Every finding on record at PruittHealth - Holly Hill, LLC

Based on observations, record review, interviews, and facility policy review, the facility failed to protect residents from smoking related accident hazards for two of four residents reviewed for smoking (Residents (R) 86 and R38) out of 24 sampled residents. The facility failed to accurately complete smoking assessments, had inadequate supervision during smoking, failed to secure the residents' smoking materials, allowed residents to smoke in proximity to others with portable oxygen tanks, and failed to enforce its smoking policy. These failures had the potential to cause accidents/hazards during smoking times that could result in bodily injury to those smoking and those near the smoking area. The facility's failure to maintain a safe environment by staff allowing residents to smoke near residents with portable oxygen tanks caused or was likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 02/26/26 and was determined to exist on 02/23/26, for 483.25 Free of Accident Hazards/Supervision/Devices at a Scope and Severity (S/S) of a J. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on 02/26/26 at 5:45 PM. The facility was notified that an acceptable plan of removal (POR) had been accepted on 02/27/26 at 11:22 AM. The survey team validated the full implementation of the facility's POR, and the Administrator was notified on 02/27/26 at 1:10 PM that the immediacy had been removed. The deficient practice remained at a scope and severity (S/S) of D (isolated No Actual Harm with Potential for More than Minimal Harm).Substandard Quality of Care was identified with the requirements at 42 CFR 483.25(i) Free of Accident Hazards/Supervision/Devices (F689 S/S: J).Findings include: 1. Review of R86's Face sheet, located in the electronic medical record (EMR) under the Resident tab, revealed R86 admitted to the facility on [DATE] with multiple diagnoses to include chronic respiratory failure, chronic obstructive pulmonary disease (COPD), and nicotine dependence, cigarettes. Review of R86's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/25/26, located under the Resident Assessment Instrument (RAI) tab in the EMR revealed R86 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated he was cognitively intact. The MDS indicated R86 did not have upper or lower extremity impairments and received oxygen therapy. Review of R86's comprehensive Care Plan, revised 01/22/26, located under the Care Plan tab in the EMR revealed [86] is a smoker and will comply with the nonsmoking facility policy and procedure with approaches that included educated the family and resident that all smoking items need to be left at the front desk, residents need to sign out prior to getting these items and leave the grounds, they are responsible for themselves once signing out, and all items are returned to the nurse upon coming back into the facility, educate the family and the patient related to the risk of smoking while on oxygen, and educate [R86] on the smoking policy and procedure. Review of R86's Physician's Orders, dated 01/21/26, located under the Orders tab in the EMR revealed an order for . oxygen at [three] 3 LPM [liters per minute] via nasal cannula continuous every shift days, nights. Review of R86's Smoking Observation Form, dated 01/22/26, located in the EMR under the Observation tab, revealed the following . UNSUPERVISED patients/residents will be allowed to smoke unsupervised at any time when their independent status has been determined by the smoking observation as evidenced by all boxes checked NO. The facility failed to ensure that all components of the smoking assessment were answered NO. The form indicated a Yes response for medical diagnosis/condition, medication created a hazard when smoking, poor judgement/non-compliance regarding safety, and a physician's order for oxygen. Review of R86's Progress Notes, dated 01/22/26, located under the Progress Notes tab in the EMR revealed Spoke with [R86's Representative] related to the risk associated with patient signing out and smoking with oxygen. He has been educated related to the risk of fire . noncompliance can result in discharge from the facility. Review of R86's PAR [Person at Risk]/Behavior, dated 02/03/26, located under the Progress Notes tab in the EMR revealed . spoke with resident regarding his increased negative behaviors. He left the facility yesterday without signing out and left his rollator in the bushes in the back parking lot .We discussed the fact that he continues to violate the smoking policy as we are a non-smoking campus and he must sign out to smoke and not have smoking paraphernalia on his person . Review of an undated document provided by the facility referred to as an Agreement, indicated R86 agreed to a smoking schedule which was to happen from 8:00 to 8:30 AM, 1:00 to 1:30 PM, 6:00 to 6:30 PM, and from 9:00 to 9:30 PM. During an observation and interview on 02/23/26 at 8:15 AM, R86 was observed sitting on his rollator and smoking a cigarette while wearing oxygen via nasal cannula (delivering supplemental oxygen or airflow directly into a patient's nostrils via a lightweight, two-pronged tube) unsupervised in the upper parking lot. The portable oxygen machine remained attached to the rollator, and R86 stated that although he turned off the portable oxygen machine beforehand, he did not remove the nasal cannula or leave the device inside the facility. During an observation on 02/23/26 at 1:34 PM, R86 was seen seated on his rollator in the facility's lower parking lot, unsupervised, smoking a cigarette while wearing a nasal cannula connected to a portable oxygen machine. During an observation on 02/24/26 at 9:18 AM, R86 proceeded to the back parking lot, where a safety ashtray was available, and retrieved a cigarette and lighter from the zipper pocket of his oxygen machine bag attached to his rollator. Review of an undated document provided by the facility referred to as an Agreement, indicated R86 agreed to a smoking schedule which was to happen from 8:00 to 8:30 AM, 1:00 to 1:30 PM, 6:00 to 6:30 PM, and from 9:00 to 9:30 PM. During an observation and interview on 02/24/26 at 11:28 AM, in the facility's lower parking lot, numerous cigarette butts were noted in the grass near a green cease fire cigarette butt receptacle. R86 was present with a portable oxygen machine attached to his rollator and smoking a cigarette, and R38 was positioned with a portable oxygen tank secured to the back of her wheelchair and smoking a cigarette. Residents reported they had signed out at the front desk prior to exiting the building and had set smoking times four times a day. R86 stated he kept his cigarettes and lighter in the zippered pocket of his oxygen machine bag. R38 reported that Medical Records kept her cigarettes and lighter secured at the front desk and provided them to her upon signing out. 2. Review of R38's Face Sheet, located in the EMR under the Resident tab revealed an admission date of 4/30/25 with diagnosis of chronic respiratory failure with hypoxia (not getting enough oxygen) and COPD. Review of R38's MDS, with an ARD of 11/25/25 and located under RAI tab of the EMR revealed R38 had a BIMS score of 15 of 15 indicating R38 was cognitively intact. Review of R 38's Care Plan, dated 10/25/2026 and located under the RAI tab in the EMR revealed R38 was non-compliant in the use of her oxygen. Review of the updated Care Plan, indicated on 02/22/26, R38 was re-educated that she needed to go off the facility grounds when smoking after turning her oxygen off. Review of R38's Smoking Observation Form, dated 02/26/26, located under the Observations tab of the EMR revealed, .Supervision will be required at all designated smoking times when the patient/resident observation identifies any potential hazard risk, as evidenced by any boxes checked Yes. The facility failed to ensure that all components of the smoking assessment were answered NO. Further review of the form indicated, Supervised Smoker.Yes. The resident was physically unable to light his/her own cigarette and Yes to the question is there a physician order for the patient/resident to use oxygen. During an observation on 02/24/26 at 1:00 PM, R38 was observed signing out to smoke. R38 was observed taking her oxygen tank outside. During an observation on 02/24/26 at 2:00 PM, R38 was observed around the corner from the front door in the parking lot to an area that had a safety butt container. R38 was noted to still have her oxygen tank attached to the back of her wheelchair. R38 indicated she knew how to turn her oxygen tank on and off. At no time were there any staff members observing R38. During an interview with R38 on 02/23/26 at 10:00 AM, R38 reported she signed out to smoke. R38 indicated she was educated on the use of oxygen while smoking. R38 indicated the facility staff kept her cigarettes up front, and she goes out every one to two hours. During an interview on 2/25/26 at 9:00 AM, LPN1 stated R38 would come up to the desk, turn her oxygen off, retrieve her cigarette, and sign out of the building. LPN1 stated she did not go out and supervise the residents who smoke. During a joint interview on 02/24/26 at 1:24 PM, the Administrator and DON stated the facility became smoke free in 2015 and no longer housed any grandfathered residents. They explained that the parking lot is not considered facility property and that the smoking schedule was intended as a suggestion rather than a formal protocol. According to both the Administrator and DON, residents who sign out are on a leave of absence (LOA), like leaving with a family member, and therefore outside the facility's responsibility. The DON also reported that smoking assessments were completed incorrectly due to staff misunderstanding the questions, though she maintained the residents were able to smoke safely and were unsupervised during smoking.

Based on observations, record review, interviews, and facility policy review, the facility failed to enforce its smoking policy by allowing residents to smoke near others using portable oxygen for two of four residents (Residents (R) 38 and R86) reviewed for smoking out of a total sample of 24 residents. This noncompliance created conditions that posed a risk of serious injury for the residents. The facility's failure to implement their smoking policy by staff allowing residents to smoke near residents with portable oxygen tanks caused or was likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 02/26/26 and was determined to exist on 02/23/26, for 483.90 Smoking Policies at a Scope and Severity (S/S) of a J. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on 02/26/26 at 12:30 PM. The facility was notified that an acceptable plan of removal (POR) had been accepted on 02/27/26 at 11:22 AM. The survey team validated the full implementation of the facility's POR, and the Administrator was notified on 02/27/26 at 1:10 PM that the Immediacy was removed. The deficient practice remained at a scope and severity (S/S) of D (isolated No Actual Harm with Potential for More than Minimal Harm).Cross Reference F689.Findings include: 1. Review of R86's Face sheet, located under the Resident tab in the electronic medical record (EMR) revealed R86 admitted to the facility on [DATE] with multiple diagnoses to include chronic respiratory failure, chronic obstructive pulmonary disease (COPD), and nicotine dependence, cigarettes. Review of R86's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/25/26, located under the Resident Assessment Instrument (RAI) tab in the EMR revealed R86 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated he was cognitively intact. The MDS indicated R86 did not have upper or lower extremity impairments and received oxygen therapy. Review of R86's Smoking Observation Form, dated 01/22/26, located in the EMR under the Observation tab revealed the following . UNSUPERVISED patients/residents will be allowed to smoke unsupervised at any time when their independent status has been determined by the smoking observation as evidenced by all boxes checked NO. The facility failed to ensure that all components of the smoking assessment were answered NO. The form indicated a Yes response for medical diagnosis/condition, medication created a hazard when smoking, poor judgement/non-compliance regarding safety, and a physician's order for oxygen. Review of R86's Progress Notes, dated 01/22/26, located under the Progress Notes tab in the EMR revealed Spoke with [R86's Representative] related to the risk associated with patient signing out and smoking with oxygen. He has been educated related to the risk of fire . noncompliance can result in discharge from the facility. Review of R86's PAR [Person at Risk]/Behavior, dated 02/03/26, located under the Progress Notes tab in the EMR revealed . spoke with resident regarding his increased negative behaviors. He left the facility yesterday without signing out and left his rollator in the bushes in the back parking lot .We discussed the fact that he continues to violate the smoking policy as we are a non-smoking campus and he must sign out to smoke and not have smoking paraphernalia on his person . During an observation and interview on 02/23/26 at 8:15 AM, R86 was observed sitting on his rollator and smoking a cigarette while wearing oxygen via nasal cannula (delivering supplemental oxygen or airflow directly into a patient's nostrils via a lightweight, two-pronged tube) unsupervised in the upper parking lot. The portable oxygen machine remained attached to the rollator. R86 stated although he turned off the portable oxygen machine beforehand, he did not remove the nasal cannula or leave the device inside the facility. During a joint interview on 02/24/26 at 1:24 PM, the Administrator and DON stated the facility became smoke free in 2015 and no longer housed any grandfathered residents. They explained that the parking lot is not considered facility property. According to both the Administrator and DON, residents who sign out are on Leave of absence (LOA), like leaving with a family member, and therefore was outside the facility's responsibility. 2. Review of R38's Face Sheet, located under the Resident tab in the EMR revealed an admission date of 4/30/25 with diagnoses including chronic respiratory failure with hypoxia (not getting enough oxygen) and COPD with acute exacerbation. Review of R 38's MDS, located under the RAI tab in the EMR with an ARD of 11/25/25 revealed R38 had a BIMS score of 15 of 15 indicating R38 was cognitively intact. During an interview on 02/23/26 at 10:00 AM, R38 stated she signed out to smoke. R38 indicated she received education regarding the use of oxygen while smoking. R38 stated the facility staff kept her cigarettes up front, and she goes out every one to two hours. During an observation on 02/24/25 at 3:30 PM, R38 was observed around the corner from the front door in the parking lot to an area that had a safety butt container. R38 was noted to still have her oxygen tank attached to the back of her wheelchair. R38 indicated she knew how to turn her oxygen tank on and off. Staff members were not present at any time to observe R38 smoking. Review of the facility's policy titled, Smoke Free Policy, revised 02/10/26, provided by the facility, revealed, Policy Statement: . Smoking will only be allowed in outdoor designated areas for those residents grandfathered in prior to January 1, 2015. The admission Director or admitting Licensed Nurse will inform patient/residents and/or legal representative of the smoking policy upon admission .Procedure: .Smoking is prohibited in any area where flammable liquids, combustible gases or oxygen are used or stored and in any other hazardous location .Grandfathered in Patients/Residents: .5. All areas where smoking is permitted shall have ashtrays of non-combustible material and safe design.6. Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted .7. Fire igniting materials (matches/lighters) and smoking materials to include cigarettes, smokeless/electronic cigarettes, vaping devices, cigars, snuff, or loose tobacco should not be kept in a patient/resident's possession. Patients/residents igniting, and smoking materials will be maintained in a secure area maintained by staff .

Based on record review, staff interviews, and review of the facility policy titled Care Plan, the facility failed to develop a person-centered, comprehensive care plan for one resident (R) (R60) out of a sample of 24. This deficient practice had the potential to place R60 at risk of not receiving services to address impaired vision.Findings include:Review of R60's Resident Face Sheet, located on the resident's dashboard in the electronic medical records (EMR) indicated the facility admitted the resident on 07/30/2021.Review of R60's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/01/2025, located under the Resident Assessment Instrument (RAI) tab in the electronic medical record, showed the resident had impaired vision and did not use glasses. The Brief Interview for Mental Status (BIMS) score was 14 out of 15, indicating the resident was cognitively intact. The Care Area Assessment (CAA) triggered vision impairment and directed staff to develop an appropriate care plan.Review of R60's care plan, located under the RAI tab in the electronic medical record, showed no evidence that the resident's impaired vision had been identified or addressed in the plan of care.Interview on 02/25/2026 at 10:48 AM with MDS Coordinator (MDSC) 1 indicated that because the CAA triggered for impaired vision, a corresponding care plan should have been developed. MDSC1 acknowledged that this had been overlooked.Interview on 02/25/2026 at 11:20 AM with the Administrator and Director of Nursing (DON) confirmed that the CAA for R60's vision had triggered and should have been addressed in the resident's care plan.Review of the policy titled Care Plan, revised 10/21/2025, documented Policy Statement: It is the policy of the health care center for each patient/resident to have a person-centered baseline care plan followed by a comprehensive care plan developed following completion of the Minimum Data Set (MDS) and Care Area Assessment (CAA) portions of the comprehensive assessment according to the Resident Assessment Instrument (RAI) Manual and the patient/resident choice. admission Comprehensive Plan Care 4. The care plan will contain 4 main components: Problem, Goal, Approaches, and Role or Accountability. Problems should be written as actual problems or conditions, potential problems or conditions, at risk for problems or conditions, or may address patient/resident limitations, maintenance level, or improvement possibilities. and resident discharge goals. Problem statements to be stated to the extent possible, in functional or behavioral terms (i.e., how is the condition a problem for the patient/resident; how does the condition limit or jeopardize the patient/resident's ability to complete tasks of daily life or affect the patient/resident's well-being.

Based on observations, staff interviews, and record review, the facility failed to ensure a medication error rate below five percent. There were two medication errors for two residents (R) (R61 and R89) observed out of 25 opportunities, resulting in a medication error rate of eight percent. This deficient practice had the potential to place R61 and R89 at risk of not receiving the correct dosage of medication. Findings include: 1. Review of R61's Face Sheet, located under the Resident tab in the electronic medical record (EMR), revealed he was admitted to the facility on [DATE] with a diagnosis of, but not limited to, type 2 diabetes mellitus without complications. Review of R61's Physician's Orders, dated 02/03/26, located under the Orders tab in the EMR, revealed an order for Humalog KwikPen Insulin (insulin lispro) insulin pen; 100 unit/ml [milliliter]; amt [amount]: Per sliding scale; .During an observation on 02/25/2026 at 11:15 AM, Registered Nurse (RN) 2 retrieved R61's insulin pen (a pen that contains the vial of insulin inside the pen and has a mechanism where the dose to be administered is set on a dial at the top of the pen, and only that amount can then be injected) from the medication cart, wiped the top with an alcohol wipe, attached a needle to the pen then dialed the dose to two units. RN2 carried the pen to R61's room. RN2 washed her hands, applied gloves, observed R61's left upper thigh, cleansed the upper thigh area with an alcohol wipe, gently inserted the pen needle into the flesh, injected the dose, then removed the needle after ten seconds. Next, RN2 carried the pen to the medication cart, disposed of the needle, and performed hand hygiene. During an interview on 02/25/2026 at 11:19 AM, RN2 confirmed she did not prime the pen after attaching the needle to it and had been trained to prime the pen. RN2 stated she did not know the reason for priming the pen, but forgot to prime it. 2. Review of R89's Face Sheet, located under the Resident tab in the EMR, revealed R89 was admitted to the facility on [DATE] with a diagnosis of, but not limited to, type 2 diabetes mellitus (DM) with hyperglycemia.Review of R89's Physician Orders, dated 04/19/2024, located under the Orders tab in the EMR, revealed an order for Humalog Kwikpen Insulin (insulin lispro) insulin pen; 100 unit/ml; amt: Per sliding scale; .During an observation on 02/25/2026 at 12:06 PM, Certified Medication Aide (CMA) 1 retrieved R89's insulin pen from the medication cart, wiped the top with an alcohol wipe, attached a needle to the pen, then dialed the selector to two units. CMA1 then carried the pen to R89's room. CMA1 washed her hands, applied gloves, observed R89's left upper arm, cleansed the upper arm with an alcohol wipe, gently inserted the pen needle into the flesh, injected the dose, then removed the needle after ten seconds. CMA1 carried the pen to the medication cart, disposed of the needle, and performed hand hygiene. During an interview on 02/25/2026 at 12:10 PM, CMA1 confirmed she did not prime the pen with two units to ensure the needle worked, to ensure the resident received the correct dosage of insulin. CMA1 stated they held a skills fair last year, and insulin pen administration was reviewed during training. During an interview on 02/25/2026 at 3:24 PM, the Director of Nursing (DON) stated they held an annual skills fair, which included insulin pen administration. The DON also stated she expected the nurses to prime the insulin pen by turning the selector to two units after attaching the needle, then pushing on the plunger, shoot the insulin in the air, and then replace the needle if the insulin does not come out of the needle. The DON indicated priming the pen was completed to ensure the pen worked and for appropriate dosing. The DON confirmed CMAs were included in the training and were allowed to administer insulin.During an interview on 02/25/2026 at 3:37 PM, the Clinical Competency Coordinator (CCC) stated that the facility's 2025 annual skills fair, held in September and October, included training on insulin pen administration. The CCC explained that nurses were instructed to prime the pen by dialing the selector to two units after attaching the needle, then shooting the insulin in the air to ensure the needle functioned properly so the resident would receive an accurate dose.

Based on record reviews and staff interviews, the facility failed to ensure eye care was provided to one resident (R) (R60) from a sample of two reviewed for eye care. Specifically, the facility failed to ensure orders were transcribed and implemented by a contracted eye exam company to provide care and services for R60. The deficient practice had the potential to place R60 at risk of unmet care needs and a diminished quality of life. Findings include:Review of R60's Face Sheet, located on the resident's dashboard in the electronic medical record (EMR), indicated the facility admitted the resident on 07/30/2021.Review of R60's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/12/2026. located under the MDS tab in the EMR. indicated the resident had vision impairment. The assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 14, which indicated little to no cognitive impairment.Review of R60's Eye Care Chart Note, dated 08/19/2025, located under the Resident tab in the EMR, indicated the resident was seen by an optometrist to address the resident's right and left eye for dry eyes. Under a section titled Assessment Plan, the Eye Doctor recommended, . Blepharitis is chronic and affecting [sic] ocular surface; recommend lid hygiene daily with a warm washcloth.Review of R60's Eye Care Chart Note, dated 12/09/2025, located under the Resident tab in the EMR, indicated that the optometrist saw the resident to address the resident's chronic dry eye. Under a section titled Medications Prescribed Today, it indicated the optometrist ordered Refresh Lacri-Lube 56.8 %-42.5 % eye ointment. Apply one millimeter ribbon behind the lower lid for both eyes every day for dry eye until 06/26/2026. The optometrist ordered Refresh Liquigel 1% liquid gel drops to apply two drops in each eye four times per day until 12/01/2026. Review of R60's Physician Orders revealed that there was no documented physician's order for eye care or the medication in the chart note written by the optometrist. Review of R60's Medication Administration Record (MAR), from 08/2025 to 02/2025, revealed there was no documentation to reflect the warm washcloth hygiene and the eye drops. During an interview and record review on 02/25/2026 at 10:31 AM, Licensed Practical Nurse (LPN) 1 reviewed R60's EMR and confirmed that the optometrist's orders for warm washcloths and eye drops were not transcribed into the clinical record and had not been carried through. LPN1 stated that typically, the optometrist will print out the orders and give them to the Social Services Director (SSD). During an interview on 02/25/2026 at 10:39 AM, the SSD stated that the process for the optometrist was to make recommendations and print the orders, which were then given to LPN1. The SSD stated the nursing team was responsible for reviewing the optometrist's orders. During an interview on 02/25/2026 at 11:20 AM, the Administrator, Director of Nursing (DON), and LPN1 were present. LPN1 stated that the orders should have been provided to the facility and then transcribed into R60's EMR. The DON stated that the optometrist typically provided the resident's orders to the facility. A request was made to the facility regarding policies for the coordination of care with contracted companies. This policy was not provided before the survey ended.

Based on observations, staff interviews, and record review, the facility failed to establish a policy governing food brought in by visitors. In addition, the facility failed to ensure a resident's personal refrigerator was free of expired items and that temperature logs were completed for the freezer for one resident (R) (R7) of 24 sampled residents. These deficient practices placed the residents at risk of foodborne illness. Findings include:Review of R7's Face Sheet, located under the Resident tab in the electronic medical record (EMR), indicated R7 was admitted to the facility on [DATE].Review of R7's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/20/2026 indicated R7 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, demonstrating the resident was cognitively intact.Interview on 02/23/2026 at 10:04 AM with R7 revealed that the resident stored food in his personal refrigerator and that staff had not cleaned it recently, although staff had taken temperatures.Observation on 02/23/2026 at 10:04 AM with Certified Nurse Aide (CNA) 5 revealed that R7's personal refrigerator contained multiple expired food items, including: almond milk dated 01/04/2026; Silk Almond Milk Vanilla from December 2025; an unlabeled, undated bowl containing a yellow substance with a black, furry growth on top; Ensure Clear dated December 2024; pre sliced [NAME] cheese dated 05/27/2025; Greek yogurt dated September 2025 and 07/02/2025. Observation also revealed the freezer compartment lacked a thermometer.In an interview on 02/23/2026 at 10:24 AM, CNA 5 confirmed that R7's refrigerator contained expired food items requiring disposal. CNA 5 reported she had cleaned the refrigerator a couple of months prior and stated she was not aware of any cleaning schedule or a designated location for documenting completion of the task.In an interview on 02/24/26 at 3:45 PM, the Maintenance Director 1 stated he entered R7's refrigerator temperatures into his maintenance program after they were documented on the personal refrigerator log. He explained that various department heads were responsible for completing daily room checks, which included recording temperatures. Maintenance Director 1 also reported that he had not been informed that the freezer lacked a thermometer and had not noticed that the freezer temperatures were not recorded on the form.In an interview on 02/25/26 at 10:39 AM, the Administrator acknowledged the facility did not have a policy addressing food brought in by visitors, nor did it have a defined cleaning schedule or assigned staff responsible for maintaining residents' refrigerators. She confirmed that freezer temperatures for R7 had not been taken because a thermometer was not in place until surveyors identified the issue the previous day. The Administrator explained that although multiple staff members were assigned to check the refrigerator temperature, none reported the freezer thermometer missing. She emphasized the importance of discarding expired items from the refrigerator and of routinely monitoring temperatures to maintain food safety.

Based on observations, staff interviews, and review of the facility's policy titled, Dietary Partner Hygiene and Dress Code, the facility failed to ensure hair nets were worn by dietary staff. Specifically, beard guards were not used by male dietary staff during preparation of meals. This had the potential to affect 80 out of 83 residents who received an oral diet. Findings included: 1. Review of the facility's policy titled Dietary Partner Hygiene and Dress Code dated 11/10/2020 revealed, Scope: This applies to all dietary partners, and any person (s) who handles and serves food employed by [NAME] Health. Hygiene: 2. Hair is covered with hair net and or cap. Facial hair is completely covered with a hair net or beard guard. Dining observation on 11/19/2024 at 12:32 pm revealed the Dietary Manager (DM) prepping trays and serving trays to residents in the main dining room. He was not wearing a beard cover. Interview on 11/20/2024 at 4:25 pm the DM revealed hairnets and beard coverings should always be used while preparing food in the kitchen. He revealed he was unsure about the policy regarding wearing beard guards while prepping trays in the dining room or serving trays. He confirmed he did not wear a beard guard on 11/19/2024. Interview on 11/20/2024 at 4:53 pm with the Director of Health Services (DHS) revealed her expectations were that all staff including the DM wear hair nets and beard coverings while serving food. She revealed there was a risk of contamination of food if beard is not covered. Interview on 11/20/2024 at 5:00 pm with the Infection Preventionist (IP) revealed that all staff prepping or serving trays should have beard coverings and hair nets on. She revealed if staff fail to cover hair, it poses a threat of contamination. 50524

Based on observations and staff interviews, the facility failed to ensure that staff's personal food items were not stored in one of one medication storage rooms. The deficient practice had the potential to increase the probability of contamination of medication and storage supplies located in the storage room area. Findings included: Review of facility's documents revealed no evidence of policy regarding medication room and storage. The policy was requested from the facility, and none was provided. Observation on 11/18/2024 at 4:30 pm during review of the medication room revealed personal food items in the medication room. Foods observed on a shelf in a cupboard next to medical supplies included a pack of hot dog buns, mustard and ketchup. The DHS (Director of Health Services) was present throughout the review of the medication room. Interview on 11/18/2024 at 4:45 pm with the DHS confirmed the personal food items were in the medication room, and she revealed her expectations were for the staff not to put personal food items in the medication room. The DHS further revealed the medication room was for the residents' medication and supplies so when there were personal food items in the medication room, the outcome would be contamination and compromise of the medication and supplies. Interview on 11/18/2024 at 5:45 pm with Licensed Practical Nurse (LPN) II revealed food items must not be in the medication room, and the medication room was for the residents' medications and supplies. She further revealed if food items were in the medication room, it was unsanitary and it would cause contamination of the medications and supplies and possible infection to residents. Interview on 11/20/2024 at 5:00 pm with the Infection Preventionist (IP) revealed food items were not to be kept in the medication room because food items could cause bacterial growth that would contaminate the medications in the medication room.

Based on observations, resident and staff interviews, and record reviews, the facility failed to provide care in a manner that maintained or enhanced residents' rights, dignity, and respect. Specifically, the facility failed to ensure that dependent residents were cleaned promptly when needed after eating, and failed to ensure the call light was in reach, for one of 14 residents (R) (R70). Findings included: Record review revealed R70 was admitted with diagnoses of but not limited to unspecified injury of the head, aneurysm of the heart, muscle weakness, unsteadiness on feet, dysphagia oropharyngeal phase, abnormal posture, and other abnormalities of gait and mobility. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Section C-Brief Interview for Mental Status (BIMS) score of 13 indicating little to no cognitive impairment. Section GG-ADL assistance needed included but not limited to, showers/baths, transfers, assist with setting up for feeding and cleaning as needed. Review of the care plan revealed a goal that R70 will be free from the negative consequences of vision loss as evidenced by remaining physically safe and participating in social and self-care activities. Assist with toileting and transfers PRN (as needed). Place call light within reach. Problem: Impaired Physical Mobility/Deconditioning related to COPD (Chronic Obstructive Pulmonary Disease), convulsions, cerebral infarction, PE (pulmonary embolism), and low back pain. ADL (Activities of Daily Living) needs will be met, and his independence potential maximized within the constraints of his illnesses through the next review. Long-term target date 11/30/2024. Review of menus revealed that breakfast was scheduled to be served to all residents from 7:30 am to 8:00 am. Observation on 11/18/2024 at 10:30 am revealed R70 in bed asleep. He did not respond when surveyor knocked on the door. The call light was on the floor and out of reach for R70. Observation on 11/19/2024 from 9:57 am to 11:20 am revealed R70 was in bed, the call light was on the floor, and he had breakfast food on his face and clothes. CNA (Certified Nursing Assistant) CC walked by and spoke to R70 but did not clean him or check to see if his call light was in reach. Interview at that time with R70 revealed he was visually impaired. Observation at 11:20 am CNA CC cleaned the resident from the food on his face, picked up the call light from the floor, gave him a bed bath and changed his clothing. This observation revealed R70 had food on his face and clothing since breakfast earlier that morning. Resident revealed was unaware of food being all over him due to vision loss. Interview on 11/19/2024 at 4:08 pm, MDS Coordinator AA revealed that residents with vision or hearing loss should have a call light accessible and staff ensured the call light was accessible by checking on residents often. Interview further revealed that residents with vision loss should be assisted with eating, should be cleaned after eating because food is often everywhere and sometimes their clothes needed changing. Interview on 11/19/2024 at 4:12 pm Licensed Practical Nurse (LPN) ZZ revealed that when residents are visually impaired the CNA and nurses should follow the care plan and ensure interventions are being followed. Staff should check every hour or as needed to ensure the residents have their call light, assist with eating if needed, and clean the resident up after they finish eating. Interview on 11/19/2024 at 4:19 pm the Director of Health Services (DHS) revealed that nursing staff should follow interventions in the care plan for residents, especially for residents who are hearing and visually impaired and dependent for ADL. She also revealed that some interventions needed updating.

Based on observations and staff interviews, the facility failed to lock one of five medication carts when not in use, failed to remove expired medication from the medication cart, and failed to place open dates on insulin and glucometer strips. This deficient practice had the potential to cause unauthorized persons to access medications and cause complications from expired and undated medication use. The facility's census was 83. Findings included: Review of facility's documents revealed no evidence of a policy for medication carts, expired or no open date for medications. The policy was requested from the facility related to medication carts, expired medication, and no open date for medications but no policy was provided. Observation on 11/17/2024 at 5:20 pm revealed medication cart was not locked on the 200 long hallway. Observation on 11/18/24 at 5:20 pm during review of medication cart 2 Short Hall cart revealed there was one bottle of Bisacodyl 5 mg (milligram) tablets which had expiration date 9/2024 on the bottle. Observation on 11/18/2024 at 5:39 pm during review of medication cart 300 Hall Cart revealed there were containers of medication which were not labelled with open dates and included one bottle of insulin, and one bottle of glucometer strips. Observation on 11/19/2024 at 4:30 pm during review of medication cart 2 Long Hall Cart revealed there were containers of medication which were not labelled with open dates including one bottle of eyedrops. Interview on 11/17/2024 at 5:22 pm with Licensed Practical Nurse (LPN) PP confirmed the medication cart was not locked. She revealed the cart could not be locked since the previous week. She revealed she was informed by the UM (Unit Manager) that she could place it against the wall with the drawers facing the wall when not in use because it could not be locked. She stated she placed it close to the nurses' station but agreed that she could not monitor it from the nurses' station because it was not in full sight. LPN PP further stated if a resident got to open the drawers and got access to the medications, it would be a risk to the resident for allergic reactions or death if they took the wrong medication and in excess quantity. Interview on 11/17/2024 at 5:42 pm the Director of Health Services (DHS) revealed she was not aware the medication cart was not closing since last week. She revealed nobody should leave medication carts unlocked, and her expectations were for the nurses to lock the medication carts when not administering medications or when leaving the cart unattended. She revealed the cart had narcotics and other medications and the outcome if the cart was left unattended would be that residents had access to the medications. She revealed this could cause harm to the residents and it could lead to the residents' death. Interview on 11/18/2024 at 5:18 pm with Registered Nurse (RN) QQ confirmed the bottle of Bisacodyl 5 mg tablets medication was expired. RN QQ revealed if the medications were expired, the medications would lose their effectiveness and would not be beneficial to the residents. Interview on 11/18/2024 at 5:25 pm with the DHS revealed her expectations were for staff to remove expired medications from the medication carts. She revealed the outcome to the residents if medications are expired would be the medications would not be effective in their treatment and the residents could have an adverse reaction from the medication. Interview on 11/18/2024 at 5:45 pm with the DHS revealed her expectation was for the nurses to put open dates on the medication containers. She revealed placing the open dates on glucometer strips and insulin was important for diabetic management, and the outcome would be, it would obscure diabetic readings if the staff were not efficiently managing the open dates on insulin and glucometer strips containers. Interview on 11/19/2024 at 11:56 am Licensed Practical Nurse (LPN) KK confirmed there were no open dates on medication containers in the medication cart. She revealed there should be open dates on the medication containers, and she also confirmed she did not write the open date on one of the medication bottles.

Based on observation, staff interviews, record reviews, and review of the facility's policy titled, Oxygen Administration, the facility failed to follow Physician Order's for four of 11 residents (R) (R338, R77, R29, and R34) reviewed for receiving oxygen. The deficient practice increased the risk of respiratory complications and infections for the residents receiving respiratory care and treatment. Findings included: Review of the policy titled Oxygen Administration revised 8/2/2023 revealed, .Policy Statement: It is the policy of the facility to provide oxygen safely and accurately to appropriate patients/residents. Oxygen will be administered by licensed personnel only when ordered by the physician, PA or NP. The physician order may be written PRN for comfort/dyspnea or may specify the number of liters, method of administration and length of time the oxygen is to be administered. 1. Review of the Electronic Medical Record (EMR) revealed R338 admitted to the facility with diagnoses of but not limited to unspecified fracture of T11-T12 sequela, collapsed vertebra, muscle weakness (generalized), unsteadiness on feet, abnormal posture, pain, reduced mobility, low back pain, neuromuscular dysfunction of bladder. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated little to no cognitive impairment. Section O revealed the resident required oxygen therapy. Review of the Physician orders revealed an order for oxygen at 3 liters per minute (LPM) per nasal cannula (NC) at 9pm with a start date of 11/1/2024. Observation on 11/17/2024 at 2:12 pm revealed R338 lying in bed receiving oxygen therapy via NC set at 2.5/LPM. Observation on 11/18/2024 at 9:30 am revealed R338 lying in bed receiving oxygen therapy via NC set at 2/LPM. Rounding on 11/18/2024 at 3:16 pm with Registered Nurse (RN) DD confirmed the LPM for R338 should be set on 3/LPM and not 2.5/LPM. She adjusted the rate to 3/LPM. RN DD revealed her expectations were that she and other nurses follow physician orders. Interview on 11/18/2024 at 4:15 pm with the Director of Health Services (DHS) revealed it was her expectation that nursing staff check oxygen concentrators every shift to ensure they are set on the prescribed rate of LPM. 36377 2. Review of the EMR revealed R77 had diagnoses of but not limited to chronic respiratory failure whether with hypoxia or hypercapnia, and paroxysmal atrial fibrillation. Review of the Admission MDS assessment dated [DATE] assessed a BIMS score of 11 which indicated moderate cognitive impairment and was assessed for oxygen use. Review of November 2024 Physician Order Form (POF) revealed an order dated 10/15/2024 for Oxygen at 2 LPM via NC continuous daily. Observation on 11/17/202 starting at 2:05 pm until l3:33 pm, and again at 5:00 pm revealed R77 receiving oxygen therapy by NC at 3 liters from the oxygen concentrator. A closer observation revealed no humidifier bottle attached to the oxygen concentrator. Interview 11/19/2024 at 11:01 am, the DHS and Unit Manager were notified by photos that R77 was receiving oxygen therapy at 3 liters instead of 2 liters by nasal cannula from her oxygen concentrator. Both staff confirmed through photos that R77's oxygen setting was set on 3 liters instead of 2 liters and that this was a deficient practice. The DHS confirmed that R77's O2 should be set on 2 liters per physician order instead of 3 liters. Unit Manager revealed that R77 had no history of changing the oxygen setting on the oxygen concentrator. Both staff revealed that the licensed nursing staff were responsible for monitoring residents' O2 Sat (oxygen saturation). 49675 3. Review of the EMR revealed R29 was admitted to the facility with diagnoses of but not limited to acute kidney failure, type two diabetes mellitus with diabetic chronic kidney disease, and hypertensive heart disease with heart failure. Review of the Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, indicating little to no cognitive impairment. Section O (Special treatments which included oxygen therapy) reported, none. Review of the physician orders revealed an order for oxygen dated 7/25/2024, oxygen at 2 LPM via nasal cannula continuous. Observations on 11/17/2024 at 1:06 pm and 4:58 pm revealed R29 received oxygen at a rate of 3 liters. The tubing nor the humidifier bottle was dated. Observations on 11/18/2024 at 2:36 pm and11/19/2024 at 11:07 am revealed R29 received oxygen with the humidifier bottle not dated. Interview on 11/18/2024 at 11:20 am with RN DD verified the physician order for oxygen at a rate of 2 liters. She looked at picture the surveyor captured and verified the oxygen was set on the wrong oxygen rate. She revealed it was the nurse's responsibility to check daily to make sure the flow rate was correct. Interview further revealed the facility did not date tubing or humidifiers, however the resident's tubing was dated for 11/17/2024 and she was unsure who dated the tubing. Interview on 11/20/2024 at 10:05 am with the DHS revealed her expectations were for nurses to follow orders and for charge nurses to check oxygen rates. She expected all oxygen rates to be set on the rate prescribed by the physician. The DHS revealed it was not the facility's policy to label or date tubing or the humidifiers for residents receiving oxygen therapy. 50524 4. Review of the EMR revealed R34 was admitted to the facility with diagnosis of but not limited to Chronic Obstructive Pulmonary Disease (COPD). Review of the Annual MDS assessment dated [DATE] documented Section C (Cognition) BIMS score of 14 which indicated little to no cognitive impairment; Section I (Active Diagnoses) included asthma, COPD, respiratory failure; Section J (Health Conditions) included shortness of breath or trouble breathing when lying flat. Review of care plan dated 10/27/2023 included, Oxygen use related to aspiration, COPD, pneumonia, terminal illness. Goal: Maintain optimal breathing and oxygen level within constraints of terminal diagnosis through next 90 days. Approach: Notify medical doctor (MD) of any changes. Maximize oxygen level through next 90 days, oxygen as needed/ordered. Oxygen saturations as needed/ordered. Review of Physician's orders dated 03/12/2024 included but not limited to Oxygen: Change respiratory circuit/supplies weekly once a day on Sunday (Sun) nights. Oxygen: Oxygen at 2 LPM via nasal cannula to keep oxygen (O2) saturation (Sats) > (above) 95% (percent) every shift day, evening, night. Oxygen: Change respiratory circuit/supplies as needed (PRN), ipratropium-albuterol solution for nebulization; 0.5 milligram (mg)-3 mg (2.5 mg base)/3 milliliter (mL); amount (amt): 1 vial; inhalation every 6 hours PRN. Interview on 11/17/2024 at 11:25 am with the DHS revealed the oxygen masks were to be stored in bags when not in use. She revealed her expectations were for the staff to place oxygen masks in bags and the tubing changed and labelled weekly. She stated if this was not done the outcome would be an infection control issue where the residents could get infections from the masks being placed on dirty surfaces. Interview on 11/19/2024 at 5:35 pm with Certified Nursing Assistant (CNA) HH stated she worked at the facility for [AGE] years and confirmed oxygen face masks should be kept in bags when not in use. Interview on 11/19/2024 at 5:45pm with Licensed Practical Nurse (LPN) II she stated oxygen masks are to be covered in bags when they are not been used. If oxygen masks were not kept in bags or covered, they can cause infection to the residents. Interview on 11/21/2024 at 5:00 pm with the Infection Preventionist revealed she stated her expectations were for oxygen masks to be covered or placed in bags when not in use. She stated if oxygen equipment were placed on dirty surfaces when not in use and they are not in bags or covered, infection can be spread to the residents.

Based on staff interviews, record reviews, and review of the facility's policy titled, Nutritional Screening and Assessments/Food Preferences, the facility failed to provide evidence that nutrition assessments were completed by the Registered Dietitian (RD) for two of 32 residents (R) (R47 and R77) reviewed. This deficient practice had the potential to place the residents at risk of nutrition problems and weight loss. Findings included: Review of the facility's policy titled Nutritional Screening and Assessments/Food Preferences dated 3/28/2024 documented, .It is the policy of the facility for each patient/resident to receive an initial nutritional screening and comprehensive nutritional assessment upon admission. Food preferences are obtained for each patients /resident upon admission and annually to assure food choices and preferences are granted. Assessments must be completed within 14 days of admission. 1. Record review for R47 revealed an admitted [DATE] with diagnoses of but not limited to dysphagia oral phase, hypertension, and acute kidney failure. Review of Physician orders revealed that R47 was prescribed a diet for NAS (No Added Sugar), mechanical soft with special instruction chopped meat in gravy. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 which indicated little to no cognitive impairment. Record review revealed that there was no nutrition assessment completed for R47 by the Registered Dietician until 11/18/2024. Review of R47's care plan created 8/6/2024 included, risk for nutrition and/or hydration risk related to acute kidney failure, dysphagia, and pneumonia. 2. Record review of R77's medical record revealed an admitted [DATE] with the following diagnoses but not limited atrial fibrillation, chronic obstructive pulmonary disease, and end stage renal disease (ESRD). Review of the Admission MDS assessment dated [DATE] assessed a BIMS score of 11, which indicated moderate cognitive impairment, and was assessed for oxygen use. Review of R77's diet order consisted of CCHO/NAS (controlled carbohydrate/no added salt) special instructions no bananas, no tomatoes, no potatoes, no oranges 1000 ml/24 hr (1000 milliliters in 24 hours) fluid restriction, nursing 280 ml:7a-7p 160 ml 7p-7a 120 ml, Dietary 720 ml: Breakfast 240 ml, lunch 240 ml, dinner 240 ml. Record review revealed that R77's nutrition assessment was not completed by the Registered Dietician until 8/5/2024. Interview on 11/19/2024 at 2:15 pm with the Registered Dietician (RD) confirmed that R47's nutrition assessment was not completed until 11/18/2024 during the survey; and that R77's nutrition assessment was not completed until 8/5/2024. The RD reported having a system in place to keep track of all assessments, and that both residents' assessments were addressed after she identified the error. Interview on 11/10/2024 at 5:19 pm, the Administrator and Director of Health Services (DHS) revealed being unaware that R47 and R77's nutrition assessments were not completed in a timely manner based on the company policy. Administrator reported her expectation that all nutrition assessments were completed in a timely.

Based on observations, staff interview, and record reviews, the facility failed to ensure that one of four residents' (R) (R39)'s catheter tubing was not coiled and correctly positioned to prevent obstruction of urinary flow out of four residents with a catheter. This deficient practice had the potential to put residents at risk for complications related to their urinary health with the possibility of urinary tract infections. Findings included: Record review of the medical record revealed R39 admitted with diagnoses of but not limited to urinary retention and neurogenic bladder. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed a Brief Interview for Mental Status (BIMS) score of 15 that indicated little to no cognitive impairment. MDS also assessed for catheter use. Review of the November 2024 Physician Order Form (POF) and Medication Administration Record (MAR) included the following order dated 6/23/2023, Suprapubic cath: 16Fr/10 bulb (16 French 10 bulb) every shift, every day, evening, night. R39's care plan created 2/28/2020 included instructions to keep drainage bag below level of bladder. Observations on 11/17/2024 at 1:34 pm to 2:55 pm, revealed R39 lying in bed with an attached catheter. Continued observation revealed the catheter tubing was coiled and hung on a dresser knob which was positioned directly across from the resident's bed. The positioning of the catheter and tubing resulted in the catheter being positioned at the height of the bed instead of positioned below the bladder. Interview with R39 at the time of the observation, R39 revealed that staff placed the bag there. Observation on 11/17/2024 at 2:58 pm with Certified Med Tech (CMA) VV and the Wound Nurse of R39 lying in bed with an attached catheter drainage bag revealed the bag was hanging on the resident's bedside drawer handle resulting in the drainage bag being at waist height. CMA VV placed a dignity bag on the catheter bag and hung the bag on the dresser knob. When asked why the bag was placed on the knob, CMA VV reported her reason for hanging the bag on the dresser knob was based on R39's preferences. CMA VV exited the room leaving the catheter drainage bag hung on the dresser knob. CMA VV reported that she was never instructed to how to hang the catheter bag. Interview at the time of observation inside R39's room with the Director of Health Services (DHS) and the Unit Manager, on 11/18/2024 at 1:30 pm, revealed R39's catheter bag and tubing were hung on dresser drawer knob above the level of the bladder and at the height of the resident bed. The DHS confirmed the drainage bag was too high and repositioned the bag below the bladder. She revealed her expectation was that staff positioned the bag correctly.

Based on observations, resident and staff interviews, record review, and review of the facility's policy titled, Oxygen Administration, the facility failed to ensure two of 33 residents (R) (R59 and R82) reviewed were free from accident hazards. Specifically, the facility failed to ensure R59 was free from exposure to harmful chemicals and R82 was free from exposure to a free-standing oxygen tank. Findings included: A facility policy for accidents and hazards was requested, however, the facility advised they did not have a policy. Review of the facility's policy titled, Oxygen Administration revised 8/2/2023 documented, .8. Racks or cart is required for stabilization of E-tanks when in use or in storage. 1. Review of R59's medical record revealed the resident was admitted with diagnoses of but not limited to type two diabetes mellitus with diabetic neuropathy, anemia, muscle weakness (generalized). Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed a Brief Interview for Mental Status (BIMS) score of 15 which indicated little to no cognitive impairment. Observation on 11/17/2024 at 1:15 pm revealed a bottle of [brand name] bleach sitting above the bathroom sink. Interview and rounding on 11/17/2024 at 1:17 pm with Registered Nurse (RN) FF verified the Clorox bleach was in R59's bathroom and confirmed chemicals such as bleach should never be stored in a resident's bathroom. Interview on 11/20/2024 at 10:03 am with the Director of Health Services (DHS) revealed that bleach nor any other chemical should be in a resident's room. She revealed it is against the facility's policy for residents to have bleach or any other hazardous chemical in rooms. She revealed training and education will be completed. 50524 2. Review of Electronic Medical Records (EMR) revealed R82 was admitted with a diagnosis of but not limited to chronic respiratory failure with hypercapnia. Review of Admission MDS assessment dated [DATE] documented Section C (Cognition) BIMS score of 15 which indicated little to no cognitive impairment, Section I (Active Diagnosis) debility, cardiorespiratory conditions, respiratory failure, Section J (Health Conditions) shortness of breath or trouble breathing with exertion. Shortness of breath or trouble breathing when sitting at rest, shortness of breath or trouble breathing when lying flat. Review of care plan dated 9/6/2024 included Oxygen, use related to morbid obesity, chronic resp (respiratory) failure. Goal: Maximize oxygen level and maintain optimal breathing. Approach: Oxygen as ordered. Review of Physician's orders dated 9/5/2024 included, but not limited to oxygen at 4 liters per minute (LPM) via (by) nasal cannula (NC) continuous every shift day, evenings, nights. Observation on 11/17/2024 at 2:01 pm revealed a free-standing oxygen tank in the corner of R82's room which was not in a rack or cart. Interview on 11/17/202 at 2:20 pm with R82 revealed the oxygen tank had been in the corner of his room for maybe a few weeks because no one had taken an oxygen tank in his room recently. Interview on 11/17/2024 at 5:11 pm the DHS confirmed the oxygen tank was in R82's room and was not in a cradle/caddy (cart or rack). She stated oxygen tanks should not be free-standing; they should be in a cradle because they can be dangerous if they fall over. She revealed her expectations were for the staff to ensure that the oxygen tanks were secured in a cradle. She stated the outcome if the oxygen tanks were not secured would be they could be projectiles and they could harm the resident and cause death. Interview on 11/17/2024 at 5:26 pm with Licensed Practical Nurse (LPN) PP revealed the oxygen tank needed to be in a holder. If it was not in a holder, it could explode if it fell over. She confirmed the resident could be hurt or get killed if the tank exploded. Interview on 11/19/2024 at 5:35 pm with Certified Nursing Assistant (CNA) HH revealed she worked at the facility for [AGE] years, oxygen tanks should be in a carrier or on the back of the wheelchair. She revealed the tank could fall and explode and harm the resident's if it was not secured in a holder. Interview on 11/19/2024 at 5:45 pm with LPN II revealed she worked at the facility for a year and a half. She revealed oxygen tanks should be kept in a roller carrier because they could fall over and hurt the resident if it is not secured. She revealed if the tank fell on the resident, it could damage the part of the body it falls on, or if it exploded it would hurt the resident even worse.

Based on observations, staff interviews, and record reviews, the facility failed to apply splints as ordered for one of 10 residents (R) (R56) receiving splints. This deficient practice had the potential to cause worsening of R56's contractures and a diminished quality of life. Findings included: Review of Electronic Medical Records (EMR) revealed R56 was admitted on [DATE] with diagnoses of but not limited to unilateral primary osteoarthritis, contractures of left hand, contracture of right hand, contracture of right elbow, contracture of left elbow, contracture of right shoulder, muscle weakness (generalized). Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Section C (Cognition) documented no Brief Interview for Mental Status (BIMS) score, as cognitive skills for daily decision making as severely impaired; Section I (Active Diagnosis) Muscle weakness (generalized); Section O (Special Treatments) range of motion (passive) and splint or brace assistance; Section GG (Functional Abilities) upper extremity impairment, lower extremity impairment. Review of the care plan dated 8/23/2024 included but not limited to, application of elbow extension, elbow orthosis, hand palm guard orthosis, hand cone orthosis, hand carrot orthosis, resting hand orthosis application for four-to-five-hour wear tolerance daily as tolerated with skin inspection following removal for redness, edema, and pain daily from 7:00 am to 11:00 pm, or twice a day from 7:00 am to 7:00 pm and 7:00 pm to 7:00 am; requires BUE PROM (bilateral upper extremity Passive Range of Motion) in all planes daily as tolerated to minimize risk of further contracture. Review of Orders dated 8/23/2024 included but not limited to Restorative: Apply R Elbow extension orthosis and B hand Palm Guard Orthosis to R (right) Elbow and B hand joints for four-to-five-hour wear tolerance daily as tolerated with skin inspection following removal for redness, edema, and pain. Observation on 11/17/2024 at 3:00 pm, on 11/18/2024 at 11:00 am and 4:00 pm, on 11/19/2024 at 10:00 am and 2:00 pm, and on 11/20/2024 at 9:00 am revealed R56 lying in bed. Resident had contractures of both hands. No splints were seen on resident at any observation. Interview on 11/20/2024 at 9:07 am with Certified Nursing Assistant (CNA) JJ revealed R56 was to have splints for his hand contractures and confirmed R56 was not wearing splints for his hands and right elbow. She looked for the splints in the drawers of the resident's bedside table and in the resident's dresser drawers, she was unable to locate R56's splints. Interview on 11/20/2024 at 9:10 am Licensed Practical Nurse (LPN) KK revealed R56 had a brace for each hand which were to be applied for four to five hours every day. She confirmed R56 did not have splints on since the survey dates 11/17/2024 through 11/20/2024. She revealed the Certified Nursing Assistants (CNA) was to apply the splints and check them off on their documentation. She revealed if the splints were not applied the contractures would get worse and also cause skin break down. Interview on 11/20/2024 at 9:14 am CNA LL revealed she had worked with the facility for three years and was assigned to R56 for this shift. She revealed she only had one resident this shift who had contractures and it was a resident on another hall. She confirmed R56 had contractures and she did not put the splints on this shift. Interview on 11/20/2024 at 9:48 am Director of Health Services (DHS) revealed her expectations were for the CNAs and nurses to apply the splints as ordered by the Physical Therapist (PT)/Occupational Therapist (OT) and doctor's orders. She revealed the outcome if the splints were not applied as ordered would be worsening of the contractures. Interview on 11/20/2024 at 9:59 pm with the PT Assistant MM and PT NN revealed R56 was discharged from therapy. They stated whenever a resident was to have a splint, they educated the CNAs about it because the CNAs were the ones to apply the splints. Interview on 11/20/2024 at 10:03 pm with the OT OO revealed R56 was discharged from therapy and the CNAs were to apply the splints as directed from the verbal education they received.

Based on observations, resident and staff interviews, record reviews, and review of the facility's policy titled, Care Plans, the facility failed to develop and implement a care plan for five residents (R) (R58, R77, R47, R29, and R338) out of 32 reviewed. Specifically, they failed to create and implement a care plan for R58 for self-administration of medication, and for R47 for oxygen use. The facility failed to follow the care plan for resident R47 reviewed for nutrition related to obtaining admission and weekly weights; and they failed to follow the care plan for three residents (R77, R29, R338) receiving oxygen therapy and ensure the oxygen flow rate for each resident was followed based on physician order. Findings included: Review of the facility's policy titled, Care Plan dated 7/27/2023 revealed, Admission Comprehensive Plan of Care 2. A comprehensive person-centered care plan will be developed by the interdisciplinary team for each patient /resident within seven days after the completion of the comprehensive assessments. The care plan serves as instructions for the patient's care and provides continuity of care by all partners. Short and concise instructions, which can be understood by all partners. 1. Record review of the medical record revealed R58 had diagnoses of but not limited to chronic kidney disease stage 3, hypo-osmolality and hyponatremia, chronic kidney disease stage 3 and anemia in chronic kidney disease. Review of R58's Physician Order Form (POF) dated November 2024 listed an order for albuterol and eyedrops. Review of resident form titled Self-Administration assessment dated [DATE] revealed R58 was assessed to self-administer eyedrop and albuterol. Review of R58 's care plan revealed no care plan to support resident assessment and authorization to self-administer medications. 2. Record review of R77's medical record revealed an admitted [DATE] with diagnoses of but not limited to chronic respiratory failure and paroxysmal atrial fibrillation. Review of the Admission MDS assessment dated [DATE] assessed a BIMS score of 11 which indicated moderate cognitive impairment and was assessed for oxygen use. Review of R77's orders included an order dated 10/15/2024 for administering oxygen therapy at 2 LPM (liters per minutes) via (by) nasal cannula continuous every shift. Review of R77's care plan created 7/31/2024 identified/documented a problem, Oxygen use related to asthma, chronic respiratory failure. Interventions included oxygen as ordered/needed. Observation on 11/17/24 from 2:05 pm until 3:33 pm, and again at 5:01 pm revealed R77 receiving oxygen therapy from an oxygen concentrator via nasal cannula (NC) at 3 liters with no humidifier bottle attached. Interview on 11/20/2024 at 1:49 pm, the MDS Coordinator AA confirmed his expectation that nursing staff follow the care plan for weights for R47. He reported being unaware that the care plan was not being followed. MDS Coordinator reported being unaware that R58 was assessed to self-administer medications. He stated that R58's medical record should include a care plan to address self-administering of medications. He reported being unaware that R77 was not receiving oxygen per physician order, and that his expectation that residents' care plans were being followed. 50169 3. Record review for R47 revealed an admitted [DATE] with diagnoses of but not limited to pneumonia, asthma, dysphagia oral phase, surgical aftercare, and cognitive communication deficit. Review of Admission MDS assessment dated [DATE] revealed Section C-Cognition included BIMS score of 13 suggesting little to no cognitive impairment; Section O-Special treatments included oxygen. Review of physician orders included order dated 10/21/2024, Oxygen at 2 LPM via NC continuous. Every shift, days, nights; Change respiratory circuit/supplies weekly once a day on Monday nights; change respiratory circuit/supplies; as needed PRN. Record review revealed there was no care plan for oxygen use and no individualized interventions to address the monitoring. Review of R47's care plan created 8/6/2024 identified/documented, Problem: nutrition and/or hydration risk related to acute kidney failure and dysphagia. Interventions included weigh and monitor results on admission, then weekly x 4 weeks (for four weeks) or until stable. Record review revealed R47 was weighed on 10/21/2024 by facility staff. Continued review revealed no other weights were recorded consecutively for four weeks after admission to monitor R47's weight. Observation on 11/17/2024 at 5:07 pm, on 11/19/2024 at 9:35 am and at 12:37 pm revealed R47 was lying in bed receiving oxygen via nasal canula. Interview during observations R47 revealed she had received oxygen since she had been in the facility. Interview on 11/19/24 at 2:00 pm, the Registered Dietician (RD) revealed that weights should be completed weekly for four weeks after admission to monitor nutrition risks, and at least monthly to monitor for weight loss. The RD revealed being unaware that R47 was not being weighed and followed for the first four weeks after their admission to facility and admission weight. Interview on 11/20/2024 at 11:10 am Unit Manager DD revealed it was the nurses' responsibility, as well as the Minimum Data Set (MDS) Coordinator to make sure that care plans were updated. Interview on 11/20/2024 at 1:25 pm MDS Coordinator AA, revealed different departments are responsible for completing the resident's care plan and MDS checked as needed to make sure all information had been entered or updated. He confirmed that R47 did not have a care plan for oxygen and the risk to a resident not being care planned correctly would be that the resident would not receive the proper care. 49675 4. Review of the medical record for R29 revealed she was admitted to the facility on [DATE] with acute kidney failure, type two diabetes mellitus with diabetic chronic kidney disease, and hypertensive heart disease with heart failure. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a BIMS score of 15, indicating little to no cognitive impairment. Section O, special treatment (included oxygen) reported none. Review of the physician orders revealed an order for oxygen dated 7/25/2024, oxygen at 2 LPM via nasal cannula continuous. Review of the care plan initiated revised on 9/9/2024, revealed that resident has diagnosis of acute respiratory failure with hypercapnia. Oxygen as needed and ordered. Oxygen saturations as needed and ordered. Observations on 11/17/2024 at 1:06 pm and 4:58 pm revealed R29 receiving oxygen at a rate of 3 liters. Interview on 11/18/2024 at 11:20 am with Registered Nurse (RN) DD verified the physician order for oxygen at a rate of 2 liters. She looked at picture the surveyor captured and verified the oxygen was set on the wrong oxygen rate. She stated it was the nurse's responsibility to check daily to make sure the flow rate is correct. Interview on 11/20/2024 at 10:05 am with the Director of Health Services (DHS) revealed her expectations were for nurses to follow orders and for charge nurses to check oxygen rates. She expected all oxygen rates to be set on the prescribed rate by the physician. Interview on 11/20/24 at 1:42 pm with MDS Coordinator AA revealed the Interdisciplinary team (IDT) oversaw development of the care plan. He revealed his expectations were that staff follow the care plan, update it accordingly, and administer oxygen per orders. He revealed all staff including Certified Nursing Assistants (CNA's) should review care plans and physician orders to ensure each resident who was on oxygen therapy had the correct flow rate. 50171 5. Review of the clinical record revealed R338 was admitted to the facility with diagnoses of but not limited to unspecified fracture of T11-T12 collapsed vertebra, muscle weakness unsteadiness on feet, abnormal posture, pain, unspecified, reduced mobility, low back pain, neuromuscular dysfunction of bladder. Review of R338's most recent MDS assessment dated [DATE] revealed a BIMS score of 15, which indicated little to no cognitive impairment. Section O revealed the resident required oxygen therapy. Review of the Physician orders revealed an order for oxygen at 3 liters per minute (LPM) per nasal cannula (NC) at 9pm with a start date of 11/1/2024. Observation on 11/17/2024 at 2:12 pm revealed R338 lying in bed receiving oxygen therapy via NC set at 2.5/LPM. Observation on 11/18/2024 at 9:30 am revealed R338 lying in bed receiving oxygen therapy via NC set at 2/LPM. Rounding on 11/18/2024 at 3:16 pm with RN DD confirmed the LPM should be set on 3/LPM and not 2.5/LPM. She adjusted the rate to 3/LPM. LPN revealed her expectations were that she and other nurses follow physician orders. Interview on 11/20/2024 at 11:10 am with RN DD revealed that it was the nurse's responsibility, as well as the MDS Coordinator to make sure that the care plan was updated. Interview on 11/20/2024 at 1:25 pm with MDS Coordinator AA revealed different departments are responsible for completing the resident's care plan. He revealed that MDS would get an email from the hospital with resident changes and MDS checked the care plan as needed to make sure all information was entered or updated. MDS coordinator AA confirmed that R338 did not have a care plan for oxygen use and that the risk to a resident not being care planned correctly would be that the resident would not receive proper care.

Based on observation and interview, the facility failed to maintain a safe, clean, comfortable, and homelike environment on one of five halls (100 hall). Specifically, the facility failed to ensure the toilet base and caulking was not stained dark brown in one shared bathroom between rooms 102, 104, and in room [ROOM NUMBER] and room [ROOM NUMBER]; failed to ensure light fixtures above resident's beds were not rusty brown colored and wall trim was not sticking out toward residents' bed in room [ROOM NUMBER]. The deficient practice caused an unsafe and unsanitary environment and had the potential to place residents at risk for avoidable injury or illness, and a diminished quality of life. Findings included: Observations on 11/17/2024 at 3:42 pm, 11/18/2024 at 2:36 pm, and 11/19/2024 at 8:30 am revealed the bathroom toilet base and caulking that is shared between rooms [ROOM NUMBERS] to be stained dark brown. Observations on 11/17/2024 at 2:45 pm, 11/18/2024 at 2:36 pm, and 11/19/2024 at 11:07 am in room [ROOM NUMBER] revealed the light fixtures above residents beds to be white with rusty brown colored spots, the toilet caulking and base to be stained brown, and the plastic trim that is placed on the middle of the wall that is the length of the wall, was pulled off the wall and sticking out toward the resident's bed. Observations on 11/17/2024 at 1:15 pm, 11/18/2024 at 2:38 pm and 11/19/2024 at 11:12 am revealed the bathroom toilet base and caulking of room [ROOM NUMBER] to be stained brown. Observation and rounding on 11/20/2024 at 3:12 pm with the Maintenance Director confirmed the toilet bases and caulking to be stained dark brown in the bathroom shared between room [ROOM NUMBER] and 104 and the toilets in rooms [ROOM NUMBERS]. The light fixtures above the residents' rooms in room [ROOM NUMBER] were rust covered, and the plastic trim in room [ROOM NUMBER] is pulling away from the wall sticking out toward the resident's bed. The Maintenance Director revealed it was his intentions to fix, repair, or replace all the identified concerns.

Based on resident and staff interviews, record review, review of the facility's Admission Packet, and review of the facility's policy titled, Advance Directive policy, the facility failed to provide residents and or their representatives written information regarding the right to accept or refuse medical or surgical treatment for three of 33 residents (R) (R45, R58, and R4) reviewed. This failure denied the residents and/or representatives the opportunity to have choices and preferences with their health care and formulating an Advance Directive. Findings included: Review of the facility's Advance Directive policy dated 11/6/17 revealed, Prior to, or upon Admission, the patient/resident and/or their responsible party will be asked about the existence of any advance directives. The Advance Directive Checklist, which is in the Georgia Admission Packet, will be completed. Review of the facility's Admission Packet revealed it did not contain language that pertained to the facility's provision of written information about the resident/representative's right to accept or refuse medical or surgical treatment. 1. R45 was admitted to the facility with diagnoses of but not limited to Alzheimer's Disease with late onset, metabolic encephalopathy, and type two diabetes mellitus with diabetic neuropathy. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R45's cognition was undetermined due to a Brief Interview for Mental Status (BIMS) score of 99, indicating the interview was unable to be completed. 36377 2. R58 was admitted to the facility with diagnoses of but not limited to chronic kidney disease stage 3 and cerebral infarction. Review of the Annual MDS assessment dated [DATE] assessed a BIMS score of 15 which indicated little to no cognitive impairment. Review of R58's November 2024 Physician Order Form dated November 2024 revealed an order for full code status. Review of R58's Advance Directive form dated 11/17/2021 documented that R58 signed the Advance Directive at the time of admission. Continued review of the Advance Directive form, and the resident's medical record revealed no written documentation or evidence to show a form, or discussion being provided to the resident/responsible party regarding a choice to accept or refuse surgical treatment. 50171 3. R4 was admitted to the facility with diagnoses of but not limited to viral pneumonia, cerebrovascular disease, unilateral primary osteoarthritis, muscle weakness (generalized), abnormal posture, rhinovirus, chronic encephalopathy, lack of coordination, abnormalities of gait and mobility, Type 2 diabetes mellitus without complications, atherosclerosis of native arteries of extremities, bilateral legs. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed a BIMS score of 15, indicating little to no cognitive impairment. Interview on 11/20/2024 at 11:27 am with the facility's Social Worker and Senior Nurse Consultant confirmed no evidence was found to support the residents, R45, R58, R4, and/or any other resident/representative had been provided written information related to their right to accept or refuse medical or surgical treatment, on or after admission to the facility. Interview on 11/20/2024 at 11:50 am with the Regional Corporate Admissions Coordinator revealed the facility used the documents that are included in the admission packet and admitted she was not familiar with an advanced directive checklist that included the right to consent or deny medical or surgical treatment.

Based on observations, resident and staff interviews, and record reviews, the facility failed to accommodate the needs of two of 8 residents (R) (R66 and R70) reviewed for accommodation of needs. Specifically, the facility failed to provide a morbid obese resident (R) (R66) with a bed that would accommodate her size; and the facility failed to ensure (R70), who was visually impaired, had a call light within reach. Findings included: A facility policy on accommodation of needs was requested but not provided. 1. Record review of the medical record revealed R66 had diagnoses of but not limited to obesity class 3, vascular dementia, cerebral vascular accidents (CVA) with left side paralysis, hemiplegia and hemiparesis following cerebral infarction. Review of R66's Quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed a Brief Interview for Mental Status (BIMS) score of 14 which indicated little to no cognitive impairment. R66's weight was assessed as 276 lbs (pounds), assessed as one-person assist with bed mobility and mechanical lift for transfer. Observation on 11/17/2024 at 1:56 pm revealed R66 lying centered in bed. Continued observation revealed the bed mattress was too narrow, not wide enough to provide space for turning on each side. Interview at that time, R66 revealed being afraid of falling on the floor when the Certified Nursing Assistant (CNA) staff rolled her on her side during incontinence care and bed baths. R66 revealed most of the time there was only one staff member assisting her. She revealed that the CNA's often tell her that she needed a bigger bed and would call another CNA to position themselves on the other side to prevent R66 from rolling off the bed. R66 revealed expressing her fears to the CNA's and a licensed nursing staff. Interview on 11/19/2024 at 2:00 pm (at the time of observation of R66's bed), the Therapy Director/Physical Therapist (PT) confirmed that based on observation of R66's body size/ measurement/alignment lying flat and centered in the bed, there was not enough space on both sides of the mattress. PT further revealed that without having guard from another staff on the opposite side of the bed, R66 was at risk of falling. She revealed she would do a referral for the facility Occupational Therapist to re-assess R66 for bed mobility because R66 was discharged from therapy. Interview on 11/18/2024 at 11:38 pm, the Director of Health Services (DHS) and Unit Manager both confirmed that R66 could use a larger bed. Both staff revealed that in the past R66 was in a larger bed. Unit Manager reported being unable to recall as to why the resident's bed was changed to a smaller bed. DHS reported that R66's bed could be extended, and a larger mattress could be provided. Interview on 11/19/2024 at 3:45 pm, the Administrator revealed that R66's bed was extended today and R66 had a wider mattress to fit the new bed extension width. The Administrator revealed being unaware that the bed was too small and recalled in the past R66 was in a larger bed due to her weight size. 49681 2. Record review revealed R70 was admitted with diagnoses of but not limited to unspecified injury of the head, aneurysm of the heart, muscle weakness, unsteadiness on feet, dysphagia oropharyngeal phase, abnormal posture, and other abnormalities of gait and mobility. Review of the Quarterly MDS assessment dated [DATE] Section C assessed R70 a BIMS score of 13 indicating little to no cognitive impairment. Section GG ADL assistance-comb hair, showers/ baths, transfers, assist with setting up for feeding and cleaning as needed. Review of the care Plan revealed a goal that R70 will be free from the negative consequences of vision loss as evidenced by remaining physically safe and participating in social & self-care activities. Assist with toileting and transfers PRN (as needed). Place call light within reach. Problem: Impaired Physical Mobility/Deconditioning related to COPD (Chronic Obstructive Pulmonary Disease), convulsions, cerebral infarction, PE (pulmonary embolism), and low back pain. R70 ADL needs will be met, and his independence potential maximized within the constraints of his illnesses through the next review. Long-term target date 11/30/2024. Review of menus revealed that the facility had scheduled breakfast to be served to all residents from 7:30 am to 8:00 am. Observation on 11/18/2024 at 10:30 am revealed R70 in bed asleep. He did not respond when surveyor knocked on the door. The call light was on the floor and out of reach for R70. Observation on 11/19/2024 from 9:57 am to 11:20 am revealed R70 was in bed, the call light was on the floor, and he had breakfast food on his face and clothes. CNA (Certified Nursing Assistant) CC walked by and spoke to R70 but did not clean him or check to see if his call light was in reach. Interview at that time with R70 revealed he was visually impaired. Observation on 11/19/2024 at 11:20 am CNA CC cleaned the resident and picked the call light up from off the floor, gave him a bed bath and changed his clothing. Observation revealed it took over 60 minutes for staff to clean R70's face and clothing from food that he had from breakfast. Resident was unaware of food being all over him due to vision loss. Interview on 11/19/2024 at 4:08 pm, MDS Coordinator AA revealed that residents with vision or hearing loss should have a call light accessible and staff ensured the call light was accessible by checking on residents often. Interview further revealed that residents with vision loss should be assisted with eating, should be cleaned after eating because food is often everywhere and sometimes their clothes needed changing. Interview on 11/19/2024 at 4:12 pm, Licensed Practical Nurse (LPN) ZZ revealed that when residents are visually impaired the CNA and nurse staff should follow the care plan and ensure interventions are being followed. Staff should check every hour or as needed to ensure the residents have access to call lights, assist with eating if needed, and clean the resident up after they finish eating. Interview on 11/19/2024 at 4:19 pm the Director of Health Services (DHS) revealed that nursing staff should follow interventions in the care plan for residents, especially for residents who are hearing and visually impaired and dependent for ADL. She also revealed that some interventions needed updating.

Based on observations, resident and staff interviews, record reviews, and review of the facility's policies titled, Self-Administration of Medications by Patients/Residents and Bedside Storage of Medications, the facility failed to ensure unauthorized medications were not stored at the bedside for three of 32 residents (R) (R58, R19, and R67) reviewed. The deficient practice had the potential to allow unauthorized access of unsecured medications to residents and visitors. Findings included: Review of the facility's undated policy titled Self-Administration of Medications by Patients/Residents documented, .Each patient/resident who desires to self-administer medication is permitted to do so if the healthcare center's Licensed Nurse and physician have determined that the practice would be safe for the patient /resident and other patients/residents of the healthcare center. If the Licensed nurse determines the patient /resident or family member to be capable of self -administration of medications, the attending physician must write an order to that effect that includes the specific medications based off of the Self-Administration Medication Observation. Review of the facility's policy titled Bedside Storage of Medications reviewed 7/2/2024 documented, Policy Statement: It is the policy of (name of facility) Pharmacy Services that bedside medication storage is permitted for sublingual and inhaled emergency medications and other medications. For patients/residents who are able to self-administer medications upon the written order of the prescriber and when it is deemed appropriate in the judgment of the healthcare centers Interdisciplinary Patient/Resident Assessment team . Scope . Procedure: 1. A written order for the bedside storage of medication is placed in the patient/resident medical record. 1. Record review of R58's medical record revealed diagnoses of but not limited to chronic kidney disease stage 3, hypertension, cerebral infarction, and cognitive functions following cerebral infarction. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 indicating little to no cognitive impairment. Review of R58's self-administration evaluation/assessment form titled Self-Administration assessment dated [DATE] revealed R58 was assessed to administer only eyedrops and albuterol at the bedside. Observation on 11/17/2024 at 3:03 pm with Certified Med Tech VV revealed the following prescription medications labeled with the resident name inside R58's room: One bottle of nasal spray (mometasone furoate nasal spray 50 mcg (microgram) dosage) and Advair Diskus (fluticasone propionate-salmeterol) blister device 250-50 mcg/dose (micrograms per dose) amount. The CMA VV confirmed the unauthorized medications and removed the medications from R58's room. Review of R58's Physician Order Form dated November 2024 and November 2024 Medication Administration Record (MAR) listed Advair Diskus fluticasone propion-salmeterol blister device 250-50 mcg/dosage amount as one of the medications for the nurse to administer. Interview on 11/18/2024 at 11:33 am the Director of Health Services (DHS) and Unit Manager, both staff confirmed being unaware that R58 had unauthorized prescription medications in her room. They revealed that R58 was authorized to only self-administered albuterol and eye drops. The DHS revealed the risk would be that other residents could come in contact with the medications. 50524 2. Review of R19's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Section C (Cognition) BIMS score of 14 which indicated little to no cognitive impairment. Review of the facility's documents revealed no evidence of physician's orders for self-administration of medication for R19. Review of the facility's documents revealed no evidence of Self-Assessment for Medication Administration for R19. Observation and interview on 11/17/2024 at 2:11 pm revealed R19 lying in bed in his room. There were 23 bottles of medications on R19's bedside table. R19 revealed he took his own vitamins which were on the table next to his bed. R19 revealed he preferred the [specific name] brand, and he took the medications whenever he wanted to. He revealed the nurses and other staff were aware of the medications being on his bedside table and they were aware he took them. 3. Review of the Electronic Medical Records (EMR) revealed R67 was admitted with a diagnosis of but not limited to chest pain. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Section C (Cognition) BIMS score of 14 which indicated little to no cognitive impairment. Section I (Active Diagnoses) listed Cardiorespiratory Conditions. Review of the care plan dated 4/13/2023 documented, Category: Pain- has potential for pain related to (r/t): history of (h/o) chest pain. Goal: will be comfortable as measured by his/family goals through next review. Approach: Complete Pain Observation on admission and as needed (PRN), administer any pain medications/interventions per physician's orders, monitor effectiveness of pain medication/intervention, provide any comfort measures, report to physician if he does not experience reduction or relief of pain after receiving prescribed interventions. Review of Physician's Orders dated 4/12/2023 included nitroglycerin tablet, sublingual; 0.4 milligram (mg); sublingual, take 1 tablet sublingually every 5 minutes x (times) 3 as needed for chest pain. As Needed PRN 1, PRN 2, PRN 3. Review of facility's documents revealed no evidence of physician's orders for self-administration of medication for R67. Review of facility's documents revealed no evidence of Self-Assessment for Medication Administration for R67. Observation and interview on 11/18/2024 at 8:37 am revealed R67 sitting on his bed in his room. He revealed he had a bottle of nitroglycerin tablets on his bedside table, and he took the tablets whenever he had chest pain. He stated he had them there because the nurses took too long to come and give the tablet to him. He revealed the nurses knew he had the medication. R67 further revealed he would bring the medication with him outside whenever his family came to visit him, and he took the nitroglycerin tablet if he had chest pain. Interview on 11/18/2024 at 9:57 am Licensed Practical Nurse (LPN) KK confirmed the bottle of nitroglycerin was at resident's bedside. She confirmed there was no physician's orders for self-administration of medication for R67. She further stated R67 was not to have the nitroglycerin at his bedside to take on his own. Interview on 11/18/2024 at 11:35am with Director of Health Services (DHS) revealed R19 was not supposed to have medication at the bedside. She revealed if residents had medications at their bedside and were self-administering medications, they were to have a self-assessment done by the Interdisciplinary Team (IDT) to see if the resident was alert and mentally and physically able to self-administer medications. She also stated R19 needed an order to self-administer medication, and he did not have an order nor a self-assessment to self-administer medication. The DHS revealed staff needed to know if and when R19 was taking the medication in order to monitor it. She revealed the outcome if residents took their own medications without proper assessment and monitoring could result in medication adverse effects and harm to the residents. Interview on 11/19/2024 at 5:35 pm with Certified Nursing Assistant (CNA) HH revealed medications should not be at the resident's bedside and she would call the nurse to tell her that there was medication at the resident's bedside. Interview on 11/19/2024 at 5:45 pm with Licensed Practical Nurse (LPN) II revealed residents should not have medication at their bedside. She revealed the resident could overdose on the medications when they take it whenever they wanted to or took more than the prescribed dosage, and the nurse did not know about it. She revealed the medication could also interfere with medications the nurse was giving them and that could cause adverse reactions for the resident.

Based on observation, interviews with a resident and staff, record review, and review of the facility's policy, it was determined that the facility failed to assess and address pain management during pressure sore treatment for one resident ("Z") with pressure sores in a sample of six (6) residents with pressure sores in a total sample of 37 residents. Findings include: According to the facility's "Pain Management Policy," the observation and re-observation of pain would be comprehensive using standardized tools and would include both subjective and objective findings from the patient/resident/family and interdisciplinary healthcare providers. The observation, planning and evaluation of all interventions would be conducted in a [MEDICATION NAME], accepting and holistic manner. If pain levels were 4 or greater then, interventions were to be implemented. A resident's plan of care would include both pharmacological and non-pharmacological interventions. According to the facility's policy for "Dressing Changes Related to Wound Treatments," there were fundamental procedures/techniques/guidelines that applied to wound dressing changes/treatments. Those might include: dressing removal, wound observation and assessment, wound bed cleansing, peri-wound cleansing, wound packing, dressing application and dressing securement. The nurse was to observe any patient/resident concerns related to pain and intervene per physician orders. According to the facility's 9/13/12 "Admission Documentation of Wound Observation and Assessment" form, resident "Z" was admitted to the facility with [DIAGNOSES REDACTED]. The right gluteal cleft wound was measured at 1.5 x 1.3 x 1 centimeter (cm) and the left gluteal cleft measured 2.3 x 1.5 x 2 cm. The nurse documented that there was no drainage or odor from site but, the resident did complain of pain in that area after wound care was completed. Licensed staff coded the resident on his/her 12/21/12 Minimum Data Set (MDS) assessment as needing extensive staff assistance with bed mobility, as having had a pressure ulcer of Stage 1 or higher and as being able to be interviewed. There was a care plan since 10/16/12 to address the resident's potential for alteration in comfort with an intervention for nursing staff to administer pain medication as requested and document its effectiveness, and to review the pain management plan and document findings. There was a care plan since 10/16/12 to address the resident's alteration in skin integrity related to having pressure sores on his/her sacral area and right heel. The interventions included for nursing staff to administer pain medication prior to initiating treatment as needed. There was a physician's orders [REDACTED]. No more than three grams of Tylenol were to be given per 24 hours. There was a physician's orders [REDACTED]. Nursing staff had given the resident one [MEDICATION NAME]/APAP 5/500 mg at 8:45 a.m. (pain medication). However, when licensed nursing staff started the pressure sore treatment an hour and fifteen minutes later, they failed to stop the treatment and assess the effectiveness of that medication and the resident's non-verbal signs of pain exhibited during a pressure sore treatment. It was observed that the licensed nursing staff did not implement any non-pharmacological interventions to address the resident's exhibited presence of pain. During an observation of pressure sore treatment on 1/24/13 from 10:07 a.m. to 11:40 a.m. with the registered nurse (RN) treatment nurse "AA", and Assistant Director of Nursing (ADON), resident "Z" flinched when the nurse cleaned the inside of the sacral pressure sore. When RN "AA" inserted the normal saline soaked gauze into the wound four separate times and then turned it inside of the wound, the resident clamped down on his/her pillow, turned his/her face into the pillow and shook. The resident flinched and squirmed in bed. When the RN measured the depth of the pressure sore by inserting a cotton swab into it, the resident flinched and his/her legs were observed to be shaking. It was observed that at no time during the treatment did the treatment nurse or the ADON attempt to stop the treatment and assess the resident's pain level except to ask the resident if he/she was okay. When treatment was completed, the resident was asked to rate his/her pain level on a scale from 1-10 with 10 being explained to the resident as the worst pain. The resident replied "7." A review of the resident's MAR indicated [REDACTED]. The nursing staff's documentation describing the resident's level of pain during the 1/24/2013 wound treatment was not consistent. A review of the nurse's 1/24/13 documentation for wound care pain assessment revealed that the nurse noted that the resident had no pain during the treatment. A review of licensed nurses documentation on the "Pain Observation Form," revealed that the resident had pain intensity of "moderate 5 - 6" on 1/24/13. However, the "Documentation of Wound Observation and Assessment Form" recorded that the resident had no pain on 1/24/13. In an interview on 1/24/13 at 10:53 a.m., RN treatment nurse "AA" stated that the resident normally giggled when the dressing change was done. However, there was no evidence of that response. During an interview on 1/24/13 at 12:25 p.m., the resident said that it had hurt when the nurse was cleaning out the inside of the wound (on 1/24/13). On 1/25/13 at 11:34 a.m., RN treatment nurse "AA" stated that there had been brown debris in the inside of the resident's wound that had not previously been there so, she "had to get it out." However, her 1/24/2013 repeated attempts to remove brown debris from the resident's pressure sore by repeatedly turning gauze into the depths of that wound produced non-verbal signs of pain for the resident. According to the American Medical Director's Association, Clinical Practice Guideline for "Pressure Ulcer Therapy Companion," use cautiously any approach to remove dead tissue from a wound as excessive pressure may damage tissue. According to the U.S. Department of Health and Human Services, Clinical Practice Guidelines for the "Treatment of Pressure Ulcers," the benefits of obtaining a clean wound must be weighed against the potential trauma to the wound bed as a result of such cleansing. Routine wound cleansing should be accomplished with a minimum of chemical and mechanical trauma. Use minimal mechanical force when cleansing an ulcer with gauze, cloth or sponges because traumatized wounds are more susceptible to infection and slower to heal. Because pain may be evoked or may be especially acute during dressing changes and debridement, the caregiver should try to prevent such discomfort or take steps to relieve it. The effectiveness of pain management interventions should be evaluated, with adjustments based on the patient's verbal and physiological responses. On 1/25/13 at 8:27 a.m., the resident reported that the treatment did not hurt like it had yesterday (1/24/13). He/She said that the dressing change that morning was not as bad as it was yesterday morning. During an interview on 1/25/13 at 3:00 p.m., the Director of Nursing (DON) stated that it was her expectation, for her staff that provided wound care, that the staff would stop the treatment if the resident showed visible signs of pain or verbalized pain, get the resident more pain medication and then reassess the resident's pain. Although the resident verbally responded "okay" when asked during the treatment how he/she was, licensed nursing staff did not stop treatment to assess the effectiveness of the pain medication that had been given, and address the non-verbal signs of pain exhibited by the resident during the procedure.

Based on record review, it was determined that the facility failed to implement care plan interventions to assess and address pain management for one resident ("Z") during pressure sore treatment, to administer medications as ordered for one resident (#58), and to provide incontinence care as needed for one resident ("C") in a total sample of 37 residents. This failure resulted in resident "Z" having had pain during a pressure sore treatment. Findings include: 1. According to the facility's 9/13/12 "Admission Documentation of Wound Observation and Assessment" form, resident "Z" was admitted to the facility with [DIAGNOSES REDACTED]. The nurse documented that the resident had complained of pain in that area after wound care was completed. Staff developed a care plan which since 10/16/12 addressed the resident's potential for alteration in comfort with an intervention for nursing staff to administer pain medication as requested and document their effectiveness, and to review the pain management plan and document the findings. The 10/16/12 care plan addressed the resident's alteration in skin integrity related to pressure sores on the sacral area and right heel. The interventions included for nursing staff to administer pain medication prior to initiating treatment as needed. However, it was observed that the licensed nursing staff failed to assess and address the resident's non-verbal signs of pain exhibited during a pressure sore treatment on 1/24/13 at 10:07 a.m. See F314 for additional information regarding resident "Z." 2. Resident #58 had a care plan since 5/02/12 to address his/her potential risk for a decrease in cardiac output related to hypertension. There was an intervention for nursing staff to give medications to the resident as ordered. However, the licensed nurses failed to administer [MEDICATION NAME] as ordered. See F309 for additional information regarding resident #58. 3. Resident "C" had a care plan since 8/22/12 to address his/her self care deficit related to being incontinent and refusing to be on an incontinence program. There was an intervention for nursing staff to provide incontinence care during their rounds and as needed. However, according to resident interview, nursing staff was not providing incontinence care as he/she needed it. See F312 for additional information regarding resident "C".

Based on record review and interview with the medical director, it was determined that the facility failed to ensure that the attending physician reviewed the total program of care for one resident (#21) of 12 residents who received [MEDICATION NAME] therapy from a total sample of 33 residents. This failure resulted in serious harm for resident #21. Therefore, it was determined that an immediate and serious threat to resident health and safety existed on 2/16/10, for one resident (#21) on [MEDICATION NAME] therapy, until 2/19/2010 when a plan of correction was implemented by the facility to abate the jeopardy situation. Findings include: Resident #21 had [DIAGNOSES REDACTED]. The resident had received [MEDICAL TREATMENT] services three times a week since December 2009. The resident was admitted to the nursing facility on 1/22/10 with physician orders [REDACTED]. The [MEDICATION NAME]/INR levels would have been scheduled to be obtained on 1/29/10, 2/5/10 and 2/12/10. The physician also ordered staff to ensure that the resident received [MEDICAL TREATMENT] services every Monday, Wednesday and Friday. However, review of the resident's clinical record revealed that licensed nursing staff had failed to obtain the [MEDICATION NAME]/INR levels as ordered by the physician on 1/29/2010, 2/5/2010 and 2/12/2010. The facility failed to obtain any of the ordered [MEDICATION NAME]/INR levels. On 2/17/2010, the resident was bleeding from his/her shunt site and hospitalized with a critically high [MEDICATION NAME] level of 55.5 and abnormally high INR level of 6.11. According to the 2/18/10 hospital's History and Physical, resident #21 was admitted to their intensive care unit on 2/17/10 with [DIAGNOSES REDACTED]. The resident was given a liter of normal saline solution to increase his blood pressure but, it remained low. In the intensive care unit, the resident was on IV [MEDICATION NAME] support (to increase blood pressure), and received 2.5 mg of vitamin K (to aid blood coagulation). According to the "physician progress notes [REDACTED]. (PA-C) had assessed the resident at the facility on 1/30/10 and the resident's attending physician had assessed the resident at the facility on 2/2/10 and 2/4/10. However, there was no indication that the attending physician and his PA-C identified that the PT/INR had not been done as ordered. After reviewing the resident's medical record on 2/18/2010 at 5:50 p.m., the medical director stated that the use of the [MEDICATION NAME] was the reason for the resident's bleeding and that the facility's failure to obtain the [MEDICATION NAME]/INR levels as ordered was a serious threat to the resident's well-being. The medical director stated that the resident's attending physician and his PA-C should have identified that the [MEDICATION NAME]/INR test had not been done on 1/29/2010 when they assessed the resident on 1/30/2010, 2/2/2010 and on 2/4/2010. The resident's attending physician failed to review the total program of care for resident #21 to include the evaluation of [MEDICATION NAME]/INR levels and monitoring of [MEDICATION NAME] therapy for the potential need for drug titration. The immediate and serious threat to resident health and safety was determined removed on 2/19/2010 but the associated non-compliance continues. The non-compliance continues in order to monitor to ensure that all of the nursing staff in-service is completed as scheduled, that all new residents' admissions laboratory test orders are reviewed within 24 hours and the DHS/Unit Managers are monitoring residents on [MEDICATION NAME] daily to ensure labs are obtained as ordered and the attending physician is notified. The scope and severity of the deficiency was reduced to a "D" level when the facility implemented the following plan of correction: 1. The medical records for all residents on [MEDICATION NAME] therapy were reviewed to verify that the physicians' orders for medication and laboratory orders (Protium/INR) were implemented as ordered. Completed 2/18/10 2. Skin assessments were done on all residents who received [MEDICAL TREATMENT] services and on all residents who were on anticoagulant therapy to observe for changes including bruising and bleeding. Completed 2/18/10 3. In-services were conducted by the Senior Care Partner and the Director of Nursing for licensed nursing staff on all shifts about monitoring residents on [MEDICATION NAME] therapy for bleeding and the prompt notification of physicians about bleeding, the acquisition of [MEDICATION NAME]/INR results as ordered by the physician, the prompt notification of physicians about abnormal [MEDICATION NAME]/INR results, the initiation of new physician's orders [REDACTED]. Licensed nursing staff not available were to be in-serviced prior to being allowed to work an assigned shift. Completed 2/18/10 4. In-services were conducted by the Senior Care Partner and the Director of Nursing for certified nursing staff on all shifts about the identification of signs and symptoms of bleeding and the prompt notification of bleeding to the nurse. Certified nursing staff not available were to be in-serviced prior to being allowed to work an assigned shift. Completed by 2/18/10 for on duty staff and by 2/22/10 for all CNAs prior to being allowed to work. 5. A comprehensive care plan was developed for resident #21 to include interventions for monitoring his/her [MEDICATION NAME] therapy. Completed 2/18/10 6. Care plans were revised on those residents on [MEDICATION NAME] therapy to include interventions to consult with physicians when there was a significant change in condition. Care plan meetings on 2/18/10 for the 12 residents on [MEDICATION NAME], revisions were written. 7. The DON or Unit Managers were to monitor residents on [MEDICATION NAME] therapy daily to ensure that laboratory tests ([MEDICATION NAME]/INR) were obtained as ordered by the physicians. Upon receipt of [MEDICATION NAME]/INR lab results, the DON or Unit Managers were to ensure that the physician received those results immediately. Begun 2/18/10 8. The Policy and Procedures for the use of [MEDICATION NAME] therapy was reviewed with nursing staff on all shifts and will be reviewed with any nursing staff not available prior to their being assigned to work. Completed by 2/18/10 for on duty staff and by 2/22/10 for all nursing staff prior to being allowed to work. 9. The medical records for residents newly admitted will be reviewed within 24 hours by the Director of Nursing or Unit Managers to ensure that laboratory orders ([MEDICATION NAME]/INR) are obtained and will be monitored by the administrative staff weekly. Begun 2/18/10.

Based on record review and staff interviews, it was determined that the facility failed to consult with the physician about a significant change in the physical condition of one resident (#21) who experienced bleeding from his/her shunt site and required emergency transport to the hospital of a sample of 12 residents on [MEDICATION NAME] therapy from a total sample of 33 residents. This failure resulted in serious harm to resident #21. Therefore, it was determined that an immediate and serious threat to resident health and safety existed on 2/16/10, for one resident (#21) on [MEDICATION NAME] therapy and who received [MEDICAL TREATMENT] services, until 2/19/10 when a plan of correction was implemented by the facility to remove the jeopardy situation. Findings include: Resident #21 had [DIAGNOSES REDACTED]. The resident had received [MEDICAL TREATMENT] services three times a week since December 2009. The resident was admitted to the facility on [DATE] with physician's orders [REDACTED]. The [MEDICATION NAME]/INR levels would have been scheduled to be obtained on 1/29/2010, 2/5/2010 and 2/12/2010. The physician also ordered that nursing staff ensured that the resident received [MEDICAL TREATMENT] services every Monday, Wednesday and Friday. Licensed nursing staff documented on the 2/16/2010 (Tuesday) at 6:45 a.m. Daily Skilled Nurses Notes that resident #21's left arm shunt was bleeding. Licensed nursing staff documented that the site was cleaned and a new pressure dressing was applied. Licensed nursing staff documented that she/he would report to the 7:00 a.m. to 3:00 p.m. nurse. On 2/16/2010 at 3:00 p.m., licensed nursing staff documented in the Daily Skilled Nurses Notes that bleeding was still noted at the resident's shunt site when the dressing was removed and a new pressure dressing was applied. Licensed nursing staff documented that she/he would report to the 3:00 p.m. to 11:00 p.m. nurse. On 2/16/2010 at 10:30 p.m., licensed nursing staff documented on the Daily Skilled Nurses Notes that the resident's left arm shunt was bleeding and that a new pressure dressing was applied. Licensed nursing staff documented that she/he would continue to monitor the resident. Licensed nursing staff documented on the 2/17/2010 at 9:00 a.m. Nursing staff documented on the Medication Administration Record (MAR) that [MEDICATION NAME] and aspirin had been given on 2/16 and 2/17/2010. Daily Skilled Nurses notes that the resident left the facility to receive [MEDICAL TREATMENT] services. On 2/17/2010 at 6:30 p.m., licensed nursing staff documented on the Daily Skilled Nurses Notes that the resident's pressure dressing on his/her shunt site was saturated with blood and that a new pressure dressing was applied. Licensed nursing staff documented that she/he would continue to monitor the resident. On 2/17/2010 at 6:40 p.m., licensed nursing staff documented that certified nursing staff notified her/him that the resident was bleeding badly and that the floor of the resident's room was covered with blood. Licensed nursing staff documented that she/he applied pressure to the resident's left arm shunt site and EMS was called to transport the resident to the hospital. Although licensed nursing staff had observed the bleeding from the resident's left arm shunt site, there was no indication that licensed nursing staff had notified the resident's attending physician about the significant change in the resident's condition (bleeding at his/her shunt site) observed on 2/16/2010 at 6:45 a.m., 3:00 p.m. and 10:30 p.m. until a significantly increased amount of bleeding was observed on 2/17/2010 at 6:50 p.m. that required emergency transport to the hospital. On 2/18/2010 at 5:45 p.m., charge nurse "A" stated that she/he did not notify the resident's attending physician about the bleeding at the left arm shunt site on 2/16/2010. "AA " stated that she/he thought that licensed nursing staff " BB " had notified the physician about the bleeding. During an interview with licensed nursing staff " BB " on 2/18/2010 at 5:50 p.m., " BB " stated that she/he did not notify the physician about the bleeding at the resident's left arm shunt site observed on 2/16/2010. According to the 2/18/2010 hospital History and Physical, resident #21 was admitted to the hospital intensive care unit on 2/17/2010 with [DIAGNOSES REDACTED]. According to the laboratory report dated 2/17/2010 at 7:45 p.m., the resident's [MEDICATION NAME] of 55..5 was a critical level (normal range 12.0 to 15.). The resident was given a liter of normal saline solution to increase his blood pressure but it remained low. In the intensive care unit, the resident was on IV [MEDICATION NAME] support, and received 2.5 mg of vitamin K. The immediate and serious threat to resident health and safety was determined removed on 2/19/2010 but the associated non-compliance continues. The noncompliance continues in order to monitor to ensure that all of the nursing staff in-service is completed as scheduled, that all new residents' admissions laboratory test orders are reviewed within 24 hours and the DHS/Unit Managers are monitoring residents on [MEDICATION NAME] daily to ensure labs are obtained as ordered and the attending physician is notified. The scope and severity of the deficiency was reduced to a "D" level when the facility implemented the following plan of correction: 1. The medical records for all residents on [MEDICATION NAME] therapy were reviewed to verify that the physicians' orders for medication and laboratory orders (Protium/INR) were implemented as ordered. Completed 2/18/10 2. Skin assessments were done on all residents who received [MEDICAL TREATMENT] services and on all residents who were on anticoagulant therapy to observe for changes including bruising and bleeding. Completed 2/18/10 3. In-services were conducted by the Senior Care Partner and the Director of Nursing for licensed nursing staff on all shifts about monitoring residents on [MEDICATION NAME] therapy for bleeding and the prompt notification of physicians about bleeding, the acquisition of [MEDICATION NAME]/INR results as ordered by the physician, the prompt notification of physicians about abnormal [MEDICATION NAME]/INR results, the initiation of new physician's orders [REDACTED]. Licensed nursing staff not available were to be in-serviced prior to being allowed to work an assigned shift. Completed 2/18/10 4. In-services were conducted by the Senior Care Partner and the Director of Nursing for certified nursing staff on all shifts about the identification of signs and symptoms of bleeding and the prompt notification of bleeding to the nurse. Certified nursing staff not available were to be in-serviced prior to being allowed to work an assigned shift. Completed by 2/18/2010 for on duty staff and by 2/22/10 for all CNAs prior to being allowed to work . 5. A comprehensive care plan was developed for resident #21 to include interventions for monitoring his/her [MEDICATION NAME] therapy. Completed 2/18/10 6. Care plans were revised on those residents on [MEDICATION NAME] therapy to include interventions to consult with physicians when there was a significant change in condition. Care plan meetings on 2/18/2010 for the 12 residents on [MEDICATION NAME] revisions were written care plan. 7. The DON or Unit Managers were to monitor residents on [MEDICATION NAME] therapy daily to ensure that laboratory tests ([MEDICATION NAME]/INR) were obtained as ordered by the physicians. Upon receipt of [MEDICATION NAME]/INR lab results, the DON or Unit Managers were to ensure that the physician received those results immediately. Begun 2/18/2010 8. The Policy and Procedures for the use of [MEDICATION NAME] therapy was reviewed with nursing staff on all shifts and will be reviewed with any nursing staff not available prior to their being assigned to work. Completed by 2/18/2010 for on duty staff and by 2/22/10 for all CNAs prior to being allowed to work . 9. The medical records for residents newly admitted will be reviewed within 24 hours by the Director of Nursing or Unit Managers to ensure that laboratory orders ([MEDICATION NAME]/INR) are obtained and will be monitored by the administrative staff weekly. Begun 2/18/2010

Based on record review, it was determined that the interdisciplinary care plan team failed to develop a comprehensive plan of care to include appropriate goals and interventions to address the identification and management of emergencies and complications to minimize the risk of bleeding for one resident (#21) of 12 residents who received anti-coagulant therapy, who had significant bleeding to warrant admission to the hospital's intensive care unit. This failure resulted in serious harm to resident #21. Therefore, it was determined that an immediate and serious threat to resident health and safety existed on 2/16/10, for one resident (#21) on [MEDICATION NAME] therapy, until 2/19/2010 when a plan of correction was implemented by the facility to remove the jeopardy situation. Findings include: According to the facility's [MEDICATION NAME] Administration and Monitoring policy, the interdisciplinary care plan team was supposed to develop a care plan for each resident on [MEDICATION NAME] (an anti-coagulant) therapy to include appropriate goals and interventions to minimize the risks of therapy such as bleeding. Although resident #21 received [MEDICATION NAME] and an aspirin daily, the team did not develop a plan of care for resident #21 to address their use. Resident #21 had [DIAGNOSES REDACTED]. The resident had received [MEDICAL TREATMENT] services three times a week since December 2009. The resident was admitted to the facility on [DATE] with physician orders [REDACTED]. of aspirin daily to the resident every day and to obtain a [MEDICATION NAME]/INR level every week and as needed to monitor the [MEDICATION NAME] therapy. The [MEDICATION NAME]/INR levels were to be obtained on 1/29/2010, 2/5/2010 and 2/12/2010. The physician also ordered that staff to ensure that the resident received [MEDICAL TREATMENT] services every Monday, Wednesday and Friday. However, a review of the residents's clinical record on 2/18/2010 revealed that licensed nursing staff had not obtained any of weekly the [MEDICATION NAME]/INR levels ordered by his/her physician. Licensed nursing staff had failed to respond promptly when they observed bleeding from the resident's shunt site on 2/16/2010 at 6:45 a.m., 3:00 p.m. and 10:30 p.m. The resident's care plan did not specifically address the resident's risk of bleeding from his/her shunt. When a significantly increased amount of bleeding was observed on 2/17/2010 at 6:50 p.m., they had the resident sent to the hospital by emergency transport. Although licensed nursing staff included that the resident went to [MEDICAL TREATMENT] in the resident's 2/10/2010 care plan, they had failed to address the resident's use of [MEDICATION NAME] and an aspirin daily, to include appropriate goals and interventions to minimize the potential risks or side effects of anti-coagulant therapy (such as bleeding), to obtain and monitor pertinent laboratory tests ([MEDICATION NAME]/INR) as ordered by the physician, and to notify the physician immediately of bleeding and abnormal [MEDICATION NAME]/INR levels. The care plan did not address the increased risks of anti-coagulant therapy for this resident who also received [MEDICAL TREATMENT] services. See F309 for additional information about resident #21. The immediate and serious threat to resident health and safety was determined removed on 2/19/2010 but the associated non-compliance continues. The noncompliance continues in order to monitor to ensure that all of the nursing staff in-service is completed as scheduled, that all new residents' admissions laboratory test orders are reviewed within 24 hours and the DHS/Unit Managers are monitoring residents on [MEDICATION NAME] daily to ensure labs are obtained as ordered and the attending physician is notified. The scope and severity of the deficiency was reduced to a "D" level when the facility implemented the following plan of correction: 1. The medical records for all residents on [MEDICATION NAME] therapy were reviewed to verify that the physicians' orders for medication and laboratory orders (Protium/INR) were implemented as ordered. Completed 2/18/10 2. Skin assessments were done on all residents who received [MEDICAL TREATMENT] services and on all residents who were on anticoagulant therapy to observe for changes including bruising and bleeding. Completed 2/18/10 3. In-services were conducted by the Senior Care Partner and the Director of Nursing for licensed nursing staff on all shifts about monitoring residents on [MEDICATION NAME] therapy for bleeding and the prompt notification of physicians about bleeding, the acquisition of [MEDICATION NAME]/INR results as ordered by the physician, the prompt notification of physicians about abnormal [MEDICATION NAME]/INR results, the initiation of new physician's orders [REDACTED]. Licensed nursing staff not available were to be in-serviced prior to being allowed to work an assigned shift. Completed 2/18/10 4. In-services were conducted by the Senior Care Partner and the Director of Nursing for certified nursing staff on all shifts about the identification of signs and symptoms of bleeding and the prompt notification of bleeding to the nurse. Certified nursing staff not available were to be in-serviced prior to being allowed to work an assigned shift. Completed by 2/18/2010 for on duty staff and by 2/22/10 for all CNAs prior to being allowed to work . 5. A comprehensive care plan was developed for resident #21 to include interventions for monitoring his/her [MEDICATION NAME] therapy. Completed 2/18/10 6. Care plans were revised on those residents on [MEDICATION NAME] therapy to include interventions to consult with physicians when there was a significant change in condition. Care plan meetings on 2/18/2010 for the 12 residents on [MEDICATION NAME] revisions were written care plan. 7. The DON or Unit Managers were to monitor residents on [MEDICATION NAME] therapy daily to ensure that laboratory tests ([MEDICATION NAME]/INR) were obtained as ordered by the physicians. Upon receipt of [MEDICATION NAME]/INR lab results, the DON or Unit Managers were to ensure that the physician received those results immediately. Begun 2/18/2010 8. The Policy and Procedures for the use of [MEDICATION NAME] therapy was reviewed with nursing staff on all shifts and will be reviewed with any nursing staff not available prior to their being assigned to work. Completed by 2/18/2010 for on duty staff and by 2/22/10 for all CNAs prior to being allowed to work . 9. The medical records for residents newly admitted will be reviewed within 24 hours by the Director of Nursing or Unit Managers to ensure that laboratory orders ([MEDICATION NAME]/INR) are obtained and will be monitored by the administrative staff weekly. Begun 2/18/2010

Based on observations, record reviews, interviews with staff and resident, it was determined that the facility failed to ensure that licensed nursing staff followed the facility's policy and procedure for [MEDICATION NAME] Administration and Monitoring and obtained PT/INR as ordered: failed to ensure that licensed nursing staff followed up in timely with an attending physician regarding his lack of response to abnormally high [MEDICATION NAME]/INR levels for three residents (#2, #26 and #29) of 12 residents on [MEDICATION NAME] therapy; failed to administer medications as ordered by the physician for four residents (#11, #12, #16 and #21) of five residents who received [MEDICAL TREATMENT] services; and failed to clarify orders for care of an infusion port with one resident's physician ( "H") from a survey sample of 19 residents and an extended sample of 14 residents. This failure resulted in the the determination of an immediate jeopardy that existed on 2/16/10 for resident #21, then removed on 2/19/10 when a corrective plan of action had been done. Findings include: According to the facility's "[MEDICATION NAME] Administration and Monitoring Policy", the Director of Nursing would maintain a list of all residents receiving [MEDICATION NAME] therapy and that the Physician order [REDACTED]. Laboratory monitoring of [MEDICATION NAME] therapy would include obtaining [MEDICATION NAME]/INR levels in 7 to 14 days after initiating or changing the [MEDICATION NAME] dose. The medical chart of each resident receiving [MEDICATION NAME] therapy would be flagged to alert nursing staff that the resident was receiving [MEDICATION NAME] therapy. The interdisciplinary care plan team would develop a care plan for each resident on [MEDICATION NAME] therapy to include appropriate goals and interventions to minimize the potential risks of that therapy such as bleeding. However, administrative nursing staff failed to ensure that licensed nursing staff followed the facility's "[MEDICATION NAME] Administration and Monitoring Policy" and obtained [MEDICATION NAME]/INR levels as ordered by the residents' physician. This failure resulted in an immediate threat to the health and safety of resident #21. According to the facility's "[MEDICATION NAME] Administration and Monitoring Policy", the physician would be notified of laboratory results immediately upon their receipt by the facility and if the INR was less than 1.5 or greater than 3.5, it may be necessary to exercise nursing judgement regarding holding a dose until the physician had responded to the laboratory test results. The DON or Administrator should contact the medical director for assistance in obtaining a timely response to abnormal laboratory test results from the resident's primary physician. However, the nursing staff failed to follow the "[MEDICATION NAME] Administration and Monitoring Policy" for residents #2, #21, #26 and #29. During an interview on 2/17/10 at 3:55 p.m., resident "L" stated that he/she went to an outside entity for [MEDICAL TREATMENT] on Mondays, Wednesdays, and Fridays at 5:05 a.m. and returned to the facility at 10 a.m. or later. 1. Resident #21 had [DIAGNOSES REDACTED]. The resident had received [MEDICAL TREATMENT] services three times a week since December 2009. The resident was admitted to the facility on [DATE] (following the acute [MEDICAL CONDITION]) with physician's orders [REDACTED]. of aspirin to the resident every day and to obtain a [MEDICATION NAME]/INR level every week and as needed to monitor the [MEDICATION NAME] therapy. However, licensed nursing staff failed to obtain the [MEDICATION NAME]/INR levels as ordered to monitor the titration level of the anti-coagulants. A licensed nurse documented on the 2/16/2010 (Tuesday) at 6:45 a.m. "Daily Skilled Nurses Notes " that resident #21's left arm shunt was bleeding. so the site was cleaned and a new pressure dressing was applied. The licensed nurse wrote that she/he would report it to the 7:00 a.m. to 3:00 p.m. nurse. On 2/16/2010 at 3:00 p.m., a licensed nurse documented in the Daily Skilled Nurses Notes that there was still bleeding at the shunt site when the dressing was removed and a new one applied. The nurse wrote that she/he would report it to the 3:00 p.m. to 11:00 p.m. nurse. On 2/16/2010 at 10:30 p.m., the licensed nurse documented on the Daily Skilled Nurses Notes that the resident's left arm shunt was bleeding so, a new pressure dressing was applied. Licensed nursing staff documented that she/he would continue to monitor the resident. Licensed nursing staff documented on the 2/17/2010 at 9:00 a.m. Daily Skilled Nurses notes that the resident left the facility to receive [MEDICAL TREATMENT] services. Although these nurses noted bleeding from the shunt, they initialed on 2/16 and 2/17 having given [MEDICATION NAME] once a day at 6 p.m. and on 2/16 initialed giving Aspirin. Resident #21 had a physician's orders [REDACTED]. The resident also had a physician's orders [REDACTED].) of Folic Acid daily, 50 mgs. of [MEDICATION NAME] for depression daily, 81 mgs. of Aspirin [MEDICAL CONDITION], 150 mgs. of [MEDICATION NAME] for high blood pressure daily, 100 mgs. of [MEDICATION NAME] for constipation daily, 750 mgs. of [MEDICATION NAME] for [MEDICAL CONDITION] twice daily and 12.5 mgs. of [MEDICATION NAME] for high blood pressure twice daily to the resident. However, review of the 2/2010 Medication Administration Record (MAR) revealed that licensed nursing staff had failed to administer those scheduled 9:00 a.m. medications to the resident on 2/3/10 and 2/17/10 when he/she had gone to an outside entity for [MEDICAL TREATMENT]. On 2/17/2010 at 6:30 p.m., licensed nursing staff documented on the Daily Skilled Nurses Notes that the resident's pressure dressing on his/her shunt site was saturated with blood, so a new pressure dressing was applied. The licensed nurse documented that she/he would continue to monitor the resident. On 2/17/10 at 6:40 p.m., the licensed nurse documented that a certified nursing assistant notified her/him that the resident was bleeding badly and that the floor of the resident's room was covered with blood. Licensed nursing staff documented that she/he applied pressure to the resident's left arm shunt site and EMS was called to transport the resident to the hospital. Although licensed nursing staff had observed bleeding from the resident's left arm shunt site beginning on 2/16/10 at 6:45 a.m. until his/her transport to the hospital on [DATE] at 6:40 p.m., there was no evidence that licensed nursing staff had consulted the resident's attending physician about the significant decline in the resident's condition (bleeding at his/her shunt site). Administrative nursing staff had failed to ensure that licensed nursing staff had followed the facility's policy to immediately consulted resident #21's physician about the significant change in the resident's condition (bleeding at his/her shunt site) and the continued administration of [MEDICATION NAME] and an aspirin. Review of the clinical record for resident #21 revealed that facility nursing staff had failed to obtain the [MEDICATION NAME]/INR levels weekly as ordered by the physician and due on 1/29/10, 2/5/10 and 2/12/10. Licensed nursing staff failed to include the resident's use of [MEDICATION NAME] in his/her comprehensive care plan dated 2/10/10. On 2/18/10 at 3:30 p.m., the Director of Nursing (DON) confirmed that nursing staff had not obtained the [MEDICATION NAME]/INR levels as ordered. The DON stated at that time that, although she was responsible for monitoring the [MEDICATION NAME]/INRs for residents receiving [MEDICATION NAME] therapy, she did not know that resident #21 received [MEDICATION NAME] or that the physician had ordered [MEDICATION NAME]/INR levels to be obtained weekly. The DON said that licensed nursing staff had failed to flag the resident's chart to alert staff that the resident received [MEDICATION NAME] therapy according to the facility's policy. During a telephone interview with the resident's [MEDICAL TREATMENT] physician on 2/18/2010 at 5:20 p.m., he stated that sometimes people receiving [MEDICAL TREATMENT] services would bleed at the shunt site, but that the facility's failure to obtain [MEDICATION NAME]/INR levels for resident #21 would have contributed to the bleeding that resulted in the resident's hospitalization . After reviewing the resident's medical record on 2/18/2010 at 5:50 p.m., the medical director stated that the use of the [MEDICATION NAME] was the reason for the resident's bleeding and that the facility's failure to obtain the ordered [MEDICATION NAME]/INR levels was a serious threat to the resident's well-being. Licensed nursing staff had failed to obtain any of the weekly ordered [MEDICATION NAME]/INR levels for resident #21. Although the facility's policy for "[MEDICATION NAME] Administration and Monitoring" was that the Director of Nursing would maintain a list of all residents receiving [MEDICATION NAME] therapy and would review the physician's orders [REDACTED].[REDACTED]. According to the physician progress notes [REDACTED]. physician had assessed the resident at the facility on 1/30/10 and the resident's attending physician had assessed the resident at the facility on 2/2/10 and 2/4/10. However, there was no indication that the attending physician or his PA-C identified that the [MEDICATION NAME]/INR had not been obtained on 1/29/10. On 2/18/2010 at 5:50 p.m., the medical director stated that the resident's attending physician and his PA-C should have identified that the [MEDICATION NAME]/INR test had not been done on 1/29/10. See F309 and F386 for additional information on resident #21. On 2/18/2010 at 10:20 a.m., the Director of Nursing stated that the facility had difficulty receiving a prompt response to abnormal [MEDICATION NAME]/INR levels from some of the residents ' physicians. Although the facility's policy documented that the medical director would be contacted for assistance in obtaining a timely response to abnormal [MEDICATION NAME]/INR results from the residents' physicians, the DON stated that the medical director had not been consulted on the continued failure of some of the physicians to respond timely to abnormal [MEDICATION NAME]/INR levels. The Director of Nursing stated that she would have expected licensed nursing staff to continue to contact the physician for his response to abnormal [MEDICATION NAME]/INR levels and to hold a resident's [MEDICATION NAME] dose until the physician responded, but they did not for residents #2, #26 and #29. 2. Resident #2 had a physician's orders [REDACTED]. On 12/28/2009, the resident's [MEDICATION NAME] was abnormally high at 27.6 (normal range between 10.5 and 13.5) and the INR was abnormally high at 4.9 (normal range between 0.77 and 1.35). Licensed nursing staff documented on the [MEDICATION NAME]/INR Report that the physician was notified about the abnormally high levels on 12/28/2009 at 9:40 a.m. However, despite the physician not responding until 2/29/2009 at 10:00 p.m., licensed nursing staff failed to attempt to contact another physician or follow-up with the resident's attending physician. Although licensed nursing staff were aware of the resident's abnormally high [MEDICATION NAME]/INR levels on 12/28/09 at 9:40 a.m., licensed nursing staff continued to give 4 milligrams of [MEDICATION NAME] to the resident at 5:00 p.m. on 12/28/09 and 12/29/09. 3. Resident #26 had a physician's orders [REDACTED]. On 9/28/09, the resident's [MEDICATION NAME] was reported as being abnormally high at 24 (normal range between 10.5 and 13.5) and his/her INR was abnormally high at 3.8 (normal range between 0.77 and 1.35). Licensed nursing staff had documented on the "[MEDICATION NAME] Anticoagulation Record" that the physician was notified about those abnormally high [MEDICATION NAME]/INR levels on 9/28/09 (Tuesday). The physician did not respond until four days later on 10/2/09 (Friday) at 4:48 p.m. when he ordered that the facility hold the resident's [MEDICATION NAME] for two days then resume the dose and recheck the [MEDICATION NAME]/INR levels in one week. However, licensed nursing staff failed to implement that order until 10/5/09 (Monday). Licensed nursing staff documented on the Medication Administration Records (MARs) for 9/09 and 10/09 having administered 6 milligrams of [MEDICATION NAME] to the resident from 9/28/09 to 10/4/09. Although licensed nursing staff had notified the physician immediately about the abnormally high [MEDICATION NAME]/INR levels for resident #26, they failed to follow-up with the physician timely about his response to the abnormally high [MEDICATION NAME]/INR levels and had failed to immediately implement his order to withhold the [MEDICATION NAME]. 4. Resident #29 had a physician's orders [REDACTED]. According to the facility's policy for "[MEDICATION NAME] Administration and Monitoring", the [MEDICATION NAME] was supposed to be administered at 5:00 p.m. unless another time was ordered by the physician The resident also had a physician's orders [REDACTED]. On 2/8/2010, the resident's [MEDICATION NAME] level was abnormally high at 24 (normal range was between 10.5 and 13.5) and the INR level was abnormally high at 4.5 (normal range between 0.77 and 1.35). Licensed nursing staff had documented on the [MEDICATION NAME]/INR Report that the physician was notified about the abnormally high levels on 2/8/2010 at 1:20 p.m. However, there was not a response until 2/8/2010 at 10:00 p.m., almost 9 hours later, when he ordered licensed nursing staff to hold the resident's [MEDICATION NAME] and obtain a [MEDICATION NAME]/INR level on 2/10/2010. However, although licensed nursing staff were aware of the abnormally high [MEDICATION NAME]/INR level on 2/8/10 at 1:20 p.m., documentation on the Medication Administration Record (MAR) for 2/2010 revealed that licensed nursing staff had administered the 3.5 milligrams of [MEDICATION NAME] to the resident at 5:00 p.m. on 2/8/10. Licensed nursing staff held the resident's [MEDICATION NAME] on 2/9/10. On 2/10/10, the resident's [MEDICATION NAME] level was even higher at 32.1 and the INR level was 6.5. Licensed nursing staff documented on the "[MEDICATION NAME]/INR Report" that the physician was notified about those abnormally high [MEDICATION NAME]/INR levels on 2/10/10 at 1:45 p.m. However, there was not a response from the physician until 10 hours later when licensed nursing staff documented in the 2/10/10 at 11:45 p.m. nurses notes that the physician ordered to stop the resident's [MEDICATION NAME] and give 2.5 milligrams of Vitamin K by mouth to the resident "now". Licensed nursing staff did not give Vitamin K to the resident "now" but gave it to him/her 9 hours later at 8:50 a.m. om 2/11/20. Licensed nursing staff had held the 5:00 p.m. dose of [MEDICATION NAME] on 2/10/10. Licensed nursing staff failed to follow-up timely with the physician on his response to the abnormally high levels. Review of the nurses notes revealed that licensed nursing staff had not monitored the resident for bleeding from 2/10/10 at 11:45 p.m. to the next nurses note dated 2/14/10 at 9:00 a.m. On 2/18/10 at 6:00 p.m., the Director of Nursing stated that nursing staff were supposed to call the on-call pharmacist if a medication was not available after hours. However, they did not do so to obtain the ordered vitamin K. See F309 for additional information regarding resident #29. 5. Resident #16 had been receiving [MEDICAL TREATMENT] services since at least 2/4/10. A review of the February 2010 Medication Administration Record (MAR) revealed that on 2/12, 2/15, and 2/17/10 ([MEDICAL TREATMENT] days), licensed nursing staff did not administer the medications scheduled to be given at 9 a.m. ( [MEDICATION NAME], and [MEDICATION NAME]) because he/she was at [MEDICAL TREATMENT]. Licensed nursing staff did not administer routinely ordered [MEDICATION NAME] that had been scheduled to have been given at 9:00 a.m. on 2/12 and 2/15/10. There was no evidence in the clinical record that nursing staff had notified the attending physician that the resident's morning medications were not given to the resident on the says that he/she went to [MEDICAL TREATMENT]. See F309 for additional information regarding resident #16. 6. Resident #12 had medical [DIAGNOSES REDACTED]. He/she went out to a [MEDICAL TREATMENT] facility. There was a physician's orders [REDACTED]. drops into each eye two times daily and 1 drop of [MEDICATION NAME] eye drops two times daily. However, according to documentation on the Medication Administration Records (MARs), licensed nursing staff failed to administer the morning dose of those medications to the resident on the days that he/she went to [MEDICAL TREATMENT], including for 3 of 7 ([MEDICAL TREATMENT]) days in February 2010 (2/8, 2/10, 2/15) and for 2 of 13 days in January 2010 (1/20 and 1/27). During an interview on 2/18/10 at 9:30 a.m., licensed nurse "JJ" stated that despite the medications having been scheduled at 9:00 a.m. or 11:00 a.m. on the days that resident #12 went to the [MEDICAL TREATMENT] facility, the morning doses of the medications were not administered unless the resident returned to the facility before 10:00 a.m. In an interview on 2/17/10 at 3:30 p.m., the DON stated that she had not been made aware that morning medications were not being administered to the residents on days they attended [MEDICAL TREATMENT]. 7. Resident #11 had medical [DIAGNOSES REDACTED]. There was a physician's orders [REDACTED]. However, documentation on the MARs revealed that licensed nursing staff failed to administer the morning doses of those medications on the days that the resident went to the [MEDICAL TREATMENT] facility, including 12 of 13 days in January 2010 and 6 of 7 days in February 2010. The [MEDICATION NAME] had been scheduled to be administered at 7:00 a.m. and 11:00 a.m. but, staff failed to administer 12 of 18 doses in February 2010, and 26 of 39 doses in January 2010. 8. Resident "H" was admitted on [DATE]. According to the orders sent from the hospital date 123/3/09, the resident's infusaport had been placed on 12/1/09. There was an order on the December Medication Administration Record (MAR), for a life port to be flushed every month with 10 milliliters of normal saline followed by the infusion of 5 milliliters of [MEDICATION NAME]. However, nursing staff failed to ensure that order had been transcribed on the January and February physician's orders [REDACTED]. According to the facility's policy on "Implanted Port Infusion Access Device maintenance" a physician' order was required to flush or change an access device. although the December medication administration record indicated that the port was supposed to be flushed monthly, in an interview on 2/17/10 at 10:00 a.m., resident "H" reported having told nursing staff that it had not been flushed since his/her admission. Licensed nursing staff failed to clarify care for the infusaport with the physician as set forth by their policy. The immediate and serious threat to resident health and safety was determined removed on 2/19/2010 but the non-compliance continues. The associated practice of noncompliance continues in order to monitor to ensure that all of the nursing staff in-service is completed as scheduled, that all new residents' admissions laboratory test orders are reviewed within 24 hours and the DHS/Unit Managers are monitoring residents on [MEDICATION NAME] daily to ensure labs are obtained as ordered and the attending physician is notified. However, based on a more than limited number of residents being affected by the nursing staff's failure to follow the facility's policy and procedures and physician's medication orders, it was determined that the scope and severity of the deficiency was reduced to a "E" level when the facility implemented the following plan of correction: 1. The medical records for all residents on [MEDICATION NAME] therapy were reviewed to verify that the physicians' orders for medication and laboratory orders (Protium/INR) were implemented as ordered. Completed 2/18/10 2. Skin assessments were done on all residents who received [MEDICAL TREATMENT] services and on all residents who were on anticoagulant therapy to observe for changes including bruising and bleeding. Completed 2/18/10 3. In-services were conducted by the Senior Care Partner and the Director of Nursing for licensed nursing staff on all shifts about monitoring residents on [MEDICATION NAME] therapy for bleeding and the prompt notification of physicians about bleeding, the acquisition of [MEDICATION NAME]/INR results as ordered by the physician, the prompt notification of physicians about abnormal [MEDICATION NAME]/INR results, the initiation of new physician's orders [REDACTED]. Licensed nursing staff not available were to be in-serviced prior to being allowed to work an assigned shift. Completed 2/18/10 4. In-services were conducted by the Senior Care Partner and the Director of Nursing for certified nursing staff on all shifts about the identification of signs and symptoms of bleeding and the prompt notification of bleeding to the nurse. Certified nursing staff not available were to be in-serviced prior to being allowed to work an assigned shift. Completed by 2/18/2010 for on duty staff and by 2/22/10 for all CNAs prior to being allowed to work . 5. A comprehensive care plan was developed for resident #21 to include interventions for monitoring his/her [MEDICATION NAME] therapy. Completed 2/18/10 6. Care plans were revised on those residents on [MEDICATION NAME] therapy to include interventions to consult with physicians when there was a significant change in condition. Care plan meetings on 2/18/2010 for the 12 residents on [MEDICATION NAME] revisions were written care plan. 7. The DON or Unit Managers were to monitor residents on [MEDICATION NAME] therapy daily to ensure that laboratory tests ([MEDICATION NAME]/INR) were obtained as ordered by the physicians. Upon receipt of [MEDICATION NAME]/INR lab results, the DON or Unit Managers were to ensure that the physician received those results immediately. Begun 2/18/2010 8. The Policy and Procedures for the use of [MEDICATION NAME] therapy was reviewed with nursing staff on all shifts and will be reviewed with any nursing staff not available prior to their being assigned to work. Completed by 2/18/2010 for on duty staff and by 2/22/10 for all CNAs prior to being allowed to work . 9. The medical records for residents newly admitted will be reviewed within 24 hours by the Director of Nursing or Unit Managers to ensure that laboratory orders ([MEDICATION NAME]/INR) are obtained and will be monitored by the administrative staff weekly. Begun 2/18/2010

Based on observation, record review, and interviews with facility staff and the medical director, it was determined that the facility failed to ensure that physicians' orders were followed to obtain [MEDICATION NAME]/INR results weekly for one resident (#21) of 12 residents who received [MEDICATION NAME] therapy and failed to ensure that physicians' medication orders were followed for seven residents (#11, #12, "L", #3, #30, #21 and #29) from a sample of 33 residents. The facility's failure to obtain weekly [MEDICATION NAME]/INR results as ordered by the physician for one resident on [MEDICATION NAME] therapy who also received [MEDICAL TREATMENT] services resulted in serious injury to resident #21. Therefore, it was determined that an immediate jeopardy existed for resident #21 from 2/16/2010 when licensed nursing staff first documented observations of bleeding from the resident's shunt site until 2/18/2010 following the resident's hospitalization on [DATE]. The immediate jeopardy was removed on 2/19/2010 when the facility implemented a plan of correction to remove the jeopardy situation. Findings include: According to the facility's "[MEDICATION NAME] Administration and Monitoring Policy", the Director of Nursing would maintain a list of all residents receiving [MEDICATION NAME] therapy and that the Physician order [REDACTED]. Laboratory monitoring of [MEDICATION NAME] therapy would include a [MEDICATION NAME]/INR 7 to 14 days after initiating or changing the [MEDICATION NAME] dose. The physician would be notified of laboratory results immediately upon their receipt by the facility and if the INR was less than 1.5 or greater than 3.5, it may be necessary to exercise nursing judgement regarding holding a dose until the physician had responded to the laboratory test results. The DON or Administrator should contact the medical director for assistance in obtaining a timely response to abnormal laboratory test results from the resident's primary physician. The medical chart of each resident receiving [MEDICATION NAME] therapy would be flagged to alert nursing staff that the resident was receiving [MEDICATION NAME] therapy. The interdisciplinary care plan team would develop a care plan for each resident on [MEDICATION NAME] therapy to include appropriate goals and interventions to minimize the risks of therapy such as bleeding. However, the facility failed to follow the [MEDICATION NAME] Administration and Monitoring Policy for residents #21 and #29 which resulted in an immediate threat to the health and safety of resident #21. 1. Resident #21 had [DIAGNOSES REDACTED]. The resident had received [MEDICAL TREATMENT] services three times a week since December 2009. The resident was admitted to the facility on [DATE] with physician orders [REDACTED]. The [MEDICATION NAME]/INR levels would have been scheduled to be obtained on 1/29/2010, 2/5/2010 and 2/12/2010. The physician also ordered staff to ensure that the resident received [MEDICAL TREATMENT] services every Monday, Wednesday and Friday. Resident #21 had physician's orders [REDACTED].) of Folic Acid daily, 50 mgs. of [MEDICATION NAME] for depression daily, 81 mgs. of Aspirin [MEDICAL CONDITION], 150 mgs. of [MEDICATION NAME] for high blood pressure daily, 100 mgs. of [MEDICATION NAME] for constipation daily, 750 mgs. of [MEDICATION NAME] for [MEDICAL CONDITION] twice daily and 12.5 mgs. of [MEDICATION NAME] for high blood pressure twice daily. However, review of the 2/2010 Medication Administration Record (MAR) revealed that licensed nursing staff had failed to give the scheduled 9:00 a.m. medications to the resident on 2/3/2010 and 2/17/2010 ([MEDICAL TREATMENT] days) or notify the physician that they had not been given. The licensed nurse staff documented on the 2/16/10 (Tuesday) at 6:45 a.m. Daily Skilled Nurses Notes that resident #21's left arm shunt was bleeding, so that the site was cleaned and a new pressure dressing was applied. The licensed nurse documented that she/he would report it to the 7:00 a.m. to 3:00 p.m. nurse. On 2/16/10 at 3:00 p.m., licensed nursing staff documented in the Daily Skilled Nurses Notes that bleeding was still noted at the shunt site when the dressing was removed, so a new pressure dressing was applied. The licensed nurse documented that she/he would report it to the 3:00 p.m. to 11:00 p.m. nurse. On 2/16/10 at 10:30 p.m., a licensed nurse documented on the Daily Skilled Nurses Notes that the resident's left arm shunt was bleeding and another new pressure dressing was applied. The licensed nurse documented that she/he would continue to monitor the resident. The licensed nurse documented on the 2/17/10 at 9:00 a.m. Daily Skilled Nurses notes that the resident had left the facility for [MEDICAL TREATMENT] services. On 2/17/10 at 6:30 p.m., the licensed nurse documented on the Daily Skilled Nurses Notes that the resident's pressure dressing on his/her shunt site was saturated with blood so, a new pressure dressing was applied. The licensed nurse wrote that she/he would continue to monitor the resident. On 2/17/10 at 6:40 p.m., the licensed nurse documented that a certified nursing assistant notified her/him that "the resident was bleeding badly" and that the floor of the resident's room was covered with blood. The licensed nurse documented that she/he applied pressure to the resident's left arm shunt site and EMS was called to transport the resident to the hospital. Although licensed nursing staff had observed bleeding from the resident's left arm shunt site, there was no evidence that the resident's attending physician was notified about the significant change in the resident's condition (bleeding at his/her shunt site). On 2/18/10 at 5:45 p.m., charge nurse "AA" stated that she/he did not notify the resident's attending physician about the bleeding at the left arm shunt site on 2/16/2010. "AA" stated that she/he thought that licensed nursing staff "BB" had notified the physician about the bleeding. During an interview with licensed nursing staff "BB" on 2/18/2010 at 5:50 p.m., "BB" stated that she/he did not notify the physician about the bleeding at the resident's left arm shunt site observed on 2/16/2010. According to the 2/18/10 hospital's History and Physical, resident #21 was admitted to the hospital intensive care unit on 2/17/10 with [DIAGNOSES REDACTED]. Review of the [MEDICAL TREATMENT] clinic documentation for 2/17/10 revealed that the resident was discharged from the [MEDICAL TREATMENT] clinic at 4:41 p.m. with prolonged bleeding after the needles were removed from his/her shunt. The [MEDICAL TREATMENT] physician documented on the 2/18/10 hospital's History and Physical that the nursing home recorded the resident's blood pressure as having been abnormally low at 50/20 prior to the resident's transport to the hospital. Review of the resident's laboratory results obtained at the time of the resident's hospital admission revealed that the resident had a critically high [MEDICATION NAME] of 55.5 (normal range was between 12.0 and 15.0) and an abnormally high INR of 6.11. The resident also had an abnormally high PTT of 119.3 (normal range between 24.3 and 37.1). The hospital's nursing staff administered 2.5 milligrams of Vitamin K to the resident. As ordered by the physician, they also administered one liter of normal saline solution (to increase the blood pressure) and intravenous [MEDICATION NAME]. The [MEDICAL TREATMENT] physician documented on the 2/18/2010 hospital History and Physical that the resident had a poor prognosis due to his/her multiple medical problems and debilitating stroke. There was no evidence in the clinical record for resident #21 that facility's nursing staff had obtained any of the [MEDICATION NAME]/INR levels weekly ordered by the physician on 1/22/2010. Furthermore, review of the resident's 2/10/10 care plan revealed that licensed nursing staff had failed to develop a comprehensive care plan to address the resident's use of [MEDICATION NAME] and Aspirin and to include appropriate goals and interventions to minimize the risks of anti-coagulant therapy such as bleeding. On 2/18/10 at 3:30 p.m., the Director of Nursing (DON) confirmed that the [MEDICATION NAME]/INR levels had not been obtained as ordered. The DON said she was responsible for monitoring the [MEDICATION NAME]/INRs for residents who received [MEDICATION NAME] therapy but, she was unaware that resident #21 received [MEDICATION NAME] and that his/her physician had ordered [MEDICATION NAME]/INR levels to be obtained weekly. Review of the resident's chart revealed that licensed nursing staff had failed to flag the resident's chart to alert staff that the resident received [MEDICATION NAME] therapy according to the facility's policy. On 2/18/10 at 3:30 p.m., the DON consulted with the [MEDICAL TREATMENT] clinic and stated that the [MEDICAL TREATMENT] clinic did not have [MEDICATION NAME]/INR results for the resident. In a telephone interview on 2/18/10 at 5:20 p.m., the resident's physician at the [MEDICAL TREATMENT] clinic said that persons receiving [MEDICAL TREATMENT] services would sometimes bleed at the shunt site, but that the facility's failure to obtain [MEDICATION NAME]/INR levels for resident #21 would have contributed to the bleeding that resulted in the resident's hospitalization . After reviewing the resident's medical record on 2/18/2010 at 5:50 p.m., the medical director stated that the use of the [MEDICATION NAME] was the reason for the resident's bleeding and that the facility's failure to obtain the [MEDICATION NAME]/INR levels as ordered was a serious threat to the resident's well-being. According to the physician progress notes [REDACTED]. physician had seen the resident at the facility on 1/30/ and the resident's attending physician had seen the resident at the facility on 2/2/2010 and 2/4/2010. However, there was no indication that the resident's attending physician or his PA-C had identified that a [MEDICATION NAME]/INR test had not been done as the physician had ordered on [DATE]. On 2/18/10 at 5:50 p.m., the medical director stated that the resident's attending physician and his PA-C should have identified that the [MEDICATION NAME]/INR test had not been done on 1/29/10 when they saw the resident on 1/30/10, 2/2/10 and on 2/4/10. Although the resident's attending physician and his/her physician's assistant saw the resident after the first PT/INR was due to have been done, they failed to identify that a [MEDICATION NAME]/INR had not been done as ordered for resident #21. 2. Resident #29 had been receiving [MEDICATION NAME] therapy since at least 6/2009. He/She had a physician's orders [REDACTED]. On 2/8/10, the resident's [MEDICATION NAME] level was abnormally high at 24 (normal range was between 10.5 and 13.5) and the INR level was abnormally high at 4.5 (normal range between 0.77 and 1.35). The physician was consulted about the abnormally high levels on 2/8/10 and ordered licensed nursing staff to hold the resident's [MEDICATION NAME] and to obtain a [MEDICATION NAME]/INR level on 2/10/10. Although licensed nursing staff held the resident's [MEDICATION NAME] on 2/9/10 and 2/10/10, the resident's [MEDICATION NAME] level on 2/10/10 was even higher at 32.1 and the INR level was 6.5. The physician was notified about the abnormally high [MEDICATION NAME]/INR levels and on 2/10/10 and issued a phone order for licensed nursing staff to stop the resident's [MEDICATION NAME] and to administer 2.5 milligrams of Vitamin K by mouth "now". However, review of the 2/10/10 at 11:45 p.m. nurses notes revealed that licensed nursing staff did not administer the Vitamin K to the resident because the medication was not available in the "PO" (by mouth) form. According to the facility's "Emergency Drug Kit Utilization Record", 2.5 milligrams of Vitamin K was not administered to the resident until 2/11/10 at 8:50 a.m., 9 hours after the "now" order. On 2/18/10 at 6:00 p.m., the DON stated that nursing staff were supposed to call the on-call pharmacist if a medication was not available after hours. However, licensed nursing staff had failed to obtain and administer the "now" dose of Vitamin K to resident #29 as ordered by the physician. The resident's [MEDICATION NAME] level was 21.7 and the INR level was 3.1 on 2/11/10 when, the resident's physician ordered licensed nursing staff to administer 2 milligrams of [MEDICATION NAME] to the resident daily. 3. Resident #11 had [DIAGNOSES REDACTED]. He/She had a physician's orders [REDACTED]. However, a review of the MARs revealed that licensed nursing staff failed to administer the morning doses of those medications consistently on the days the resident went to [MEDICAL TREATMENT], including 12 of 13 days in January 2010 and 6 of 7 days in February 2010. The [MEDICATION NAME] was scheduled to be administered at 7:00 a.m. and 11:00 a.m. but, nursing staff failed to give the resident 12 of 18 doses in February 2010, and 26 of 39 doses in January 2010. Resident #11 had a physician's orders [REDACTED]. However, nursing staff's documentation in the MAR and nurse's notes revealed that they had failed to monitor and record the resident's blood pressure after returning from [MEDICAL TREATMENT] on 3 of 13 days in December 2009, 7 of 13 days in January 2010, and 2 of 7 days in February 2010. On 2/17/10 at 2:00 p.m., the Director of Nursing (DON) stated that vital signs taken before and after [MEDICAL TREATMENT] were supposed to be documented on either the resident's MAR or in the nurse's notes. On 2/17/10 at 3:30 p.m., the DON stated that she had not been made aware that morning medications were not being administered to the residents on days they went to [MEDICAL TREATMENT] 4. Resident "L" had [DIAGNOSES REDACTED]. He/she had been receiving [MEDICAL TREATMENT] services three times weekly since at least 2/4/10. The resident stated during an interview on 2/17/10 at 3:55 p.m. that he/she went for [MEDICAL TREATMENT] treatments on Mondays, Wednesdays, and Fridays. He/She said that he/she usually left the facility around 5:05 a.m. and did not return until 10 a.m. or later. A review of the February 2010 Medication Administration revealed that on 2/12, 2/15, and 2/17/10 licensed nursing staff did not administer the medications scheduled to be given at 9 a.m. ([MEDICATION NAME], or [MEDICATION NAME]) because the resident was at [MEDICAL TREATMENT]. In addition, licensed nursing staff also did not administer [MEDICATION NAME] scheduled to be given at 9 a.m. on 2/12 and 2/15/10. There was no evidence in the clinical record that nursing staff had notified the attending physician that the resident was not receiving scheduled medications on [MEDICAL TREATMENT] days. 5. Resident #12 had medical [DIAGNOSES REDACTED]. There was a physician's orders [REDACTED]. times daily and 1 drop of [MEDICATION NAME] eye drops two times daily. However, review of the Medication Administration Records (MARs) revealed that licensed nursing staff had consistently failed to administer the morning dose of those medications on days when the resident received [MEDICAL TREATMENT], including 3 of 7 days in February 2010 and 2 of 13 days in January 2010. On the 1/20/10 MAR, licensed nursing staff documented that the medications were not administered because the resident was out of the facility for [MEDICAL TREATMENT]. During an interview on 2/18/10 at 9:30 a.m., licensed nurse "JJ" stated that despite the medications being scheduled at 9:00 a.m. or 11:00 a.m., on days that the resident received [MEDICAL TREATMENT] the morning doses of medications were not given unless the resident returned to the facility before 10:00 a.m. There was a physician's orders [REDACTED]. However, according to documentation in the MAR and nurse's notes, nursing staff failed to monitor and record the resident's heart rate and blood pressure after [MEDICAL TREATMENT] on 2 of 13 days in December 2009, on 1 of 13 days in January and 3 of 7 days in February 2010. 6. Resident #3 had a [DIAGNOSES REDACTED]. The resident also had a physician's orders [REDACTED]. The resident's hemoglobin level was 10.8 on 1/25/10 and 11.5 on 2/5/10. However, review of the Medication Administrative Record (MAR) for 2/2010 revealed that licensed nursing staff had failed to administer the [MEDICATION NAME] to the resident as scheduled on 2/4/10 and 2/11/10 when his/her hemoglobin level was less than 12. 7. Resident #30 had [DIAGNOSES REDACTED]. There was a physician's orders [REDACTED]. However, during an observation on 2/19/10 at 9:00 a.m., the [MEDICATION NAME]-TTS patch on the resident's chest was dated 2/1/10. A review of the resident's February 2010 MAR revealed that nursing staff should have applied a [MEDICATION NAME]-TTS patch on 2/1/10, 2/8/10 and 2/15/10. However, there was no evidence that the 2/8/10 and 2/15/10 patches had been applied as ordered. During an observation of the resident with the DON on 2/19/10 at 9:30 a.m., she confirmed that the patch on the resident dated 2/1/10 was the [MEDICATION NAME]-TTS patch. The immediate and serious threat to resident health and safety was determined removed on 2/19/2010 but the associated non-compliance continues. The noncompliance continues in order to monitor to ensure that all of the nursing staff in-service is completed as scheduled, the all new residents' admissions laboratory test orders are reviewed within 24 hours and the DHS/Unit Managers are monitoring residents on [MEDICATION NAME] daily to ensure labs are obtained as ordered and the attending physician is notified. The are more than a limited number of residents affected by the facility practice. The scope and severity of the deficiency was reduced to a "E" level when the facility implemented the following plan of correction: 1. The medical records for all residents on [MEDICATION NAME] therapy were reviewed to verify that the physicians' orders for medication and laboratory orders (Protium/INR) were implemented as ordered. Completed 2/18/10 2. Skin assessments were done on all residents who received [MEDICAL TREATMENT] services and on all residents who were on anticoagulant therapy to observe for changes including bruising and bleeding. Completed 2/18/10 3. In-services were conducted by the Senior Care Partner and the Director of Nursing for licensed nursing staff on all shifts about monitoring residents on [MEDICATION NAME] therapy for bleeding and the prompt notification of physicians about bleeding, the acquisition of [MEDICATION NAME]/INR results as ordered by the physician, the prompt notification of physicians about abnormal [MEDICATION NAME]/INR results, the initiation of new physician's orders [REDACTED]. Licensed nursing staff not available were to be in-serviced prior to being allowed to work an assigned shift. Completed 2/18/10 4. In-services were conducted by the Senior Care Partner and the Director of Nursing for certified nursing staff on all shifts about the identification of signs and symptoms of bleeding and the prompt notification of bleeding to the nurse. Certified nursing staff not available were to be in-serviced prior to being allowed to work an assigned shift. Completed by 2/18/2010 for on duty staff and by 2/22/10 for all CNAs prior to being allowed to work . 5. A comprehensive care plan was developed for resident #21 to include interventions for monitoring his/her [MEDICATION NAME] therapy. Completed 2/18/10 6. Care plans were revised on those residents on [MEDICATION NAME] therapy to include interventions to consult with physicians when there was a significant change in condition. Care plan meetings on 2/18/2010 for the 12 residents on [MEDICATION NAME] revisions were written care plan. 7. The DON or Unit Managers were to monitor residents on [MEDICATION NAME] therapy daily to ensure that laboratory tests ([MEDICATION NAME]/INR) were obtained as ordered by the physicians. Upon receipt of [MEDICATION NAME]/INR lab results, the DON or Unit Managers were to ensure that the physician received those results immediately. Begun 2/18/2010 8. The Policy and Procedures for the use of [MEDICATION NAME] therapy was reviewed with nursing staff on all shifts and will be reviewed with any nursing staff not available prior to their being assigned to work. Completed by 2/18/2010 for on duty staff and by 2/22/10 for all CNAs prior to being allowed to work . 9. The medical records for residents newly admitted will be reviewed within 24 hours by the Director of Nursing or Unit Managers to ensure that laboratory orders ([MEDICATION NAME]/INR) are obtained and will be monitored by the administrative staff weekly. Begun 2/18/2010