Every finding on record at Plantation Manor Nursing And Rehab Center, LLC

Based on interview and record review, the facility failed to ensure that licensed nurses assessed resident's needs for 1 (#14) of 1 (#14) resident sampled for urinary catheter or urinary tract infections (UTI). The failed practice was evidenced by Resident #14 being diagnosed with a UTI on 12/23/2025 with no record of assessments or interventions in the medical record by licensed nursing staff on 12/24/2024 or 12/25/2025 directly related to her diagnoses of a UTI. Findings:Resident #14Record review revealed Resident #14 was originally admitted to the facility on [DATE] and had a readmission from a hospital on [DATE]. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had a Brief Interview of Mental Status (BIMS) score of 15 which indicated she had no cognitive impairment. Review of diagnoses revealed Resident #14 had been diagnosed with type 2 diabetes mellitus, history of UTI, and chronic kidney disease.Further review of the medical record revealed the following nurses progress notes:12/23/2024 at 11:10 Lab / Radiology NoteNote Text: Lab results from 12/20 urinalysis (UA) - UA blood 3+, UA protein 2+, UA nitrite Positive, UA leukocytes 3+, UA white blood cells 40-50, UA red blood cells 40-50, UA bacteria 3+; Urine culture results from 12/20 greater than 2 organisms recovered, non-predominant. Greater than 10,000 colony units per milliliter. Please submit another sample if clinically indicated. Results given to S3Nurse Practitioner (NP).12/26/2024 at 10:48 General Nurses Note Note Text: received order per S3NP for Ciprofloxacin 500 milligrams 1 pill by mouth twice daily x 7 days for UTI. Further review of nurses progress notes revealed no documented evidence of Resident #14 being assessed for signs or symptoms of a UTI on 12/24/2024 or 12/25/2025. On 08/06/2025 at 9:13 a.m. an interview with Resident #14 was conducted in the day area. Resident #14 was alert and oriented. Resident #14 reported she went to the hospital on the day after Christmas (12/26/2024). Resident #14 reported that she got sick and was confused that evening so they sent her to the hospital. Resident #14 reported she received intravenous fluids and antibiotics at the hospital for over a week. Resident #14 reported she felt achy all over on Christmas Eve (12/24/2024) and Christmas day (12/25/2024). Resident #14 reported she did not get antibiotics for her Urinary Tract Infection (UTI) until the evening of 12/26/2024. On 08/06/2025 at 10:01 a.m., an interview with S3NP revealed she was aware of the abnormal UA and was monitoring symptoms but was waiting for clarification of culture results to start antibiotics since 2 organisms were growing. She reported Resident #14 was stable until the night of 12/26/2024. On 08/06/2025 at 11:25 a.m., an interview with S2Director of Nursing (DON) was conducted in her office. S2DON confirmed there was no record of nursing assessments in the progress notes or temperatures recorded on 12/24/2024 or 12/25/2025 to specifically monitor the severity of the urinary tract infection identified on 12/23/2024 for Resident #14.

Based on observation, interviews, and record reviews, the facility failed to ensure a resident was assessed quarterly for 1 (#37) of 4 (#30, #37, #43, and #124) residents sampled for medication administration. The facility failed to ensure 1) Resident #37 was assessed quarterly for self-administration of medications, 2) a specific order was obtained for self-administration of medications for Resident #37, and 3) the care plan for Resident #37's included self-administration of medications with the specified medications to be self-administered.Findings:Review of the facility's Self-Administration of Medication, undated, Policy and Procedure revealed the following, in part:It is the policy of this facility that each resident has the right to self-administer medications, but is the responsibility of the interdisciplinary team to determine that it is safe prior to the resident exercising that right.2. If the resident wishes to self-administer medications, the Interdisciplinary Team (IDT) must assess the resident's overall ability to safely administer his/her own medications.3. To assess whether the resident is able to self-administer medications, the criteria on the Assessment for self-administration of medications form will be used. If the Interdisciplinary Team determines that the resident is unable to self-administer medications, because this would be a danger to the resident or to others, then the Interdisciplinary Team may not grant the right to self-administer medications. If the right is granted, a specific order to self-administer must be obtained which includes how, when, and for what reason the medication can be used.4. When a resident self-administers medication, he/she will be reassessed at least quarterly for continued safety of this practice. The IDT will complete this assessment using the Assessment for self-administration of medications. If in the IDT's professional judgment, the resident is unable to safely self-administer his medication, the medical doctor will be contacted to discontinue the order for self-administration.7. Self-administration of bedside medications must be careplanned, including the specific order, granting of approval by IDT, and monitoring for compliance.Review of the record for Resident #37 revealed an admission date of 09/08/2024 with diagnoses including bilateral primary osteoarthritis of knee, cellulitis of unspecified part of limb, acute upper respiratory infection, dysphagia, pulmonary embolism, and chronic obstructive pulmonary disease.Review of Resident #37's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident's Brief Interview for Mental Status (BIMS) score was 15 indicating no cognitive impairment.During medication administration observation with S4Licensed Practical Nurse (LPN) on 08/06/2025 at 8:15 a.m. revealed Resident #37 had a Ventolin (Albuterol) inhaler and Nasonex (nasal spray) at his bedside. Resident #37 administered his nasal spray 1 spray in each nostril. S4LPN confirmed these 2 medications are kept in resident's room and are self-administered by the resident. An interview on 08/06/2025 at 8:15 a.m. with Resident #37 confirmed he has his Albuterol inhaler and nasal spray at his bedside, resident confirmed he does self-administer these medications as ordered. Resident #37 confirmed he uses his Albuterol inhaler 2 puffs every 6 hours as needed and his nasal spray 1 spray in each nostril daily.Review of Resident #37's August 2025 Physician's Orders revealed an order dated 01/15/2025 for a Ventolin Hydrofluoroalkane (HFA) Inhalation Aerosol Solution 108 (90 base) micrograms/actuate (Albuterol Sulfate) 2 puffs inhale orally every 6 hours as needed for wheezing related to chronic obstructive pulmonary disease. Further review revealed an order dated 07/18/2024 for Nasonex 24 hour nasal suspension 1 spray in both nostrils one time a day for acute upper respiratory infection. Resident #37's Physician's Orders did not specify that each of these medications were to be kept at bedside and self-administered by the resident.Review of Resident #37's Assessment for Self-Administration of Medications dated 01/15/2025 revealed resident was determined to be safe and able to self-administer medications but did not identify the specific medications that the resident was determined to be safe to administer.Review of the July and August 2025 Medication Administration Records (MAR) for Resident #37 revealed the 2 medications listed above do not specify that each of these medications are kept at the bedside and should be administered by the resident.Review of Resident #37's current care plan revealed no documentation identifying that resident was determined to be safe to self-administer any of his medications.An interview on 08/06/2025 at 10:05 a.m. with S5LPN revealed that Resident #37 does have his nasal spray and Albuterol inhaler at his bedside and self-administers these 2 medications. S5LPN confirmed that Resident #37's physician's orders did not identify that these 2 medications were to be self-administered by Resident #37. S5LPN reported she completed the Assessment for Self-Administration of Medications on 01/15/2025 for Resident #37 but has not completed this assessment quarterly.An interview on 08/06/2025 at 2:35 p.m. with S2Director of Nursing (DON) confirmed the facility failed to ensure Resident #37 was assessed for self-administration of medications quarterly. S2DON confirmed the facility failed to ensure documentation of self-administration of bedside medications including specific order and monitoring for compliance was added to Resident #37's care plan. S2DON confirmed the facility failed to ensure Resident #37's physician's orders included a specified order to self-administer medications including how, when, and for what reason the medications can be used.

Based on record review and interview the facility failed to ensure a resident with a new diagnosis of schizophrenia was referred to the appropriate state agency for Preadmission Screening and Resident Review (PASARR) Level II evaluation as required for 1 (#12) of 2 (#12, #13) residents reviewed for PASARR requirements. Findings:Record review revealed Resident #12 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left dominate side, depression, gastroesophageal reflux disease without esophagitis, dysphagia following unspecified cerebrovascular disease, muscle wasting and atrophy both thighs, generalized muscle weakness, need for assistance with personal care, other abnormalities of gait and mobility, and other lack of coordination. Further review revealed Resident #12 was diagnosed with schizoaffective disorder, bipolar type, on 04/01/2025.Review of Form142 (Louisiana Department of Health and Hospitals Medicaid Program Notice of Medical Certification) revealed Resident #12 was approved for Medicaid/Private medical eligibility services effective 02/21/2022. Further review of the Form 142 revealed a Level II decision was not required on 03/02/2022. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 9 which indicated Resident #12 had moderate cognitive impairment for daily decision making. Review of section N revealed Resident #12 received antipsychotic medication and antidepressant medication. Review of the active August 2025 Physician Orders revealed an order dated 04/01/2025 for Risperdal 0.5 milligram (mg) tablet give 1 tablet by mouth two times daily for schizoaffective disorder, bipolar type.On 08/05/2025 at 9:49 a.m., during an interview with S2Director of Nursing (DON), surveyor requested the PASARR Level II for Resident #12 and the facility's policy for obtaining a PASARR II.Review of Resident #12's record revealed no documented evidence that a Level II PASARR was completed after Resident #12 was diagnosed with schizoaffective disorder, bipolar type, on 04/01/2025. On 08/05/2025 at 3:25 p.m., an interview with S2DON confirmed a PASARR Level II screening had not been submitted to the appropriate state agency for Resident #12 after the new diagnoses of schizoaffective disorder, bipolar type, on 04/01/2025.

Based on observations, record reviews and interview the facility failed to ensure drugs and biologicals were stored properly by having medications at resident's bedside for 1 (#71) of 1 resident reviewed for medication storage. Findings: Review of the facility's Medication Storage in the Facility policy (undated) revealed the following in part: Policy: Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing or medical personnel and pharmacy personnel. 2. Only licensed nurses, the consultant pharmacist, and those lawfully authorized to administer mediations are allowed access to medications. Review of the medical record for Resident #71 revealed an admission date of 01/09/2025. Resident #71 had diagnoses that included altered mental status, hypertensive heart disease, depression, reflux, heart failure, atrial fibrillation, rhabdomyolysis, dementia, muscle wasting, and cognitive communication deficit.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #71 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated intact cognition for daily decision making. Review of the current care plan for Resident #71 revealed impaired cognitive function/dementia or impaired thought processes related to dementia. Further review of the care plan revealed to administer medications as ordered, communicate with the resident/family/caregivers regarding resident's capabilities and needs. The resident needed specific supervision assistance with all decision making. On 08/04/2025 at 9:00 a.m. observation of Resident #71 revealed she was in the room lying in bed, and one bottle of Tums (antacid) and one bottle of Systane complete eyedrops (eye lubricant) was located on top of Resident #71's refrigerator beside her bed. At that time an interview with Resident #71 revealed she thought a friend had brought her the medications and she will take the medications when needed. On 08/05/2025 at 8:45 a.m. observation of Resident #71 revealed she was lying in bed, and one bottle of Tums and one bottle of Systane complete eyedrops was noted on top of the refrigerator beside her bed.Review of the Resident #71's August 2025 physician's orders revealed no documented evidence of an order for Tums or Systane eyedrops. On 08/05/2025 at 8:55 a.m. S2Director of Nursing (DON) was notified of medications at Resident #71's bedside. At that time observation of Resident #71's room with S2DON revealed Resident #71 had a bottle of Tums and a bottle of Systane eyedrops located on top of the refrigerator in her room. S2DON confirmed Resident #71 did not have a physician's order for the medications and the medications should not be stored at Resident #71's bedside available for use.

Based on observation, record review and interview the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. The facility failed to date multi dose insulin pens when first used for 6 (#33, #39, #50, #100, #104, #225) of 6 (#33, #39, #50, #100, #104, #225) insulin pens observed without a date and by not discarding 1 (#225) of 1 (#225) insulin pens within 28 days after the first use. Findings: On 07/10/2024 at 3:07 p.m. observation of Hall A medication cart revealed the following insulin pens were not dated upon first use: Resident #33: Novolog and Basaglar (Lantus) pens were not dated when first used. Resident #39: Novolog and Basaglar (Lantus) pens were not dated when first used. On 07/10/2024 at 3:15 p.m., an interview with S3Licensed Practical Nurse (LPN) confirmed the insulin pens should have been dated when first used and were not for resident #33 and resident #39. On 07/10/2024 at 3:25 p.m. observation of Hall B medication cart revealed the following insulin pens were not dated upon first use: Resident #50: Lantus pen was not dated when first used. Resident #100: Lantus pen and Novolog pen were not dated when first used. Resident #104: Lantus pen was not dated when first used. Resident #225: Lantus pen was not dated when first used. Further observation of Hall B medication cart revealed resident #225's Lispro Kwik Pen was dated 09/06/2023. On 07/10/2024 at 3:40 p.m., an interview with S3LPN confirmed the insulin should have been dated when first used for resident #50, #100, #104, and #225, and the insulin for resident #225 dated 09/06/2023 should have been discarded. On 07/10/2024 at 4:35 p.m., an interview with S2Director of Nurses (DON) confirmed the facility's written policy and procedure for insulin guidelines did not have any instructions regarding dating of insulin when it is first used, however it is standard practice to date the insulin when it is first used.

Based on observations and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to ensure random and personal items were not stored in the laundry department. Findings: On 07/08/2024 at 3:00 p.m., an observation of the laundry department revealed the following items were observed on a shelf that was designated for clean mops: 1-large pair of scissors, 1-insulated pink colored drinking glass, 4-sharpies, 1-pair of ear pods, and 1-pair of eye glasses. Further observation revealed the following: 1-large hand held tape dispenser and a purse were stored on a shelf with clean clothing. 1-long cord and cell phone charger was stored on a table that was designated for folding resident clean clothing and linens. The cell phone charger and cord was laying on top of and in direct contact with the table top. 1-gray tote bag was on the floor between a large and small washing machines. After the observation was completed, S6Laundry Worker revealed the cell phone cord/charger were her personal belongings. S6Laundry Worker reported that the gray tote bag belonged to S7Laundry Worker. On 07/08/2024 at approximately 3:15 p.m., an observation of the laundry department with S1Administrator and S8Laundry Supervisor was conducted. S1Administrator confirmed the items listed above should not have been kept in laundry room.

Based on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming and hygiene for 1 (#56) of 1 (#56) resident reviewed for activities of daily living. Findings: Record review revealed resident #56 was admitted to the facility on [DATE] with diagnoses including cerebrovascular accident, congestive heart failure, edema, and glaucoma. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for resident #56 revealed a brief interview of mental status could not be completed due to memory problems, and severely impaired cognitive skills for daily decision making. Further review of the MDS data revealed resident #56 was dependent on staff for activities of daily living care which included personal hygiene. On 07/08/2024 at 1:55 p.m., observation revealed resident #56 had long fingernails with jagged edges to both hands. The right hand was noted to be contracted. On 07/09/2024 at 11:43 a.m., an observation with S5Certified Nurse Aide (CNA) was conducted in the room of resident#56. S5CNA confirmed resident #56`s fingernails were long and jagged to both hands. S5CNA confirmed resident #56 was dependent on staff for activities of daily living (ADL) care. S5CNA partially opened resident #56`s contracted right hand and there was a foul odor coming from his right hand. On 07/10/2024 at 8:32 a.m., observation of resident #56 was conducted in his room with S5CNA. Both hands still had long jagged fingernails and the right hand was contracted. A foul odor was noted when S5CNA partially opened resident #56`s contracted right hand. On 07/10/2024 at 08:32 a.m., S2Director of Nurses (DON) was informed resident #56 had long jagged nails and his contracted right hand had an odor. S2DON agreed resident #56`s nails should have been trimmed and his contracted right hand should not have an odor.

Based on record review, observations and interviews, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 (#73) of 2 (#71 & #73) residents reviewed for positioning. The facility failed to address the positioning needs for resident #73. Findings: Review of the record for resident #73 revealed the resident was admitted on [DATE] with diagnoses of Down syndrome, myocardial infarction, atrial fibrillation, diabetes, muscle wasting and atrophy, congestive heart failure, incontinence without sensory awareness, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had modified independent cognitive skills for daily decision making. The resident's mobility device was a wheelchair. The resident required partial/moderate assistance with toilet hygiene and dressing and the resident required substantial/maximal assistance with personal hygiene and shower/bathe. The resident was always incontinent of bowel and bladder. The resident had no speech and was rarely/never understood. An interview with S4Certified Nursing Assistant (CNA) on 07/10/2024 at 12:30 p.m. revealed resident #73 used his wheelchair for mobility daily. Observation on 07/08/2024 at 11:56 a.m. revealed resident #73 was up in his wheelchair in the day area on his hall and his feet were not touching the floor. Resident #73 was unable to be interviewed. Observation on 07/08/2024 at 1:20 p.m. revealed resident #73 was up in his wheelchair in the dining room and his right foot was not touching the floor. Observation on 07/09/2024 at 11:26 a.m. and 3:37 p.m. revealed resident #73 was up in his wheelchair in the dining room. His feet were not touching the floor. Observation on 07/10/2024 at 8:05 a.m. revealed the resident was propelling his wheelchair down the hall using his upper body and his feet were not touching the floor. Observation on 07/10/2024 at 11:37 a.m. revealed the resident up in his wheelchair in the dining room. His right foot was not touching the floor and part of his left foot was touching the floor. An interview with S2Director of Nurses on 07/10/2024 at 2:45 p.m. confirmed resident #73 should have support for his lower extremities.

Based on observations, interview and record review the facility failed to implement a comprehensive person-centered plan of care to attain or maintain a resident`s highest practicable physical well-being for 1 (#109) of 1 (#109) residents reviewed for the use of a wander guard as a restraint along with the use of compression stockings. Findings: On 07/18/2023 at 12:55 pm, observation revealed Resident #109 was sitting near the front door next to staff. One to two plus edema was noted to both feet. Compression socks were not on Resident #109`s lower extremities. Resident #109 had a wander guard bracelet on her left ankle. On 07/19/2023 at 08:27 am, an observation conducted in Resident #109`s room revealed she was sitting in a chair at a bedside table eating breakfast. Two plus edema was observed to both feet. Resident #109 had a wander guard bracelet on her left ankle. Record review revealed Resident #109 was admitted to the facility on [DATE] with diagnoses that included vascular dementia, heart failure, restlessness, anxiety, and need for assistance with personal care. Review of minimum data set assessment completed on 06/19/2023 revealed a brief interview of mental status (BIMS) score of 4 which indicated severe cognitive impairment. Further review of functional status revealed all ADL (activities of daily living) care required at the minimum, staff supervision for all tasks. Review of active physician orders for July 2023 revealed the following: Compression stockings on in morning Compression stockings off every night Wander guard bracelet Review of the medication administration record for the month of July 2023 revealed the compression stockings were placed on every day as ordered and the wander guard bracelet was recorded as being on her left ankle daily. On 07/19/2023 at 10:49 a.m., an observation and interview was conducted with S2Director of Nursing (DON) in the room of Resident # 109. S2DON confirmed compression stockings were not on as recorded on the medication administration record for 07/19/2023 at 9:00 a.m. S2DON confirmed compression stockings should not be worn over a wander guard bracelet and the physician should be notified of the issue.

Based on observations, record reviews, and interviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 2 (#98 & #120) of 2 residents reviewed for skin conditions. The facility failed to identify skin tears for residents #98 and #120. Findings: Resident #98 Observation on 07/17/2023 at 9:15 a.m. revealed resident #98 was up in her wheelchair in her room. Resident #98 had skin tear and bruise to right forearm approximately an inch long. There was a band-aid above the skin tear. Review of the medical record for resident #98 revealed the resident was admitted on [DATE] with diagnoses of insomnia, fracture 5th metacarpal bone left hand, chronic pain, mild protein - calorie malnutrition, Alzheimer's disease, dysphagia, anxiety and history of falling. Review of the Quarterly Minimum Data Set, dated dated dated [DATE] revealed resident #98 had severely impaired cognitive skills for daily decision making. The resident required two person extensive assistance with bed mobility, transfer, and toilet use and one person extensive assistance with personal hygiene. The resident was incontinent of bowel and bladder. The resident was at risk for developing pressure ulcers. Review of the Braden Risk assessment dated [DATE] revealed resident #98 was at a moderate risk of developing pressure ulcers. Review of the careplan revealed a history of a skin tear with the following intervention: full skin evaluation with bath/shower. Review of the Incident & Accident Reports for the past 6 months revealed there was no documentation of the skin tear and bruise on the right forearm observed on 07/17/2023. Review of the Skin Inspection Report revealed skin inspection were performed on 07/17/2023 and 07/18/2023. Further review of the skin assessment revealed the skin recorded as intact. An interview with S5Certified Nursing Assistant (CNA) on 07/19/2023 at 12:45 p.m. revealed she saw the skin tear on resident #98's right forearm on Monday, 07/17/2023. She did not report the skin tear on Monday. S5CNA thought nursing staff already knew about it because there was a band-aid on her arm. An interview with S6Licensed Practical Nurse (LPN) on 07/19/2023 at 12:56 p.m. revealed she was unaware of the skin tear on resident #98's right forearm. S6LPN reported there should be an Incident &Accident Report done for the skin tear. An interview with S2Director of Nursing (DON) on 07/19/2023 at 1:35 p.m. confirmed the skin tear was not identified by the skin assessments on the 07/17/2023 and 07/18/2023. S2DON further confirmed an Incident & Accident Report should be performed for skin tears. Resident #120 Observation on 07/17/2023 at 1:30PM revealed resident #120 was sitting in his wheelchair at the door to his room. Further observation revealed a skin tear on his right forearm approximately one inch in length and small other skin tears to his right arm. The resident also had multiple bruises to his arms. Review of the medical record revealed the resident was admitted on [DATE] with diagnoses of osteoarthritis to right knee, stage IV pressure ulcer to right hip, anxiety, skin changes, constipation, hemorrhoids, dysuria, depression, peripheral vascular disease, Chronic Obstructive Pulmonary Disease, hypertension, reflux, atrial fibrillation, edema, and obesity. Review of the Quarterly Minimum Data Set, dated dated dated [DATE] revealed the resident was independent with cognitive skill for daily decision making. The resident required one person supervision for bed mobility, transfer, and toilet use and one person limited assistance with dressing and personal hygiene. The resident was continent of bowel and occasionally incontinent of bladder. The resident was admitted with stage IV pressure ulcer and 1 venous/arterial ulcer. Review of the physician orders for July 2023 revealed the resident received Eliquis 5 milligrams 1 tablet two times a day every day and monitor for abnormal signs and symptoms of bleeding related to anticoagulant therapy every shift. Review of the Medication Administration Record for July 2023 revealed 0 (bleeding not noted) was documented every shift when monitoring for abnormal signs & symptoms of bleeding related to anticoagulant therapy. Review of the careplan revealed the resident had altered skin integrity - has actual pressure ulcers to sacrum and venous ulcer to left great toe. Further review revealed the following interventions: head to toe weekly assessment weekly, report skin breakdown or changes skin, and head to toe skin assessment 3 times a week. Review of the Incident & Accident Reports for the past 6 months revealed there was no documentation of the skin tears and bruises on the right arm observed on 07/17/2023. An interview with S7Treatment Nurse on 07/19/2023 at 11:26 a.m. revealed she does daily skin check on residents with pressure ulcers. S7Treatment Nurse was notified of the skin tear at this time. S7Treatment Nurse revealed that there should be an Incident & Accident Report on the skin tear. An interview with S6LPN on 07/19/2023 at 12:56 p.m. revealed she was unaware of the skin tear on resident #120's right arm. S6LPN reported there should be an Incident &Accident Report done for the skin tear. An interview with S2DON on 07/19/2023 at 1:35 p.m. confirmed the skin tear had not been identified by staff. S2DON further confirmed an Incident & Accident Report should be performed for skin tears.

Based on observations, record reviews and interviews, the facility failed to ensure a resident fed by enternal means received appropriate treatment and services to prevent complications including but not limited to dehydration and metabolic abnormalities for 2 (#40, #73) of 2 (#40, #73) residents investigated for tube feeding. Findings: Resident #73 On 07/17/2023 at 02:36 p.m., an observation of Resident #73 revealed her tube feeding bag did not have a legible date on the bag or the specific type of tube feeding written on the bag. On 07/17/2023 at 03:01 p.m., an observation was conducted in Resident #73's room with S3 Licensed Practical Nurse (LPN). S3LPN confirmed Resident #73`s tube feeding bag was not labeled correctly. Record review revealed Resident #73 was admitted to the facility on [DATE] with diagnoses that included hemiplegia following stroke, gastrostomy, dysphagia following stroke, and muscle wasting. Most recent minimum data set assessment completed on 05/24/2023 revealed Resident #73 had severe cognitive impairment, dependent on staff for all activities of daily living(ADL) care, and Resident #73 had a feeding tube. Further record review revealed the following active physician order for July 2023: Jevity 1.5 per percutaneous endoscopic gastrostomy (PEG) tube at 35 cubic centimeters/hour. On 07/17/2023 at 03:10 p.m., an observation and interview with S2Director of Nursing (DON) was conducted in the room of Resident #73. S2DON confirmed the tube feeding bag date was not legible and the feeding bag was not labeled to acknowledge the contents. S2DON confirmed the label on the tube feeding bag should have included a legible date and the type of feeding in the bag. 43405 Findings Resident #40 Review of the medical record for resident #40 revealed an admitted [DATE] with diagnoses including dysphagia, cellulitis, chronic systolic heart failure, type 2 diabetes mellitus, permanent atrial fibrillation, and chronic pain. Review of the current physician's orders revealed an order dated 06/12/2023 to flush peg tube with 100 cubic centimeters (cc) of water every 4 hours. Review of the June 2023 and July 2023 Medication Administration Record (MAR) revealed peg tube flushes were administered 4 times per day, instead of 6 times per day as ordered. Review of the current care plan revealed resident #40 had a peg tube. Further review of the care plan revealed an intervention dated 06/12/2023 to flush peg tube with 100 cc's water every 4 hours. An interview on 07/19/2023 at 1:15 p.m. with S4Licensed Practical Nurse (LPN) revealed that resident #40 had an order dated 06/12/2023 to flush peg tube with 100 cc's water every 4 hours, which would be 6 times per day. S4LPN confirmed that the June 2023 and July 2023 MAR had documented evidence that peg tube was flushed with 100 cc's of water 4 times per day, instead of 6 times per day as ordered. An interview on 07/19/2023 at 1:40 p.m. with S2Director of Nurses (DON) confirmed that resident #40 had an order dated 06/12/2023 to flush peg tube with 100 cc's of water every 4 hours, which is 6 times per day. S2DON confirmed that the June 2023 and July 2023 MAR revealed the peg tube was flushed with 100 cc's of water 4 times per day, instead of 6 times per day as ordered.

Based on record reviews and interview, the facility failed to implement a comprehensive person-centered care plan for 4 (#1, #2, #4, #5) of 5 (#1 - #5) residents reviewed for nutrition. The facility had incomplete documentation of the residents' meal intake percentages. Findings: Resident #1 Review of the medical record revealed the resident was admitted on [DATE] with diagnoses of heart disease, hypertension, dementia, dysphagia following cerebral infarction, gastroesophageal reflux disease, vitamin deficiency, need for assistance with personal care, and muscle wasting and atrophy. Review of the Minimum Data Set, dated dated dated [DATE] revealed the resident had severely impaired cognitive skills for daily decision making. The resident required extensive assistance for eating, bed mobility, personal hygiene, transfers, and toileting. Review of the physician orders for December 2022 revealed the following diet order: regular with chopped meats (resident is a feeder) ice cream to lunch and supper meals. Review of the care plan revealed: potential for altered nutrition and dehydration related to weight below ideal body weight, vitamin deficiency, and gastroesophageal reflux disease. Review of the interventions revealed resident must be fed at all times and monitor % meal intake and offer alternate if < 50% consumed. Review of the Meal Intake Roster from 10/01/2022 - 12/08/2022 revealed there was no documented evidence of meal intake percentages on 109 meals. An interview with S1Director of Nursing on 12/28/2022 at 2:00PM confirmed the resident's meal intake percentages should be documented as per the plan of care. Resident #2 Review of the medical record revealed the resident was admitted on [DATE] with diagnoses of Alzheimer's, hypertension, heart disease, anxiety, vitamin deficiency, muscle wasting, reflux, and delirium. Review of the Minimum Data Set, dated dated dated [DATE] revealed the resident had severely impaired cognitive skills for daily decision making. The resident required extensive assistance for eating, bed mobility, personal hygiene, transfers, and toileting. Review of the physician orders for December 2022 revealed the following diet order: mechanical soft diet, add house shake to lunch and supper tray (may assist with feeding 6:30 a.m., 11:00 a.m., and 4:30 p.m. everyday). Review of the care plan revealed: potential for altered nutrition and dehydration related to dementia, delirium, and anxiety. Review of the interventions revealed allow resident ample time to consume meals, monitor % of meal intake and offer alternate, and provide assist with dining as needed. Review of the Meal Intake Roster from 11/01/2022 - 12/27/2022 revealed there was no documented evidence of meal intake percentages for 19 meals. An interview with S1Director of Nursing on 12/28/2022 at 2:00PM confirmed the resident's meal intake percentages should be documented as per the plan of care. Resident #4 Review of the medical record revealed the resident was admitted on [DATE] with diagnoses of anxiety, vitamin deficiency, dysphagia, dementia, and reflux. Review of the Minimum Data Set, dated dated dated [DATE] revealed the resident had severely impaired cognitive skills for daily decision making. The resident required extensive assistance for eating, bed mobility, personal hygiene, transfers, and toileting. Review of the physician orders for December 2022 revealed the following diet order: mechanical soft with soft meat with nectar thick liquids with cranberry juice each meal. Review of the care plan revealed potential for altered nutrition and dehydration related to dementia and dysphagia. Review of the interventions revealed: allow ample time to consume meals and or snacks, monitor % of meal intake and offer alternate if less than 50% consumed, and must be fed all meals and snacks. Review of the Meal Intake Roster from 11/01/2022 - 12/27/2022 revealed there was no documented evidence of meal intake percentages for 20 meals. An interview with S1Director of Nursing on 12/28/2022 at 2:00PM confirmed the resident's meal intake percentages should be documented as per the plan of care. Resident #5 Review of the medical record revealed the resident was admitted on [DATE] with diagnoses of Alzheimer's, mild protein calorie malnutrition, dementia, vitamin deficiency, and anemia. Review of the Minimum Data Set, dated dated dated [DATE] revealed the resident had severely impaired cognitive skills for daily decision making. The resident required extensive assistance for eating, bed mobility, personal hygiene, transfers, and toileting. Review of the physician orders for December 2022 revealed the following diet order: pureed diet with nectar thick liquids with double meats, milk with all meals, give ice cream or chocolate pudding with lunch and dinner. Review of the care plan revealed potential for altered nutrition and dehydration related to Alzheimer's, depression, and dementia. Review of the interventions revealed monitor meal intake and if less than 50% consumed offer alternate and must be fed at all times. Review of the Meal Intake Roster from 11/01/2022 - 12/27/2022 revealed there was no documented evidence of meal intake percentages for 19 meals. An interview with S1Director of Nursing on 12/28/2022 at 2:00PM confirmed the resident's meal intake percentages should be documented as per the plan of care.

Based on observation, record review, and interview, the facility failed to ensure residents who were unable to carry out activities of daily living receive the necessary services to maintain good personal hygiene by failing to ensure resident's fingernails were cleaned and trimmed in a timely manner for 2 (#5, #28) of 3 (#5, #28, #89) residents reviewed for activities of daily living. Findings: Resident #5 Record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS (Minimum Data Set) dated 07/19/2022 revealed BIMS (Brief Interview for Mental Status) score 3 which represents severe cognitive impairment. Resident #5 required extensive assistance of one person with personal hygiene. On 07/25/2022 at 01:42PM an observation of Resident #5 revealed his finger nails on both hands were long with a dark brown grimy substance under fingernails right hand. On 07/26/2022 at 08:42AM an observation of Resident #5 revealed his fingernails on both hands long with a dark brown grimy substance under fingernails right hand. On 07/26/2022 at 11:32AM an interview conducted with S2DON (Director of Nursing) in Resident #5's room. S2DON confirmed Resident #5's fingernails were long, dirty, and needed to be cleaned and trimmed. Resident #28 Record review revealed Resident #28 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS (Minimum Data Set) dated 07/20/2022 revealed BIMS (Brief Interview for Mental Status) score 12 which represents moderate cognitive impairment. Resident #28 required assistance with personal hygiene. On 07/25/2022 at 2:05PM an observation of Resident #28 revealed his fingernails on both hands were long with a dark brown grimy substance noted under finger nails. O 07/26/2022 at 08:44AM an observation of Resident #28 revealed his fingernails on both hands were long with a dark brown grimy substance noted under fingernails. On 07/26/2022 at 11:35AM an interview conducted with S2DON (Director of Nursing) in Resident #28's room. S2DON confirmed Resident #28 fingernails were long, dirty, and needed to be cleaned and trimmed.

Based on observation, record review and interview the facility failed to ensure the resident had clean bed linens for 1 (#45) of 24 sampled residents. Findings: On 07/13/2021 at 09:33 AM, observation of Resident #45 revealed he was lying in bed, fully dressed with the bed sheets down to his feet. Observation of the bottom bed sheet Resident #45 was lying on revealed dried urine stains on the sheets. Interview at that time with S3 CNA (Certified Nurses Assistant) confirmed she had already bathed resident #45 that morning but did not change the bed sheets. S3 CNA revealed Resident #45 was going to [CONDITION(S)] at 10:00 AM and S3 CNA was going to change the sheets at that time. On 07/15/2021 record review revealed Resident #45 had diagnoses of post-surgery on the GU (genitourinary) system on 04/01/2021, Ventral hernia surgery without obstruction/gangrene on 07/11/2021 with Jackson [NAME] drain in place, End Stage [CONDITION(S)] on [CONDITION(S)], Anxiety, Paranoid [CONDITION(S)], Chronic Pain, Incontinence, Type 2 DM (Diabetes), [CONDITION(S)], and fistula of intestines. Review of the plan of care revealed: self-care deficit: Resident #45 will receive person-centered care- needs assist with bathing, hygiene, dressing and grooming related to muscle weakness. Bath per schedule by staff- staff to assist as needed to complete task, assist with hygiene, dressing, and grooming as needed. On 07/15/2021 at 09:23 AM, review of the bathing roster dated 07/12/2021 through 07/14/2021 revealed documentation showed Resident #45 received a complete bed bath on 07/13/2021 at 8:56 AM. On 07/15/21 09:10 AM, interview with S4 CNA Supervisor confirmed the bed sheets should have been changed when the bath was given to Resident #45 and the resident should not have been left on the urine stained sheets.

Based on interview and record review, the facility failed to ensure each resident had the right to accept or refuse medical treatment by failing to ensure a residents code status was accurately documented for 1 (#45) of 2 sampled residents whose advance directives were reviewed. Findings: Review of the medical records revealed resident #45 was admitted on [DATE]. Review of the advance directives revealed there was a handwritten physician order [REDACTED]. On 9/17/19 at 2:50pm, interview with #S2DON confirmed the computerized physician orders [REDACTED].

Based on observation, record review and interview the facility failed to ensure adequate supervision and assistance devices were in place to prevent accidents for 1 (#73) of 2 (#74, #86) residents reviewed for accidents out of a total sample of 37. Findings: Resident # 74 record review revealed an admission date of [DATE] with admitting [DIAGNOSES REDACTED]. Record review revealed current physician orders [REDACTED]. 3/10/17- Non-skid socks to both feet at all times, and, 11/8/17- Pressure pad alarm to bed and chair at all times. On 09/10/18 at 9:50 AM, Resident # 74 was observed sitting up in wheelchair in her room. There was no pressure pad alarm to wheelchair or bed. She was wearing regular white socks. She was not wearing non-skid socks as ordered. On 09/11/18 at 11:46 AM, Resident # 74 was observed with no pressure pad alarm to wheelchair or bed. She was wearing regular cotton socks. She was not wearing non-skid socks. On 09/12/18 at 09:29 AM, Resident # 74 was observed sitting up in wheelchair in hallway. No chair pad alarm was on wheelchair nor on bed in room. Resident # 74 smiled and pointed to the non-skid socks she was wearing then gave me the thumbs up signal while smiling. Record review revealed Resident #74 had three documented falls in the last 120 days. Falls were dated 5/19/18, 7/14/18 and 9/11/18 with no major injuries reported. On 9/12/18 at 9:35AM, an interview with S7LPN (Licensed Practical Nurse) verified that resident #74 did not have the pressure pad alarms as ordered by the physician. S7LPN stated the non-skid socks were probably an intervention related to a fall that happened on 9/11/18. On 09/12/18 at 10:30AM, an interview with S2DON (Director of Nursing) confirmed resident #74 should have had pressure pad alarms to bed and wheelchair, as well as non-skid socks to both feet at all times.

Based on record review and interview the facility failed to maintain medical records on each resident that are accurately documented for 3 (#55, #72, and #115) of 3 (#55, #72 and #115) residents initiated for inaccurate documentation in resident records in a total sample of 37 residents as evidenced by: 1. Inaccurately documenting resident #72 had padded siderails; 2. Inaccurately documenting resident #115 was wearing skin sleeves and a lumbar vest; and 3. Not documenting resident #55 received a milkshake as recommended by the Registered Dietician. Findings: Resident #72 Review of the medical record for resident #72 revealed [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. Observation of the resident on 09/10/18 - 09/12/18 revealed the resident had turn bars on the bed and they were not padded. Review of the 09/10/18 - 09/12/18 Medication Administration Record revealed the nurses had documented that the resident had padded half siderails. On 09/12/18 at 2:30PM S2Director of Nursing observed the resident with the surveyor. S2Director of Nursing confirmed the resident currently had turn bars that were not padded. S2Director of Nursing confirmed the nurses had documented on the Medication Administration Record that the resident had half padded siderails. Resident #115 Review of the medical record for sampled resident #115 revealed [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. Further review of the physician orders [REDACTED]. Observation of the resident on 9/10/18 at 10:00AM and 2:10PM, 09/11/18 at 9:30AM and 12:50PM, and on 09/12/18 at 10:00AM and 1:30PM revealed the resident was sitting in her wheelchair and she was wearing a short sleeve shirt. Further observation of the resident revealed she had multiple bruises on bilateral arms and the resident was not wearing skin sleeves or long sleeves and she was not wearing a lumbar support vest. Review of the (MONTH) (YEAR) Medication Administration Record revealed documentation on 09/10/18 - 09/12/18 that the resident was wearing skin sleeves or long sleeves. Further review Medication Administration Record revealed documentation that the resident was wearing the lumbar support vest. On 09/12/18 at 2:15PM S2Director of Nursing confirmed the resident was not wearing the skin sleeves or long sleeves and was not wearing the lumbar support vest. S2Director of Nursing further confirmed the nurses were documenting the resident was wearing skin sleeves and the lumbar support vest. Resident #55 Record review revealed resident #55 was admitted to the facility in 2011 and had [DIAGNOSES REDACTED]. The resident was currently receiving hospice services with a primary [DIAGNOSES REDACTED]. Review of weights for resident #55 revealed the following: 07/01/18- 122 lbs (pounds), 08/01/18- 124.5 lbs, and, 09/01/18- 120 lbs. Review of current physician's orders [REDACTED]. admit to hospice for comfort and palliative care for terminal end stage [MEDICAL CONDITION], [MEDICATION NAME] (appetite stimulant) 200 milligrams daily, diet order- regular puree, yogurt with every meal, add V8 juice to lunch- double portions for breakfast only- resident to sit up 90 degrees during meals and for 30 minutes after, and feed resident all meals and snacks. On 09/13/18 at 10AM, an interview with S5LPN (Licensed Practical Nurse) confirmed the resident is receiving hospice services. When asked about the resident's nutritional status, LPN reported that the resident eats well some days and other days does not finish her meals. Review of S6Registered Dietitian notes dated 08/09/18 revealed, in part, a recommendation to add a milkshake at 3PM daily made from chocolate or strawberry ice cream. Further review of physician's orders [REDACTED]. On 09/13/18 at 11:30AM, an interview with S2DON (Director of Nursing) confirmed that there was a recommendation of milkshake daily a 3PM and further confirmed there was no documentation that the resident was receiving the shake or how much of the milkshake resident #55 was consuming daily for a resident that was currently experiencing weight loss.

Based on observation, record review, and interview, the facility failed to failed develop and implement a comprehensive person-centered plan of care for each resident for 1 (#50) of 6 residents reviewed for accidents out of total resident sample of 37. The facility failed to ensure that resident #50 had a pressure alarm in her chair and bed at all times per the physician's orders [REDACTED]. Findings: Review of the medical record revealed that resident #50 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of the (MONTH) (YEAR) physician's orders [REDACTED]. Review of the medical record revealed care planning for problem onset date of 1/22/18; at risk for falls related to joint replacement surgery to right hip, post [MEDICAL CONDITION], muscle wasting and atrophy, lack of coordination, unsteadiness, and dizziness. The documented approaches were pressure alarm to bed and chair at all times and encourage to call for assistance before trying to ambulate. On 09/12/18 at 2:00PM, an observation revealed that resident #50 was sitting a recliner, in her room. Further observation revealed that there was not a pressure alarm in the resident's recliner chair and bed. On 09/12/18 at 3:24PM, an interview with S4CNA (Certified Nursing Assistant) was conducted and she revealed that she was the CNA assigned to work with resident #50 on 09/12/18 from 3:00PM through 11:00PM. A visual observation of the resident's room was conducted with S4CNA. Observation revealed resident #50 was sitting in her recliner. With the resident's permission, S4CNA observed the seat of the recliner chair. The observation revealed that there was not a pressure alarm in place. Further observation revealed that there was not a pressure alarm in place on the resident's bed. S4CNA confirmed that there was no pressure alarm device in place to the chair and bed at the time of the observation. On 09/12/18 at 4:13PM, an interview with S3RN (Registerd Nurse) was conducted and she was notified of the above findings. An observation of the resident's room with S3RN was conducted. Resident #50 was observed sitting in her recliner. S3RN observed both the recliner and bed. She confirmed that there was not a pressure alarm device in place at the time of the observation. On 09/12/18 at 4:22PM, an interview and record review S3RN was conducted. S3RN reviewed the (MONTH) (YEAR) physician's orders [REDACTED]. S3RN confirmed that resident #50 did not have a pressure alarm device in place to her chair and bed as ordered by the physician and in accordance with the resident's written plan of care. On 09/13/18 at 2:35PM, an interview with S2DON (Director of Nursing) conducted and she was notified of the findings. She confirmed that a pressure alarm device should have been implemented as per the physician's orders [REDACTED].#50's written plan of care.

Based on record review and interview the facility failed to have a discharge summary that included a recapitulation of the resident's stay that included: diagnoses, course of illness, treatment or therapy and pertinent lab, radiology, consultation results; a reconciliation of all pre-discharge medications with the resident's post-discharge medications; and a post-discharge plan of care to indicate where the individual planned to reside and any arrangements that were made for follow-up care for 1 (#118) of 2 (#118, #120 ) discharged records reviewed in a universal sample size of 37. Findings: Resident #118 Record review revealed Resident # 118 was admitted to the facility from the hospital on 07-25-18 with a [DIAGNOSES REDACTED]. The resident was discharged on [DATE] with no return anticipated. Review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident had a (Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident had no deficits in cognition. The resident required extensive assistance with bed mobility, transfers, dressing and toileting. Review of the care plan revealed the resident's goal was to return to a prior level of function before the fracture, to be able to be weight bearing with therapy and to progress to walking. Further review of the record revealed there was no documentation a discharge summary had been performed that would include a recapitulation of the resident's stay and treatment. Review of the nurse note dated 08-19-18 revealed at 7:10AM the resident and her husband informed the nurse at the nurse station that she was going home. She stated her insurance had released her to go home. The resident was still wearing a walking boot with toe touch only on the right leg. She stated she had an appointment with her orthopedic doctor on Tuesday. The resident was encouraged not to push herself at home as she was still unsteady with transfers. She was assisted by wheelchair to her car. On 09/13/18 at 02:48 PM an interview with S2DON there was no documentation of a discharge summary for Resident #118. She stated that normally they begin discharge planning about 2 weeks prior to discharge, but in this resident's case, they did not have time to develop a discharge summary as the resident left suddenly.

Based on observation, record review and interview the facility failed to maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by allowing a resident's catheter tubing to touch the floor for 1 (#62) of 2 (#62, #116) residents observed for catheter care in a universal sample size of 37 residents. There was a total of 7 residents with catheters in the facility. Findings: Record review for Resident # 62 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of the MD orders revealed the resident was currently being treated with antibiotics for a urinary tract infection and was to have her temperature taken every shift while on the antibiotic. Review of the MDS dated [DATE] revealed a BIMS score of 11 which indicated the resident had moderate cognitive impairment. The resident required extensive assistance with bed mobility, transfers, dressing, eating and toileting. Observation on 09/11/18 at 09:27 AM the resident was sitting up in a wheelchair. The resident had a foley catheter present with sediment noted in the tubing. The catheter bag was attached to a bag on the back of the wheelchair. The catheter tubing was touching the floor. Observation on 09/12/18 at 2:20PM revealed the resident was sitting in a wheelchair in the dining room playing BINGO. The resident had a foley catheter that was attached to a covered bag on the back of the wheelchair. The tubing of the catheter was touching the floor. Observation on 09/12/18 at 03:15 PM the resident was seated in her wheelchair in the day area of the nurse's station watching the television. The resident's Foley catheter was attached to a covered bag on the back of the wheelchair. The catheter tubing was touching the floor. On 09/13/18 at 11:42 AM during an interview S2DON was informed the resident's catheter tubing was observed touching the floor at times during the survey.

Based on record review and interview, the facility failed to immediately notify a resident's physician that the resident was having signs and symptoms of bleeding for 1 of 1 sampled resident on [MEDICATION NAME] therapy in a total sample of 5 (Sample #2) As a result, sampled resident #2 suffered Actual Harm when she began to exhibit signs of bleeding and the facility failed to notify the physician until three days later, when the resident was hospitalized with [MEDICATION NAME] toxicity and died less than 24 hours later. Findings: Review of the medical record for sampled resident #2 revealed an admitted [DATE] with [DIAGNOSES REDACTED]. Further review of the record revealed that the resident was prescribed [MEDICATION NAME] (blood thinner) 4mg daily in [DATE] and [DATE]. The resident had a physician order [REDACTED]. Review of the physician order [REDACTED]. The physician also ordered the resident ' s PT/INR level to be rechecked in 7 days (on [DATE]). Review of the resident ' s nurses notes dated [DATE] at 2PM revealed that the results of the resident ' s PT/INR blood levels were faxed to the physician. There was no documented evidence in the record that the facility had ensured that the physician received and responded to the fax. Review of the resident ' s nurses notes dated [DATE] at 11AM revealed that the facility received a response from the physician two days after faxing the lab results. The physician ordered (in response from the lab results dated [DATE]) to increase the resident ' s [MEDICATION NAME] to 6mg daily every Monday, Wednesday and Friday and [MEDICATION NAME] 5mg daily every Tuesday, Thursday, Saturday and Sunday. The physician also ordered the facility to recheck the resident ' s PT/INR blood levels in 7 days (due [DATE]). Review of the nurses notes dated [DATE] revealed that the lab called regarding the resident ' s critical (high) PT/INR blood levels. A physician ordered dated [DATE] revealed an order to hold the [MEDICATION NAME] for three days and then repeat PT/IN (due [DATE]). The order further revealed to not resume [MEDICATION NAME] until the physician was aware of the blood levels. Review of the resident ' s record revealed that on [DATE] at 3:30PM, the resident was directly admitted to the hospital with [REDACTED]. The resident was at the hospital at the time that the physician was faxed. The resident returned to the facility on [DATE] at 11:15PM with orders to resume previous nursing home medications. On [DATE], the facility received an order from the resident ' s physician to hold the [MEDICATION NAME] for three days and recheck the PT/INR blood levels in one week. Review of the nurses notes dated [DATE] at 5PM revealed that the resident ' s abnormal (high) PT/INR lab results were faxed to the physician. On [DATE], the facility received an order to continue administering [MEDICATION NAME] daily and recheck PT/INR level in three days (due [DATE]). Review of the medical record revealed that the PT/INR blood level that was ordered by the physician to be checked on [DATE] was not performed. The facility continued to administer the resident [MEDICATION NAME] daily in [DATE], although there were no current blood levels. Review of the nurses notes dated [DATE] at 12:30AM revealed that the nurse was called to the resident ' s room by the CNA because the resident had dried blood on her mouth. The notes revealed that the resident had no active bleeding and that the nurse would inform the next shift. There was no documented evidence that the nurse performed any further assessments to determine if the bleeding was related to the resident ' s [MEDICATION NAME] blood levels. There was no documented evidence that the resident ' s physician was immediately notified. Further review of the record revealed that the nurse faxed the physician ' s office on [DATE] at 4:34AM. There was no documented evidence that the facility had ensured that the physician received and responded to the fax. Review of the resident ' s [DATE] MAR indicated [REDACTED]. Review of the nurses notes dated [DATE] at 5:30AM revealed that upon entering the resident ' s room, the nurse observed dried blood on the resident ' s lips and in her mouth. The notes revealed that the resident stated that she had coughed up two blood clots earlier. The notes stated that the nurse cleaned the resident ' s lips and provided mouth care. There was no documented evidence that the nurse performed any further assessments to determine if the bleeding was related to the resident ' s [MEDICATION NAME] blood levels. There was no documented evidence that the resident ' s physician was immediately notified that the resident had been coughing up blood. Further review of the record revealed that the nurse faxed the physician ' s office on [DATE] at 8:04AM. There was no documented evidence that the facility had ensured that the physician received and responded to the fax. Review of the resident ' s [DATE] MAR indicated [REDACTED]. Review of the nurses notes dated [DATE] at 1:15PM revealed that the resident asked the nurse if she had seen her leg. The notes revealed that the resident had a 10cm dark purple area to her right inner thigh with surrounding skin that was red and warm to touch. Further review of the notes revealed that the resident ' s physician had been faxed earlier that morning regarding the resident spitting up blood, but the facility had not received a response from the physician. The nurses notes dated [DATE] at 1:30PM revealed that the facility notified the local emergency room that they were transferring the resident. On [DATE] at 1:50PM, the resident was transported by ambulance to the emergency room . The resident had been receiving [MEDICATION NAME] daily up to this date, with no current blood levels obtained since [DATE]. Review of the emergency department notes dated [DATE] at 1:57PM revealed that the resident had a large hematoma on her right inner thigh, bleeding gums, multiple bruises on the upper and lower extremities, and dried blood noted in the mouth and around lips. Review of the lab results dated [DATE] at 2:20PM revealed the resident ' s PT/INR was critically high. The resident ' s PT was greater than 100 (Normal PT is between 23XXX,[DATE].3) The resident ' s INR was greater than 10 (Normal INR is ,[DATE]). These increased levels indicated that the resident ' s blood was extremely thin. The physician diagnosed the resident with [MEDICATION NAME] toxicity. On [DATE] at 4:40PM, the resident expired at the hospital with a [DIAGNOSES REDACTED]. On [DATE] at 10:50AM, interview with S7ADON and S1Administrator confirmed that the facility failed to immediately notify resident #2' s physician that she was having signs and symptoms of bleeding, beginning on [DATE]. S1Administrator and S7ADON further confirmed that the resident's physician was not notified until [DATE], after the resident continued to have symptoms of bleeding, including coughing up blood.

Based on record review and interview, the facility failed to meet professional standards of quality by failing to follow the physicians orders for obtaining blood work (PT/INR) for 1 of 1 sampled resident on [MEDICATION NAME] (blood thinning) therapy requiring frequent PT/INR blood testing in a total sample of 5 (Sample #2). As a result, resident #2 suffered Actual Harm when she began having signs and symptoms of bleeding, was hospitalized and expired within 24 hours as a result of [MEDICATION NAME] toxicity. Findings: Review of the medical record for sampled resident #2 revealed an admitted [DATE] with [DIAGNOSES REDACTED]. Further review of the record revealed that the resident was prescribed [MEDICATION NAME] (blood thinner) 4mg daily in [DATE] and [DATE]. The resident had a physician order [REDACTED]. Review of the physician order [REDACTED]. The physician also ordered the resident ' s PT/INR level to be rechecked in 7 days (on [DATE]). Review of the resident ' s nurses notes dated [DATE] at 2PM revealed that the results of the resident ' s PT/INR blood levels were faxed to the physician. There was no documented evidence in the record that the facility had ensured that the physician received and responded to the fax. Review of the resident ' s nurses notes dated [DATE] at 11AM revealed that the facility received a response from the physician two days after faxing the lab results. The physician ordered (in response from the lab results dated [DATE]) to increase the resident ' s [MEDICATION NAME] to 6mg daily every Monday, Wednesday and Friday and [MEDICATION NAME] 5mg daily every Tuesday, Thursday, Saturday and Sunday. The physician also ordered the facility to recheck the resident ' s PT/INR blood levels in 7 days (due [DATE]). Review of the nurses notes dated [DATE] revealed that the lab called regarding the resident ' s critical (high) PT/INR blood levels. A physician ordered dated [DATE] revealed an order to hold the [MEDICATION NAME] for three days and then repeat PT/IN (due [DATE]). The order further revealed to not resume [MEDICATION NAME] until the physician was aware of the blood levels. Review of the resident ' s record revealed that on [DATE] at 3:30PM, the resident was directly admitted to the hospital with [REDACTED]. The resident was at the hospital at the time that the physician was faxed. The resident returned to the facility on [DATE] at 11:15PM with orders to resume previous nursing home medications. On [DATE], the facility received an order from the resident ' s physician to hold the [MEDICATION NAME] for three days and recheck the PT/INR blood levels in one week. Review of the nurses notes dated [DATE] at 5PM revealed that the resident ' s abnormal (high) PT/INR lab results were faxed to the physician. On [DATE], the facility received an order to continue administering [MEDICATION NAME] daily and recheck PT/INR level in three days (due [DATE]). Review of the medical record revealed that the PT/INR blood level that was ordered by the physician to be checked on [DATE] was not performed. The facility continued to administer the resident [MEDICATION NAME] daily in [DATE], although there were no current blood levels. Review of the nurses notes dated [DATE] at 12:30AM revealed that the nurse was called to the resident ' s room by the CNA because the resident had dried blood on her mouth. The notes revealed that the resident had no active bleeding and that the nurse would inform the next shift. There was no documented evidence that the nurse performed any further assessments to determine if the bleeding was related to the resident ' s [MEDICATION NAME] blood levels. There was no documented evidence that the resident ' s physician was immediately notified. Further review of the record revealed that the nurse faxed the physician ' s office on [DATE] at 4:34AM. There was no documented evidence that the facility had ensured that the physician received and responded to the fax. Review of the resident ' s [DATE] MAR indicated [REDACTED]. Review of the nurses notes dated [DATE] at 5:30AM revealed that upon entering the resident ' s room, the nurse observed dried blood on the resident ' s lips and in her mouth. The notes revealed that the resident stated that she had coughed up two blood clots earlier. The notes stated that the nurse cleaned the resident ' s lips and provided mouth care. There was no documented evidence that the nurse performed any further assessments to determine if the bleeding was related to the resident ' s [MEDICATION NAME] blood levels. There was no documented evidence that the resident ' s physician was immediately notified that the resident had been coughing up blood. Further review of the record revealed that the nurse faxed the physician ' s office on [DATE] at 8:04AM. There was no documented evidence that the facility had ensured that the physician received and responded to the fax. Review of the resident ' s [DATE] MAR indicated [REDACTED]. Review of the nurses notes dated [DATE] at 1:15PM revealed that the resident asked the nurse if she had seen her leg. The notes revealed that the resident had a 10cm dark purple area to her right inner thigh with surrounding skin that was red and warm to touch. Further review of the notes revealed that the resident ' s physician had been faxed earlier that morning regarding the resident spitting up blood, but the facility had not received a response from the physician. The nurses notes dated [DATE] at 1:30PM revealed that the facility notified the local emergency room that they were transferring the resident. On [DATE] at 1:50PM, the resident was transported by ambulance to the emergency room . The resident had been receiving [MEDICATION NAME] daily up to this date, with no current blood levels obtained since [DATE]. Review of the emergency department notes dated [DATE] at 1:57PM revealed that the resident had a large hematoma on her right inner thigh, bleeding gums, multiple bruises on the upper and lower extremities, and dried blood noted in the mouth and around lips. Review of the lab results dated [DATE] at 2:20PM revealed the resident ' s PT/INR was critically high. The resident ' s PT was greater than 100 (Normal PT is between 23XXX,[DATE].3) The resident ' s INR was greater than 10 (Normal INR is ,[DATE]). These increased levels indicated that the resident ' s blood was extremely thin. The physician diagnosed the resident with [MEDICATION NAME] toxicity. On [DATE] at 4:40PM, the resident expired at the hospital with a [DIAGNOSES REDACTED]. On [DATE] at 10:50AM, interview with S7ADON and S1Administrator confirmed that the facility failed to follow the physicians orders for the lab work (PT/INR) that was ordered for [DATE]. They further revealed that the nurses continued to administer the resident [MEDICATION NAME] daily, although the lab work was not obtained. *****that the physician order [REDACTED]. S7ADON confirmed that the resident ' s physician was not immediately notified on [DATE] and [DATE] regarding the bleeding. S7ADON and S1Administrator further confirmed that the last PT/INR obtained was on [DATE] and that the facility continued to administer the [MEDICATION NAME] (blood thinner) after the resident displayed signs and symptoms of bleeding. that the physician order [REDACTED]. S7ADON confirmed that the resident ' s physician was not immediately notified on [DATE] and [DATE] regarding the bleeding. S7ADON and S1Administrator further confirmed that the last PT/INR obtained was on [DATE] and that the facility continued to administer the [MEDICATION NAME] (blood thinner) after the resident displayed signs and symptoms of bleeding. The facility 1) failed to perform an assessment to determine if a resident ' s bleeding from her mouth was related to the resident ' s [MEDICATION NAME] blood levels (PT/INR) and 2) failed to assess and monitor the resident ' s PT/INR blood levels prior to administering [MEDICATION NAME] after the resident began coughing up blood for 1 of 1 sampled resident receiving [MEDICATION NAME] therapy in a total sample of 5 (Sample #2). The facility continued to administer resident #2 a blood thinner medication, [MEDICATION NAME], after she exhibited signs and symptoms of bleeding. As a result, resident #2