-5mg per day with dosage adjustments based on results of INR determinations. Step 2. Day that INR is stabilized in the therapeutic range: Check INR daily. Adjust warfarin dose based on the results of INR determinations. Patients stabilized in the therapeutic range: Intervals between subsequent INR determinations should be based upon the physician's judgement of the patient's reliability and response to warfarin in order to maintain the individual within therapeutic range. Acceptable intervals for INR determinations are normally within the range 1-4 weeks after a stable dosage has been determined. Most patients are satisfactorily maintained on warfarin at a dose of 2-10mg. A review of the facility's policy titled, Medication Administration General Guidelines, dated 05/2016, revealed that medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. The policy also revealed, under the medication preparation section, that prior to administration, review and confirm MEDICATION ORDERS FOR [REDACTED]. Under the medication administration tab: medications are administered in accordance with written orders of the prescribers. If a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current [DIAGNOSES REDACTED]. If necessary, the nurse contacts the prescriber for clarification. This interaction with the pharmacy and the resulting order clarification are documented in nursing notes and elsewhere in the medical record as appropriate. 2. A review of Resident #95's clinical record revealed she was admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. The state form 3008 reflected the resident was transferred to the facility for physical therapy. A review of Resident #95's Admission Minimum Data Set (MDS), dated [DATE], revealed the resident scored a 14/15 on her Brief Interview for Mental Status indicating no cognitive impairment. Review of current medications revealed the resident received an anticoagulant three times during the look back period. A review of the Physician's Order Sheet dated 3/06/2017 revealed an order for [REDACTED]. These ordereds were entered correctly into the EMAR. A review of the physician orders, dated 3/06/2017 at 22:22 p.m. showed an order for [REDACTED].#95's clinical record found she was never diagnosed with [REDACTED]. A review of the 24-hour chart check showed that the Employee #G, RN, checked off orders that were placed on 3/06/2017. The 24-hour chart check instructions stated that the designated nurse will review all physician orders for the previous 24-hours for verification that orders have been noted, transcribed as noted, materials/supplies/medications have been ordered, labs and diagnostics have been ordered and appropriate departments notified. The nurse signature for each day noted below indicates verification and follow-through for all physician orders. A review of the Care Plan, dated 3/22/2017, revealed a focus of being at risk for abnormal bleeding, hemorrhage, and bruising related to anticoagulant use for A fib (atrial fibrillation; an abnormal heart rhythm) with a goal that the resident will be free from signs and symptoms of abnormal bleeding through next review. Interventions included: encourage resident to report any signs of bleeding or bruising, lab work as ordered, medication as ordered, observed for bleeding gums, nose bleeds, unusual bruising, tarry black stools, pink or discolored urine to nurse and/or MD, report to physician and s/s of abnormal bleeding, hemorrhage and bruising, and skin checks per facility protocol. A review of the clinical record found no history or basis for a [DIAGNOSES REDACTED].#95's care plan. A review of the admission nursing note from 3/03/2017 at 6:30 p.m. revealed Resident #95 was alert and oriented. Vitals were within normal limits. No complaint, signs, or symptoms of distress. Skin intact and able to voice needs. MD (Medical doctor) notified of orders and verified. Review of nurse notes on 3/26/2017 at 05:00 a.m. revealed Resident noted with cough and SOB (shortness of breath); Duoneb (aerosaled inhaled medication) given as ordered; writer noted blood in mucus when resident coughed; ESNF (telemedicine) notified of resident condition and new order received for CXR (chest x-ray) x 2 view writer notified resident of new order; call light within reach. A nurse note, dated 3/26/2017 at 6:45 a.m., depicted, writer notified that resident noted with red and dark area in diaper with urine; writer notified ESNF; new order received for CBC with diff (complete blood count with differential), CMP (complete metabolic panel), and U/A and C&S (urine analysis with culture and sensitivity); resident notified. A review of a nursing note dated 3/26/2017 at 9:00 p.m. revealed, All labs, x-ray, and urine called in to ARNP (Advanced Registered Nurse Practitioner) n/o (new order) received and noted. Resident had no discomfort present this p.m. No bloody sputum. Fluids encouraged and offered. A nursing note on 3/27/2017 at 9:30 a.m. revealed patient refused meds, patient able to open eyes, patient O2 saturation (oxygen level) 93% on 2L/min via NC (nasal cannula), pulse 72, respirations 18, blood pressure 160/74. Reported patient refused meds, called to MD in a.m., refused ABT (antibiotic). A nursing note dated 3/27/2017 at 12:00 p.m. revealed, spoke with ARNP for Medical Director, reported patient did not receive ABT in a.m., pupils equal and reactive in a.m. when assessed and vitals taken at 9:30 a.m. and 10:00 a.m. A nursing note on 3/27/2017 at 1:00 p.m. revealed, patient's C.N.A. (certified nursing assistant) got attention of nurse at 12:15 p.m. Went to assess patient. Patient displayed labored breathing, O2 saturation 85% (90-100% normal), patient not responding to voice, touch. Call to MD. Administered Duoneb to patient, O2 sat increased to 93% on 2L/min (oxygen). Received order to send patient to ER for evaluation and treatment. Blood sugar 191, blood pressure 184/77, pulse 68, O2 93%. EMS arrived within 5 minutes. During assessment, patient's pupils became enlarged and patient's arms became stiff. Patient sent to ER with all paperwork. Family notified. A review of ESNF PROGRESS NOTE/ORDERS dated 3/27/2017 at 05:05 a.m. revealed; reason for call is cough and SOB with phlegm (mucus). Ordered placed for CXR - 2 view (SOB, cough with sputum) and notify attending physician of eCare SNF orders in the morning. An eCare SNF PROGRESS NOTE/ORDER dated 3/27/2017 at 06:50 a.m. revealed a chief complaint of blood urine, history of anemia. Orders UA/C&S, CBC, and CMP, notify attending physician of eCare SNF orders in the morning. A review of the Transfer Form, dated 3/27/2017, revealed the reason for the transfer was AMS (altered mental status) and decreased O2 saturation (low oxygen level). A review of the electronic Medication Administration Record [REDACTED]. The EMAR did not include a lab box to enter appropriate lab values. The nurses who administered the Coumadin at bedtime were Employees #D Licensed Practical Nurse (LPN), #E Registered Nurse (RN), #H (LPN), #I (LPN), #J (LPN), #K (LPN), and #L (LPN). A review of Physician's progress notes on 3/06/2017 portrayed; patient presents after admission to local hospital due to abdominal pain. Patient has a history of hiatal hernia and gastritis noted on multiple EGDs (esophagogastroduodenoscopy; a scope with light and camera is used to look at digestive tract). Patient was evaluated by gastroenterology and urology. Patient reports feeling tired and is resting comfortably. Also, complaint of cough and sore throat with sinus pressure. Resident is in no acute distress, lethargic and anxiousness. Cardiovascular assessment revealed regular heart rate and rhythm. Normal S1/S2 (heart sounds). The plan included medications and lab work. Coumadin/Warfarin was not on the list of medications in the plan and anticoagulant monitoring was also not on the plan. A review of a physician progress notes [REDACTED].#95 toER on [DATE] secondary to AMS (altered mental status). Expired same day. Contact with hospitalist, revealed bleeding (illegible). ARNP performed chart review the same day. Rounds indicate medication error, which placed patient on medications not ordered for her. Discussion with facility staff has indicated immediate attention to error along with corrective action plan. Review of hospital records revealed Resident #95's PT on 3/27/2017 was >170.0 second(s) and the INR was >13. The therapeutic range for PT time is 10-20 seconds (fda.gov) and a therapeutic INR is between 0.8-1.2 (fda.gov). Review of a local hospital History and Physical, dated 3/27/2017, noted that Resident #95 was admitted to the hospital emergency room unresponsive to verbal and tactile stimuli (sound or touch). Computerized Tomography scan (CT scan) showed a significant intracranial hemorrhage with [DIAGNOSES REDACTED] (water on the brain). The emergency physician spoke with Resident #95's family who were unsure of the CODE STATUS but stated that she would not likely want intubation or other mechanical means of sustaining life. Resident #95's family was present and informed by the emergency physician that she would not likely survive. Resident #95 had recently been admitted to the local hospital for an upper gastrointestinal bleed. In addition, apparently when resident arrived to the rehabilitation facility, she was put on Coumadin. The onset is unknown. The course and duration of symptoms is constant. [DIAGNOSES REDACTED]. Resident received a dose of vitamin K (reversal for blood thinning medications) in the emergency room . The emergency physician spoke with family again who reiterated that they did not want heroic measures performed such as intubation or surgery. An interview was conducted on 4/13/2017 at 2:26 p.m. with the emergency room (ER) physician who cared for Resident #95 on 3/27/2017. The ER physician stated that Resident #95 arrived in the ER in bad shape. Resident #95 had a severe intracranial hemorrhage that was not survivable. The ER physician stated that he was in contact with the hospitalist who contacted the nursing home and primary care physician regarding recent lab work. The ER physician stated that the significance of coagulation numbers showed Resident #95 was severely anticoagulated, which led to the hemorrhage. The ER physician would expect someone who was receiving Coumadin to receive monitoring for dosage adjustments. The ER physician also mentioned that Resident #95 recently left the hospital with an upper gastrointestinal bleed and blood thinners is the worst thing the resident could be put on. An interview was conducted on 4/12/2017 at 1:49 p.m. with the Director of Quality Assurance (DQA) regarding Resident #95. The DQA responded that on 3/27/2017 the nurses reported to her that an ER physician called and asked for the current INR for Resident #95 and they did not see an INR in the chart. The ER physician notified Resident #95's primary care physician (PCP) and the PCP called the facility inquiring why the resident was on Coumadin. At that time, we started an immediate investigation. The DQA stated that the resident died due to Coumadin toxicity. There was an order in Resident #95's chart for Coumadin that should not have been there. The medical director came in on the following day for an ad hoc QAPI (quality assurance performance improvement) meeting on 3/28/2017 with the Executive Director (ED), Director of Clinical Services (DCS), Regional Director of Clinical Services (RDCS), and Regional Director of Operations (RDO). An interview was conducted with the nurse (Employee H, LPN) who entered the Coumadin order for Resident #95. The nurse remembered entering the order for Resident #95. The Nurse responded that there was a physician order for [REDACTED].#280 and Resident #95 on her 3-11 assignment the night of 3/6/2017. The facility could not determine exactly how the wrong order was placed in the eMAR system but it appeared as though Employee H had the eMAR system open to the wrong resident when she put the order into the electronic system. The medical director was asked to review both records to verify that Resident #280 was not harmed due to the medication error of missing increased Coumadin from 5mg to 6mg for approximately 6 days. PT and INR tests revealed Resident #280 had therapeutic Coumadin levels per MD during chart review. The nurse who entered the orders incorrectly was suspended pending investigation and was then terminated. All residents receiving Coumadin were audited for current diagnosis. A Coumadin log was initiated and additional documentation added for INR lab. Nurses have to enter an INR into the EMAR (electronic medication administration record) prior to administering Coumadin. The 11-7 nurse (Employee G) who was responsible for doing the 24-hour chart check was suspended and then terminated for not following process. Each nurse who administered the Coumadin received a first and final write up for not verifying the INR prior to medication administration. The first and final write up means if they make another error they will be terminated. The DQA was asked what process was in place prior to being informed of the error. The DQA stated that basically nurses would get an order for [REDACTED]. The DQA has been employed for four years as the DQA. The surveyor informed the DQA that there was a log for Coumadin in the past; the DQA was unaware of what happened to it. An in house audit was completed on all residents to ensure all were receiving the correct medications. Audits were also completed for residents receiving Coumadin and anticoagulants. The audits for Coumadin and anticoagulants are now audited daily. The DQA ran a report listing all orders for the last 24 hours and they go through all new orders. The DQA stated that Resident #95 would have shown up due to a new order being entered for Coumadin. During a phone interview with the medical director/attending physician on 4/13/17 at 10:45 a.m., the physician stated that another physician working with him might have seen Resident #95 while he was in the facility as we have someone in the building almost every day. I know that the orders related to warfarin (Coumadin) and other items were not signed off and if they were in our box, would have been signed off by either the physician or the ARNP (advanced registered nurse practitioner). When a telephone order is given, the nurse would put it in the computer and print off the order and put it in the physician box for a review and signature. Then the physician signs the stack in the box or the ARNP based on the order and the medication. An alert for warfarin should have been made and we never received that either. No one in our staff ever signed off on the order. If you look at the order in both residents' charts, you will see that another resident's orders (Resident #280) went to Resident #95. I reviewed the charts and the staff did contact the ESNF (telemedicine) for Resident #95's possible hematuria. The practitioner is available when they call and speak to someone and they do record all the calls. The ESNF has verbal, face time and televisual services available. I know the facility has been in-serviced on the process but I am not sure if they are using more than the telephone. I would think the physician would ask about the medications the resident was receiving. I reviewed this case and there should have been pertinent information conveyed from an SBAR (Situation, Background, Assessment and Recommendation). Supposedly, there was a glitch in the communication. The file for Resident #95 went to the medical examiner, they took over the case, and the hospitalist and hospital physician were spoken to. The death was recorded at the medical examiner as accidental death. The resident did have a variety of cardiovascular diseases, with anticoagulants, they don't cause the bleeding but if you start bleeding, they can't stop the bleeding. This resident most likely would have bled in the brain but we would never know if or when and how bad the bleed would have been. 3. A review of Resident #280's clinical record revealed she was admitted to the facility on [DATE] with relevant [DIAGNOSES REDACTED]. A review of the admission physician progress notes [REDACTED]. A review of the physician orders revealed Resident #280 received titrated doses of Coumadin for a [DIAGNOSES REDACTED]. The resident had labs ordered for PT/INR on night shift every Sunday and Wednesday from 2/24/17 - 3/7/17 and PT/INR on the night shift every Monday and Thursday from 3/7/17 - 3/11/17. On 3/6/2017, a hand written physician order was placed to increase Coumadin from 5 mg to 6 mg by mouth daily. This order was never placed in the facility's eMAR system for Resident #280 and according to interviews and record review was incorrectly placed in the eMAR system for Resident #95. 4. An interview was conducted with Employee BB, LPN, an employee of 7 years, on 4/12/2017 at 1:23 p.m. regarding Coumadin monitoring. Employee #BB, LPN, responded that the facility used to log PT/INR in the treatment book, but once they began using a computer system roughly four (4) months ago we stopped monitoring it in the treatment book. Employee #BB, LPN, was asked what the process was for monitoring PT/INR in January. Employee #BB, LPN, responded she was unaware of the process for monitoring PT/INR because it was taken care of on the 3-11 shift. Employee #BB, LPN, did not know where they charted the labs and if the physician was aware of the labs. Employee #BB, LPN, stated that recently we started doing it the old way again, which is much more efficient. We check the date, there is a place to sign that says the doctor was notified, place to document if the order was changed and next order date for labs unless they are ordered routinely. Employee #BB, LPN, responded that the system works much better now. An interview on 4/12/2017 at 2:11 p.m. was conducted with the Director of Clinical Services (DCS) regarding current audits. The DCS responded that the staff received education and were in-serviced. Coumadin logs were initiated and are checked daily. We are also checking orders daily specifically, orders for Coumadin, Lovenox (blood thinner) and medications requiring special orders like prescriptions that need to be faxed to the pharmacy. The DCS responded that all the orders were checked for the last 3 months once we were notified of the issue from the hospital. The DCS stated that the 11-7 nurse (Employee G, RN) was in charge of the 24-hour chart checks and failed to notice the error. The DCS responded that nothing was in place after the 11-7 nurse checked to recheck or identify any issues. It is the expectation of the DCS, that staff check the orders and notify the physician/supervisor of issues. The DCS would expect the staff to alert someone regarding this error. During this same interview, the DCS was asked to describe the process for entering orders into the computer for a resident arriving from the hospital. The DCS responded that a nurse would enter the orders from the hospital records. At this time, a second nurse would check off that each medication was added. A call would then be placed to the MD and orders would be verified. The physician can discontinue or start a new order. When entering a telephone order the 11-7 nurse checks the order. The unit manager and DCS check the orders as well now. That intervention previously was not in place. The DCS stated that all nurses who administered Coumadin to Resident #95 received a first and final write up. All nurses were provided with training and we will continue to give training. An interview was conducted on 4/12/2017 at 2:43 p.m. with the regional director of clinical services (RDCS) regarding Resident #95. The RDCS stated that the IDT team (interdisciplinary team) met on 3/07/2017 to go over orders from the weekend. The IDT team reviewed the order but no one questioned the order or verified it. The RDCS was asked to explain the care plan that was created for Resident #95 for anticoagulant use. The RDCS stated we reviewed that and do not know where the [DIAGNOSES REDACTED]. The RDCS was informed the medication was ordered on [DATE] and a care plan was not created until 3/22/2017 and the RDCS responded we know. The RDCS stated that the first system failure was the 24-hour chart check. The nurse signed off that both charts were reviewed but had the nurse actually looked at the charts, he would have caught the error. The RDCS stated, We dropped the ball. An interview was conducted on 4/13/2017 at 12:38 p.m. with Employee #DD, MDS, regarding Resident #95. Employee #DD created the care plan for Resident #95 and confirmed the care plan [DIAGNOSES REDACTED]. Employee #DD does not know where the [DIAGNOSES REDACTED].#DD remembers that the order for the Coumadin read CVA. Employee #DD was asked what the process was for creating a new care plan for a resident. Employee #DD responded that we look at orders daily but do not study them. The focus was on the ones that require a care plan. We investigate the chart for the care plan and chart categories of medications. An interview was conducted on 4/12/2017 at 5:00 p.m. with Employee #D, LPN, who works all three shifts. Employee #D, LPN, responded that when administering medications she checks the five rights every time. Employee #D, LPN, stated that she follows physician's orders for medications that require monitoring. Employee #D, LPN responded that if a resident is on Coumadin you check the PT/INR prior to administering as part of the five rights and that has been in place now since March. Prior to March, Employee #D, LPN, stated that she just gave the medications as scheduled and monitored the labs as ordered

Based on review of the Administrator's job description, review of the facility's policy and procedure for general medication administration, resident record review, for Resident #280 and Resident #95, and interviews with facility administration, the medical director, and nursing staff the facility failed to provide resource management to meet the needs for two (#95 & 280) of seven sampled residents receiving [MEDICATION NAME]. The Administration did not ensure the direct functions and operations of the facility were in accordance with current regulations governing long term care facilities and did not apply processes to ensure accurate medication administration. Resident #95 received [MEDICATION NAME] daily, in error, without any monitoring while on this high-risk medication. Record review for Resident #280 showed an order to increase [MEDICATION NAME] as part of their therapy. This order was never placed in Resident #280's chart due to being transcribed into Resident #95's chart in error. Resident #95 developed a significant [MEDICAL CONDITION], severe anticoagulation, and [MEDICATION NAME] toxicity leading to Resident #95's death. The failure of the facility staff to identify the transcription error in Resident #95's electronic medical administration record (EMAR) and suggest monitoring for this high-risk medication resulted in findings of past noncompliance at the Immediate Jeopardy level identified on [DATE] as occurring on [DATE]. The administration team was notified on [DATE] at 4:53 p.m. The Immediate Jeopardy was determined to be corrected on [DATE], prior to the facility visit. Findings included: 1. Review of the Administrator's Job Description revealed the Basic Function was described as Responsible for directing the overall operation of the facility's activities in accordance with current applicable federal, state and local standards, guidelines and regulations and as directed by the governing board and for ensuring that the highest degree of quality patient/resident care is maintained at all times. The Essential Functions included Establish and direct the implementation of written policies and procedures that reflect the goals and objectives of the facility, Ensure that all personnel, patients/residents, visitors and the general public follow established policies and procedures. The functions included Responsible for the overall quality assessment and improvement program and the coordination of quality assessment and improvement activities. The Specific Requirements required Knowledgeable of nursing and medical practices and procedures, as well as laws, regulations and guidelines pertaining to hospital and skilled nursing facility operations, Ability to plan, organize, develop, implement, and interpret the programs, goals, objectives, policies and procedures, etc., that are necessary for providing quality patient/resident care and maintaining a sound operation. 2. A review of the facility policy titled, Medication Administration General Guidelines, dated ,[DATE], revealed that medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. The policy also provided under the medication preparation section that prior to administration, review and confirm MEDICATION ORDERS FOR [REDACTED]. Under the medication administration tab: medications are administered in accordance with written orders of the prescribers. If a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current [DIAGNOSES REDACTED]. If necessary, the nurse contacts the prescriber for clarification. This interaction with the pharmacy and the resulting order clarification are documented in nursing notes and elsewhere in the medical record as appropriate. 3. An interview was conducted on [DATE] at 1:49 p.m. with the Director of Quality Assurance (DQA) regarding Resident #95. The DQA responded, that on [DATE], the nurses reported to her that an ER (emergency room ) physician called and asked for the current INR (International Normalizing Ratio; a measure of blood clotting time) for Resident #95 and they did not see an INR in the chart. The ER physician notified Resident #95's primary care physician (PCP) and the PCP/medical director called the facility inquiring why the resident was on [MEDICATION NAME]. At that time, we started an immediate investigation. The DQA stated that Resident #95 died due to [MEDICATION NAME] toxicity. There was an order in Resident #95's chart for [MEDICATION NAME] that should not have been there. The medical director came in on the following day for an ad hoc QAPI (quality assurance performance improvement) meeting on [DATE] with the Executive Director (ED), Director of Clinical Services (DCS), Regional Director of Clinical Services (RDCS), and Regional Director of Operations (RDO). An interview was conducted with the nurse (Employee H, LPN) who entered the [MEDICATION NAME] order for Resident #95. The nurse remembered entering the order for Resident #95. The Nurse responded that there was a physician order for [REDACTED].#H, LPN, had Resident #280 and Resident #95 on her ,[DATE] assignment the night of [DATE]. The facility could not determine exactly how the wrong order was placed in the EMAR system but it appeared as though Employee H, LPN, had the EMAR system open to the wrong resident when she put the order into the electronic system. The medical director was asked to review both records to verify that Resident #280 was not harmed due to the medication error of missing increased [MEDICATION NAME] from 5mg to 6mg for approximately 6 days. PT ([MEDICATION NAME] time) and INR tests revealed Resident #280 had therapeutic [MEDICATION NAME] levels per MD during chart review. The nurse who entered the orders incorrectly was suspended pending investigation and was then terminated. All residents receiving [MEDICATION NAME] were audited for current diagnosis. A [MEDICATION NAME] log was initiated and additional documentation added for INR lab. Nurses have to enter an INR into the EMAR now in order to administer [MEDICATION NAME]. The ,[DATE] nurse (Employee G) who was responsible for doing the 24-hour chart check was suspended and then terminated for not following the process. Each nurse who administered the [MEDICATION NAME] received a first and final write up for not verifying the INR prior to medication administration. The first and final write up means if they make another error they will be terminated. The DQA was asked what process was in place prior to being informed of the error. The DQA stated that, basically, nurses would get an order for [REDACTED]. The DQA had been employed for four years as the DQA. The surveyor informed the DQA that there was a log for [MEDICATION NAME] in the past; the DQA was unaware of what happened to it. An in house audit was completed on all residents to ensure all were receiving the correct medications. Audits were also completed for residents receiving [MEDICATION NAME] and anticoagulants. The audits for [MEDICATION NAME] and anticoagulants are now audited daily. The DQA ran a report listing all orders for the last 24 hours and they go through all new orders. The DQA stated that Resident #95 would have shown up due to a new order being entered for [MEDICATION NAME]. 4. An interview was conducted on [DATE] at 09:41 a.m. with Resident #95's son. The son stated that recently, Resident #95 had been hospitalized for [REDACTED]. Resident #95's son stated that he was unsure of the timeframe the resident was expected to be at the skilled nursing facility. The staff at the facility had informed him that Resident #95 was being uncooperative with treatment and expected to be staying at the facility long term prior to the resident expiring. Resident #95's son stated that the day after Resident #95's passing; his brother went to the facility to collect her belongings. The nursing home administrator (NHA) informed the brother that the QA (quality assurance) discovered Resident #95 was receiving [MEDICATION NAME] without an order. Resident #95's son stated that the emergency physician called the medical examiner's office based on the condition, issues with the brain, and blood chemistry. The son stated that the medical examiner ruled the death accidental due to a major stroke caused by [MEDICATION NAME] toxicity. 5. An interview was conducted on [DATE] at 2:26 p.m. with the emergency room physician who cared for Resident #95 on [DATE]. The ER physician stated that Resident #95 arrived in the ER in bad shape. Resident #95 had a severe [MEDICAL CONDITION] that was not survivable. The ER physician stated that he was in contact with the hospitalist who contacted the nursing home and primary care physician regarding recent lab work. The ER physician stated that the significance of coagulation numbers showed Resident #95 was severely anticoagulated, which led to the hemorrhage. The ER physician would expect someone who was receiving [MEDICATION NAME] to receive monitoring for dosage adjustments. The ER physician also mentioned that Resident #95 recently left the hospital with an upper [MEDICAL CONDITION] (on [DATE]) and blood thinners is the worst thing the resident could be put on. 6. A review of Resident #95's clinical record revealed she was admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. The state form 3008 showed the resident was transferred to the facility for physical therapy. A review of the admission nursing note from [DATE] at 6:30 p.m. found Resident #95 was alert and oriented. Vitals were within normal limits. No complaint, signs, or symptoms of distress. Skin intact and able to voice needs. MD (Medical doctor) notified of orders and verified. A review of Physician's progress notes on [DATE] revealed patient presents after admission to local hospital due to abdominal pain. Patient has a history of hiatal hernia and gastritis noted on multiple EGDs (esophagogastroduodenoscopy; a scope with light and camera is used to look at digestive tract). Patient was evaluated by [MEDICATION NAME] and urology. Patient reports feeling tired and is resting comfortably. Also, complaint of cough and sore throat with sinus pressure. Resident is in no acute distress, lethargic and anxiousness. Cardiovascular assessment revealed regular heart rate and rhythm. Normal S1/S2 (heart sounds). The plan included medications and lab work. [MEDICATION NAME]/[MEDICATION NAME] was not on the list of medications in the plan and anticoagulant monitoring was also not on the plan. A review of the physician orders, dated [DATE] at 22:22 p.m., found an order for [REDACTED].#95 was never diagnosed with [REDACTED]. The order sheet did not contain a signature from the physician on the form. A review of the 24-hour chart check showed that the Employee #G, RN, initialed off orders that were placed on [DATE]. The instructions contained on the 24 hour chart check form included that The designated nurse will review all physician orders for the previous 24-hours for verification that orders have been noted, transcribed as noted, materials/supplies/medications have been ordered, labs and diagnostics have been ordered and appropriate departments notified. The nurse signature for each day noted below indicates verification and follow-through for all physician orders. A review of Resident #95's Admission Minimum Data Set (MDS), dated [DATE], revealed the resident scored a ,[DATE] on her Brief Interview for Mental Status indicating no cognitive impairment. Review of current medications revealed the resident received an anticoagulant three times during the look back period. A review of the Care Plan, dated [DATE], revealed a focus of being at risk for abnormal bleeding, hemorrhage, and bruising related to anticoagulant use for A fib ([MEDICAL CONDITION]; an abnormal heart rhythm) with a goal that the resident will be free from signs and symptoms of abnormal bleeding through next review. Interventions included: encourage resident to report any signs of bleeding or bruising, lab work as ordered, medication as ordered, observed for bleeding gums, nose bleeds, unusual bruising, tarry black stools, pink or discolored urine to nurse and/or MD, report to physician and s/s of abnormal bleeding, hemorrhage and bruising, and skin checks per facility protocol. A review of the clinical record revealed no history or basis for a [DIAGNOSES REDACTED].#95's care plan. A review of nurse notes on [DATE] at 05:00 a.m. found Resident noted with cough and SOB (shortness of breath); [MEDICATION NAME] (aerosaled inhaled medication) given as ordered; writer noted blood in mucus when resident coughed; ESNF (telemedicine) notified of resident condition and new order received for CXR (chest x-ray) x 2 view writer notified resident of new order; call light within reach. A nurse note, dated [DATE] at 6:45 a.m., revealed writer notified that resident noted with red and dark area in diaper with urine; writer notified ESNF; new order received for CBC with diff (complete blood count with differential), CMP (complete metabolic panel), and U/A and C&S (urine analysis with culture and sensitivity); resident notified. A review of a nursing note, dated [DATE] at 9:00 p.m., related, All labs, x-ray, and urine called in to ARNP (Advanced Registered Nurse Practitioner) n/o (new order) received and noted. Resident had no discomfort present this p.m. No bloody sputum. Fluids encouraged and offered. A nursing note on [DATE] at 9:30 a.m. found, patient refused meds, patient able to open eyes, patient O2 saturation (oxygen level) 93% on 2L/min via NC (nasal cannula), pulse 72, respirations 18, blood pressure ,[DATE]. Reported patient refused meds, called to MD in a.m., refused ABT (antibiotic). A nursing note dated [DATE] at 12:00 p.m. revealed, spoke with ARNP for Medical Director, reported patient did not receive ABT in a.m., pupils equal and reactive in a.m. when assessed and vitals taken at 9:30 a.m. and 10:00 a.m. A nursing note on [DATE] at 1:00 p.m. revealed, patients' C.N.A. (certified nursing assistant) got attention of nurse at 12:15 p.m. Went to assess patient. Patient displayed labored breathing, O2 saturation 85% (,[DATE]% normal), patient not responding to voice, touch. Call to MD. Administered [MEDICATION NAME] to patient, O2 sat increased to 93% on 2L/min (oxygen). Received order to send patient to ER for evaluation and treatment. Blood sugar 191, blood pressure ,[DATE], pulse 68, O2 93%. EMS arrived within 5 minutes. During assessment, patient's pupils became enlarged and patient's arms became stiff. Patient sent to ER with all paperwork. Family notified. A review of the Transfer Form, dated [DATE], revealed the reason for the transfer was AMS (altered mental status) and decreased O2 saturation (low oxygen level). A review of a physician progress notes [REDACTED].#95 toER on [DATE] secondary to AMS. Expired same day. Contact with hospitalist, revealed bleeding (illegible). ARNP performed chart review the same day. Rounds indicate medication error, which placed patient on medications not ordered for her. Discussion with facility staff has indicated immediate attention to error along with corrective action plan. A review of the electronic Medication Administration Record [REDACTED]. The EMAR did not include a lab box to enter appropriate lab values. The nurses who administered the [MEDICATION NAME] at bedtime were Employees #D Licensed Practical Nurse (LPN), #E Registered Nurse (RN), #H (LPN), #I (LPN), #J (LPN), #K (LPN), and #L (LPN). 7. A review of Wittkowsky, Ann, The American Society of Health System Pharmacists, Chapter 24 [MEDICATION NAME], page 358 revealed: The intensity of [MEDICATION NAME] therapy is monitored by evaluation of the [MEDICATION NAME] time (PT), expressed as the INR . Table 24.7 summarizes the Frequency of INR monitoring and Patient Assessment. If the initiation method, then after administration of the first dose of [MEDICATION NAME]/[MEDICATION NAME], monitor the INR daily through day four of administration. If utilizing the average daily dosing method, monitor the INR every ,[DATE] days until the INR is greater than the lower limit of the desired therapeutic range then within 1 week. After hospital discharge: if the patient is stable, monitor the INR within ,[DATE] days, if the patient is unstable monitor the INR within ,[DATE] days. During the first month of treatment, monitor the INR at least weekly. The routine follow up for an INR of a medically unstable patient is every ,[DATE] weeks. 8. A review of the Geriatric Dosage Handbook 12th Edition 2007, pg. 1179, Initiation of Oral Anticoagulation with [MEDICATION NAME] revealed: Dosing of [MEDICATION NAME] ([MEDICATION NAME]) must be individualized according to patient response to the drug as indicated by the INR. Step 1. Obtain baseline INR. Begin therapy with [MEDICATION NAME] with a dose ,[DATE]mg per day with dosage adjustments based on results of INR determinations. Step 2. Day that INR is stabilized in the therapeutic range: Check INR daily. Adjust [MEDICATION NAME] dose based on the results of INR determinations. Patients stabilized in the therapeutic range: Intervals between subsequent INR determinations should be based upon the physician's judgement of the patient's reliability and response to [MEDICATION NAME] in order to maintain the individual within therapeutic range. Acceptable intervals for INR determinations are normally within the range ,[DATE] weeks after a stable dosage has been determined. Most patients are satisfactorily maintained on [MEDICATION NAME] at a dose of ,[DATE]mg. 9. A review of a local hospital emergency room History and Physical, dated [DATE], revealed Resident #95 was admitted to the hospital emergency room unresponsive to verbal and tactile stimuli (sound or touch). Computerized Tomography scan (CT scan) showed a significant [MEDICAL CONDITION] (abnormal bleeding in the brain) with [DIAGNOSES REDACTED] (water on the brain). The emergency physician spoke with Resident #95's family who were unsure of the code status but stated that she would not likely want intubation or other mechanical means of sustaining life. Resident #95's family was present and informed by the emergency physician that she would not likely survive. Resident #95 had recently been admitted to the local hospital for an upper [MEDICAL CONDITION]. In addition, apparently when resident arrived to the rehabilitation facility she was put on [MEDICATION NAME]. The onset is unknown. The course and duration of symptoms is constant. [DIAGNOSES REDACTED]. Resident received a dose of vitamin K (reversal for blood thinning medications) in the emergency room . The emergency physician spoke with family, again, who reiterated that they did not want heroic measures performed such as intubation or surgery. Further review of hospital records revealed Resident #95's PT on [DATE] was >170.0 second(s) and the INR was >13. The therapeutic range for PT time is ,[DATE] seconds (fda.gov) and a therapeutic INR is between 0XXX,[DATE].2 (fda.gov). 10. A review of the consultant pharmacist's, physician recommendations for Resident #95, dated [DATE], revealed no recommendations were made related to the [MEDICATION NAME]. In addition, no recommendation for lab monitoring was noted. The only recommendation in place for Resident #95 related to discontinuing of an antidepressant, which was followed through on. An interview was conducted on [DATE] at 12:25 p.m. with the facility's consultant pharmacist regarding Resident #95. The consultant pharmacist was asked how he confirmed that [MEDICAL CONDITION] [REDACTED].#95 as noted on the physician order entered in the EMAR for [MEDICATION NAME] 6 mg dated [DATE]. The consultant pharmacist stated that once a [DIAGNOSES REDACTED]. The consultant pharmacist stated that eventually he would expect to see an order for [REDACTED]. The consultant pharmacist was asked if they had logs before and he responded yes, but had not seen them in a while and he did not want to comment any further on it. 11. An interview was conducted on [DATE] at 12:38 p.m. with Employee #DD, MDS, regarding Resident #95. Employee #DD created the care plan for Resident #95 dated [DATE] and confirmed the care plan [DIAGNOSES REDACTED]. Employee #DD did not know where the [DIAGNOSES REDACTED].#DD remembered that the order for the [MEDICATION NAME] read [MEDICAL CONDITION]. Employee #DD was asked what the process was for creating a new care plan for a resident. Employee #DD responded that we look at orders daily but do not study them. The focus was on the ones that require a care plan. We investigate the chart for the care plan and chart categories of medications. During a phone interview with the medical director/attending physician on [DATE] at 10:45 a.m., the physician stated that another physician working with him might have seen Resident #95 while he was in the facility as we have someone in the building almost every day. I know that the orders related to [MEDICATION NAME] ([MEDICATION NAME]) and other items were not signed off and if they were in our box, would have been signed off by either the physician or the ARNP (advanced registered nurse practitioner). When a telephone order is given, the nurse would put it in the computer, print off the order, and put it in the physician box for a review and signature. Then the physician signs the stack in the box or the ARNP based on the order and the medication. An alert for [MEDICATION NAME] should have been made and we never received that either. No one in our staff ever signed off on the order. If you look at the order in both residents' charts, you will see that another resident's orders went to Resident #95 instead of Resident #280. I reviewed the charts and the staff did contact the ESNF (telemedicine) for Resident #95's possible hematuria. The practitioner is available when they call and speak to someone and they do record all the calls. The ESNF has verbal, face time and televisual services available. I know the facility has been in-serviced on the process but I am not sure if they are using more than the telephone. I would think the physician would ask about the medications the resident was receiving. I reviewed this case and there should have been pertinent information conveyed from a SBAR (Situation, Background, Assessment and Recommendation). Supposedly, there was a glitch in the communication. The file for Resident #95 went to the medical examiner, they took over the case, and the hospitalist and hospital physician were spoken to. The death was recorded at the medical examiner as accidental death. The resident did have a variety of cardiovascular diseases, with anticoagulants, they don't cause the bleeding but if you start bleeding, they can't stop the bleeding. This resident most likely would have bled in the brain but we would never know if or when and how bad the bleed would have been. An interview was conducted with Employee BB, LPN, an employee of 7 years, on [DATE] at 1:23 p.m. regarding [MEDICATION NAME] monitoring. Employee #BB, LPN, responded that the facility used to log PT/INR in the treatment book, but once they began using a computer system roughly four (4) months ago we stopped monitoring it in the treatment book. Employee #BB, LPN, was asked what the process was for monitoring PT/INR in January. Employee #BB, LPN, responded she was unaware of the process for monitoring PT/INR because it was taken care of on the ,[DATE] shift. Employee #BB, LPN, did not know where they charted the labs and if the physician was aware of the labs. Employee #BB, LPN, stated that recently we started doing it the old way again, which is much more efficient. We check the date, there is a place to sign that says the doctor was notified, place to document if the order was changed and next order date for labs unless they are ordered routinely. Employee #BB, LPN, responded that the system works much better now. An interview on [DATE] at 2:11 p.m. was conducted with the Director of Clinical Services (DCS) regarding current audits. The DCS responded that the staff received education and were in-serviced. [MEDICATION NAME] logs were initiated and are checked daily. We are also checking orders daily specifically, orders for [MEDICATION NAME] (blood thinner) and medications requiring special orders like prescriptions that need to be faxed to the pharmacy. The DCS responded that all the orders were checked for the last 3 months once we were notified of the issue from the hospital. The DCS stated that the ,[DATE] nurse (Employee G, RN) was in charge of the 24-hour chart checks and failed to notice the error. The DCS responded that nothing was in place after the ,[DATE] nurse checked to recheck or identify any issues. It was the expectation of the DCS, that staff check the orders and notify the physician/supervisor of issues. The DCS would expect the staff to alert someone regarding this error. During this same interview, the DCS was asked to describe the process for entering orders into the computer for a resident arriving from the hospital. The DCS responded that a nurse would enter the orders from the hospital records. At this time, a second nurse would check off that each medication was added. A call would then be placed to the MD and orders would be verified. The physician can discontinue or start a new order. When entering a telephone order the ,[DATE] nurse checks the order. The unit manager and DCS check the orders as well now. That intervention previously was not in place. The DCS stated that all nurses who administered [MEDICATION NAME] to Resident #95 received a first and final write up. All nurses were provided with training and we will continue to give training. An interview was conducted on [DATE] at 2:43 p.m. with the regional director of clinical services (RDCS) regarding Resident #95. The RDCS stated that the IDT team (interdisciplinary team) met on [DATE] to go over orders from the weekend. The IDT team reviewed the order but no one questioned the order or verified it. The RDCS was asked to explain the care plan that was created for Resident #95 for anticoagulant use. The RDCS stated we reviewed that and do not know where the [DIAGNOSES REDACTED]. The RDCS was informed the medication was ordered on [DATE] and a care plan was not created until [DATE] and the RDCS responded we know. The RDCS stated that the first system failure was the 24-hour chart check. The nurse signed off that both charts were reviewed but had the nurse actually looked at the charts, he would have caught the error. The RDCS stated, We dropped the ball. The Nursing Home Administrator (NHA) was present during the interview conducted on [DATE] at 1:49 p.m. with the Director of Quality Assurance, on [DATE] at 2:11 p.m. with the Director of Clinical Services, and on [DATE] at 2:43 p.m. during an interview with the Regional Director of Clinical Services. The NHA did not offer any answers and deferred all questions to the other parties present. An interview was conducted on [DATE] at 8:54 a.m. with the NHA regarding the ESNF telemedicine services. The NHA stated that they (practitioners) had access to PCC (point click care; electronic charting system). They can review the resident chart with the nurse when called. If the resident is not prescribed something for the current condition, the telemedicine practitioner can write a prescription, fax it over and we can get it to the pharmacy. On [DATE] at 5:16 p.m., an interview was conducted with Employee #E, RN, who worked the ,[DATE] shift and had been employed for only 1 month at the facility. Employee #E, RN, stated that prior to administering medications that she checks the five rights of medication administration every time. Employee #E, RN, responded she monitors medications based off physician orders. For a resident who is receiving [MEDICATION NAME] we check the PT/INR and labs as well as the five rights. If no labs were ordered for PT/INR, it should be questioned and calling the doctor is required. Employee #E, RN, remembers Resident #95. She worked with Resident #95 while she was being trained by Employee #H, LPN. Employee #E, RN, remembered administering medications to Resident #95 including [MEDICATION NAME]. Employee #E, RN, did not recall any incidents involving Resident #95 while the resident was in the facility but was made aware after the resident was transferred to the hospital. To her knowledge, Employee #E, RN, administered medications to Resident #95 without error. Employee #E, RN, responded that Resident #95 should not have received [MEDICATION NAME] and that was why she passed away. Employee #E, RN, received a write up for the error. Employee #E, RN, also received training regarding PT/INR labs, calling the doctor every time you get the results. Will call the doctor if no labs are ordered. Employee #E, RN, stated that [MEDICATION NAME] cannot be given without PT/INR results. An interview was conducted on [DATE] at 5:00 p.m. with Employee #D, LPN, who works all three shifts. Employee #D, LPN, responded that when administering medications she checks the five rights every time. Employee #D, LPN, stated that she follows physician's orders for medications that require monitoring. Employee #D, LPN responded that if a resident is on [MEDICATION NAME] you check the PT/INR prior to administering as part of the five rights and that has been in place now since March. Prior to March, Employee #D, LPN, stated that she just gave the medications as scheduled and monitored the labs as ordered. If no labs were ordered, Employee #D, LPN, stated that she should have questioned it. Employee #D, LPN, remembered Resident #95's name but was not very familiar with her. Employee #D, LPN, did remember administering medications to Resident #95 including [MEDICATION NAME]. Employee #D, LPN, was not aware of any incidents involving Resident #95 while she was a resident in the facility but was aware of what happened once the resident was transferred to the hospital. Employee #D, LPN, revealed that she did receive a write up for the error. Employee #D, LPN, was able to verify and convey that she had received in-service training on the new [MEDICATION NAME] process and the logs for monitoring medications. An interview was conducted on [DATE] at 8:24 a.m. with Employee #K, LPN. Employee #K, LPN, was asked when administering medications are there any verifications that need to be done prior to administering the medication. Employee #K, LPN stated that if parameters were ordered I would follow them. If the resident was on [MEDICATION NAME] she would check the log for lab work (now). Before the incident she would check the lab work in the morning, would document the PT/INR numbers. Now this information is put in the trea