Every finding on record at Pruitthealth - Virginia Park

Based on observations, staff interviews, record reviews, and review of the facility policy titled, Wound Observation and Assessment Documentation, the facility failed to perform consistent weekly skin assessments and failed to follow up on identified skin issues for one resident (R) (R51) of thirteen residents. Actual Harm was identified to have occurred on March 21, 2025, when R51 sustained a pressure ulcer to the left ankle due to the facility not conducting routine skin checks while wearing a wander guard. Findings include: A review of the policies titled, Wound Observation and Assessment Documentation, revised 06/14/2024, revealed under section, 13. Documentation Form - Document wound assessment/observation utilizing the wound management system/events/observations using the Electronic Health Record. Daily documentation is required unless a change is noted then documentation will be completed in the womb manager dot room assessment and documentation is completed weekly and when there is significant change was in the documentation of womb observation and assessment form dot wall measurements are completed weekly and when there is significant change in room status by the SIC RN. Licensed Practical Nurses may be allowed to document if allowed by State Board . Under section, 14. Weekly Body Audits: as an integral part of the pressure ulcer prevention program, and audit of all residents will be completed on admission and readmission, prior to any discharge or transfer unless the residents clinical condition prohibits the audits such as with an emergency transport and a minimum of every week the Director of Health Services (DHS) or RN Supervisor will develop a schedule of when each resident is to have the scan audit completed by the assigned charge nurse each week. This procedure is in addition to the responsibility of each partner to notify the Skin Integrity Coordinator (SIC) or designee when an area of altered skin integrity is identified . Review of the clinical electronic record for R51 revealed she was admitted to the facility on [DATE] with diagnoses that included but not limited to type 2 diabetes mellitus without complications, urinary tract infection, vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 5, indicating he had severe cognitive impairment. Record review of the physician's orders revealed R51 with a start date of 6/10/2021 to check wander guard placement and function. Orders start date on 10/11/2021 to check wander guard placement on left leg. Orders start date of 7/29/2022 to check wander guard to left leg for placement, swelling, redness and pain every shift. Orders start date on 4/23/2025 of arterial injury to cleanse left ankle with normal saline and paint with betadine and cover with rolled gauze and tape as needed. Record review of the care plan dated 4/22/2025 for R51 with a problem of resident having an arterial ulcer to the anterior lower ankle and resident having diagnosis of diabetes. Goals of resident's ulcer will not increase in size, will not exhibit signs of infection, and ulcers will heal without complications. Interventions approaches are assessing circulation, motion and sensation of both lower extremities daily, report discoloration, swelling and pain upon daily assessments. Record review of Braden Scale for predicting pressure sore risk dated 11/25/2024 revealed R51 at ten (10) points indicating a high risk for developing pressure sores. Interview on 6/11/2025 at 1:43 pm with Director of Health Services (DHS) stated the facility has two wound nurses but the main one is Licensed Practical Nurse (LPN) II. She stated once a staff that does direct care identifies a wound, they are required to report it immediately to the nurse. She stated they begin a Stop-and-Watch process so it can be given to the wound nurse for observation to start treatment, check computer for interact notes, complete a Sbar documentation, contact wound doctor or Nurse Practitioner (NP), and notify the residents' family representative. She stated R51 currently has a wound that was found in March and is being treated for it by the wound nurse. Interview on 6/11/2025 at 2:10 pm with LPN II Wound Care Nurse mentioned she treats R51's wound and it has almost completely healed. She stated she does weekly measurements. She confirmed from her knowledge that R51 developed the wounds from an old wandering alarm guard device that was located on her ankle. She stated, since the time the wound was discovered, the facility changed the style of the device to be placed on our residents' wrist area instead. Interview on 6/12/2025 at 1:33 pm with DHS and LPN II both confirmed they believe the wound came from the old wandering guard ankle bracelet. DHS stated the Certified Nursing Assistant (CNA) who originally found the wound a month before discovering it again while she was assisting resident in bathroom and giving her a shower and noticed it on her ankle. DON stated CNA LL immediately reported it to LPN KK, who was the nurse assigned to the resident's hall. She stated, Here is a written statement of the nurse explaining the wound was found a month prior to reporting it the second time but failed to do a Stop and Watch process to properly notify the Wound Care Nurse so she could immediately assess the wound on the resident. DON stated, a whole month later our Restorative Nurse noticed it while during a door alarm testing of the ankle device. LPN II stated, we changed our skin audit forms to be more detailed after the incident happened with R51. DON stated, I have no answer as to why LPN KK did what she did and why it took so long for her to report it, but I can say that maybe because she did not have a unit nurse manager during that period, and we just got one at the beginning of June. Interview on 6/12/2025 at 1:51 pm with CNA JJ who reported she noticed the wound and reported it immediately to the charge nurse. She stated they are now doing daily testing and weekly audits on the devices to ensure its effectiveness. She stated she logs the information in a binder and the nurse puts it in the residents' electronic medical records. CNA JJ reported they currently have a total of thirteen residents on wandering alarm guard devices. She stated, I am glad about the new style device because the other one had sharp rough edges around the band that could easily irritate or rub against the skin. Interview on 6/12/2025 at 4:00 pm with DHS revealed her expectation for her nursing staff is to always follow their standard procedures on reporting once a concern is identified. She confirmed that everyone should be looking and doing a skin check assessment especially when the residents have their weekly showers and bed baths. She confirmed that R51 received physician's orders of a start date of 6/3/2021 to receive the wandering alarm device on her ankle. She stated after the incident of her developing a pressure ulcer, the facility changed the device style and her physician's orders were changed effective on 4/22/2025. She stated, I stress to my staff all the time that we have a process and protocol we must follow at all times. When it was brought to my attention a month later that a resident developed a pressure ulcer, but it was not properly reported, I reacted with our facility-wide immediate jeopardy process. The facility implemented the following: 1. Root Cause Analysis on 4/22/2025 - with root cause determined to be a performance related issue related to the experienced nurse that discovered the wound not following procedures. Antiquated wander guard system needed to be replaced due to required bands having an edge than can cause skin injury. Solution: Staff education, a Performance improvement Plan for monitoring skin integrity program, and push approval for a new wander guard system installation with soft bands that resemble a smart watch. 2. Body Audits on residents completed 4/23/2025 - 4/27/2025 3. Skin assessment for resident dated 4/23/2025 indicating wound to ankle 4. 4/23/2025 Skin Observation; focus observation, shower sheets to include every nurse is responsible for doing skin assessments weekly. 5. Beginning 4/23/2025 audits began by the skin integrity nurse on a weekly basis for 5 residents per week related to weekly skin note completion, care plans are updated, and RP notification of identification/progress of skin integrity issues. 6. 4/24/2025 Record of Partner Corrective Action Form dated 4/24/2025 indicating on 3/21/2025 employee observed an open area on resident but did not address or assess for treatment. Staff involved was suspended for three days. 7. 4/30/2025 Ad Hoc QAPI meeting regarding wound system/pressure wounds and will be followed in QAPI monthly for three months. 8. New wander guard system installed on 5/1/2025 and soft wristband transmitters were placed on residents on 5/5/2025. 9. Education provided on 5/6/2025 and 5/26/2025 - 5/28/2025 education related to abuse(neglect), specialty mattress and floating heels, skin moisturizer, shower sheets, Stop and Watch and reporting wounds 10. Wound Audit dated 5/29/2025 indicating date wound identified, site of the wound, treatment orders in place match the site, documentation of doctor and responsible part, care plan updated with interventions, wound assessment completed every seven days. Cross-refer to F-656

Based on observations, staff interviews, record review, and a review of the facility's policy titled, Care Plans, the facility failed to develop a care plan for one resident(R) (R51) related to wound care for one of 31 sampled residents. Actual Harm was identified on March 21, 2025, when R51 sustained a pressure ulcer to the left ankle due to the facility not conducting routine skin checks while wearing a wander guard. Findings included: Review of the policies titled, Care Plans, revised 7/27/2023, indicated under section, admission Comprehensive Plan of Care - 3. The comprehensive person -centered care plan is developed to include measurable goals and time frames to meet a patient/resident's medical, nursing and psychosocial needs the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial needs that are identified in the comprehensive assessment . Review of the admission Minimum Data Set (MDS) dated [DATE], revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 5, indicating he had severe cognitive impairment. Record review of the physician's orders revealed R51 with a start date of 6/10/2021 to check wander guard placement and function. Orders start date on 10/11/2021 to check wander guard placement on left leg. Orders start date of 7/29/2022 to check wander guard to left leg for placement, swelling, redness and pain every shift. Orders start date on 4/23/2025 of arterial injury to cleanse left ankle with normal saline and paint with betadine and cover with rolled gauze and tape as needed. Interview on 6/12/2025 at 1:33 pm with Director of Nursing (DON) confirmed she requires each staff that is responsible for that care area to update the care plan and not the MDS Coordinator. She stated that Licensed Practical Nurse (LPN) II is the wound care nurse; therefore, she is responsible for communicating to the restorative department and MDS Coordinator to update the care plan for the equipment's functioning. She confirmed and stated, the resident's care plan only covers the working and functioning of the wandering alarm device's equipment but not any monitoring of the resident's skin for at risk breakdowns while utilizing the device. Cross-refer to F686 The facility implemented the following: 1. Root Cause Analysis on 4/22/2025 - with root cause determined to be a performance related issue related to the experienced nurse that discovered the wound not following procedures. Antiquated wander guard system needed to be replaced due to required bands having an edge than can cause skin injury. Solution: Staff education, a Performance improvement Plan for monitoring skin integrity program, and push approval for a new wander guard system installation with soft bands that resemble a smart watch. 2. Body Audits on residents completed 4/23/2025 - 4/27/2025 3. Skin assessment for resident dated 4/23/2025 indicating wound to ankle 4. 4/23/2025 Skin Observation; focus observation, shower sheets to include every nurse is responsible for doing skin assessments weekly. 5. Beginning 4/23/2025 audits began by the skin integrity nurse on a weekly basis for 5 residents per week related to weekly skin note completion, care plans are updated, and RP notification of identification/progress of skin integrity issues. 6. 4/24/2025 Record of Partner Corrective Action Form dated 4/24/2025 indicating on 3/21/2025 employee observed an open area on resident but did not address or assess for treatment. Staff involved was suspended for three days. 7. 4/30/2025 Ad Hoc QAPI meeting regarding wound system/pressure wounds and will be followed in QAPI monthly for three months. 8. New wander guard system installed on 5/1/2025 and soft wristband transmitters were placed on residents on 5/5/2025. 9. Education provided on 5/6/2025 and 5/26/2025 - 5/28/2025 education related to abuse(neglect), specialty mattress and floating heels, skin moisturizer, shower sheets, Stop and Watch and reporting wounds 10. Wound Audit dated 5/29/2025 indicating date wound identified, site of the wound, treatment orders in place match the site, documentation of doctor and responsible part, care plan updated with interventions, wound assessment completed every seven days.

Based on observations, staff interviews, and record reviews, the facility failed to ensure the bilevel positive airway pressure, (BiPAP) was properly stored in a manner to prevent contamination for one of 19 residents (R) (R54). The deficient practice had the potential to increase the risk of respiratory infection. Findings include: Review of the medical record for R54 revealed the resident was admitted to the facility with a diagnosis of but not limited to sleep apnea (sleep disorder characterized by repeated pauses in breathing), shortness of breath, and acute upper respiratory infection. Review of the most recent Quarterly Minimum Data Set (MDS) dated [DATE] revealed R54 had a Brief Interview for Mental Status (BIMS) of 14 indicating little to no cognitive impairment. Further review in Section O (Special Treatments, Procedures, and Programs) stated R54 is on respiratory therapy. Review of care plan documented R54 has a diagnosis of sleep apnea and uses a BiPAP machine. Review of the Physician's Orders documented BiPAP every night at bedtime and PRN (as needed) with sleep. Observations on 6/10/2025 at 10:51 am and 6/10/2025 at 4:33 pm revealed R54 BiPAP mask was lying on his bed uncovered. Observation and interview on 6/11/2025 at 10:42 am with License Practical Nurse (LPN) BB and Nurse Navigator confirmed R54 BiPAP mask was not properly stored and stated the staff should come behind R54 to store the mask in the bag attached to the concentrator. Interview on 6/11/2025 at 2:04 pm with the Director of Nursing (DON) stated there should be a bag to place the mask for the BiPap materials.

Based on observations, interviews, and review of the facility policy titled, Infection Control-Housekeeping Services the facility failed to ensure three of 18 rooms (Rm 306, 307, and 308) on the 300 Hall Packaged Terminal Air Conditioner (PTAC) units air filters were free or dirt and debris. The deficient practice had the probability of diminishing the air quality for the residents residing in rooms 306, 307 and 308. Findings include: Review of the facility policy titled, Infection Control-Housekeeping Services revised date 10/16/2023 revealed under Policy Statement: It is the policy of this facility to ensure housekeeping services will be performed on a routine and consistent basis to ensure an orderly, sanitary, and comfortable environment. Observation on 6/10/2025 at 11:57 am in room [ROOM NUMBER]B revealed the PTAC unit had brownish material with debris and dark colored build up noted on the control board, the vent filters were covered with brownish and black substances. Observation on 6/10/2025 at 12:10 pm in room [ROOM NUMBER]B revealed the PTAC unit filter was covered with black and brownish debris and a gray-like substance. Observation on 6/10/2025 at 12:20 pm in room [ROOM NUMBER]A revealed the PTAC unit filter was covered with black and brownish substance and was not attached to the unit but laying in the floor underneath. Interview on 6/12/2025 at 7:13 am with the Administrator in room [ROOM NUMBER]B confirmed the vents, air filter and PTAC unit being covered with debris and dirt like substance. During the interview the Administrator revealed that Maintenance was responsible for the filters and housekeeping was responsible for the cleaning of the units. Observation and interview on 6/12/2025 at 11:05 am with the Maintenance Director, Housekeeping Supervisor, and Administrator confirmed all observations during confirmation rounds. Interview on 6/12/2025 at 1:45 pm with the Housekeeping Supervisor revealed that the PTAC units are wiped down on the outside by housekeepers and maintenance is responsible for ensuring the filters are cleaned. Interview on 6/12/2025 at 1:45 pm with the Maintenance Director revealed he is responsible for cleaning the PTAC filters. The Maintenance Director revealed the PTAC filters are paper filters, and he replaces them with new filters when needed.

Based on observations, staff interviews, record review, and review of the facility's policy titled, Medication Administration: General Guidelines, the facility failed to adequately assess one of 31 Residents (R) (R269) for self-administration of medication. Findings include: Review of the facility's policy titled, Medication Administration: General Guidelines with a revised date of 4/10/2019 documented Under the section Procedure: (3) Patients/residents are allowed to self-administration medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. 1. R269 was admitted to the facility on [DATE] with a diagnosis of but not limited to vascular dementia with agitation, cognitive communication deficit, and depression. Review of R269 Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 10 indicating moderate cognitive impairments. Review of the care plan revealed R269 was not documented for self-administration of medication. Review of Physician's Orders for R269 revealed no orders were found for eye drops (lubricant and redness reliever). Review of R269's clinical record revealed there was no self-administration for medication assessment. During an observation on 6/10/2025 at 10:19 a.m. revealed R269 had two 0.5 fl. Oz (Fluid Ounces) bottles of lubricating eye drops on her bedside table. During a walk-through observation and interview on 6/10/2025 at 11:14 am with Licensed Practical Nurse (LPN) AA, LPN BB, and the Nurse Navigator confirmed the two bottles of lubricating eye drops sitting on R269 bedside table. During the observation LPN AA confirmed that R269 had not been assessed for self-administration of medication. During an interview on 6/11/2025 at 2:04 pm with the Director of Nursing (DON) revealed that medications should not be at any resident's bedside. She stated the residents must be assessed and approved for self-administration of medication. If a resident is approved then medications should be locked, care planned, and residents assessed on a quarterly basis. DON continued to state she expects the rounds to be conducted properly to ensure there are not any unauthorized medications at the residents' bedside.

Based on observations, staff interviews, record reviews, review of the facility's policy titled, Covid-19 Isolation and Cohorting Process, and review of the Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic the facility failed to follow droplet transmission-based precautions procedures prior to entering and exiting Covid positive resident rooms on one of four halls. Findings include: Review of the facility's policy titled Covid-19 Isolation and Cohorting Process dated 11/13/2023 under the section titled, Entering or Exiting Confirmed Positive or Suspected of COVID-19 Infection room revealed 6) N95 Masks and eye protection must be changed to appropriate mask (and eye protection), if indicated, after exiting a room on Transmission-Based Precautions. Review of the Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated May 8, 2023 revealed, If masks are used during the care of patient for which a NIOSH Approved respirator or facemask is indicated for personal protective equipment (PPE) (e.g., NIOSH Approved particulate respirators with N95 filters or higher during the care of a patient with SARS-CoV-2 infection, facemask during a surgical procedure or during care of a patient on Droplet Precautions), they should be removed and discarded after the patient care encounter and a new one should be donned. Observation on 1/2/2024 at 11:45 am of Licensed Practical Nurse (LPN) II entering a Droplet Transmission Based Precaution (TBP), Covid positive room, 113. She donned gown and gloves. LPN II already had on an N-95 mask and was wearing a pair of glasses that did not have side protection and she did not put on a face shield. Observation on 1/2/2024 at 11:55 am of LPN II exiting room [ROOM NUMBER] revealed she did not remove her N-95 mask and put on a new mask. Observation on 1/2/2024 at 12:02 pm of Respiratory Therapist (RT) FF and Certified Nursing Assistant (CNA) HH donned gown and gloves. Both already had on an N-95 mask and the RT was wearing glasses with no side protection, and neither put on a face shield or goggles upon entering TBP room [ROOM NUMBER]. Observation on 1/2/2024 at 12:07 pm of RT FF exit room [ROOM NUMBER] and did not remove her N-95 mask and put on a new mask. RT FF walked down to the nurse station and into her office. She was observed to take her bare hand and pull her mask down and pick up a cup and drink from it. Observation on 1/2/2024 at 12:20 pm of Phlebotomist GG don gown, gloves, and face shield. She was wearing an N-95 mask and entered a Droplet TBP, Covid positive room, 111. Observation on 1/2/2024 at 12:28 pm of Phlebotomist GG exit room [ROOM NUMBER]. Still wearing her face shield and N-95 mask, she walked down the hall and into the Lab Room behind the nurse station and discarded the face shield into the trash can. She pulled her mask down using her bare hand. During this time an interview was conducted with Phlebotomist GG and she revealed it was ok for her to discard her face shield in the trash in the lab room and to wear her N-95 mask after being in the Covid positive TBP room. Observation on 1/2/2024 at 12:32 pm of CNA HH opened the door of room [ROOM NUMBER]. She was wearing gloves but did not have her gown on. CNA HH reached and pulled the dirty linen cart to the doorway of room [ROOM NUMBER] and shut the door. She opened the door back up and had linens in her gloved left hand. As she used her gloved right hand to open the top of the dirty linen cart, she rubbed the linens in her hand up against her ungowned clothing as she was placing the linens inside the dirty linen cart and then shut the top of the linen cart. Interview on 1/2/2024 at 12:40 pm with CNA HH revealed the linens she was disposing of were not wet but were linens from the residents bedding and were considered dirty linen. Interview on 1/2/2024 at 12:50 pm with the Assistant Director of Nursing (ADON), and acting Infection Control Preventionist (ICP) in the facility, revealed when a resident is on Droplet Precautions, she expects staff to wash or sanitize their hands, don gown, gloves, mask, and face shield. She revealed if the staff member has glasses on without side protection, she expects them to put on the face shield and stated that there must be side protection for the eyes and that regular glasses would not suffice, and a face shield must be worn as well. She revealed that upon exiting the TBP room she expects the Personal Protective Equipment (PPE) to be removed while in the resident room and the staff members should wash or sanitize their hands and don a new mask after exiting the room. ADON revealed if the staff do not doff the PPE there was a potential to put others at risk. Interview on 1/4/2024 at 1:00 pm with the facility Regional [NAME] President of Operations revealed the video from the facility cameras were viewed and education was provided to those staff who did not practice proper infection control practices as identified on the 100 hall on 1/2/2024.

Based on staff interviews, record review, and review of facility's policy titled, Refusal of Care Against Medical Advice, the facility failed to document the risks and benefits of remaining at the facility, and notification of the physician at the time of discharge for one of 29 sampled Residents (R) (R116) that discharged from the facility Against Medical Advice (AMA). Findings included: Review of the facility's policy titled Refusal of Care Against Medical Advice dated 11/29/2022 revealed, in Section Five (5) Determine Capacity the following: (a) In the event a resident refuses treatment, medication, or services that may maintain, save, prolong, or terminate his/her life, an assessment of decision-making capacity shall be performed. (b) A physician must personally examine the resident to determine if they lack sufficient capacity to make significant decisions regarding their medical treatment or the ability to communicate by any means such decisions. (c) . The physician's findings must be documented using the Assessment of Decision-Making Capacity Form, which shall become a permanent part of the resident's medical record. Section 6 Documentation: (a) The attending physician, with assistance from the healthcare center staff, shall inform the resident of the benefits, risks, and possible negative consequences of the refusal of care. The physician will document the contents of the communication in the physician notes. (b) The Refusal of Care Against Medical Advice Form shall be completed and signed by the attending physician, the patient or the patient's legal representative, and a witness. (c) The Refusal of Care Against Medical Advice Form shall become a permanent part of the patient's medical record. Review of R116's medical record revealed she was admitted with a primary diagnosis of pathological hip fracture and fall on same level from slipping, tripping, and stumbling. R116 's medical history revealed the resident had a history of hemiplegia and hemiparesis following cerebrovascular disease affecting left dominant side, generalized muscle weakness, repeated falls, need assistance with personal care, difficulty walking, and hypertension. Further review of medical records revealed, R116 left the facility AMA on 10/11/2023. Review of R116's Discharge Minimum Data Set (MDS) assessment dated [DATE] revealed, Section C-Cognitive Patterns indicated the resident's cognitive skills for daily decision making was severely impaired; Section GG-Functional Abilities and Goals indicated resident required partial/moderate assistance with toileting and personal hygiene and substantial/maximal assistance with lower body dressing. Review of R116's progress note dated 10/11/2023 at 2:12 am revealed, the Family of R116 came to the facility to discharge resident. Three nurses advised the family against being discharged . The Family of R116 insisted on getting her out of the facility. A family member was allowed to enter hallway because one of the other family members began making threats and using vulgar language. A family member transported the resident against medical advice and was given the resident's personal belongings upon discharge. Two additional family members assisted in the car transfer at approximately 1:45 a.m. Review of R116's medical record revealed there was no evidence that the risks, benefits, and possible negative consequences of the AMA were documented on the Refusal of Care Form. The record lacked documentation that the physician was notified of the AMA. In addition, there was no evidence in the medical records to indicate discharge instructions and medications were given to R116 or the resident's representative at the time of the discharge. Review of medical records under the Social Services Progress Notes revealed no documentation related to the AMA discharge. Review of medical records revealed there was no evidence of documentation made by the physician regarding the AMA Discharge. Interview conducted on 1/3/2024 at 9:42 am with the Social Service Director (SSD) revealed she was made aware R116 discharged from the facility AMA. SSD verified she did not follow up on the resident after the discharge. SSD further stated that the Nurse Navigator usually followed up with residents post discharge, but that position was vacant. SSD verified that there was no documentation in the record related to discharge instructions, AMA form, or disposition of medications upon discharge. SSD stated that she was responsible for ensuring that the AMA's are in the closed record. Interview conducted on 1/3/2024 at 10:06 am with the Director of Health Services (DHS) revealed that when a resident discharged AMA, the staff would determine the reason for discharge, notify the physician and State Agency, and document the communication between all parties involved. DHS stated the discharge instructions and medications are provided at the time of discharge for residents and/or residents family including a resident who left AMA. DHS stated that the SSD was responsible for making sure the AMA was signed. DHS stated that she usually checked the progress notes to see if the physician was notified but did not remember if she had checked R116's record. DHS verified there was not any documentation in the record related to the physician being informed of the AMA or a signed AMA form in the record. DHS stated that the Nurse Navigator usually followed up after a discharge to check on the resident and would make sure documentation was in the record related to AMA discharge. Interview conducted on 1/3/2024 at 10:37 am with the Medical Records Clerk revealed that all documents were scanned into the R116's medical record and that there was not an overflow of paper records in the facility. She further stated that R116's closed record was complete and there were not any additional documents related to her care in the facility. Interview conducted on 1/3/2024 at 11:31 am with the Administrator revealed it was his expectation that the process should be followed to include getting the form signed if there was time to get it done, notify the physician, notify the Nurse Navigator for documenting and following up post discharge. The Administrator stated the Nurse Navigator that worked at the facility during that time is no longer employed at the facility.

Based on observations, resident and staff interviews, record review, and review of the facility's policy titled, Self-Administration of Medications by Patients/Residents, the facility failed to assess and obtain a physician order for one of 29 sampled Residents (R) (R75) to safely self-administer and store nebulizer treatments at bedside. This failure had the potential for medication error and to alter the effectiveness of the medication. Findings include: Review of the facility's policy titled, Self-Administration of Medications by Patients/Residents dated 12/2/2022 under the Policy Statement revealed, 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 that patient/resident and other patients/residents of the healthcare center. Under the section titled Procedure revealed, 1. The opportunity to self-administer medications is reviewed during the routine assessment by the healthcare center's interdisciplinary team utilizing the Electronic Health Record Observation tool, Medication Self-Administration Observation. 2. If a resident or family member desires to self-administer medications, an assessment is conducted by the licensed nurse to assess the individual's cognitive, physical, and visual ability to carry out this responsibility. Also, the resident or family member in conjunction with the facility nurse should utilize the Electronic Health Record Observation tool, Medication Self-Administration Observation to complete the administration of the medication. 3. 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 the self-administration medication observation 5. Bedside Storage of Medications is permitted only when it does not present a risk to confused patients/residents who wander into rooms of, or room with, patients/residents who self-administer. The following conditions are met for bedside storage to occur: The manner of storage prevents access by other patients or residents. Locking drawers or cabinets are required only if unlocked storage is ineffective. The medication provided to the patient or resident for bedside storage are kept in the package as dispensed by the provider pharmacy. The Electronic Health Record Medication Administration record form is printed and maintained at the bedside and is reviewed on each nursing shift, and the administration information is transferred to the electronic medical medication record. Notation of each dose is made using licensed nurse initials in the appropriate space and note in the nursing comments resident/patient self-administered medication(s). Only one signature per shift is required by the nurse documenting the patient/resident's report of self-administration. Attending physician enters an order on the electronic health record for bedside. Observation and interview on 1/2/2024 at 2:34 pm with R75 revealed, nebulizer medication vials in a Styrofoam cup located on R75's overbed table. R75 stated, she administered her own DuoNeb nebulizer treatments every 12 hours and albuterol nebulizer treatments as needed every four hours. Observation and interview with R75 on 1/2/2024 at 3:40 pm revealed multiple nebulizer medication vials (clear colored vials and saline vials (pink colored vials) in a small Styrofoam cup located on the R75's overbed table. R75 stated, she used saline to assist with coughing up and clearing phlegm from her tracheostomy. Observation on 1/3/2024 at 12:17 pm revealed nebulizer medication vials and saline vials inside a Styrofoam cup located on R75's over bed table. Review of R75's Electronic Medical Record (EMR) revealed she was readmitted to the facility with diagnoses that included acute respiratory failure. Review of R75's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 12, which indicated moderate cognitive impairment. Review of R75's Self-Administration of Medication dated 12/29/2023 at 1:33 pm under subsection, Self-Determination revealed, the resident did not want to self-administer medications. Under subsection, Evaluation revealed, it was not appropriate for the resident to self-administer medications and resident prefers nursing staff to administer medications. Review of R75's Physician Orders with start date of 12/28/2023 included but was not limited to ipratropium-albuterol solution for nebulization; 0.5 milligrams (mg)-3 mg (2.5 mg base)/3 milliliters (ml); one vial - inhalation twice a day; ipratropium-albuterol solution for nebulization; 0.5 mg-3 mg (2.5 mg base)/3 ml; one vial, inhalation every six hours as needed. Interview conducted on 1/3/2024 at 12:01 pm with Licensed Practical Nurse (LPN) JJ revealed that the proper procedure to follow when a resident wants to self-administer medication, would be for the nurse to notify the physician to obtain an order and assess the resident which would include an assessment of memory, vision, comprehension, and observation of medication self-administration. She stated the medication would not be left at the bedside, but it would be located on the nurse's medication cart. Interview conducted on 1/3/2024 at 12:39 pm with Respiratory Therapist (RT) FF revealed that she was aware that R75 self-administered her nebulizer treatments and performed self-tracheostomy care. She stated that she had given R75's nebulizer medication vials each day and that they were kept at her bedside for her to self-administer nebulizer treatments. She stated R75 had been self-administering nebulizer treatments for a long time and was uncertain of the exact time frame she began. She confirmed and verified the care plan on the EHR indicated R75 would self-administer her nebulizer treatments. She confirmed and verified the assessment dated [DATE] titled Self-Administration of Medications assessment indicated R75 would not be self-administering medications. She confirmed and verified there was no physician order for R75 to self-administer nebulizer treatments or perform self-tracheostomy care. An interview conducted on 1/3/2024 at 1:02 pm with the Director of Nursing (DON) revealed that she was not aware of any resident in the facility who was self-administered any medications. She stated she expected staff to notify her of a resident's desire to self-administer medications so that she could verify all policies and protocols were properly followed to allow for this. She confirmed and verified the nursing assessment Self-Administering of Medications indicated that R75 would not be self-administering any medication, she confirmed and verified there was not physician order for R75 to self-administer nebulizer treatments. Interview conducted on 1/3/2024 at 5:45 pm with the Senior Nurse Consultant confirmed and verified the assessment completed on 12/29/2023 indicated R75 would not be self-administering medications. She confirmed and verified there was not a physician order for R75 to self-administer nebulizer treatments. Cross Reference F657

Based on observations, interviews, and record review, the facility failed to ensure one of 29 sampled Residents (R) (R568) reviewed for limited range of motion received passive range of motion exercises as needed to address limited range of motion in her bilateral upper extremities. This failure created a potential for worsening contracture (fixed resistance to passive stretch), pain, or skin breakdown. Findings include: During an observation and interview on 1/2/2024 at 11:28 am revealed Family of R568 performed Passive Range of Motion (PROM) exercises to R568's bilateral arms and hands, then placed a rolled washcloth into both hands. The Family of R568 stated after R568's stroke, the staff at the hospital expressed how important it was for her to receive exercises to prevent her arms and hands from contracture. Further interview with the Family of R568 revealed the facility staff did not provide exercises. During an observation on 1/3/2024 at 11:55 am revealed, R568 lying in bed with a hand roll intact to her left hand and the right hand closed. During an observation and interview on 1/4/2024 at 9:59 am revealed Certified Nursing Assistant (CNA) CC providing Activities of Daily Living (ADL) care for R568. CNA CC opened R568's hands and placed a rolled washcloth in each hand. CNA CC stated that both of R568's hands were contracted, and she would only apply washcloths to them. Further interview with CNA CC revealed, she did not perform any type of stretching to her hands or arms. Review of R568's Electronic Medical Record (EMR) revealed a diagnosis including cerebral infarction. Review of R568's most recent Quarterly Minimum Data Set (MDS) dated [DATE] revealed she was dependent for all ADLs and had limited range of motion on one side in the upper and lower extremities. Review of R568 's active Physician's Orders, located in the Orders tab of the EMR, revealed there was not an order for passive range of motion. Review of R568's Occupational Therapy Progress and Discharge Summary dated 6/28/2023 revealed, Long-Term Goals were made for caregiver: Home Exercise Program as of 6/28/2023 - Caregiver will be able to assist patient to complete home exercise program for Bilateral Upper Extremity Passive Range of Motion (PROM) with maximum assistance (76-99%). Review of R568's Activities of Daily Living (ADL) Tracker for November 1, 2023, through January 3, 2024, revealed there was no evidence of any documentation related to the staff performing Range of Motion (ROM) exercises for R568. During an interview on 1/3/2024 at 1:23 pm with Licensed Practical Nurse (LPN) AA revealed R568 was not receiving ROM exercises to reduce the risks of contractures. LPN AA stated R568 was total care and required assistance from the staff for any functional movement. LPN AA further stated that it was the responsibility of the therapy department to provide residents with exercises. LPN AA also stated that staff did not perform exercises for R568, but he had witnessed the resident's family performing exercises for her. During an interview on 1/3/2024 at 2:01 pm with Therapy Manager revealed that R568 had been on the caseload for Occupational Therapy and the last end of care was 6/28/2023. Therapy Manager further stated R568 had severe hypertonicity and increased tone of bilateral upper extremities and no splinting was recommended at that time of discharge. Therapy Manager also stated that resident was discharged from skilled therapy to a Caregiver Functional Exercise Program for PROM to her upper extremities. During an interview on 1/3/2024 at 2:18 pm with Restorative Aide (RA) DD revealed that she performed range of motion and splinting for residents in the facility. RA DD further stated R568 was not on her caseload and in some cases residents would be referred to floor maintenance (CNAs on the floor) for exercises. RA DD also stated that if R568 was placed on a Functional ROM Program, that care should be documented in the ADLs record. RA DD confirmed R568 did not have anything on the ADL sheet to indicate resident was receiving ROM exercises by the floor CNAs. During an interview on 1/3/2024 at 2:33 pm with CNA CC revealed that she would often work with R568. CNA CC stated she made sure she placed a rolled washcloth in R568 hands each day to keep her hands from closing. CNA CC stated that she did not exercise R568 hands and arms because she had not been informed it was her responsibility. During an interview on 1/3/2024 at 2:49 pm with Director of Health Services (DHS) revealed that if a resident was on a Functional Range of Motion program, the CNAs assigned to that resident completed ROM during ADL care. DHS further stated the ROM exercises should be documented on the ADL Plan of Care. DHS verified that there was not any documentation in R568's record related to passive range of motion being performed. DHS further stated that no one communicated to her that R568 should be on a Functional Range of motion Program. During a follow-up interview with the DHS on 1/4/2024 at 8:48 am revealed Therapy did not inform the nursing department that R568 should be placed on a Functional PROM program from the therapy department. DHS stated there was a breakdown in communication and her expectations were that all care be provided as deemed necessary for each resident in the facility. A copy of the Facility's Range of Motion and Functional Range of Motion Program guidelines/Policy was requested during the survey but was not provided prior to exit. The Regional Nurse Consultant informed the Surveyor that the facility did not have a policy for range of motion, and only had a step-by-step guide of how to perform the exercises. Cross Reference F656

Based on observations, resident and staff interviews, record review, and review of the facility's policy titled Care Plans, the facility failed to revise the comprehensive care plan as needed related to self-administration of nebulizer treatments for one of 29 sampled Residents (R) (R75) following a hospital stay. This failure had the potential for the resident not to receive treatment and care according to her needs. Findings include: A review of the facility's policy titled Care Plans, dated 7/27/2023 under section titled, Care Plan Review and Update revealed, 1. Comprehensive care plans should be reviewed not less than quarterly according to the OBRA MDS schedule, following the completion of the assessment. Care plan updates/reviews will be performed within 7 days of each quarterly assessment, each acute change in condition, and as needed following each hospital stay 4. Care plans will be updated by nurses, Case Mix Directors (CMD), or any other interdisciplinary team member so that the care plan will reflect the patient/resident's needs at any given moment. A review of the Electronic Medical Record (EMR) revealed R75 readmitted to the facility on [DATE] with diagnoses listed but not limited to acute respiratory failure. A review of R75's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 12, which indicated R75 was cognitively intact. A review of R75's care plan dated 5/24/2023 indicated Resident to self-administer albuterol nebulizer treatment as ordered. Goals included but not limited to maintain patient air way. Interventions included but not limited to nebulizer treatments to be kept at bedside and replenished as needed. A review of R75's Self-Administration of Medication dated 12/29/2023 at 1:33 pm under subsection, Self-Determination revealed, the resident did not want to self-administer medications. Under subsection, Evaluation revealed, it was not appropriate for the resident to self-administer medications and resident prefers nursing staff to administer medications. A review of the EMR revealed Physician's Orders for R75 that included but not limited to ipratropium-albuterol solution for nebulization; 0.5 milligrams (mg)-3 mg (2.5 mg base)/3 milliliter (ml); one vial - inhalation twice a day; ipratropium-albuterol solution for nebulization; 0.5 mg-3mg (2.5 mg base)/3 ml; one vial, inhalation every six hours as needed. An observation and interview conducted on 1/2/2024 at 2:34 pm with resident R75 of nebulizer medication vials located on R75's overbed table was observed in a Styrofoam cup. R75 stated she administered her own nebulizer treatments of duo-nebs every 12 hours and albuterol nebulizer treatments as needed every four hours. An observation and interview conducted with R75 on 1/2/2023 at 3:40 pm revealed a small Styrofoam cup located on the R75's overbed table contained multiple nebulizer medication vials and saline vials. R75 stated she used saline to assist with coughing up and clearing phlegm from her tracheostomy. An observation conducted on 1/3/2024 at 12:17 pm revealed a Styrofoam cup located on R75 over bed table had nebulizer medication vials (clear colored vials) and saline vials (pink colored vials) inside the cup. An interview conducted on 1/3/2024 at 1:02 pm with the Director of Nursing (DON) revealed that she was not aware of any resident in the facility who was self-administered any medications. She stated she expected staff to notify her of a resident's desire to self-administer medications so that she could verify all policies and protocols were properly followed to allow for this. She confirmed and verified the nursing assessment Self-Administering of Medications indicated that R75 would not be self-administering any medication, she confirmed and verified there was not physician order for R75 to self-administer nebulizer treatments. An Interview conducted on 1/3/2024 at 1:15 pm with the Registered Nurse (RN) MDS Director EE revealed that when updating care plans it was the care plan coordinators responsibility to review the care plans and all supporting documents to verify that care plans were correct. She verified this was not done for R75 upon readmission to the facility from the hospital. She confirmed and verified on 12/29/2023 a Self-Administration of Medication Assessment was completed and indicated that R75 would not be self-administering medications. She confirmed and verified that there was not a physician order for the resident to self-administer nebulizer treatments and care plan was not revised. Cross Reference F554

Based on staff interviews, record review, and review of the facility's policy titled, Care Plan, the facility failed to ensure that a care plan was developed for one of 29 sampled Residents (R) (R568) reviewed for limitation in range of motion and Activities of Daily Living (ADL) deficits. This failure had the potential for the resident not to receive treatment and care according to her needs. Findings include: Review of the facility's policy titled Care Plan dated 7/27/2023 Policy Statement revealed, 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. Under section titled, Admission Comprehensive Plan of Care revealed, .3. The comprehensive person-centered care plan is developed to include measurable goals and timeframes to meet patient/resident's medical, nursing, psychological needs, the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychological needs that are identified in the comprehensive assessment. Review of R568's medical records revealed she admitted with diagnoses that included cerebral infarction, muscle spasms, and generalized muscle weakness. Review of R568's Quarterly Minimum Data Set (MDS) dated [DATE] revealed she was dependent for all Activities of Daily Living (ADLs) and had limited range of motion on one side in the upper and lower extremities. Review of R568's care plans with last review/revised date of 1/2/2024 revealed, there was not a care plan to address resident's bilateral hand contractures with interventions to reduce the progression of the contracture or a care plan related to resident being dependent on staff for ADL care. During an interview on 1/3/2024 at 1:23 pm with Licensed Practical Nurse (LPN) AA revealed R568 was not receiving range of motion exercises to reduce the risks of contractures. LPN AA stated R568 was total care and required assistance from staff for any functional movement. During an interview on 1/4/2024 at 8:35 am with Registered Nurse (RN), MDS Director revealed that R568 was dependent on staff for ADLs and had hand contractures. RN MDS Director verified that the resident did not have a care plan related to ADL deficits and limitations in ROM. RN MDS Director stated resident was total care, had limitations in ROM in upper and lower extremities. RN MDS Director acknowledged there should be a care plan. RN MDS Director stated the care plan was not developed because it was overlooked. During an interview on 1/4/2024 at 8:48 am with the Director of Health Services revealed that her expectations for all residents with contractures and required assistance with ADLs should have a care plan with interventions for their plan of care. DHS verified R568 did not have care plans developed. Cross Reference F688 47146

Based on observations, record review, interviews, and review of the policy titled Quality Assurance and Performance Improvement (QAPI) Plan, the facility failed to have an effective Quality Assurance process to implement action plans for identified systemic quality deficiencies. Specifically, the facility failed to maintain a safe temperature range of 71 to 81°F, during four out of five survey days. The census was 116. On 6/16/2022, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Health Services (DHS) were informed of the Immediate Jeopardy (IJ) on 6/16/2022 at 4:53 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on 6/13/2022. The IJ is outlined as follows: The facility failed to maintain the facility at a safe temperature range of 71 to 81°F for 116 residents. Specifically, on 6/13/2022 at 3:30 p.m., the facility's hall temperatures were noted to be 84 degrees Fahrenheit (F). On 6/13/2022 at 6:13 p.m., ten portable air conditioning arrived at the facility and installed throughout the hallways; however, this intervention failed and did not cool the facility to a safe temperature range. On 6/14/2022 at 4:54 p.m., the facility's hall temperature was noted to be 88 degrees F at the highest; the highest resident room temperature was 88 degrees F. On 6/15/2022 at 6:34 p.m., the facility's hall temperature was noted to be 89 degrees F at the highest; the highest resident room temperature was 91 degrees F. Observation of on 6/13/2022 of a resident who was in a vegetative state and who has a [CONDITION(S)] revealed the resident was flush and warm to touch. The resident's room temperature was 83.1 degrees F. Observation on 6/15/2022 revealed a resident who was observed to be flush. The resident's temperature was taken by a facility nurse and revealed a body temperature of 100.6 degrees F. The facility's QAPI committee identified the need for interventions for the facility to maintain safe temperatures when an ongoing issue with the facility's HVAC system was identified. However, there was no documented evidence provided to show interventions identified in the facility's QAPI plan were implemented. Specifically, the plan identified that the facility would access the temperatures of the facility and any identified temperatures above 81 degrees F would be acted on; however, the survey team was not provided with any documented temperatures. Furthermore, when the facility implemented their plan of portable air conditioners, the facility's temperatures continued to exceed the safe operating temperature range which placed all residents of the facility at harm or death. The IJ was related to the facility's noncompliance with the program requirements, as follows: F584: 483.10(i)(6)- Comfortable and safe temperature levels (Scope/Severity[S/S]: L.) F867: 483.75(g)(2)(ii) - Qapi/qaa Improvement Activities (Scope/Severity[S/S]: L.) The IJ situation was ongoing at the time of exit on 6/16/2022. Findings include: Review of facility policy titled, Quality Assurance and Performance Improvement Plan, revised 7/6/16 revealed the activities of QAPI involve members at all levels of the organization to: Identify opportunities for improvement; Address gaps in systems or processes; Develop and implement an improvement or corrective plan; Continuously monitor effectiveness of interventions. Observation on 6/13/22 at 2:45 p.m. the survey team became aware of the increasing temperatures in the facility and contacted the Maintenance Director. On 6/13/22 at 3:30 p.m., the Maintenance Director performed a temperature check of the 300 Hallway, which revealed it was 84 degrees Fahrenheit (F). The Maintenance Director stated, We have a weak system and because of the heat outside, it is not cooling appropriately. The resident rooms have their own cooling system. Interview on 6/13/22 at 3:32 p.m. with the Administrator stated he was informed of the current facility temperature of 84 degrees F by the Maintenance Director. He stated he has been dealing with this issue for three years. The Administrator stated last year the facility ordered the portable air conditioning units right before 7/2/21 and the year before the portable air conditioning units were ordered right before August 2020. He stated he has ordered portable air conditioning units now to keep the facility cool and expects the units to arrive soon. Interview on 6/13/22 at 4:11 p.m. with R#113 stated that it is hot in the hallways. R#113 stated, This is how it has been in the summers. Last year they had air conditioners (AC) brought in and put them throughout the facility. Interview on 6/13/22 at 4:20 p.m. R#12 was observed seated in his wheelchair on the 400 hallway and to have flushed skin and sweating on his face. R#12 stated the facility felt hot and was like this last year. Interview on 6/13/22 at 4:27 p.m. with Licensed Practical Nurse (LPN) DD stated Today is the hottest day so far. It has been hot before, but not this hot. Interview on 6/13/22 at 4:44 p.m. with the Maintenance Director, revealed the Administrator ordered the portable AC units after the discussion regarding the air temperature in the hallway. Interview on 6/13/22 at 6:12 p.m. with Certified Nursing Assistant (CNA) EE, stated ten portable AC units had arrived and staff members began putting the AC units together. Observations on 6/14/22 from 4:44 p.m. through 5:13 p.m. during a walk through of the facility with the Maintenance Director revealed temperatures were elevated as follows: 100 hallway near room [ROOM NUMBER] - 82 degrees F; and 100 hallway return air at ceiling 102 degrees F; 200 hallway near room [ROOM NUMBER] - 82 degrees F; room [ROOM NUMBER] - 85 degrees F (AC on; window open); 200 hallway near room [ROOM NUMBER]- 83 degrees F; 300 hallway near room [ROOM NUMBER] - 86 degrees F; room [ROOM NUMBER] - 87 degrees F; 300 hallway near nurses station - 85 degrees F; 300 hallway near room [ROOM NUMBER] - 84 degrees F; room [ROOM NUMBER] - 86 degrees F (R#47 stated, I'm hot in here); 300 hallway near room [ROOM NUMBER] - 84 degrees F; room [ROOM NUMBER] - 88 degrees F (window open); 400 hallway near day area - 88 degrees F; 400 hallway near room [ROOM NUMBER] - 82 degrees F; room [ROOM NUMBER] - 82 degrees F (AC not on in room); 400 hallway near room [ROOM NUMBER] - 84 degrees F; room [ROOM NUMBER] - 82 degrees F; 400 hallway near room [ROOM NUMBER] - 84 degrees F; room [ROOM NUMBER] - 83 degrees F. Even though the facility implemented the intervention of portable air conditioners, the facility's temperatures continued to remain at unsafe levels. Interview on 6/15/22 at 8:25 p.m. with the Administrator, revealed he had a plan of care (QAPI plan) in place for the temperature concerns, but stated he did not expect the survey team to enter the facility on a Sunday. During further interview, the Administrator stated the plan included a quote to have the heating, ventilation, and air conditioning (HVAC) system in the lobby replaced and the chillers in the basement replaced. He stated the HVAC system in the lobby was on a separate system that is just for the lobby area. The Administrator stated, when the chillers are repaired in the basement, that would fix the temperature issues in the remainder of the facility and resident rooms. The Administrator further stated the chiller in the basement stopped working in 2018 or 2019. He was unable to provide an answer why the HVAC system had not been previously repaired. Review of the facility's performance improvement plan (PIP) titled, Construction POC [plan of care] with a target end date of 7/31/22, included the HVAC system in the overall goal. Per the plan, a temperature audit was completed on 6/13/22 with temperature of 83 degrees F and revealed the Administrator implemented the heat plan. Under the Interventions section of the POC, there was a start date listed as 6/13/22 but the following intervention was listed on 5/23/22, Asses [sic] hallway temps, room temp, pass ice water, pass cold towels, order portal AC unit and Assess resident body temperature [sic] for heat exhaustion. Assess residents as needed. The heat plan was implemented after the survey team identified the rising temperature levels; however, the plan failed as the temperatures remained at unsafe levels. Review of the facility's Change Order Proposal, dated 5/23/22 revealed the quote indicated the following: Description of work: Lobby HVAC repair. Per request of [facility name], an investigation of the HVAC problems in the main lobby and in the basement was completed. The investigation revealed the lobby HVAC had a bad coil, and the basement needs a new compressor for the pneumatic controls. Further review of the quote revealed once these two items are addressed, all HVAC problems experienced in the lobby will be correct. Cross Refer F584

Based on observations and interviews, the facility failed to maintain the facility at a safe temperature range of 71 to 81 degrees Fahrenheit (F) on four of four hallways, during four out of five survey days. Additionally, the facility failed to maintain a homelike environment for 24 of 63 rooms in the facility. On 6/16/2022, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Health Services (DHS) were informed of the Immediate Jeopardy (IJ) on 6/16/2022 at 4:53 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on 6/13/2022. The IJ is outlined as follows: The facility failed to maintain the facility at a safe temperature range of 71 to 81°F for 116 residents. Specifically, on 6/13/2022 at 3:30 p.m., the facility's hall temperatures were noted to be 84 degrees Fahrenheit (F). On 6/13/2022 at 6:13 p.m., ten portable air conditioning arrived at the facility and installed throughout the hallways; however, this intervention failed and did not cool the facility to a safe temperature range. On 6/14/2022 at 4:54 p.m., the facility's hall temperature was noted to be 88 degrees F at the highest; the highest resident room temperature was 88 degrees F. On 6/15/2022 at 6:34 p.m., the facility's hall temperature was noted to be 89 degrees F at the highest; the highest resident room temperature was 91 degrees F. Observation of on 6/13/2022 of a resident who was in a vegetative state and who has a [CONDITION(S)] revealed the resident was flush and warm to touch. The resident's room temperature was 83.1 degrees F. Observation on 6/15/2022 revealed a resident who was observed to be flush. The resident's temperature was taken by a facility nurse and revealed a body temperature of 100.6 degrees F. The facility's QAPI committee identified the need for interventions for the facility to maintain safe temperatures when an ongoing issue with the facility's HVAC system was identified. However, there was no documented evidence provided to show interventions identified in the facility's QAPI plan were implemented. Specifically, the plan identified that the facility would access the temperatures of the facility and any identified temperatures above 81 degrees F would be acted on; however, the survey team was not provided with any documented temperatures. Furthermore, when the facility implemented their plan of portable air conditioners, the facility's temperatures continued to exceed the safe operating temperature range which placed all residents of the facility at harm or death. The IJ was related to the facility's noncompliance with the program requirements, as follows: F584: 483.10(i)(6)- Comfortable and safe temperature levels (Scope/Severity[S/S]: L.) F867: 483.75(g)(2)(ii) - Qapi/qaa Improvement Activities (Scope/Severity[S/S]: L.) The IJ situation was ongoing at the time of exit on 6/16/2022. Additionally. Substandard Quality of Care was identified with the requirements at 42 C.F.R. 483.10(i)(6) -- Comfortable and safe temperature levels (F584, Scope/Severity: L). Findings include: 1. Observation on 6/13/22 at 2:45 p.m. the survey team became aware of the increasing temperatures in the facility and contacted the Maintenance Director. On 6/13/22 at 3:30 p.m., the Maintenance Director performed a temperature check of the 300 Hallway, which revealed it was 84 degrees Fahrenheit (F). The Maintenance Director stated, We have a weak system and because of the heat outside, it is not cooling appropriately. He stated the resident rooms have their own cooling system. Interview on 6/13/22 at 3:32 p.m. with the Administrator, stated he was informed of the current facility temperature of 84 degrees F by the Maintenance Director. He stated he has been dealing with air conditioner issues for three years. The Administrator stated last year the facility ordered portable air conditioning units right before 7/2/21 and the year before the portable air conditioning units were ordered right before August 2020. He stated he has ordered portable air conditioning units now to keep the facility cool and expects the units to arrive soon. Interview on 6/13/22 at 4:10 p.m. with resident (R) (R#47) stated her room was hot. She checked her air conditioning (AC) unit and stated, It's on high fan but doesn't feel like anything is coming out. I don't think it's working; it's not blowing cold air. Interview on 6/13/22 at 4:11 p.m., R#113 stated that it was hot in the hallways. He stated, This is how it has been in the summers. Last year they had air conditioners (AC) brought in and put them throughout the facility. Observation on 6/13/22 at 4:12 p.m., R#69 who was a resident with a [CONDITION(S)] and in a vegetative state, was observed with flushed skin and warm to touch. The Director of Health Services (DHS) and the Maintenance Director verified R#69's room temperature above the head of bed was 83.1 degrees F. The Maintenance Director checked air conditioner in the room and noticed the air vent was covered with plants. He removed the plants. Interview on 6/13/22 at 4:13 p.m., R#18 stated, It is hot out in the hallways, but I have my AC in my room to get cool. Observation and interview on 6/13/22 at 4:14 p.m., R#58 was observed seated in his wheelchair on the 400 Hallway with sweat on his forehead and face. He stated, It was hot in the hallway. Observation and interview on 6/13/22 at 4:15 p.m., in R#99's room, she stated, I'm burning up. The AC unit was observed with fan set to maximum, the temperature was set to maximum cool and minimal output of air was observed. Interview on 6/13/22 at 4:15 p.m. R#61 stated, I feel hot. Feels like no air is coming out of the air conditioning unit. Interview on 6/13/22 at 4:19 p.m. with Licensed Practical Nurse (LPN) FF while passing medications on the 400 Hallway, stated, It is so hot, I can't think. She stated the facility had been hot in the last week but today has been the hottest day so far. Interview on 6/13/22 at 4:20 p.m., R#12 was observed seated in his wheelchair on the 400 hallway and to have flushed skin and sweating on his face. R#12 stated the facility felt hot and was like this last year. Interview on 6/13/22 at 4:27 p.m. with LPN DD stated, Today is the hottest day so far. It has been hot before, but not this hot. A facility walk-through to assess temperatures throughout the facility was conducted on 6/13/22 from 4:30 p.m. until 4:43 p.m. with the Maintenance Director. The temperatures were as follows: 300 hallway near room 316 - 90 degrees F; 400 hallway near room 405 - 86 degrees F; Room 413 - 85 degrees (AC not on in resident's room at this time per resident's preference); 200 hallway near room 205 - 86 degrees F; Room 201 - 86 degrees F; 100 hallway near room 110 - 82 degrees F; 300 hallway near room 317 - 82 degrees F; 300 hallway near room 308 - 81 degrees F; 400 hallway near nurses' station - 84 degrees F; 400 hallway near room 412 - 86 degrees F; and room 410 - 87 degrees F (ac not on in room and the window was open). Interview on 6/13/22 at 4:44 p.m. with the Maintenance Director, revealed the Administrator ordered the portable AC units after the discussion regarding the air temperature in the hallway. Review of weather in Atlanta, GA on 6/13/22 at 5:01 p.m. indicated the current temperature per Accuweather.com: 96 degrees F; feels like 102 degrees. Interview on 6/13/22 at 6:12 p.m. with Certified Nursing Assistant (CNA) EE, stated ten portable AC units had arrived and staff members began putting the AC units together. Review of the facility procedure entitled, Code Purple: Severe Hot Weather with Loss of Cooling which indicated, Utilize the following procedure to prevent hyperpyrexia (abnormally high body temperature). If there is a loss of cooling function during hot weather when the facility's temperature reaches 81 degrees F and remains so for four (4) hours. Move patients/residents to another air-conditioned part of the facility, if available Encourage patients/residents to take in more fluids and keep hydrated .Monitor body temperature .Monitor environmental temperatures A facility walk-through was conducted on 6/14/22 at 4:44 p.m. until 5:13 p.m. with the Maintenance Director, to assess temperatures throughout the facility. The walk-through was completed while the ten portable AC units were in place throughout the facility. The temperatures were as follows: 300 hallway near room 316 - 90 degrees F; Room 312 - 87 degrees F; 300 hallway near nurses station - 85 degrees F; 300 hallway near room 311 - 84 degrees F; Room 310 - 86 degrees F (R#47 stated, I'm hot in here); 300 hallway near room 305 - 84 degrees F; Room 301 - 88 degrees F (window open); 400 hallway near day area - 88 degrees F; 400 hallway near room 421 - 82 degrees F; Room 413 - 82 degrees F (AC not on in room); 400 hallway near room 411 - 84 degrees F; Room 408 - 82 degrees F; 400 hallway near room 401 - 84 degrees F; Room 403 - 83 degrees F; 200 hallway near room 204 - 82 degrees F; Room 205 - 85 degrees F (AC on; window open); 200 hallway near room 201- 83 degrees F; 100 hallway near room 113 - 83 degrees F; 100 hallway near room 110 - 82 degrees F; and 100 hallway return air at ceiling 102 degrees F. This observation verified the portable AC units were not sufficiently cooling the building. Observation and interview on 6/15/22 at 10:54 a.m., R#111's room was observed to be warm, and window was open. R#111 stated the AC unit had never worked and the AC was observed to not be in working order. The Maintenance Director was notified. A facility walk-through was conducted on 6/15/22 at 4:18 p.m. until 5:02 p.m. with the Maintenance Director. The walk-through was completed while the ten portable AC units were in place throughout the facility. The temperatures were as follows: 300 hallway near room 317 - 85 degrees F; 300 hallway near room 308 - 83 degrees; Room 310 - 85 degrees F (R#47 complained of being hot at this time); Room 301 - 83 degrees F; 100 hallway near room 103 - 82 degrees F; Room 105 - 85 degrees F (R#120 complained of being hot); Room 205 - 86 degrees F; Room 209 - 85 degrees F; Room 419 - 82 degrees F; Room 414 - 82 degrees F; Room 410 - 82 degrees F; Room 411 - 83 degrees F; Room 403 - 85 degrees F (R#67 appeared flushed. LPN GG assessed R#67's body temperature to be 100.6). This observation verified the portable AC units were not sufficiently cooling the building. A follow-up facility walk-through was conducted on 6/15/22 at 6:34 p.m. with the Maintenance Director and the DHS. The walk-through was completed while the ten portable AC units were in place throughout the facility. The temperatures were as follows: Room 105 - 88 degrees F; Room 101 - 89 degrees F; Room 107 - 83 degrees F; 100 hallway near room 112 - 88 degrees F; 200 hallway near room 203 - 83 degrees F; 200 hallway near room 201 - 88 degrees F; Room 204 - 89 degrees F; 300 hallway near room 314 - 89 degrees F; Room 310 - 91 degrees F; Room 306 - 84 degrees F (R#61 complained of being warm); Room 305 - 88 degrees F; Room 421 - 85 degrees F; 400 hallway near room 416 - 83 degrees F; Room 413 - 84 degrees F; Room 404 - 85 degrees F; Room 401 - 82 degrees F. This observation verified the portable AC units were not sufficiently cooling the building. 2. Observation on 6/13/22 at 2:05 p.m., a walk-through of the rooms on the 400 Hallway revealed the following: Room 424 - wall scuffed around the perimeter of the room; hole in the wall behind bed A; peeling plaster behind bed A and B; bathroom vinyl peeling near toilet. Room 423 - peeling plaster on walls near bed A and B; scraping along walls. Room 421 - scraping along walls and peeling plaster on walls behind both beds. Room 422 - scraping along walls and behind both beds; peeling vinyl on floor and a hole in wall on left side of toilet; cracked caulking around sink; scraping and scuffing along the perimeter of the bathroom. Room 420 - rusted and molded AC unit with condensation on top; peeling plaster behind both beds; peeling wood on bathroom door; peeling vinyl at entry of bathroom door; peeling wall behind toilet; cracked caulking around sink; ceiling tile above bed B coming down. Room 419 - rusted AC unit with condensation on top with black substance; walls splattered with brown liquid substance. Room 418 - scuffing and peeling along walls and behind bed A and B; holes behind bed B; peeling vinyl in bathroom and near toilet. Room 417 - scuffing and peeling along walls; caulking peeling around bathroom sink. Room 415 - AC unit leaking onto the floor with a sheet laid over the water, scuffing and peeling along walls. caulking cracking around sink in the bathroom. Room 414 - AC leaking under flooring; holes in wall near D bed. faucet constantly running and making shrill sound; hole in wall behind toilet. Observation and interview on 6/16/22 from 9:10 a.m. through 11:00 a.m., a facility walk-through with the Maintenance Director on the 400 Hall was conducted. He stated he does rounds daily. He stated he picks two hallways per week and fixes the issues in order of priority. During further interview, the Maintenance Director stated he was constantly being pulled away in the middle of one project to start a different project. The Maintenance Director verified the concerns needed for the following rooms: Room 414 - the AC unit drain is clogged. The water is coming inside the room instead of draining out and draining under the floor. Room 415 - the AC is leaking; room needs painting throughout and caulking bathroom sink. Room 417 - needs paint throughout; caulking needed around sink. Room 424 - needs painting throughout and patching of holes; molding is down but not putting back up cause constantly coming down in the rooms when staff raise the bed. vinyl needs repair in the bathroom and sink needs caulking. Room 423 - needs painting throughout. Room 420 - need blinds; painting and patching of holes; vinyl repair in bathroom and caulking around the toilet. Room 422 - needs painting throughout, vinyl repair in bathroom and patching of holes in the bathroom. Room 421 - painting and patching of holes; caulking needed in bathroom; ceiling tiles in bathroom need repair. Room 419 - ceiling tile needs repair; painting throughout room; caulking in bathroom. Room 418 - needs painting and patching of holes in room and in bathroom. Room 416 - needs stripping and caulking in the bathroom. Room 413 - needs painting throughout. ceiling tile repair. toilet needs to be re-caulked and vinyl repair around the toilet Room 412 - light fixture needs to be replaced above bed b. painting throughout. Room 410 - ceiling tiles above bed B need repair. painting throughout. Room 411 - painting throughout; walls need mud and paint. 4 holes in bathroom wall needs painting and patching. vent in ceiling above toilet is loose and needs repair. Room 409 - light not working in bathroom; needs painting throughout. Room 408 - needs blinds, painting throughout, bathroom needs caulking and painting. Room 407 - caulking, painting, sheetrock repair around the molding. Room 406 - sheetrock and vinyl repair in bathroom; vinyl peeling at threshold. Room 405 - painting throughout. ceiling tile repair above bed B. need strip in threshold of bathroom. Room 404 - ceiling tile above bed C needs to be replaced, sheetrock repair in bathroom along with molding behind toilet. Room 403 - painting throughout. Room 402 - bathroom needs painting; wallpaper in disrepair; needs sheetrock Room 401 - painting needed near bed B; sheetrock repair at molding; 2 holes in ceiling tiles in bathroom; caulking needed around bathroom sink. Interview on 6/16/22 at 11:20 a.m. with the Administrator, stated that it is his expectation for the maintenance director to do rounds and address issues as they come about. The Administrator stated the facility did not have a policy on preventative maintenance.

Based on observations, interviews, record review, and policy review, the facility failed to implement/develop care plans for four residents (R) (R#64, R#69, R#96, and R#100) of 41 sampled residents. Specifically, not implementing care plan related to oxygen administration for R#64, R#69, and R#100; and not developing care plan for R#96 for self-administration of medications. Findings include: Review of facility policy titled, Care Plans, revised 7/21/21, revealed the comprehensive person-centered care plan is developed to include measurable goals and timeframe's to meet a patient/resident's medical, nursing, and psychosocial needs, the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial needs that are identified in the comprehensive assessment. 1. A review of the clinical record for R#64 revealed resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#64's care plan dated 12/6/21 and revised 6/13/21 during the survey, revealed R#64 required oxygen therapy with her [CONDITION(S)]. Interventions to care include instruct staff to administer O2 [oxygen] as ordered. During observations conducted on 6/12/22 at 2:00 p.m. revealed R#64's oxygen was set at three liters/per minute (LPM) and on 6/13/22 at 11:15 a.m., her oxygen was set at 1.5 LPM respectively, per [CONDITION(S)] collar. This was confirmed by Licensed Practical Nurse (LPN) AA, Respiratory Therapist (RT), and Respiratory Therapy Director (RTD). Review of R#64's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Special instructions: keep oxygen saturation (SPO2) greater than 92%. 2. A review of the clinical record for R#69 revealed resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#69's care plan revised 5/3/22 revealed resident uses oxygen related to [CONDITION(S)] and the use of a [CONDITION(S)]. Interventions to care include instructing staff to administer oxygen as ordered, and oxygen saturations as ordered. Further review revealed R#69 is at risk for impaired gas exchange related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff is instructed to administer oxygen as ordered. During observations conducted on 6/12/22 at 2:08 p.m. revealed R#69's oxygen flow rate was set three LPM and on 6/13/22 at 11:42 a.m., her oxygen flow rate was set 1.5 LPM, respectively, per [CONDITION(S)] collar. This was confirmed by LPN AA, RT, and RTD. Review of R#69's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. A review of the clinical record for R#100 revealed resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#100's care plan, dated 2/11/22 and revised 6/13/22 during the survey, revealed resident has the potential for complications related to [CONDITION(S)]/use of oxygen. Interventions to care include provide oxygen as ordered. Observation on 6/12/22 at 1:51 p.m. and 6/13/22 at 11:26 a.m. revealed R#100's oxygen setting was 1.5 LPM via [CONDITION(S)]. This was confirmed by LPN AA, RT, and RTD. Review of R#100's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 6/13/22 at 4:03 p.m. with Director of Health Services (DHS), stated her expectation is for staff to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DHS confirmed the staff had not followed the care plan related to oxygen administration. During further interview, she stated there are some communication challenges between respiratory therapy and nursing staff. 4. A review of the clinical record for R#96 revealed resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation and interview on 6/12/22 at 10:55 a.m., R#96 was observed to have a nebulizer and ten vials of [MEDICATION(S)] inhalation on top of his bedside table. He stated that he did his own nebulizer treatments. Observation on 6/13/22 at 6:00 p.m., R#96 was in his room performing his nebulizer treatment. There were no staff members present during this observation. Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#96's care plan, dated 5/11/22, revealed no evidence the resident was assessed for self-administration of medications or had physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Interview on 6/14/22 at 10:25 a.m. with LPN HH, reviewed R#96's medical record and confirmed he did not have a care plan for self-administration of medication. Interview on 6/14/22 at 10:36 a.m., the DHS reviewed R#96's electronic medical record and confirmed that R#96 did not have a care plan for self-administration of medication. Interview on 6/14/22 at 10:37 a.m. with the Corporate Nurse Consultant confirmed the absence of a care plan for self-administration of medication for R#96. The Corporate Nurse Consultant stated any resident that self-administers medication should have a care plan. Interview on 6/14/22 10:45 a.m. with the Minimum Data Set Coordinator (MDSC) reviewed R#96's care plan and confirmed he did not have a care plan to self-administer medications. During further interview, the MDSC stated that any resident that self-administers medication should have a care plan with goals and interventions Cross Refer F695 and F684

Based on observations, record review, interviews, and policy review titled Resident Independent Self-Administration and Medication Assistance of Medication, the facility failed to ensure one of 41 sampled residents (R) (R#96) had a physician's order for self-administration of respiratory medications prior to nebulizer medications being kept at bedside and self-administered by resident. Findings include: Review of facility policy titled, Resident Independent Self-Administration and Medication Assistance of Medication, dated 8/1/12, revealed self-administering of medications by a resident is permitted only: upon specific written orders of the physician or other authorized healthcare provider, obtained on a semi-annual basis. A review of the clinical record for R#96 revealed resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation and interview on 6/12/22 at 10:55 a.m., R#96 was observed to have a nebulizer and [MEDICATION(S)] (ten vials) on top of his bedside table. He stated that he did his own nebulizer treatments. During further interview, he stated, When I run out of my medicine, the nurses bring me some more. Observation on 6/13/22 at 6:00 p.m., R#96 was in his room performing his nebulizer treatment. There were no staff members present during this observation. Review of June 2022 Physician Order (PO) revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no evidence that resident had an order to self-administer this medication. Review of Self-Administration of Medication, dated 2/16/22 and 5/19/22, revealed List medications resident would like to self-administer. Inhalers. Interview on 6/14/22 at 10:25 a.m., Licensed Practical Nurse (LPN) HH stated that R#96 self-administers his inhalers and nebulizer treatment. He stated resident keeps his nebulizer and medication on top of his bedside table for convenience. During further interview, LPN HH confirmed R#96 did not have a physician's order for self-administration of his nebulizer medications. Interview on 6/14/22 at 10:31 a.m., LPN II stated there was no physician's order for R#96 to self-administer his medications. Interview on 6/14/22 at 10:36 a.m., with the Director of Health Services (DHS), stated that there should be an assessment to deem the resident competent to self-administer medications and there should be a physician's order identifying which medications the resident can self-administer. The DHS confirmed that R#96 did not have a physician's order for self-administration of medication. Interview on 6/14/22 at 10:37 a.m., the Corporate Nurse Consultant reviewed R#96's electronic medical record (EMR) and confirmed the absence of a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During a follow-up interview on 6/14/22 at 10:43 a.m., the DHS stated she reviewed the Self-Administration of Medication assessment and revealed R#96 was assessed for self-administration of his inhalers. She stated the assessment should have also addressed the resident's nebulizer treatments. Interview on 6/14/22 at 10:59 a.m., LPN DD stated she assessed R#96 for his inhalers. When asked about an assessment for self-administration of the nebulizer treatment, she stated she should have included the nebulizer but overlooked it. During further interview, LPN DD stated she informed R#96 to keep his nebulizer and medication on top of his bedside table.

Based on record review and interview, the facility failed to maintain complete and accurately documented medical records for three of six residents (R) (R#87, R#26, R#47) records reviewed related to advance directives. Specifically, R#87 and R#26's code status levels were listed as Do Not Resuscitate (DNR); however, the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: 1. Review of the clinical record for R#87 revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the clinical record revealed R#87 is currently listed as a do not resuscitate (DNR). Review of R#87's General Order dated [DATE] revealed under other description her Code Status listed as full code. Review of R#87's care plan dated [DATE] revealed category Advanced Directives Code Status as DNR. Review of R#87's POLST (physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on [DATE] at 2:21 p.m. with the Corporate Nurse Consultant stated if a resident was found unresponsive, the staff would check the banner of the electronic medical record (EMR) face sheet for the code status. The Corporate Nurse Consultant confirmed if the banner code status does not match the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A request was made for a facility policy regarding the accuracy of medical records. The Administrator stated the facility had no such policy. 2. Review of the clinical record for R#26 revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the clinical record revealed R#26 is currently listed as a do not resuscitate (DNR). Review of R#26's General Order revealed an order dated [DATE], revealed under other description her Code Status listed as full code. Review of R#26's care plan dated [DATE] revealed category Advanced Directives indicated Allow Natural Death. Interview on [DATE] at 11:26 a.m. with Licensed Practical Nurse (LPN) AA was asked how would the staff know if R#26 was a DNR or a Full Code, if resident is found unresponsive? She stated, I look at my computer and verify what code status they are. LPN AA was asked to look up R#26's code status. She looked R#26's code status and stated, she is a DNR per her face sheet and the medication administration record (MAR) banner. Interview on [DATE] at 11:45 a.m. with the Respiratory Therapy Director was asked where she would locate the resident's code status? She stated, it's on her MAR and face sheet. She proceeded to verify R#26's code status as a DNR, per the EMR. Interview on [DATE] at 4:03 p.m. with Director of Health Services (DHS) was asked where would you expect to see the resident's code status? The DHS stated, I would refer to the face sheet and banner. The DHS was asked if the banner should reflect the physician orders? The DHS stated, yes, the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DHS confirmed that R#26 current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 3. Review of the clinical record for R#47 revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the clinical record revealed R#47 is currently listed as Full Code status. Review of R#47's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review of R#47's clinical record revealed her Admission Packet dated [DATE] indicated patient/resident is unable to comprehend what advance directive are, but this was explained to the family as part of our community education effort. Review of R#47's care plan dated [DATE] revealed category Advanced Directives indicated Attempt Resuscitation [full code]. Interview on [DATE] at 4:00 p.m. with the DHS, stated if a resident were to stop breathing or had no pulse, the nurse would need to check the doctor's order to verify the resident's code status. During further interview, she stated the nurse could also check the face sheet to determine code status. The DHS stated she was not aware of discrepancy in code status for R#47. Interview on [DATE] at 6:50 p.m. with the Social Services Director (SSD), stated R#47's Advance Directives status is to be resuscitated [full code]. Interview on [DATE] at 1:18 p.m. with LPN BB, confirmed that R#47's PO was a DNR. LPN BB stated that in an emergency, she would go by the PO to determine advance directive; if the resident was found with no pulse or respirations, cardiopulmonary resuscitation would not be performed due to DNR status. Interview on [DATE] at 1:44 p.m. with LPN CC stated that the nurse that transcribed the PO for Do Not Resuscitate no longer works at the facility. She confirmed that R#47's current Advance Directive order in the EMR was for DNR. During further interview, LPN CC stated that the nurse could check the POLST, if the resident had one. She confirmed that R#47 did not have a POLST on file. Interview on [DATE] at 2:20 p.m. with the Corporate Nurse Consultant, stated that if a resident were to be found with no pulse or respirations, the nurse should check the EMR banner. The Corporate Nurse Consultant confirmed that R#47's PO and documented code status were not the same. Interview on [DATE] at 5:23 p.m. with R#47 confirmed that in the event her heart was to stop, or she had no respirations, her wishes are for the staff to perform CPR (cardiopulmonary resuscitation).

Based on observations, interviews, record reviews, and facility policy review, the facility failed to ensure that three residents (R) (R#64, R#69, and R#100) of 11 residents that had tracheostomies with oxygen masks, received the correct physician ordered oxygen concentration. Findings Include: Review of the facility's policy titled Oxygen Administration dated 11/22/21, revealed the policy of [facility name] is to provide oxygen safely and accurately to appropriate patients .Oxygen will be administered by licensed personnel only when ordered by the physician, physician assistant (PA), or Nurse Practitioner (NP). 1. A review of the clinical record for R#64 revealed resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#64's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/26/22 revealed the residents Brief Interview for Mental Status (BIMS) was not completed due to resident is rarely/never understood. Respiratory treatments- oxygen therapy, suctioning, [CONDITION(S)] care was not checked. Review of R#64's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Special instructions: keep oxygen saturation (SPO2) greater than 92%. Review of R#64's care plan dated 12/6/21 and revised 6/13/21 during the survey, revealed R#64 required oxygen therapy with her [CONDITION(S)]. Interventions to care include instruct staff to administer O2 [oxygen] as ordered, change respiratory supplies as ordered/needed, monitor lung sounds as needed, monitor oxygen saturation via pulse oximetry as needed, and monitor and report signs of [CONDITION(S)]. Review of R#64's Respiratory Care Observation dated 6/12/22 at 1:58 p.m. revealed R#64's oxygen saturations was 96% and the resident's oxygen was set on 2 liters/minute (LPM). There was no documentation of the resident being in respiratory distress. Review of R#64's Respiratory Care Observation dated 6/13/22 at 10:00 a.m. revealed R#64's oxygen saturations was 96% on 2 LPM. There was no documentation of the resident being in respiratory distress. Observation on 6/12/22 at 2:08 p.m. revealed R#64's oxygen was set at three LPM per [CONDITION(S)] collar. Observation on 6/13/22 at 11:15 a.m. revealed R#64's oxygen was set at 1.5 LPM per [CONDITION(S)] collar. 2. A review of the clinical record for R#69 revealed resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#69's quarterly MDS with an ARD of 4/19/22 revealed the resident did not have a BIMS completed due to the resident was rarely/never understood. Respiratory treatments- oxygen therapy, suctioning, [CONDITION(S)] care was checked. Review of R#69's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#69's care plan revised 5/3/22 revealed resident uses oxygen related to [CONDITION(S)] and the use of a [CONDITION(S)]. Interventions to care include instructing staff to administer oxygen as ordered, and oxygen saturations as ordered. Further review revealed R#69 is at risk for impaired gas exchange related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff is instructed to administer oxygen as ordered. Observe oxygen precautions .monitor oxygen saturation via pulse oximetry every shift. Review of R#69's Respiratory Care Observation dated 6/12/22 at 9:10 a.m. revealed R#69's oxygen saturation was 95% and the resident's oxygen was set on two LPM. There was no documentation of the resident being in respiratory distress. Review of R#69's Respiratory Care Observation dated 6/13/22 at 9:15 a.m. revealed R#69's oxygen saturation was 99% and the resident's oxygen was set on two LPM. There was no documentation of the resident being in respiratory distress. Observation on 6/12/22 at 2:08 p.m. revealed R#69's oxygen flow, was set at three LPM per [CONDITION(S)] collar. Observation on 6/13/22 at 11:42 a.m. revealed R#69's oxygen flow, was set at 1.5 LPM, per [CONDITION(S)] collar. 3. A review of the clinical record for R#100 revealed resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#100's quarterly MDS with an ARD of 5/16/22 revealed the resident's BIMS score was not completed due to the resident was rarely/never understood. Respiratory treatments- oxygen therapy, suctioning, [CONDITION(S)] care was checked. Review of R#100's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#100's care plan, dated 2/11/22 and revised 6/13/22 during the survey, revealed resident has the potential for complications related to [CONDITION(S)]/use of oxygen. Interventions to care include provide oxygen as ordered, monitor and report signs of [CONDITION(S)], monitor and report signs of respiratory distress. Review of R#100's Respiratory Care Observation dated 6/12/22 at 12:53 p.m. revealed R#100's oxygen saturation was 98% on two LPM oxygen flow. There was no documentation of the resident being in distress. Review of R#100's Respiratory Care Observation dated 6/13/22 at 8:45 a.m. revealed R#100's oxygen saturations was 97% on one LPM oxygen flow. This observation note was documented on 6/13/22 at 12:51 p.m., after surveyor brought it to attention of the Respiratory Therapy Director (RTD). There was no documentation of the resident being in distress. Observation on 6/12/22 at 1:51 p.m. and 6/13/22 at 11:26 a.m. revealed R#100's oxygen setting was 1.5 LPM via [CONDITION(S)]. The resident was not in any respiratory stress. Interview on 6/12/22 at 1:51 PM with the Respiratory Therapist (RT) and the RTD, confirmed with observations that the oxygen flow rate for R#64, R#69, and R#100's was set incorrectly for the three residents. The RT stated that R#64 was in respiratory distress on Sunday morning and, he had titrated R#64's oxygen. There was no documentation to support this. Interview on 6/13/22 11:15 a.m. with Licensed Practical Nurse (LPN) AA, confirmed with observations of R#64, R#69, and R#100's oxygen flow rate settings were wrong and provided the resident's correct oxygen flow rate per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on record review, interviews, and review of the Resident Assessment Instrument (RAI,) the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the resident's status for two of 41 sampled residents (R) (R#46 and R#64). Findings include: 1. Review of the Resident Assessment Instrument (RAI) section J1800 revealed code one, yes: if the resident has fallen since the last assessment, proceed to section J1900. A review of the clinical record for R#46 revealed resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#46's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/11/22 revealed R#46 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating the resident had moderate cognitive impairment. Further review under section J1800, indicated the resident had not had a fall since admission or prior assessment .whichever is more recent. Review of R#46's care plan updated 4/18/22 included risk for falls with interventions. Review of R#46's Event documentation dated 3/22/22, revealed the resident had an unwitnessed fall on 3/22/22. Review of R#46's Progress Notes dated 3/22/22 indicated the resident had a unwitnessed fall on 3/22/22. Review of R#46's Occurrence Reduction Program Documentation dated 3/22/22 stated the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 6/12/22 at 1:53 p.m. with R#46 stated she fell a few months ago but was not able to give the exact date. She stated she thought she had a sore on her buttocks due to the fall. Interview on 6/14/22 at 11:40 a.m. with the Director of Health Services (DHS), stated when residents have a fall, the nurse does an assessment, enters a progress note, and does a post fall report. If the fall was unwitnessed, she stated neuro-checks are performed, and follow-up is done for six weeks in the facility's morning meetings. During further interview, she stated any falls should also be included in the quarterly or annual Minimum Data Set (MDS) per the Resident Assessment Instrument (RAI) Manual. Interview on 6/14/22 04:19 p.m. with the Minimum Data Set Coordinator (MDSC), confirmed R#46's fall on 3/22/22 was not on the quarterly MDS dated [DATE], but stated it should have been. 2. Review of the Resident Assessment Instrument (RAI) section O0100C, O0100D and O0100E, indicated to check all treatments, procedures and programs the resident received in the last 14 days. A review of the clinical record for R#64 revealed resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#64's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/26/22 revealed R#64 was not assessed as having respiratory treatments- oxygen therapy, suctioning, and [CONDITION(S)] care. Review of R#64's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 6/14/22 at 10:27 a.m. with the MDSC, confirmed that R#64's MDS should had reflected the resident's need for oxygen, suctioning, and [CONDITION(S)] care.

Based on observations, interviews, record reviews, and policy review, the facility failed to ensure medications were administered as ordered for one of 41 sampled residents (R) (R#323). Findings include: Review of the facility's policy titled Medication and Treatment Administration Guidelines dated 3/18 revealed medications and treatments administered immediately following administration or per state specific standards .medications not administered according to medical practitioner's orders are reported to the attending medical practitioner and documented in the clinical record including the name and dose of the medication and reason the medication was not administered .The licensed nurse is responsible for validating documentation is completed for any medication administered during the shift .vital signs are taken and recorded prior to the administration of vital sign dependent medications in accordance with medical practitioner's orders . A review of the clinical record for R#323 revealed resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#323's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's Quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 15, which indicated no cognitive impairment. Review of a Grievance/Complaint dated 2/28/22 included complaints that the resident was not receiving all her medications. Review of June 2022 Physician Orders, revealed orders for the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [MEDICATION(S)] tab 75 milligrams (mg) - give one tablet by mouth once daily for blood clot prevention, ordered 2/22/22. 2. [MEDICATION(S)] 20 mg - give one tablet by mouth once a day at 9:00 a.m., ordered 2/22/22; give 20 mg tablet at 2:00 p.m. for congestive heart failure, ordered 3/7/22. 3. [MEDICATION(S)] 40 mg - give one tablet by mouth once daily at 1:00 p.m., ordered 3/9/22. 4. [MEDICATION(S)] 80 mg - give one tablet by mouth once daily 7:00 a.m. - 7:00 p.m., ordered 3/9/22. 5. [MEDICATION(S)] 100 mg - give one capsule by mouth three times per day for [CONDITION(S)], ordered 2/22/22. 6. [MEDICATION(S)] 100 mg - give one tablet by mouth three times per day for hypertension, ordered 2/22/22. 7. [MEDICATION(S)] 25 mg - give one tablet by mouth three times per day for hypertension, ordered 2/22/22. 8. miconazole-3 200 mg - give one suppository vaginally at bedtime for [MEDICATION(S)] vulvovaginitis, ordered 2/25/22- 2/28/22. 9. [MEDICATION(S)] 17 gram (gm) - give 17 gm/dose by mouth once daily, ordered 2/22/22 - 2/25/22. 10. [MEDICATION(S)] 30 mg - give one tablet by mouth at bedtime for depression, ordered 2/22/22. 11. [MEDICATION(S)] 30 mg - give one tablet by mouth once daily for hypertension, ordered 2/22/22. 12. [MEDICATION(S)] 20 mg - give one tablet by mouth twice daily, ordered 2/23/22. 13. [MEDICATION(S)] 40mg- 14. potassium chloride 10 milli-equivalent (meq) take one tablet by mouth twice a day for GERD ([CONDITION(S)]) ordered 2/22/22. 15. potassium chloride 20 meq - give one tablet by mouth twice daily, ordered 3/9/22. 16. [MEDICATION(S)] 80 mg - give one tablet by mouth at bedtime for [CONDITION(S)], ordered 2/24/22. 17. probiotic formula 1 billion -250 Interview cell-mg- give one capsule by mouth once daily as probiotic supplement, ordered 2/22/22. 18. senna-s 8.6-50 mg - take two tablets by mouth once daily for constipation, ordered 2/22/22. 19. [MEDICATION(S)] 20 mg - give one tablet by mouth once daily for blood clot prevention, ordered 2/22/22. 20. [MEDICATION(S)] 2 mg - give one tablet by mouth at bedtime, ordered 4/14/22. Review of R#323's February 2022, March 2022, and April 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [MEDICATION(S)] 75 mg on 2/23/22, 3/12/22, 3/13/22, 3/27/22, and 4/9/22 2. [MEDICATION(S)] 20 mg on 2/23/22 3. [MEDICATION(S)] 40 mg on 3/12/22, 3/13/22, and 4/10/22 4. [MEDICATION(S)] 80 mg on 3/9/22, 3/12/22, and 3/13/22 5. [MEDICATION(S)] 100 mg on 2/23/22, 3/12/22,03/13/22, 3/15/22, 3/27/22, 4/9/22, 4/10/22, and 4/12/22 6. [MEDICATION(S)] 100 mg on 2/23/22, 3/07/22, 3/12/22, 3/13/22,3/15/22, 3/27/22, 4/09/22, 4/10/22, and 4/12/22 7. [MEDICATION(S)] 25 mg on 2/23/22, 3/07/22, 3/12/22, 3/13/22, 3/15/22, 4/09/22, 4/10/22, and 4/12/22 8. miconazole-3 200 mg on 2/28/22 9. miralalax 17 gram on 2/23/22 10. [MEDICATION(S)] 30 mg on 3/12/22, 3/15/22, and 4/12/22 11. [MEDICATION(S)] 30 mg on 2/23/22, 3/12/22, 3/13/22, 3/27/22, and 4/09/22 12. [MEDICATION(S)] 20 mg on 2/23/22, 3/12/22, and 3/13/22 13. [MEDICATION(S)] 40 mg on 2/23/22, 3/12/22, 3/13/22, 3/27/22, 4/09/22, and 4/12/22 14. potassium chloride 10 meq on 3/12/22, 3/13/22, 3/27/22, 4/09/22, and 4/10/22 15. potassium chloride 20 meq on 3/09/22 16. [MEDICATION(S)] 80 mg 3/12/22, 3/15/22, and 4/12/22 17. probiotic formula 1 billion-250 cell-mg on 3/12/22, 3/13/22, 3/27/22, and 4/09/22 18. senna-s 8.6-50 mg on 3/12/22, 3/13/22, 3/27/22, 4/09/22 19. [MEDICATION(S)] 20 mg on 3/12/22, 3/15/22, 4/12/22 20. [MEDICATION(S)] 2 mg 4/13/22 Interview on 6/15/22 at 8:51 p.m. with Licensed Practical Nurse (LPN) CC, confirmed that there were no signatures for medications being refused by R#323. LPN CC stated she was not sure why the medications were not administered or why documentation would not have been completed. She further stated that the resident would always take her pain medications and [MEDICATION(S)]; at times she would refuse her stool softener. Interview on 6/16/22 at 10:00 a.m. with the Director of Health Services (DHS), confirmed if a nurse doesn't document that a medication was administered, then it wasn't done; DHS confirmed there was no documentation of R#323 refusing medications.

Based on interview and record review, the facility failed to convey resident fund account balance for one resident (R#3) of three residents reviewed for resident funds within 30 days. Findings include: Review of a facility policy titled Resident Trust Policy dated ,d+[DATE] revealed a policy statement Upon written authorization of a resident, the healthcare center must safeguard, manage, and account for the personal funds of the resident deposited with the healthcare center. The policy further specified 8. Upon discharge or death of a resident with personal funds deposited with the center, the center must convey the resident's funds along with a final accounting to resident or individual or probate jurisdiction administering the resident's estate within 30 days. Record review revealed that R#3 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Agreement, for R#3, revealed the resident signed the agreement on [DATE]. Review of the Social Services Progress note, dated [DATE], titled Initial Post Admissions Conference Meeting held on [DATE], revealed the resident's family member was in attendance via telephone. The note revealed that both the resident and family were included in the discussion of the following: resident's code status, re-hospitalization , therapy goals, and discharge planning was discussed with the family member. It was determined the resident would remain in the facility as a long-term resident. The Baseline care plan was reviewed with the family. Review of the Face Sheet for R#3 revealed the resident was listed as the responsible party although the family member was listed as the first call. Review of the insurance information listed on the Face Sheet revealed the resident was Medicaid pending with Medicare primary upon Admission. Review of the Resident Statement Landscape revealed the facility began receiving the resident's Social Security check on [DATE] with a payment of $500.00 recorded on [DATE] which was deducted for Care Cost Auto Withdrawal dated [DATE]. No other deposits or withdrawals were noted prior to [DATE]. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R#3 had a Brief Interview for Mental Status (BIMS) score of 6, indicating moderate to severe impairment in cognitive skills for decision making (decisions poor; cues/supervision required). Review of a Social Services Progress Note, dated [DATE], revealed the resident is requesting a room change due to conflicts with the roommate. Roommate keeps the Television (TV) too loud and requesting another bed, stating her bed sinks down. Maintenance notified and room change is being arranged. Review of a Nurses Progress Note, dated [DATE] at 6:17 p.m., revealed the resident is out of bed in the wheelchair (W/C). Awake, alert and oriented X 3, (indicating the resident is oriented to Person, Place and Time). An interview with the Financial Counselor (FC) on [DATE] at 1:40 p.m. revealed that she was not in the FC position in 2020 when residents had received a COVID stimulus check. The previous FC who would have handled the residents' personal funds at that time had retired. The FC reviewed R#3's Resident Statement Landscape document and indicated the credited amount of $1200.00 on [DATE]. The FC confirmed in reviewing the document that the facility had withdrawn $1000.00 of the deposited amount toward the resident's past due balance. According to the FC the facility would have been required to obtain verbal and written agreement from the resident or responsible party before the withdrawal could have been made. An interview with the Administrative Assistant AA on [DATE] at 1:36 p.m. revealed that she assisted the Financial Counselor (FC) with maintaining documentation pertaining to resident personal funds. The Administrative Assistant AA revealed that when the government sent residents a COVID stimulus check in 2020, the check amount was deposited to each resident's personal funds account. The Administrative Assistant AA further revealed that if a resident was deceased when the facility received their stimulus check, the check was sent back to the government. For those residents who did receive a COVID stimulus check, the facility could not withdraw the check amount for payment on their account without permission from the resident and/or responsible party. An interview with the Administrator on [DATE] at 2:35 p.m. revealed during reviewed R#3's Resident Statement Landscape document and agreed the [DATE] deposit to R#3's personal funds was for a check in the amount of $1200.00 was received as a COVID stimulus payment. The Administrator further acknowledged the facility had withdrawn $1000.00 on [DATE] and documented the description for the withdrawal as being Care Cost Payment. The Administrator stated he did not know if the resident had given the FC authorization to withdraw the additional payment, but the FC had spent a lot of time going on the units and talking with residents regarding their financial accounts. A follow up interview with the Administrator on [DATE] at 3:20 p.m. revealed a Resident Account document that demonstrated R#3's balances and transactions for [DATE] and [DATE]. The document indicated on [DATE], R#3 owed a balance of $577.00 and on [DATE] owed a balance of $423.00. The documented reflected payment for both balances was made on [DATE], the date $1000.00 had been withdrawn from R#3's personal funds account. The Administrator stated this documentation demonstrated that the withdrawal of $1000.00 from the resident's personal funds account was for a past due amount owed by R#3. An interview with the family member of R#3 on [DATE] at 3:55 p.m. revealed that the resident had a stroke prior to being admitted to the facility on [DATE] and was confused. The family member stated the resident nor family members received a printout of the resident's personal funds account. They were aware R#3 had received a COVID stimulus check and that the facility had kept it. The Administrator presented a document on [DATE] that stated R#3 had given verbal permission for the facility to withdraw money from the resident's personal funds account to pay for a past due balance for the months of [DATE] and [DATE]. The document specified $577.00 would be withdrawn to pay a past due balance for [DATE] and $423.00 for [DATE]. The document was signed by facility staff on [DATE] and specified resident gave verbal consent. A post survey telephone interview on [DATE] at 1:05 p.m. revealed that R#3 did have a personal fund balance of $480.00 at the time of the resident's passing. The Administrator confirmed that the family of R#3 had not been contacted regarding the fund balance, after the resident expired on [DATE]. He revealed that the facility policy indicated that since the resident was her own responsible party and had not signed a document to pay the balance to the family upon her passing, then the funds should be refunded to Social Security Administration (SSA). The Administrator further revealed that a check had been sent to the SSA on [DATE] although the check had been returned to the facility due to staff not working onsite due to Covid-19 restrictions. The Administrator could not explain why the family had not been contacted to determine if the resident had an Estate set up to receive the funds.

Based on record review and interview, the facility failed to provide adequate assistance to prevent a fall for 1 of 4 sampled residents reviewed for falls (R90); Resident (R) 90 was repositioned with only one staff member who could not support her weight and R90 fell to the floor, sustaining a fracture. Findings include: R90's record was reviewed on 8/22/16 at 11:20 a.m. R90's [DIAGNOSES REDACTED]. Review of an Annual MDS (Minimum Data Set) assessment, dated 2/2/16, indicated R90 was alert and oriented to person time and place. The MDS assessment indicated R90 was totally dependent and required the assistance of 2 or more staff for bed mobility. Review of a facility Admission Interim Care Plan Form, dated 7/11/16, indicated the resident was at risk for falls and required 2 person assist with activities of daily living (ADLs). Review of a care plan for risk for falls, dated 2/13/16, indicated R90 required 2 staff to assist with activities of daily living (ADLs). During an interview on 8/22/16 at 11:00 a.m., R90 indicated that on 2/13/16, Certified Nurse Aide (CNA 114) rolled her over to be changed and she rolled out of bed. R90 verified only CNA 114 was present at the time. Review of a communication form to the hospital, dated 2/13/16, indicated fell out of bed during ADLs . Review of a facility Post-Incident Actions form, dated 2/13/16, indicated Resident was receiving ADL care when the bottom half her her (sic) body slipped out of the bed she was then held by staff member under the arms to keep her from falling all the way out of the bved (sic) until help arrived. At that time the sound of her shoulder popped . Review of a final report from the hospital, dated 2/15/16, indicated presented with acute right humeral (bone in the shoulder joint) fracture and found to be hypotensive in the ED (emergency room ) . During an interview on 8/22/16 at 2:20 p.m., the Director of Nursing (DON) indicated only 1 CNA was providing care and stated There should have been two CNAs. The DON indicated it was on the care plan and CNA 114 would have known R90 required two person assist (Cross Reference F282). The DON also indicated CNA 114 had not firmed the mattress up properly prior to turning the resident. The DON indicated she had terminated CNA 114 and inserviced all of the other CNAs. A facility Separation Notice dated 2/26/16, indicated the CNA had been terminated.

Based on record review and interview, the facility failed to ensure care was provided according to the care plans for 1 of 4 sampled residents reviewed for falls (R90), and for 1 of 13 sampled residents reviewed for pressure sores (R91). Specifically, the facility: -failed to follow Resident (R) 90's plan of care requiring 2 staff assist to reposition the resident in bed which resulted in a fall with fracture (Cross Reference to F323), and -failed to follow R91's plan of care requiring a pressure relief device in the resident's wheelchair. Findings include: 1. Review of the 2/2/16 Annual MDS (Minimum Data Set) assessment, indicated R90 was alert and oriented to person, time and place, was totally dependent and required the assistance of 2 or more staff for bed mobility. Review of the 2/13/16 risk for falls care plan indicated R90 required 2 staff to assist with activities of daily living (ADLs). The 2/13/16 Post-Incident Actions form indicated Resident was receiving ADL care when the bottom half her her (sic) body slipped out of the bed she was then held by staff member under the arms to keep her from falling all the way out of the bved (sic) until help arrived. At that time the sound of her shoulder popped . Review of a final report from the hospital, dated 2/15/16, indicated presented with acute right humeral (bone in the shoulder joint) fracture . in the ED (emergency room ). R90 was interviewed on 8/22/16 at 11:00 a.m. R90 said, on 2/13/16, the Certified Nurse Aide (CNA) rolled her over to be changed and she rolled out of bed. R90 verified there was only 1 CNA present at the time, CNA114. The Director of Nursing (DON) was interviewed on 8/22/16 at 2:20 p.m. The DON said only 1 CNA was providing care at that time and stated, There should have been two CNAs. The DON indicated it was on the care plan and CNA 114 would have known R90 required two person assist. The DON indicated she had terminated CNA114 and inserviced all of the other CNAs. 2. R91 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 7/12/16 Quarterly MDS and the 8/16/16 Significant Change MDS indicated the resident was dependent on staff for all ADLs, including bed mobility and all transfers. R91 was responsive to her name but was confused and disoriented. Review of the 8/24/16 Wound and Skin Status Report revealed the resident had a large sacrum stage 3 (full thickness tissue loss) pressure sore originally noted on 6/29/16. The area measured 1.4 x 1.5 x 0.10 centimeters that had enlarged to an additional sacral area assessed to be unstageable with slough/ eschar (dead tissue). This additional unstageable area measured 0.4 x 0.20 x 0.20 centimeters and was proximal to the original area. The 8/16/16 plan of care for R91 indicated potential for skin breakdown due to impaired mobility and incontinence of bowel and bladder. Care plan approaches included treatments as ordered and pressure reduction device to bed/ chair as indicated. The pressure device on the bed was an air loss mattress initiated on 10/27/15. On 8/24/16 at 3:20 p.m. R91 was transferred to a wheelchair by two CNAs. The wheelchair did not contain a pressure relief device as documented in the plan of care (Cross Reference F314). Licensed practical nurse (LPN) 3 confirmed during interview on 8/24/16 at 3:35 p.m. that the wheelchair should have had a pressure relief device in place.

Based on observation, record review, resident interview, and staff interview, the facility failed to ensure that staff provided care in a manner which maintained dignity for two (2) residents ("Q" and "S") from a survey sample of thirty-five (35) residents. This failure resulted in psychological harm for Resident "S", who stated he felt really bad after requesting assistance while feeling short of breath but being told by staff that he did not need to call for suctioning every hour. This also resulted in psychological harm for Resident "Q", who was observed to cry when referring to an incident during which she alleged a staff member grabbed a call light from her hand and told her she was using the call light too much. Findings include: 1. Record review for Resident "S" revealed a Quarterly Minimum Data Set (MDS) assessment having an Assessment Reference Date in August of 2014 which documented in Section C - Cognitive Patterns that the resident had a Brief Interview for Mental Status (BIMS) Summary Score of 14, indicating that the resident was cognitively intact. Section I - Active [DIAGNOSES REDACTED]. During an observation conducted on 10/08/2014 at 10:43 a.m. in the hall outside of Resident "S"'s room doorway, the 300 Hall Unit Manager "HH" was overheard asking the resident what he needed. The resident requested to see the Respiratory Therapist. Unit Manager "HH" responded by telling the resident that the Respiratory Therapist said she had just recently seen him and that he could not keep calling every hour for suctioning. A later observation of 10/08/2014 at 10:45 a.m. revealed Resident "S" receiving a nebulizer treatment. During an interview conducted on 10/08/2014 at 10:46 a.m. with Resident "S", the resident stated that he was short of breath and needed suctioning, and confirmed that the nurse had just told him that he did not need to call for suctioning every hour. The resident stated that it make him feel really bad being treated that way because he knew when he needed to be suctioned and it was hard to breathe when he was congested. During an interview conducted on 10/10/2014 at 4:30 p.m. with the Director of Nursing (DON), the DON stated that he expected resident call lights to be answered as soon as possible, regardless of how many times the resident pressed the call light. During an interview conducted on 10/08/2014 at 1:58 p.m. with the Nurse Educator, she stated she provided in-service training on professionalism and customer service, and also spoke to staff on a routine basis informing them that the facility was considered the resident's home. Review of an In-Service training record dated 05/08/2014, entitled Customer Service, revealed that in-service training had been provided to facility staff on that date related to customer service, reminding staff to always be respectful and courteous to residents. The signature page for this 05/08/2014 Customer Service In-Service documented that the 300 Hall Unit Manager was in attendance. 2. Record review for Resident "Q" revealed a Quarterly MDS assessment having an Assessment Reference Date in July of 2014 which documented, in Section C - Cognitive Patterns, that the resident had a BIMS Summary Score of 14, indicating that the resident was cognitively intact. Section I - Active [DIAGNOSES REDACTED]. Section H - Bladder and Bowel documented that Resident "Q" had experienced frequent episodes of urinary incontinence and bowel incontinence during the look-back period, and Section G - Functional Status documented that the resident required the extensive assistance of staff for toilet use. During an interview conducted on 10/07/2014 at 11:00 a.m. with Resident "Q", the resident stated that about one (1) month prior, she had pressed the call light to get assistance in changing a soiled brief. Resident "Q" stated that a certified nursing assistant (CNA) came into the room to answer the call light, but the CNA then grabbed the call light out of the resident's hand and told her she had been using the call light too much. Resident "Q" stated this had happened only once, and denied abuse, but stated this action was disrespectful. During a subsequent interview with Resident "Q" conducted on 10/10/2014 at 4:00 p.m., the resident was observed to cry as she again recounted the incident of one (1) month prior, initially referenced in the 10/07/2014, 11:00 a.m. interview referenced above, when the resident stated that a CNA had grabbed the call light from her hand and told her she was using the call light too much. During an interview conducted on 10/10/2014 at 4:30 p.m., the DON stated he expected staff to answer resident call lights with respect.

Based on observation, record review, resident interview, and staff interview, the facility failed to ensure that services were provided in accordance with resident Care Plans regarding staff reassurance for one (1) resident ("S") who exhibited anxiety; regarding prompt assistance with toileting for one (1) resident ("Q") who was incontinent of bowel/bladder; and regarding Passive Range of Motion (ROM) for one (1) resident (#53) who had bilateral upper-extremity impairment. The total survey sample was thirty-five (35) residents. This resulted in psychological harm for Resident "S", who voiced feeling really bad after being told by staff that he could not call for suctioning every hour, and for Resident "Q", who cried when recalling an alleged incident involving staff grabbing the call light after her request for assistance with toileting. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment of August 2014 for Resident "S" documented a Brief Interview for Mental Status (BIMS) Score of 14 in Section C - Cognitive Patterns, indicating the resident was cognitively intact. Section I - Active [DIAGNOSES REDACTED]. Further record review for Resident "S" revealed a Care Plan entry referencing a Problem/Need, originally dating from March of 2014, which identified the resident to be at risk for impaired gas exchange with shortness of breath related to a [DIAGNOSES REDACTED]. An Approach included on Resident "S"'s Care Plan related to his impaired gas exchange/shortness of breath specified that staff was to reassure and calm the resident if anxiety was present. However, during a 10/08/2014, 10:43 a.m. observation, after Resident "S" requested to see the Respiratory Therapist, the 300 Hall Unit Manager "HH" was overheard to tell the resident that he could not call every hour for suctioning. During interview on 10/08/2014 at 10:46 a.m., Resident "S" acknowledged the nurse told him he did not need to call every hour, further stating it make him feel really bad being treated that way. During a 10/10/2014, 4:30 p.m. interview, the Director of Nursing (DON) acknowledged that call lights should be answered promptly. Cross refer to F241, example 1, for more information regarding Resident "S". 2. Resident "Q"'s July 2014 Quarterly MDS documented in Section C-Cognitive Patterns a BIMS Score of 14, indicating the resident was cognitively intact. Section I - Active [DIAGNOSES REDACTED]. Section H - Bladder/Bowel documented Resident "Q"'s frequent episodes of urinary/bowel incontinence, and Section G-Functional Status documented the resident required extensive assistance with toileting. Further record review for Resident "Q" revealed a Care Plan Problem/Need originally dating from February of 2014 which identified that the resident experienced frequent episodes of bowel and/or bladder incontinence. Approaches referenced on Resident "Q"'s Care Plan to address her incontinence specified that staff answer the call bell promptly and provide incontinence care after each episode of incontinence. However, during a 10/07/2014, 11:00 a.m. interview, Resident "Q" stated that about a month before, she had a soiled brief and called for help, but the certified nursing assistant came to the room, grabbed the call light and said she was using it too much. In a 10/10/2014, 4:00 p.m. interview, Resident "Q" was observed to cry as she discussed the incident. Cross refer to F241, example 2, for more information regarding Resident "Q". 3. Resident #53's Annual MDS of May 2014 documented [DIAGNOSES REDACTED]. Section G - Functional Status documented bilateral upper-extremity impairment in ROM for Resident #53. Review of Resident #53's Care Plan revealed a Problem/Need originally dating from 07/10/2013 which identified the resident was under Restorative Programs, including the provision of Passive ROM to both upper extremities. Approaches related to this Problem/Need included to provide Resident #53 with Restorative Nursing program services as ordered. Resident #53's October 2014 physician's orders [REDACTED]. However, further record review revealed no evidence to indicate that Resident #53 was receiving Passive ROM to the upper extremities, two (2) sets of ten (10) repetitions (6) six times per week as ordered, despite the Care Plan specifying that Resident #53 was to receive Restorative Nursing Program services as ordered by the physician. During a 10/09/2014, 4:00 p.m. interview, Licensed Practical Nurse "LL" acknowledged a physician's orders [REDACTED].#53's upper extremities, and further acknowledged, during interview on 10/10/2014 at 12:10 p.m., the lack of evidence of Passive ROM being provided to Resident #53. Cross refer to F318 for more information regarding Resident #53.

Based on record review and staff interview, the facility failed to have an effective Quality Assessment and Assurance Committee that developed and implemented a process to ensure medication administration in accordance with physicians' orders, and which ensured the ongoing monitoring of plans of action implemented to correct identified problems with the facility's laboratory service procedures. This resulted in significant medication errors involving the administration of anticoagulant and/or cardiovascular drug therapy for seven (7) residents (#1, #20, #21, #22, #24, #26, and "B"), and resulted in the failure to provide pain management as ordered for two (2) residents ("C" and "Z"), of the total survey sample of thirty-three (33) residents. Specifically, Residents #20, #21, #22, #24, and #26 failed to receive anticoagulant drug therapy as ordered, while Resident #1 failed to receive both anticoagulant drug therapy and a [MEDICATION NAME] Time/International Normalized Ratio laboratory test as ordered. Resident "B" also failed to receive anticoagulant drug therapy as ordered, and failed to receive cardiovascular medication as ordered. Additionally, Residents "C" and "Z" had a history of [REDACTED]. The facility thus failed to ensure a system to provide the accurate administration of resident drug therapy, and the provision of laboratory services, in conformance with physicians' orders. This resulted in a situation in which the facility's non-compliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility's Administrator was informed of the Immediate Jeopardy on October 16, 2013 at 11:25 a.m. The non-compliance related to the Immediate Jeopardy was identified to have existed as of September 13, 2013 (the date the facility failed to obtain a [MEDICATION NAME] Time/International Normalized Ratio (PT/INR) laboratory test for Resident #1, which was ordered as a repeat for a report of 09/11/2013 which had revealed high PT/INR levels of 39.2 and 4.34, respectively, and also then resumed the resident's [MEDICATION NAME] drug therapy with no order), continued through October 16, 2013, and was removed on October 17, 2013. The facility implemented a credible allegation of jeopardy removal related to the Immediate Jeopardy on October 16, 2013. During an interview conducted on 10/18/2013 at 1:10 p.m., the Administrator stated that the facility's Quality Assessment and Performance Improvement (QAPI) committee had not identified an issue involving significant medication administration errors, and provided no evidence of a plan of action to address this problem. The Administrator did indicate the QAPI Committee's awareness of a problem involving the facility's laboratory services procedures, but acknowledged that she could present no evidence of the Committee's ongoing monitoring of corrective procedures which had been developed and implemented related to the identified laboratory problems. An allegation of jeopardy removal was received on October 16, 2013. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on October 17, 2013, and the facility remained out of compliance at a lower scope and severity of "E" while the process of evaluating modifications of the medication administration and laboratory requisition systems continued. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the administration of resident medication and the facility's process for obtaining and reporting laboratory testing results. Observations were made of medication administration to assess staffs' conformance with physicians' medication orders. Findings include: An interview was conducted with the Administrator on 10/18/2013 at 1:10 p.m. related to the facility's QAPI Committee. During this interview, the Administrator was asked about the QAPI Committee's oversight of the facility's medication administration processes and laboratory testing procedures. The Administrator was questioned regarding the QAPI Committee's evaluation of medication administration and laboratory services. She stated that the QAPI Committee had not identified or trended problems related to the facility's process of medication administration to residents. She provided no specific information related to QAPI Committee evaluation of medication administration in the facility or trending of medication errors. She also provided no evidence of any corrective actions which had been developed, implemented, and monitored by the QAPI Committee related to medication errors involving residents of the facility. The Administrator stated that the QAPI Committee had evaluated an identified problem related to the provision of laboratory services. She stated that a new system had been put into place which included the use of laboratory logs and an auditing system. However, the Administrator further stated that these corrective actions related to facility laboratory services had failed because the staff assigned to monitor the implementation of, and compliance with, the newly-developed corrective actions had failed to monitor as planned. The Administrator provided no information related to the QAPI Committee's ongoing monitoring of the implementation of these corrective actions regarding laboratory services, or of any analysis by the Committee of causal factors related to the facility's failure to comply with the newly-developed action plan for laboratory services. Cross refer to F309 and F333. The facility failed administer medications in a manner to ensure that Residents #1, #20, #21, #22, #26 and "B" were free of significant medication errors. Residents #1, #20, #21, #22, #26 and "B" all had physicians' orders for anticoagulant drug therapy and/or cardiovascular drug therapy and laboratory testing related to anticoagulant drug therapy. However, this complaint survey revealed a pattern of significant medication errors related to the administration of medications involving all of these residents. Also, Residents "A" and "C" had a documented history of pain, and had physicians' orders to allow for effective pain management of their pain. However, the facility failed to administer these pain medications as ordered for these residents, even though the resident's had expressed to staff that they were experiencing pain. Both residents continued to experience pain. Based on the above, the facility's QAPI Committee failed to ensure the necessary monitoring of a plan of action, developed by the facility in response to identified problems with the laboratory services procedures, to ensure the implementation of, and staffs' conformance with, the newly-developed interventions, and also to assess the need to make revisions to the laboratory services action plan. The QAPI Committee also failed to provide evidence of ongoing monitoring of the facility's medication administration procedures and an effective plan of action to address a pattern of significant medication errors involving resident anticoagulant and cardiovascular drug therapy. This failure had caused, or had the likelihood to cause, serious harm, injury, impairment or death to these residents. The Immediate Jeopardy was determined to have been removed on 10/17/2013, at which time the facility had presented and implemented an allegation of jeopardy removal with the following interventions: A. On October 5, 2013, the facility's DON and Assistant Director of Nursing (ADON) conducted audits on all residents receiving anticoagulant drug therapy to ensure that all residents had accurate medication orders and correct laboratory orders. B. On October 5, 2013, the DON, Unit Managers, and the Director of Education (DEQ) reviewed all physician's orders [REDACTED]. Physicians were notified of any discrepancies, and new physicians' orders were received as needed. C. On October 5, 2013, all facility medication carts were audited by the DON, Unit Managers, the DEQ, and the facility's pharmacy consultant to ensure that the correct dosages of all anticoagulant medications, and all other medications, were present. D. On October 5, 2013, the facility implemented a procedure by which the DON/DEQ/Unit Managers would review all physicians' telephone orders daily to ensure the accuracy of any changes related to resident anticoagulant drug therapy. The findings and noted errors or discrepancies will be documented on the Supervisor's Report. Physicians would be notified of any identified discrepancies. E. On October 10, 2013, the facility completed staff in-service training which stressed the importance of ensuring medication orders had been transcribed accurately and timely, in accordance with facility policies. As of that date, one-hundred (100) percent of all licensed nursing staff had received training. F. On October 10, 2013, the facility completed staff in-service training on ensuring new medication orders were provided to the pharmacy via facsimile in a timely manner, per facility policy and procedure. The medication administration policy and procedure were presented, as well as a specific discussion regarding [MEDICATION NAME] dosage administration, per physician's orders [REDACTED]. G. On October 10, 2013, the facility completed staff in-service training which covered the importance of informing physicians of PT/INR laboratory test results in a timely manner, per facility protocol and policy. As of that date, one-hundred (100) percent of all licensed nursing staff had received training. H. On October 10, 2013, the facility completed staff in-service training related to the signs and symptoms of bleeding for residents receiving anticoagulant drug therapy. As of that date, one-hundred (100) percent of all licensed nursing staff had received training. I. On October 11, 2013, the facility contracted with a new pharmacy provider. This pharmacy provider would aid the facility with ensuring that medication therapy was administered in conformance with physicians' orders and per facility policies and procedures. J. On October 12, 2013, the newly-contracted pharmacy provider company conducted audits to assess the conformance with the facility's policies and procedures regarding accurate resident physician's orders [REDACTED]. This was to ensure that the facility followed policies and procedures for the proper administration of medications. K. On October 12, 2013, the facility implemented a procedure by which the Administrator, DON, or designated Nursing Supervisor would review entries on resident MARs daily to ensure accuracy of transcribed anticoagulant orders. Findings would be documented on the Supervisor's Report, and physicians would be notified of any discrepancies. L. On October 12, 2013, the facility implemented a procedure by which the Administrator, DON, or designated Nursing Supervisor would review all Laboratory Books daily to ensure that PT/INR laboratory tests were logged correctly to ensure completion, and are also obtained in a timely manner per physicians' orders. M. On October 12, 2013, the facility developed and implemented a new form, the [MEDICATION NAME]/Anticoagulant Record Form, by which the DON or Unit Managers would document all PT/INR physicians' orders, the results of laboratory tests, and physician notification of laboratory test results. N. On October 12, 2013, the facility implemented a procedure by which the Administrator, DON, or designated Unit Manager would review all PT/INR laboratory results daily to ensure prompt notification to the physician is completed. Once physician notification was completed, the Nursing Supervisor would document this notification on the [MEDICATION NAME]/Anticoagulant Record. O. On October 12, 2013, the facility implemented a procedure by which the DON or designated Unit Manager would track the requisition of PT/INR laboratory tests until laboratory test results are received and physicians are notified of the results. This tracking will be conducted daily on an ongoing basis, and will be documented on the [MEDICATION NAME]/Anticoagulant Record Form. P. On October 13, 2013, the facility implemented a procedure by which the Administrator, DON, or designated Nursing Supervisor would conduct daily audits of the Laboratory Books and [MEDICATION NAME]/Anticoagulant Record to ensure that laboratory tests results were obtained and physicians were notified in a timely manner. Q. On October 13, 2013, the facility implemented a procedure by which the Administrator or DON would conduct sampled audits of the Laboratory Book, [MEDICATION NAME]/Anticoagulant Record, MARs, and physician's orders [REDACTED]. Areas of concern would be reported to the Quality Assessment and Performance Improvement (QAPI) Committee monthly by the Administrator for the Committee's review, modification, and Performance Improvement. R. On October 16, 2013, the facility implemented a procedure requiring that ongoing in-service education will be provided to all nursing staff on a quarterly and annual basis related to the policies and procedures for the ordering of laboratory tests, the documentation of laboratory testing results in the clinical record, and the process of notifying the physician of results in a timely manner. Also, nursing staff would be trained on the proper administration of anticoagulants, and other medications, in accordance with facility policies and procedures. Additionally, this new policy requires that all newly-hired nurses will be trained on these facility policies and procedures upon hire. Included in this procedure was the provision that staff conformance with medication administration and facility laboratory protocols would be tracked by the facility's QAPI Committee, who will then determine the need for additional training, based on staff performance. S. On October 16, 2013, the QAPI Committee met to discuss this Immediate Plan of Correction Implementation for the Removal of Immediate Jeopardy. The next scheduled QAPI Committee meeting is scheduled for October 24, 2013, for the review of these new procedures implemented by the facility regarding medication administration and laboratory procedures. Based on these corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice was removed on October 17, 2013. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. As of October 12, 2013, the facility implemented new procedures by which administrative staff would conduct daily MAR indicated [REDACTED]. On October 12, 2013, the facility had also developed and implemented a new [MEDICATION NAME]/Anti-coagulant Record Form to be utilized by supervisory nursing staff for the documentation of PT/INR orders, laboratory testing results, and physician notification. However, due to the newly-implemented status of these critical procedures regarding the supervisory nursing staffs' monitoring of anticoagulant order transcription accuracy and PT/INR order receipt and follow-up, as well as the newly-implemented forms to document this monitoring, nursing staffs' ongoing application with these new procedures, continued compliance could not be entirely assured as of the completion of this complaint survey. In addition, on October 16, 2013, the facility had instituted a new policy requiring that all newly-hired licensed nursing staff would receive training on the facility's policies and procedures related to laboratory testing, and the administration of resident medications, including anticoagulant drug therapy. However, this October 16, 2013, training procedure was implemented only two days prior to the exit date of this complaint survey, thus not allowing an adequate period of time to assess the facility's application and compliance. Also, the facility had implemented a procedure by which monitoring would be completed, by the Administrator or DON, of the facility's compliance with anticoagulant and laboratory testing policies and procedures, as reflected on the Laboratory Book, [MEDICATION NAME]/Anticoagulant Records, resident MARs, and physician's orders [REDACTED]. The results of this monitoring would then be reported to the QAPI Committee monthly for the Committee ' s review, evaluation, and ultimate determination of the need for potential policy/procedure modification. However, though the QAPI Committee had met on October 16, 2013, to discuss and review these new policies and procedures established by the facility, the QAPI Committee will not meet again until October 24, 2013, to begin the ongoing process of monitoring staffs' compliance with the new procedures. Thus, the Committee's ongoing process of facility procedural oversight could not be evaluated at the time of survey completion. Therefore, the non-compliance continues, but the scope and severity is reduced to an "E" level.

Based on record review, staff interview, Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]' orders, for eight (8) residents (#20, #21, #22, #24, #26, "A", "B", and "C") who were ordered to receive anticoagulant, cardiovascular and/or [MEDICATION NAME] medications, and failed to administer anticoagulant medication and perform a laboratory test as ordered for one (1) resident (#1), on the total survey sample of thirty-three (33) residents. Specifically, for Residents #20, #21, #22, #24, and #26, the facility failed to administer anticoagulant drug therapy as ordered by the physician. Resident #26 was subsequently determined, via a laboratory test, to have significantly elevated [MEDICATION NAME] Time and International Normalized Ratio (PT/INR) levels of 53.5 and 6.53, respectively. For Resident #1, the facility failed to administer anticoagulant drug therapy and perform laboratory testing as ordered. For Resident "B", the facility failed to administer anticoagulant and cardiac drug therapy as ordered, and for Residents "A" and "C", the facility failed to administer [MEDICATION NAME] drug therapy as ordered. This resulted in a situation in which the facility's non-compliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility's Administrator was informed of the Immediate Jeopardy on October 16, 2013, at 11:25 a.m. The non-compliance related to the Immediate Jeopardy was identified to have existed as of September 13, 2013 (the date the facility failed to obtain a [MEDICATION NAME] Time/International Normalized Ratio (PT/INR) laboratory test for Resident #1, which was ordered as a repeat for a report of 09/11/2013 which had revealed high PT/INR levels of 39.2 and 4.34, respectively, and also then resumed the resident's [MEDICATION NAME] drug therapy with no order), continued through October 16, 2013, and was removed on October 17, 2013. The facility implemented a credible allegation of jeopardy removal related to the Immediate Jeopardy on October 16, 2013. During interview on 10/18/2013 at 1:00 p.m., the Administrator indicated that the facility had not been aware, prior to this complaint survey, of significant issues involving resident medication administration, but did acknowledge the problems involving significant medication administration errors found as a result of this survey. The Administrator further acknowledged that, prior to this survey, the facility had not developed and implemented measures to address a problem involving a pattern of significant medication errors. However, the Administrator did acknowledged the facility's prior awareness of a problem related to laboratory testing, but stated that the facility had failed to conform with corrective procedures which had been initially developed to address this laboratory problem. The facility's failure to implement systems which ensured the accurate provision of drug therapy and laboratory services, in accordance professional nursing standards of practice, resulted in the failure to administer anticoagulant drug therapy as ordered to Residents #1, #20, #21, #22, #24, and #26, the failure to administer both anticoagulant and cardiovascular drug therapy to Resident "B" as ordered, the failure to administer pain medication to Residents "A" and "C", as ordered, and the failure to obtain a laboratory test as ordered for Resident #1. An allegation of jeopardy removal was received on October 16, 2013. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on October 17, 2013, and the facility remained out of compliance at a lower scope and severity of "E" while the process of evaluating modifications of the medication administration and laboratory requisition systems continued. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the administration of resident medication and the facility's process for obtaining and reporting laboratory testing results. Observations were made of medication administration to assess staffs' conformance with physicians' medication orders. Findings include: The Georgia Registered Professional Nurse Practice Act, Article 43-26-3(6), indicates that the practice of nursing includes the supervision of medication administration, as prescribed by a physician. Article 43-26-3(8) of this Act also specifies that the nurse will provide diagnostic studies as authorized by protocol. 1. Resident #26's Minimum Data Set (MDS) of 08/20/2013 documented, in Section I - Active Diagnoses, [MEDICAL CONDITION], Hypertension, and Diabetes Mellitus. A 09/19/2013 Physician's Interim/Telephone Orders (PI/TO) for Resident #26 ordered a 5 mg. dose of [MEDICATION NAME]. However, the September 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. doses on 09/19/2013, 09/20/2013, 09/23/2013, and 09/24/2013, instead of 5 mgs., as ordered. A 09/25/2013 laboratory report for Resident #26 then documented significantly elevated PT and INR levels of 53.5 and 6.53, respectively. During interview on 10/17/2013 at 3:00 p.m., the Assistant Director of Nursing acknowledged this error. Based on the above, the facility failed to administer [MEDICATION NAME] anticoagulant drug therapy to Resident #26, in accordance with the physician's order and professional nursing standards of practice, and the resident was found to have elevated PT/INR levels of 53.5 and 6.53, respectively. Cross refer to F333, example 1, for more information regarding Resident #26. 2. Resident #1's MDS of 06/11/2013 documented diagnoses, in Section I - Active Diagnoses, of Hypertension and [MEDICAL CONDITION], and the current Physician's Orders documented [DIAGNOSES REDACTED]. A 09/11/2013, 4:00 p.m. PI/TO for Resident #1 specified to hold [MEDICATION NAME] 4 mg. for two (2) days, repeat a PT/INR on 09/13/2013, and to resume [MEDICATION NAME] 3.5 mg. therapy on 09/13/2013 if the INR level was between 2.0 and 3.0. However, Resident #1's September 2013 MAR indicated [REDACTED]. Additionally, the PT/INR laboratory test ordered to be repeated on 09/13/2013 was not done, but the September and October 2013 MARs documented that [MEDICATION NAME] therapy was restarted on 09/13/2013 and continued through October 3, 2013, with no laboratory results or physician's order to resume the drug. During a 10/04/2013, 4:00 p.m. interview, the Director of Nursing (DON) acknowledged that [MEDICATION NAME] was resumed on 09/13/13 in the absence of the ordered laboratory test result. Based on the above, the facility failed to administer [MEDICATION NAME] anticoagulant drug therapy and obtain an ordered laboratory test for Resident #1, in accordance with physician's orders and professional nursing standards of practice. Cross refer to F333, example 2, for more information regarding Resident #1. 3. Resident #22's MDS of 07/10/2013 documented, in Section I-Active Diagnoses, Diabetes Mellitus and Hypertension. The resident's September 2013 MAR indicated [REDACTED]. daily. A PI/TO of 09/25/2013 specified to hold Resident #22's [MEDICATION NAME] for only two (2) days. However, Resident #22's September and October 2013 MARs documented that staff continued to hold [MEDICATION NAME] from 09/27/2013 through 10/03/2013, with no physician's order to hold. A 10/04/2013 PI/TO again ordered daily [MEDICATION NAME] 4 mg. doses, but the October 2013 MAR indicated [REDACTED]. During a 10/16/2013, 11:48 a.m. interview, the DON acknowledged the above. Based on the above, the facility failed to administer [MEDICATION NAME] anticoagulant drug therapy to Resident #22, in accordance with physician's orders and with professional nursing standards of practice. Cross refer to F333, example 3, for more information regarding Resident #22. 4. Resident "B"'s MDS of 08/06/2013 documented, in Section I - Active Diagnoses, Heart Failure and Hypertension. The resident's October 2013 Physician's Orders documented an additional [DIAGNOSES REDACTED]. twice daily, and the anticoagulant drug [MEDICATION NAME] 5 mgs. daily. However, Resident "B"'s October 2013 MAR indicated [REDACTED]. During a 10/04/2013, 4:00 p.m. interview, the DON acknowledged that [MEDICATION NAME] and Carvedilol were not administered as ordered. Based on the above, the facility failed to administer the heart-failure medication Carvedilol and the anticoagulant medication [MEDICATION NAME] to Resident "B", in accordance with physicians' orders and with professional nursing standards of practice. Cross refer to F333, example 4, for more information regarding Resident "B". 5. Resident #20's MDS of 08/16/2013 documented, in Section - Active Diagnoses, [MEDICAL CONDITIONS], Diabetes Mellitus, [MEDICAL CONDITION] and Hypertension. The October 2013 Physician Orders also documented a history of [MEDICAL CONDITION] with vessel graft, and a physician's order for [MEDICATION NAME] 2 mgs. daily. A 10/07/2013, 1:23 p.m. PI/TO specified to increase Resident #20's [MEDICATION NAME] dose to 2.5 mgs, but the October 2013 MAR indicated [REDACTED]. at 5:00 p.m. on 10/07/2013, and also on 10/08/13 and 10/09/13, in error. During a 10/11/2013, 2:10 p.m. interview, the DON acknowledged the above. Based on the above, the facility failed to administer Resident #20's [MEDICATION NAME] anticoagulant drug therapy in accordance with the physician's order, and with professional nursing standards of practice. Cross refer to F333, example 5, for more information regarding Resident #20. 6. Resident #21's MDS of 09/24/2013 documented, in Section I - Active Diagnoses, [MEDICAL CONDITIONS], Hypertension, and [MEDICAL CONDITION]. Physician's orders included the anticoagulant drug [MEDICATION NAME] 4 mgs. daily. However, even though a physician's order on a 09/25/2013 laboratory report, received at 11:53 a.m., specified to hold Resident #21's [MEDICATION NAME] for two days, the September 2013 MAR indicated [REDACTED]. During a 10/11/2013, 2:40 p.m. interview, the DON acknowledged the above. Based on the above, the facility failed to administer Resident #21's [MEDICATION NAME] anticoagulant drug therapy, as specified by the physician's order and in accordance with professional nursing standards of practice. Cross refer to F333, example 6, for more information regarding Resident #21. 7. Resident #24's MDS of 08/20/2013 documented, in Section I - Active Diagnoses, [MEDICAL CONDITION] and Hypertension, and the August 2013 MAR indicated [REDACTED] A physician's order for Resident #24 specified [MEDICATION NAME] 3 mgs. daily, but record review revealed no evidence that the [MEDICATION NAME] 3 mg. dose was given on 08/07/2013 at 5:00 p.m. An 08/08/2013, 12:22 p.m. PI/TO specified to start [MEDICATION NAME] 3.5 mgs. daily, but record review revealed no evidence that the 08/08/2013, 5:00 p.m. [MEDICATION NAME] 3.5 mg. dose was administered. During a 10/17/2013, 2:15 p.m. interview, the ADON acknowledged the above. Based on the above, the facility failed to administer Resident #24's [MEDICATION NAME] anticoagulant therapy as ordered and in accordance with professional nursing standards of practice. Cross refer to F333, example 7, for more information regarding Resident #24. 8. Resident "C"'s MDS of 07/09/2013 documented Diabetes Mellitus in Section I - Active Diagnoses. A physician's order for Resident "C" specified the pain medication [MEDICATION NAME]-[MEDICATION NAME] 325 mgs/7.5 mgs. every six (6) hours as needed for pain. However, Resident "C"'s September 2013 MAR indicated [REDACTED]. Based on the above, the facility failed to administer Resident "C"'s pain medication, and thus failed to provide Pain Management, as ordered by the physician, and in accordance with professional nursing standards of practice. Cross refer to F309, example #1, for more information regarding Resident "C". 9. Resident "A"'s MDS of 08/13/2013 documented Diabetes Mellitus in Section I - Active Diagnoses, and a physician's order specified application of a [MEDICATION NAME] 75 mcg/hr patch every three days for limb pain. However, Resident "A"s September 2013 MAR indicated [REDACTED]. During a 10/11/2013, 11:40 a.m. interview, the DON acknowledged the above. Based on the above, the facility failed to administer Resident "A"'s pain medication, thus failing to provide Pain Management as ordered by the physician and in accordance with professional nursing standards of practice. Cross refer to F309, example 2, for more information regarding Resident "A". The Immediate Jeopardy was determined to have been removed on 10/17/2013, at which time the facility had presented and implemented an allegation of jeopardy removal with the following interventions: A. On October 5, 2013, the facility's DON and Assistant Director of Nursing (ADON) conducted audits on all residents receiving anticoagulant drug therapy to ensure that all residents had accurate medication orders and correct laboratory orders. B. On October 5, 2013, the DON, Unit Managers, and the Director of Education (DEQ) reviewed all Physician's Orders Forms and physicians' telephone orders for all residents receiving anticoagulant drug therapy to ensure the accuracy of the medications ordered. Physicians were notified of any discrepancies, and new physicians' orders were received as needed. C. On October 5, 2013, all facility medication carts were audited by the DON, Unit Managers, the DEQ, and the facility's pharmacy consultant to ensure that the correct dosages of all anticoagulant medications, and all other medications, were present. D. On October 5, 2013, the facility implemented a procedure by which the DON/DEQ/Unit Managers would review all physicians' telephone orders daily to ensure the accuracy of any changes related to resident anticoagulant drug therapy. The findings and noted errors or discrepancies would be documented on the Supervisor's Report. Physicians would be notified of any identified discrepancies. E. On October 10, 2013, the facility completed staff in-service training which stressed the importance of ensuring medication orders had been transcribed accurately and timely, in accordance with facility policies. As of that date, one-hundred (100) percent of all licensed nursing staff had received training. F. On October 10, 2013, the facility completed staff in-service training on ensuring new medication orders were provided to the pharmacy via facsimile in a timely manner, per facility policy and procedure. The medication administration policy and procedure were presented, as well as a specific discussion regarding [MEDICATION NAME] dosage administration, per physicians' orders. As of that date, one-hundred (100) percent of all licensed nursing staff had received training. G. On October 10, 2013, the facility completed staff in-service training which covered the importance of informing physicians of PT/INR laboratory test results in a timely manner, per facility protocol and policy. As of that date, one-hundred (100) percent of all licensed nursing staff had received training. H. On October 10, 2013, the facility completed staff in-service training related to the signs and symptoms of bleeding for residents receiving anticoagulant drug therapy. As of that date, one-hundred (100) percent of all licensed nursing staff had received training. I. On October 11, 2013, the facility contracted with a new pharmacy provider. This pharmacy provider would aid the facility with ensuring that medication therapy was administered in conformance with physicians' orders and per facility policies and procedures. J. On October 12, 2013, the newly-contracted pharmacy provider company conducted audits to assess the conformance with the facility's policies and procedures regarding accurate resident Physician's Orders Forms, medication cart content, and medication pass. This was to ensure that the facility followed policies and procedures for the proper administration of medications. K. On October 12, 2013, the facility implemented a procedure by which the Administrator, DON, or designated Nursing Supervisor would review entries on resident MARs daily to ensure accuracy of transcribed anticoagulant orders. Findings would be documented on the Supervisor's Report, and physicians would be notified of any discrepancies. L. On October 12, 2013, the facility implemented a procedure by which the Administrator, DON, or designated Nursing Supervisor would review all Laboratory Books daily to ensure that PT/INR laboratory tests were logged correctly to ensure completion, and were also obtained in a timely manner per physicians' orders. M. On October 12, 2013, the facility developed and implemented a new form, the [MEDICATION NAME]/Anticoagulant Record Form, by which the DON or Unit Managers would document all PT/INR physicians' orders, the results of laboratory tests, and physician notification of laboratory test results. N. On October 12, 2013, the facility implemented a procedure by which the Administrator, DON, or designated Unit Manager would review all PT/INR laboratory results daily to ensure prompt notification to the physician is completed. Once physician notification was completed, the Nursing Supervisor would document this notification on the [MEDICATION NAME]/Anticoagulant Record. O. On October 12, 2013, the facility implemented a procedure by which the DON or designated Unit Manager would track the requisition of PT/INR laboratory tests until laboratory test results are received and physicians are notified of the results. This tracking will be conducted daily on an ongoing basis, and will be documented on the [MEDICATION NAME]/Anticoagulant Record Form. P. On October 13, 2013, the facility implemented a procedure by which the Administrator, DON, or designated Nursing Supervisor would conduct daily audits of the Laboratory Books and [MEDICATION NAME]/Anticoagulant Record to ensure that laboratory tests results were obtained and physicians were notified in a timely manner. Q. On October 13, 2013, the facility implemented a procedure by which the Administrator or DON would conduct sampled audits of the Laboratory Book, [MEDICATION NAME]/Anticoagulant Record, MARs, and Physician's Order sheets twice a week for four (4) weeks, then weekly for four (4) weeks, then monthly. Areas of concern would be reported to the Quality Assessment and Performance Improvement (QAPI) Committee monthly by the Administrator for the Committee's review, modification, and Performance Improvement. R. On October 16, 2013, the facility implemented a procedure requiring that ongoing in-service education will be provided to all nursing staff on a quarterly and annual basis related to the policies and procedures for the ordering of laboratory tests, the documentation of laboratory testing results in the clinical record, and the process of notifying the physician of results in a timely manner. Also, nursing staff would be trained on the proper administration of anticoagulants, and other medications, in accordance with facility policies and procedures. Additionally, this new policy requires that all newly-hired nurses will be trained on these facility policies and procedures upon hire. Included in this procedure was the provision that staff conformance with medication administration and facility laboratory protocols would be tracked by the facility's QAPI Committee, who will then determine the need for additional training, based on staff performance. S. On October 16, 2013, the QAPI Committee met to discuss this Immediate Plan of Correction Implementation for the Removal of Immediate Jeopardy. The next QAPI Committee meeting is scheduled for October 24, 2013, for the review of these new procedures implemented by the facility regarding medication administration and laboratory procedures. Based on these corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice was removed on October 17, 2013. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. As of October 12, 2013, the facility implemented new procedures by which administrative staff would conduct daily MAR indicated [REDACTED]. On October 12, 2013, the facility had also developed and implemented a new [MEDICATION NAME]/Anti-coagulant Record Form to be utilized by supervisory nursing staff for the documentation of PT/INR orders, laboratory testing results, and physician notification. However, due to the newly-implemented status of these critical procedures regarding the supervisory nursing staffs' monitoring of anticoagulant order transcription accuracy and PT/INR order receipt and follow-up, as well as the newly-implemented forms to document this monitoring, nursing staffs' ongoing application of these new procedures, continued compliance could not be entirely assured as of the completion of this complaint survey. In addition, on October 16, 2013, the facility had instituted a new policy requiring that all newly-hired licensed nursing staff would receive training on the facility's policies and procedures related to laboratory testing, and the administration of resident medications, including anticoagulant drug therapy. However, this October 16, 2013, training procedure was implemented only two days prior to the exit date of this complaint survey, thus not allowing an adequate period of time to assess the facility's application and compliance. Also, the facility had implemented a procedure by which monitoring would be completed, by the Administrator or DON, of the facility's compliance with anticoagulant and laboratory testing policies and procedures, as reflected on the Laboratory Book, [MEDICATION NAME]/Anticoagulant Records, resident MARs, and Physician's Orders Sheets twice weekly for four weeks, then weekly for four weeks, then monthly. The results of this monitoring would then be reported to the QAPI Committee monthly for the Committee's review, evaluation, and ultimate determination of the need for potential policy/procedure modification. However, though the QAPI Committee had met on October 16, 2013, to discuss and review these new policies and procedures established by the facility, the QAPI Committee will not meet again until October 24, 2013, to begin the ongoing process of monitoring staffs' compliance with the new procedures. Thus, the Committee's ongoing process of facility procedural oversight could not be evaluated at the time of survey completion. Therefore, the non-compliance continues, but the scope and severity is reduced to an "E" level.

Based on observation, record review, staff interview, resident interview, Medication Administration Record review, and resident laboratory report review, the facility failed to ensure that seven (7) residents (#1, #20, #21, #22, #24, #26, and "B") were free of significant medication errors, regarding the administration of anticoagulant and/or cardiovascular drug therapy, and regarding laboratory testing related to resident anticoagulant drug therapy. The total survey sample was thirty-three (33) residents. Specifically, for Resident #24, who had [DIAGNOSES REDACTED]. Subsequently, on 09/13/2013 for Resident #1, who had [DIAGNOSES REDACTED]. the drug through 10/03/2013. However, the facility failed to identify these significant medication errors involving Resident #24 and Resident #1, occurring on 08/07/2013 and 09/13/2013, respectively. Then, for Resident #26, from 09/19/2013 through 09/25/2013, the facility administered double-doses of [MEDICATION NAME] anticoagulant drug therapy on four (4) separate days, and the resident was then found to have significantly elevated PT/INR levels of 53.5 and 6.53, respectively. On 09/25/2013, for Resident #21, facility staff failed to hold [MEDICATION NAME] drug therapy as ordered in response to a laboratory report of 09/25/2013 which revealed high PT/INR results of 32.5 and 3.39, respectively. On 09/27/2013, for Resident #22, the facility began holding [MEDICATION NAME] doses and continued holding through 10/03/2013, with no physician's order to hold the drug, and then failed to resume [MEDICATION NAME] therapy as ordered on [DATE], not actually resuming the drug until 10/06/2013. On, 10/02/2013 and 10/03/2013, for Resident "B" who had [DIAGNOSES REDACTED]. And, on 10/07/2013, for Resident #20 who had [DIAGNOSES REDACTED]. The facility's failure to promptly identify and address this pattern of significant medication errors resulted in a situation in which the facility's non-compliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility's Administrator was informed of the Immediate Jeopardy on October 16, 2013 at 11:25 a.m. The non-compliance related to the Immediate Jeopardy was identified to have existed as of September 13, 2013 (the date the facility failed to obtain a [MEDICATION NAME] Time/International Normalized Ratio (PT/INR) laboratory test for Resident #1, which was ordered as a repeat for a report of 09/11/2013 which had revealed high PT/INR levels of 39.2 and 4.34, respectively, and also then resumed the resident's [MEDICATION NAME] drug therapy with no order), continued through October 16, 2013, and was removed on October 17, 2013. The facility implemented a credible allegation of jeopardy removal related to the Immediate Jeopardy on October 16, 2013. The Administrator indicated that while the facility had been unaware of the significant issues involving medication administration, problems with the provision of laboratory services had been identified and corrective procedures had been put into place. However, the Administrator further acknowledged that the facility had failed to consistently adhere to these corrective procedures, and issues with laboratory services had continued. The facility's failure to provide systems which ensured the accurate provision of drug therapy and laboratory services, in accordance with physicians' orders and the needs of residents, resulted in significant medication errors related to the failure to administer anticoagulant drug therapy as ordered to Resident #1, Resident #20, Resident #21, Resident #22, Resident #24, and Resident #26, the failure to administer both anticoagulant and cardiovascular drug therapy as ordered to Resident "B", and the failure to obtain laboratory tests as ordered for Resident #1. An allegation of jeopardy removal was received on October 16, 2013. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on October 17, 2013, and the facility remained out of compliance at a lower scope and severity of "E" while the process of evaluating modifications of the medication administration and laboratory requisition systems continued. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the administration of resident medication and the facility's process for obtaining and reporting laboratory testing results. Observations were made of medication administration to assess staffs' conformance with physicians' medication orders. Findings include: 1. Record review for Resident #26 revealed an Annual Minimum Data Set (MDS) assessment having an Assessment Reference Date of 08/20/2013 which documented diagnoses, in Section I - Active Diagnoses, which included [MEDICAL CONDITION], Hypertension, and Diabetes Mellitus. A physician's order of 09/11/2013 specified that Resident #26 receive [MEDICATION NAME] Sodium ([MEDICATION NAME]) 5.5 milligrams (mgs.) by mouth each evening. A laboratory report for Resident #26 dated 09/18/2013 documented a significantly high [MEDICATION NAME] Time (PT) of 40.2 seconds (Reference Range, 11.0 - 15.0) and a significantly elevated International Normalized Ratio (INR) of 4.48 (Recommended Therapeutic Range, 2.00 - 3.50). A hand-written notation on this laboratory report indicated to decrease the [MEDICATION NAME] dose to 5 mgs as the daily dose. This hand-written notation also specified to obtain a PT/INR laboratory test the following Wednesday (09/25/2013) The September 2013 Medication Administration Record (MAR) for Resident #26 documented the order referenced above, with a start date of 09/18/2013, which specified to administer [MEDICATION NAME] Sodium 5 mgs. each evening, and documented that a 5 mg. dose of [MEDICATION NAME] Sodium was administered, as ordered, on 09/18/2013 at 5:00 p.m. A subsequent Physician's Interim/Telephone Orders (PI/TO) form dated 09/19/2013 also specified that the dose of Resident #26's [MEDICATION NAME] ([MEDICATION NAME] Sodium) be decreased to 5 mgs, and specified that a PT/INR laboratory test be obtained the following Wednesday, 09/25/2013. The order referenced on this 09/19/2013 PI/TO for [MEDICATION NAME] 5 mgs. daily and a PT/INR laboratory test to be done on 09/25/2013 mirrored the same hand-written orders for [MEDICATION NAME] and PT/INR laboratory testing referenced on the 09/18/2013 laboratory test referenced above. However, further review of Resident #26's September 2013 MAR referenced above revealed a second entry, with a start date of 09/19/2013, which indicated to administer [MEDICATION NAME] Sodium 5 mgs. by mouth each evening at 5:00 p.m. Therefore, there were two (2) separate September 2013 MAR entries, one dating from 09/18/2013 and one dating from 09/19/2013, both specifying to administer [MEDICATION NAME] 5 mgs. each evening to Resident #26. Further review of this September 2013 MAR revealed that Resident #26 received two (2) separate 5 mg. doses of [MEDICATION NAME] at 5:00 p.m. on 09/19/2013, 09/20/2013, 09/23/2013, and 09/24/2013, thus receiving a double-dose of [MEDICATION NAME] on those four (4) days. This MAR documented that Resident #26 received only one (1) 5 mg. dose of [MEDICATION NAME] on 09/21/2013 and 09/22/2013. Therefore, Resident #26 had received double-doses (two 5 mg. doses, instead of one 5 mg. dose as ordered) of [MEDICATION NAME] on four separate days (09/19/2013, 09/20/2013, 09/23/2013, and 09/24/2013). Review of the 09/25/2013 laboratory report for Resident #26, which was obtained as ordered on the 09/19/2013 PI/TO referenced above and after the resident had received double-doses of [MEDICATION NAME] on four (4) days, revealed a significantly elevated PT level of 53.5 seconds, and a significantly elevated INR of 6.53. A hand-written notation on this laboratory report indicated to hold the resident's [MEDICATION NAME]. During an interview with the Assistant Director of Nursing (ADON) conducted on 10/17/2013 at 3:00 p.m., the ADON acknowledged the [MEDICATION NAME] medication error involving Resident #26, as referenced above. Based on the above, despite Resident #26, who received [MEDICATION NAME] anticoagulant drug therapy, having significantly elevated PT/INR levels of 40.2 and 4.48, respectively, on 09/18/2013, and despite an order to thus decrease the resident's [MEDICATION NAME] dose to 5 mgs. daily, the facility subsequently administered two (2) separate 5 mg. doses of [MEDICATION NAME], in error, to this resident on four (4) separate days between 09/19/ and 09/24/2013. Resident #26 was then found to have even more significantly elevated PT/INR levels of 53.5 and 6.53, respectively, on 09/25/2013. 2. Record review for Resident #1 revealed an Annual MDS assessment with an Assessment Reference Date of 06/11/2013 which documented, in Section I - Active Diagnoses, that the resident had [DIAGNOSES REDACTED]. The October 2013 Physician's Orders for Resident #1 also documented the [DIAGNOSES REDACTED]. A physician's order, originally dating from 08/23/2013, specified that Resident #1 receive the anticoagulant drug [MEDICATION NAME] 4 mgs. by mouth daily for [MEDICAL CONDITION] Fibrillation. Another physician's order, originally dating from 05/08/2013, specified that a PT/INR laboratory test be done every month. A laboratory report form for Resident #1, dated as having been collected on 09/11/2013, documented a high PT of 39.2 seconds (Reference Range, 11.0 to 15.0 seconds), and an elevated INR of 4.34 (Recommended Therapeutic Range, 2.0 to 3.0 for the prevention of systemic embolism). A printed notation on this laboratory report indicated that these elevated PT/INR laboratory test results had been reported back to the facility on [DATE] at 3:22 p.m. A PI/TO form for Resident #1, also dated 09/11/2013 and timed at 4:00 p.m. (38 minutes after the facility received the elevated PT/INR laboratory test results referenced above), referenced an order to hold the resident's [MEDICATION NAME] drug therapy for two (2) days, and to repeat the PT/INR laboratory test on 09/13/2013. This PI/TO form also specified to resume the resident's [MEDICATION NAME] therapy on 09/13/2013, but only if the repeated INR level was between 2.0 and 3.0, and also at a lower dose of [MEDICATION NAME] 3.5 mgs. However, even though the physician's order referenced above, obtained on 09/11/2013 at 4:00 p.m., specified to hold Resident #1's [MEDICATION NAME] drug therapy, review of Resident #1's September 2013 MAR revealed that a 4 mg. dose of [MEDICATION NAME] was documented as having been administered to the resident at 5:00 p.m. on 09/11/2013. This September 2013 MAR documented that Resident #1's [MEDICATION NAME] 4 mg. dose was held on 09/12/2013, in accordance with the 09/11/2013 PI/TO order referenced above Further record review for Resident #1 revealed no evidence to indicate that the PT/INR laboratory test, ordered to be repeated on 09/13/2013 per the 09/11/2013 PI/TO referenced above, was done. During an interview conducted on 10/04/2013 at 3:40 p.m., Charge Nurse "GG" stated she had contacted the laboratory and confirmed that the PT/INR ordered to be completed for Resident #1 on 09/13/2013 had not been done, and that no PT/INR laboratory tests had been performed for Resident #1 since the 09/11/2013 laboratory test. However, even though the 09/13/2013 repeat PT/INR laboratory test had not been done for Resident #1 as ordered, and even though the resumption of the resident's [MEDICATION NAME] drug therapy was to be contingent on an INR result of between 2.0 and 3.0 to be determined by that laboratory test, further review of Resident #1's September 2013 MAR revealed an entry indicating that on 09/13/2013, [MEDICATION NAME] 3.5 mg. drug therapy was initiated. As indicated above, there was no evidence of an INR result having been obtained for Resident #1 upon which to base the resumption of this [MEDICATION NAME] drug therapy, per the PI/TO order. There was also no evidence to indicate that the physician had been made aware that the 09/13/2013 PT/INR laboratory testing had not been performed as ordered for Resident #1, or that a specific physician's order had been obtained to resume the [MEDICATION NAME] therapy. Despite that fact, Resident #1's September 2013 and October 2013 MARs documented that Resident #1 received daily doses of [MEDICATION NAME] 3.5 mg. from September 13, 2013, through October 3, 2013 (a total of 21 [MEDICATION NAME] doses). During an interview with Medication Nurse "HH" conducted on 10/04/2013 at 3:25 p.m. regarding Resident #1's [MEDICATION NAME] therapy, Nurse "HH" acknowledged that Resident #1 had been receiving [MEDICATION NAME] drug therapy. This nurse stated that she had been administering 4 mg. doses of [MEDICATION NAME] to Resident #1 (rather than 3.5 mg. [MEDICATION NAME] doses, as documented on the MARs referenced above), and further stated that she was uncertain of how much [MEDICATION NAME] the resident was supposed to receive at that point. During a 10/04/2013, 3:25 p.m. observation of the blister pack card containing Resident #1's current supply of [MEDICATION NAME] tablets, with Nurses "GG" and "HH" in attendance, it was noted that the resident's current supply of [MEDICATION NAME] tablets was labeled as [MEDICATION NAME] Sodium ([MEDICATION NAME]) 4 mg. tablets. Three (3) 4 mg. tablets of [MEDICATION NAME] Sodium remained in the blister pack card, which was dated as having been dispensed by the pharmacy on 09/28/2013 as a seven (7) day supply. During an interview with the Director of Nursing (DON) conducted on 10/04/2013 at 4:00 p.m., the DON acknowledged that Resident #1's [MEDICATION NAME] drug therapy had been resumed on September 13, 2013, even though the ordered INR laboratory test to support the resumption of the drug therapy had not been completed. The DON stated that she had contacted the Physician's Assistant on 10/04/2013, and that a STAT PT/INR would be obtained. Additionally, when questioned regarding the actual dose of [MEDICATION NAME] that Resident #1 had received, the DON indicated that she could contact the pharmacy. During a subsequent interview with the DON conducted on 10/04/2013 at 4:15 p.m., she stated that she had confirmed with pharmacy personnel that the pharmacy had supplied only [MEDICATION NAME] 4 mg. doses for Resident #1, rather than 3.5 mg [MEDICATION NAME] doses, as documented on the resident's MARs. Review of the 10/04/2013 laboratory test report for Resident #1, which was done as indicated in the 10/04/2013, 4:00 p.m. DON interview referenced above, revealed that the PT result remained elevated at 25.1 seconds. Based on the above, Resident #1 received [MEDICATION NAME] anticoagulant drug therapy for a [DIAGNOSES REDACTED]. The facility also resumed [MEDICATION NAME] drug therapy on 09/13/2013, even though the physician had ordered for this [MEDICATION NAME] drug therapy to be resumed only as based on the results of the ordered 09/13/2013 INR laboratory test, which the facility failed to obtain. The facility then administered this [MEDICATION NAME] drug therapy, in error, daily through 10/03/2013 (a total of 21 days). A subsequent laboratory test for Resident #1 done on 10/04/2013, the first date of this complaint survey and after the resident had received [MEDICATION NAME] for 21 days in error, revealed that the PT remained elevated at 25.1 seconds. 3. Record review for Resident #22 revealed a Quarterly MDS having an Assessment Reference Date of 07/10/2013 which indicated in Section I - Active [DIAGNOSES REDACTED]. The resident's September 2013 MAR also documented [DIAGNOSES REDACTED]. A physician's order for Resident #22, originally dating from 08/22/2013, specified that the resident receive a dose of [MEDICATION NAME] 4 mgs. every day. A laboratory report dated 09/25/2013 for Resident #22 revealed a high PT of 39.8 seconds, and an elevated INR of 4.42. A PI/TO form of 09/25/2013 specified an order to hold the resident's [MEDICATION NAME] for two (2) days, and to obtain a repeat PT/INR laboratory test on 09/27/2013. Resident #22's September 2013 MAR documented that the resident's [MEDICATION NAME] 4 mg. doses were held on 09/25/2013 and 09/26/2013, in conformance with the 09/25/2013 physician's order referenced above. Record review also revealed a laboratory report for Resident #22, obtained on 09/27/2013 as ordered, which indicated a high PT result of 28.7 seconds and an INR within the therapeutic range of 2.87. However, further record review for Resident #22 revealed no evidence to indicate that facility staff notified the physician of the results of the 09/27/2013 PT/INR laboratory test referenced above upon receipt. Rather, a notation of 10/07/2013 documented physician notification of the laboratory test results on that date, thus representing a ten (10) day delay in physician notification. Additionally, even though the 09/25/2013 order had specified to hold Resident #22's [MEDICATION NAME] dose for only two (2) days (09/25/2013 and 09/26/2013), and even though there was no evidence of physician consultation related to the 09/27/2013 laboratory results or resumption/modification of the [MEDICATION NAME] therapy, further review of Resident #22's September and October 2013 MARs revealed that the resident's daily [MEDICATION NAME] doses were held on 09/27/2013, 09/28/2013, 09/29/2013, 09/30/2013, and 10/01/2013 in error. There was no evidence of a physician's order to hold the [MEDICATION NAME] doses on those dates. A laboratory report dated 10/02/2013 for Resident #22 then revealed a high PT of 17.0 seconds, but a sub-therapeutic INR result of 1.44. Record review revealed no evidence to indicate that the physician was notified of these laboratory test results on 10/02/2013, or that a physician's order referencing the resident's [MEDICATION NAME] therapy was obtained on that date. However, further review of Resident #22's October 2013 MAR revealed that staff continued to hold the resident's 4 mg. dose of [MEDICATION NAME] on 10/02/2013 and 10/03/2013, in error, with no evidence of a physician's order to hold the drug. A 10/04/2013 PI/TO form, timed at 4:45 p.m., for Resident #22 then ordered to resume the resident's daily [MEDICATION NAME] 4 mg. drug therapy. However, further review of Resident #22's October 2013 MAR revealed that nursing staff continued to hold the resident's [MEDICATION NAME] drug therapy, in error, on that date of 10/04/2013, and also on 10/05/2013. This October 2013 MAR documented that Resident #22's daily [MEDICATION NAME] 4 mg. drug therapy was not resumed until 10/06/2013 (two days after the 10/04/2013 PI/TO order specified that the [MEDICATION NAME] therapy be resumed on that date). During an interview with the DON conducted on 10/16/2013 at 11:48 a.m., the DON acknowledged that nursing staff had failed to clarify Resident #22's physician's orders regarding [MEDICATION NAME] drug therapy, as referenced above. The DON also acknowledged that staff failed to resume Resident #22's [MEDICATION NAME] drug therapy on 10/04/2013 as ordered, and did not resume the [MEDICATION NAME] drug therapy until 10/06/2013. Based on the above, for Resident #22 who had [DIAGNOSES REDACTED]. The facility then failed to resume Resident #22's daily [MEDICATION NAME] drug therapy on 10/04/2013, as ordered, but rather finally resumed the ordered daily [MEDICATION NAME] therapy two (2) days later on 10/06/2013, resulting in a two-day delay in the resumption of drug therapy. 4. Record review for Resident "B" revealed an Admission MDS assessment with an Assessment Reference Date of 08/06/2013 which documented, in Section C - Cognitive Patterns, that the resident had a Brief Interview for Mental Status score of 15, thus indicating that the resident was cognitively intact. Section I - Active [DIAGNOSES REDACTED]. Review of Resident "B"'s October 2013 Physician's Orders revealed an additional [DIAGNOSES REDACTED]. These current Physician's Orders also specified that Resident "B" was to receive the cholesterol/cardiovascular drug [MEDICATION NAME] Sodium 50 mgs, 1 tablet at bedtime nightly; the heart-failure drug Carvedilol 3.125 mgs, 1 tablet twice daily, at 9:00 a.m. and 5:00 p.m.; and the anticoagulant drug [MEDICATION NAME] 5 mgs., 1 tablet daily at 5:00 p.m. However, review of the October 2013 MAR for Resident "B" revealed the following: - An MAR notation documented that the 10/02/2013, 9:00 a.m. and 5:00 p.m., and the 10/03/2013, 5:00 p.m. doses of Carvedilol were not administered. Notations on the e-MAR Administration Record indicated that for the 10/02/2013, 9:00 a.m. dose, and the 10/03/2013 5:00 p.m. dose, the medication was on order/re-order. An e-MAR Administration Record notation for the 10/02/2013, 5:00 p.m. dose indicated that nursing staff were awaiting delivery of the medication. - An MAR notation documented that the 10/01/2013 and 10/02/2013, 9:00 p.m. doses of [MEDICATION NAME] Sodium were not administered. Notations on the e-MAR Administration Record indicated that these 10/01/2013 and 10/02/2013 [MEDICATION NAME] doses were not administered due to nursing staff awaiting delivery of the medication. - An MAR notation documented that the 10/02/2013, 5:00 p.m. dose of [MEDICATION NAME] was not administered. An e-MAR Administration Record notation indicated that nursing staff were awaiting delivery of the medication. During an interview with Resident "B" conducted on 10/04/2013 at 8:45 a.m., the resident stated that the facility ran out of his/her [MEDICATION NAME] on 10/02/2013. The resident added that facility staff had not administered the Carvedilol since 10/02/2013. During an interview with the DON conducted on 10/04/2013 at 4:00 p.m., the missed medication doses for Resident "B" were discussed. The DON acknowledged that the [MEDICATION NAME] and Carvedilol doses were not administered to the resident because they were unavailable, according to the e-MAR notes. Based on the above, Resident "B" had [DIAGNOSES REDACTED]. However, the facility failed to administer the resident's heart-failure medication Carvedilol, anticoagulant medication [MEDICATION NAME], and cardiovascular medication [MEDICATION NAME] as ordered by the physician. 5. Record review for Resident #20 revealed an Admission MDS assessment with an Assessment Reference Date of 08/16/2013 which indicated, in Section - Active Diagnoses, that the resident had [DIAGNOSES REDACTED]. Review of Resident #20's October 2013 Physician Orders form revealed that the resident had a history of [REDACTED]. daily. A laboratory report dated 10/07/2013 for Resident #20 revealed a high PT result of 19.4 seconds (Reference Range, 11.0 - 15.0), but a low INR of 1.71 (Recommended Reference Range, 2.00 - 3.5). A PI/TO form, also dated 10/07/2013 and timed at 1:23 p.m., specified to increase the dose of the resident's [MEDICATION NAME] to 2.5 mgs. However, despite the 10/07/2013 PI/TO referenced above, which had been received at 1:23 p.m., ordered that Resident #20's [MEDICATION NAME] dose be increased to 2.5 mgs., review of the resident's October 2013 MAR revealed that Resident #20 was administered a dose of only 2 mgs. of [MEDICATION NAME] later in the afternoon at 5:00 p.m. on 10/07/2013, and continued to received only 2 mg. [MEDICATION NAME] daily doses on 10/08/2013 and 10/09/2013, in error. During an interview with the DON conducted on 10/11/2013 at 2:10 p.m., the DON acknowledged that the physician's order for Resident #20's [MEDICATION NAME] therapy had not been implemented correctly. Based on the above, even though the Resident #20 had a low INR of 1.71 on 10/07/2013, as referenced above, and even though the physician ordered, on 10/07/2013 at 1.23 p.m., that the resident's [MEDICATION NAME] dose be increased from 2.0 to 2.5 mgs., Resident #20 was administered a dose of only 2 mgs. of [MEDICATION NAME] later in the afternoon of 10/07/2013, and also received only 2 mg. doses of [MEDICATION NAME], in error, for the next two days of 10/08/2013 and 10/09/2013. 6. Record review for Resident #21 revealed an Annual MDS assessment with an Assessment Reference Date of 09/24/2013 which documented in Section I - Active [DIAGNOSES REDACTED]. A physician's order for Resident #21, originally dating from 08/22/2013, specified that the resident receive the anticoagulant drug [MEDICATION NAME] 4 mgs. by mouth daily. Another physician's order specified that the resident also receive a dose of the anticoagulant Aspirin 81 mgs. daily. A laboratory report for Resident #21 dated 09/25/2013 revealed a high PT result of 32.5 seconds, and an elevated INR of 3.39. A printed notation on this laboratory report documented that these laboratory results had been reported from the laboratory company back to the facility on [DATE] at 11:53 a.m. A hand-written notation on this laboratory report specified a physician's order to hold the resident's [MEDICATION NAME] therapy for two (2) days, and to then obtain a repeat INR laboratory test on Friday, 09/27/2013. However, even though the 09/25/2013 physician's order for Resident #21 referenced above (which was obtained by the facility at 11:53 a.m. after a laboratory report revealing elevated PT/INR results) specified to hold the resident's [MEDICATION NAME] therapy for two (2) days, review of the resident's September 2013 MAR revealed that nursing staff administered the scheduled 09/25/2013, 5:00 p.m. dose of [MEDICATION NAME] 4 mgs. to the resident, in error. This MAR documented that the 09/26/2013 dose of [MEDICATION NAME] was held, as ordered. During an interview with the DON conducted on 10/11/2013 at 2:40 p.m., the DON acknowledged that Resident #21's 09/25/2013 dose of [MEDICATION NAME] 4 mgs. was not held as ordered, and that the physician's order to hold the [MEDICATION NAME] for two (2) days had not been followed. Based on the above, despite Resident #21 having [DIAGNOSES REDACTED]. 7. Record review for Resident #24 revealed an Annual MDS assessment having an Assessment Reference Date of 08/20/2013 which documented diagnoses, in Section I - Active Diagnoses, which included [MEDICAL CONDITION] and Hypertension. The resident's August 2013 MAR also documented an additional [DIAGNOSES REDACTED]. A physician's order for Resident #24, originally dating from 07/10/2013, specified that the resident was to receive [MEDICATION NAME] 3 mgs. daily. However, review of the August 2013 MAR revealed no evidence to indicate that Resident #24 received the ordered [MEDICATION NAME] 3 mg. dose on 08/07/2013, scheduled to be given at 5:00 p.m. An 08/08/2013 PI/TO form, timed at 12:22 p.m., for Resident #24 specified to discontinue the 3 mg. dose of [MEDICATION NAME], and to start [MEDICATION NAME] 3.5 mgs. by mouth daily. However, review of the August 2013 MAR revealed no evidence to indicate that the resident received the 08/08/2013, 5:00 p.m. [MEDICATION NAME] 3.5 mg. dose as ordered. During an interview with the ADON conducted on 10/17/2013 at 2:15 p.m., the ADON acknowledged the [MEDICATION NAME] medication error involving Resident #24 referenced above. Based on the above, despite Resident #24 having [DIAGNOSES REDACTED]. The Immediate Jeopardy was determined to have been removed on 10/17/2013, at which time the facility had presented and implemented an allegation of jeopardy removal with the following interventions: A. On October 5, 2013, the facility's DON and Assistant Director of Nursing (ADON) conducted audits on all residents receiving anticoagulant drug therapy to ensure that all residents had accurate medication orders and correct laboratory orders. B. On October 5, 2013, the DON, Unit Managers, and the Director of Education (DEQ) reviewed all Physician's Orders Forms and physician's telephone orders for all residents receiving anticoagulant drug therapy to ensure the accuracy of the medications ordered. Physicians were notified of any discrepancies, and new physicians' orders were received as needed. C. On October 5, 2013, all facility medication carts were audited by the DON, Unit Managers, the DEQ, and the facility's pharmacy consultant to ensure that the correct dosages of all anticoagulant medications, and all other medications, were present. D. On October 5, 2013, the facility implemented a procedure by which the DON/DEQ/Unit Managers would review all physicians' telephone orders daily to ensure the accuracy of any changes related to resident anticoagulant drug therapy. The findings and noted errors or discrepancies will be documented on the Supervisor's Report. Physicians would be notified of any identified discrepancies. E. On October 10, 2013, the facility completed staff in-service training which stressed the importance of ensuring medication orders had been transcribed accurately and timely, in accordance with facility policies. As of that date, one-hundred (100) percent of all licensed nursing staff had received training. F. On October 10, 2013, the facility completed staff in-service training on ensuring new medication orders were provided to the pharmacy via facsimile in a timely manner, per facility policy and procedure. The medication administration policy and procedure were presented, as well as a specific discussion regarding [MEDICATION NAME] dosage administration, per physician's orders. As of that date, one-hundred (100) percent of all licensed nursing staff had received training. G. On October 10, 2013, the facility completed staff in-service training which covered the importance of informing physicians of PT/INR laboratory test results in a timely manner, per facility protocol and policy. As of that date, one-hundred (100) percent of all licensed nursing staff had received training. H. On October 10, 2013, the facility completed staff in-service training related to the signs and symptoms of bleeding for residents receiving anticoagulant drug therapy. As of that date, one-hundred (100) percent of all licensed nursing staff had received training. I. On October 11, 2013, the facility contracted with a new pharmacy provider. This pharmacy provider would aid the facility with ensuring that medication therapy was administered in conformance

Based on record review, staff interview, resident interview, Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"C" and "Z"), related to the administration of anticoagulant medication or [MEDICATION NAME] medication as ordered by the physician, on the total survey sample of thirty-three (33) residents. Specifically for Resident #26, who had [DIAGNOSES REDACTED]. Additionally, for Resident #1, the facility failing to obtain the ordered laboratory testing related to the resident's [MEDICATION NAME] anticoagulant drug therapy, and also resumed the [MEDICATION NAME] therapy with no order. This resulted in a situation in which the facility's non-compliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility's Administrator was informed of the Immediate Jeopardy on October 16, 2013 at 11:25 a.m. The non-compliance related to the Immediate Jeopardy was identified to have existed as of September 13, 2013 (the date the facility failed to obtain a [MEDICATION NAME] Time/International Normalized Ratio (PT/INR) laboratory test for Resident #1, which was ordered as a repeat for a report of 09/11/2013 which had revealed high PT/INR levels of 39.2 and 4.34, respectively, and also then resumed the resident's [MEDICATION NAME] drug therapy with no order), continued through October 16, 2013, and was removed on October 17, 2013. The facility implemented a credible allegation of jeopardy removal related to the Immediate Jeopardy on October 16, 2013. The Administrator indicated that the facility had been unaware of significant issues related to medication administration errors and thus had not put corrective actions into place. However, the Administrator acknowledged the significant medication errors involving resident drug therapy for the sampled residents of this complaint survey. The facility's failure to put into place systems which ensured the accurate provision of drug therapy, in accordance with physicians' orders and the needs of residents, resulted in neglect by the failure to administer anticoagulant drug therapy as ordered to Resident #26. The facility also failed to administer [MEDICATION NAME] medications to Resident "C" and Resident "Z" as ordered, even after the residents had expressed pain. An allegation of jeopardy removal was received on October 16, 2013. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on October 17, 2013, and the facility remained out of compliance at a lower scope and severity of "D" while the process of evaluating modifications of the medication administration and laboratory requisition systems continued. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the administration of resident medication and the facility's process for obtaining and reporting laboratory testing results. Observations were made of medication administration to assess staffs' conformance with physicians' medication orders. Findings include: 1. Record review for Resident #26 revealed a Minimum Data Set (MDS) assessment of 08/20/2013 which documented, in Section I - Active Diagnoses, [MEDICAL CONDITION], Hypertension, and Diabetes Mellitus, and a 09/11/2013 physician's orders [REDACTED]. each evening. A laboratory report of 09/18/2013 for Resident #26 documented a high PT of 40.2 seconds, and an elevated INR of 4.48. A notation on this report decreased the [MEDICATION NAME] dose to 5 mgs. daily, and ordered a PT/INR laboratory test on 09/25/2013. A 09/19/2013 Physician's Interim/Telephone Orders (PI/TO) form also ordered a [MEDICATION NAME] dose of 5 mgs. However, the September 2013 MAR indicated [REDACTED]., one with a start date of 09/18/2013 and one with a start date of 09/19/2013. This MAR indicated [REDACTED]. doses (double-doses) of [MEDICATION NAME] at 5:00 p.m. on 09/19/2013, 09/20/2013, 09/23/2013, and 09/24/2013. A subsequent 09/25/2013 laboratory report for Resident #26 documented a significantly elevated PT level of 53.5 seconds, and a significantly elevated INR of 6.53. During a 10/17/2013, 3:00 p.m. interview, the Assistant Director of Nursing acknowledged this [MEDICATION NAME] medication error. Based on the above, despite Resident #26 having significantly elevated PT/INR levels of 40.2 and 4.48, respectively, on 09/18/2013, the facility subsequently administered two (2) separate 5 mg. doses of [MEDICATION NAME], in error, on 4 separate days between 09/19/ and 09/24/2013. The resident was found to have even higher PT/INR levels of 53.5 and 6.53, respectively, on 09/25/2013. This resulted in neglect for Resident #26. Cross refer to F333, example #1, for more information regarding Resident #26. 2. Resident #1's MDS of 06/11/2013 documented, in Section I - Active Diagnoses, Hypertension and [MEDICAL CONDITION]. The October 2013 physician's orders [REDACTED].) daily for [MEDICAL CONDITION] Fibrillation. A 09/11/13 laboratory report for Resident #1 documented high PT/INR levels of 39.2 and 4.34, respectively. A Physician's Interim/Telephone Orders (PI/TO) of 09/11/2013 ordered to hold [MEDICATION NAME] for two (2) days, to repeat the PT/INR test on 09/13/2013, and to resume [MEDICATION NAME] therapy at 3.5 mgs. on 09/13/2013 if the INR level was between 2.0 and 3.0. However, record review for Resident #1 revealed no evidence to indicate that the PT/INR laboratory test ordered for 09/13/2013 was done. During interview on 10/04/2013 at 3:40 p.m., Charge Nurse "GG" acknowledged the 09/13/2013 PT/INR had not been done. Additionally, even in the absence of the ordered 09/13/2013 PT/INR, and with no evidence of physician consultation regarding the Resident #1's [MEDICATION NAME] drug therapy on that date, Resident #1's September and October 2013 MARs documented that [MEDICATION NAME] drug therapy was restarted on 09/13/2013 (with no order), and that the resident received daily doses of [MEDICATION NAME] from September 13, 2013, through October 3, 2013. During interview on 10/04/2013 at 4:00 p.m., the Director of Nursing (DON) acknowledged that Resident #1's [MEDICATION NAME] had been resumed on 09/13/2013, in error, and that a STAT PT/INR had been ordered. Review of the results of this STAT PT/INR of 10/04/2013 revealed an elevated PT result of 25.1 seconds. Based on the above, the facility neglected Resident #1, who received [MEDICATION NAME] drug therapy for a [DIAGNOSES REDACTED]. [REDACTED]. Cross refer to F333, example 2, for more information regarding Resident #1. 3. Record review for Resident "C" revealed a Quarterly MDS of 07/09/2013 which documented, in Section C - Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 14, indicating that the resident was cognitively intact. The resident's September 2013 Physician order [REDACTED]. A physician's orders [REDACTED]. every six (6) hours as needed for pain, and another physician's orders [REDACTED]. Resident "C"'s September 2013 MAR indicated [REDACTED]. However, further review of Resident "C"'s September 2013 MAR indicated [REDACTED]. During a 10/11/2013, 1:45 p.m. interview, Resident "C" stated that when he/she had requested pain medication, sometimes staff had not given the pain medication as requested. Based on the above, despite Resident "C" having a [DIAGNOSES REDACTED]. The facility thus neglected Resident "C" by failing to provide effective pain management. Cross refer to F309, example 1, for more information regarding Resident "C". 4. Record review for Resident "Z" revealed an MDS of 08/13/2013 which documented a BIMS score of 15, and documented, in Section I - Active Diagnoses, [DIAGNOSES REDACTED]. However, review Resident "Z"'s September 2013 MAR indicated [REDACTED]. During a 10/16/2013, 3:10 p.m. interview, Resident "Z" stated that [MEDICATION NAME]es had not been applied as ordered, and that he/she had experienced pain. During a 10/11/2013, 11:40 a.m. interview, the DON acknowledged that on 09/16/2013 and 09/19/2013, [MEDICATION NAME]es had not been applied as ordered. Based on the above, the facility failed to apply [MEDICATION NAME]es as ordered for Resident "Z"s limb pain, and the resident experienced pain. The facility therefore neglected Resident "Z" by failed to provide effective pain management. Cross refer to F309, example 2, more information regarding Resident "Z". The Immediate Jeopardy was determined to have been removed on 10/17/2013, at which time the facility had presented and implemented an allegation of jeopardy removal with the following interventions: A. On October 5, 2013, the facility's DON and Assistant Director of Nursing (ADON) conducted audits on all residents receiving anticoagulant drug therapy to ensure that all residents had accurate medication orders and correct laboratory orders. B. On October 5, 2013, the DON, Unit Managers, and the Director of Education (DEQ) reviewed all physician's orders [REDACTED]. Physicians were notified of any discrepancies, and new physicians' orders were received as needed. C. On October 5, 2013, all facility medication carts were audited by the DON, Unit Managers, the DEQ, and the facility's pharmacy consultant to ensure that the correct dosages of all anticoagulant medications, and all other medications, were present. D. On October 5, 2013, the facility implemented a procedure by which the DON/DEQ/Unit Managers would review all physicians' telephone orders daily to ensure the accuracy of any changes related to resident anticoagulant drug therapy. The findings and noted errors or discrepancies will be documented on the Supervisor's Report. Physicians would be notified of any identified discrepancies. E. On October 10, 2013, the facility completed staff in-service training which stressed the importance of ensuring medication orders had been transcribed accurately and timely, in accordance with facility policies. As of that date, one-hundred (100) percent of all licensed nursing staff had received training. F. On October 10, 2013, the facility completed staff in-service training on ensuring new medication orders were provided to the pharmacy via facsimile in a timely manner, per facility policy and procedure. The medication administration policy and procedure were presented, as well as a specific discussion regarding [MEDICATION NAME] dosage administration, per physician's orders [REDACTED]. G. On October 10, 2013, the facility completed staff in-service training which covered the importance of informing physicians of PT/INR laboratory test results in a timely manner, per facility protocol and policy. As of that date, one-hundred (100) percent of all licensed nursing staff had received training. H. On October 10, 2013, the facility completed staff in-service training related to the signs and symptoms of bleeding for residents receiving anticoagulant drug therapy. As of that date, one-hundred (100) percent of all licensed nursing staff had received training. I. On October 11, 2013, the facility contracted with a new pharmacy provider. This pharmacy provider would aid the facility with ensuring that medication therapy was administered in conformance with physicians' orders and per facility policies and procedures. J. On October 12, 2013, the newly-contracted pharmacy provider company conducted audits to assess the conformance with the facility's policies and procedures regarding accurate resident physician's orders [REDACTED]. This was to ensure that the facility followed policies and procedures for the proper administration of medications. K. On October 12, 2013, the facility implemented a procedure by which the Administrator, DON, or designated Nursing Supervisor would review entries on resident MARs daily to ensure accuracy of transcribed anticoagulant orders. Findings would be documented on the Supervisor's Report, and physicians would be notified of any discrepancies. L. On October 12, 2013, the facility implemented a procedure by which the Administrator, DON, or designated Nursing Supervisor would review all Laboratory Books daily to ensure that PT/INR laboratory tests were logged correctly to ensure completion, and are also obtained in a timely manner per physicians' orders. M. On October 12, 2013, the facility developed and implemented a new form, the [MEDICATION NAME]/Anticoagulant Record Form, by which the DON or Unit Managers would document all PT/INR physicians' orders, the results of laboratory tests, and physician notification of laboratory test results. N. On October 12, 2013, the facility implemented a procedure by which the Administrator, DON, or designated Unit Manager would review all PT/INR laboratory results daily to ensure prompt notification to the physician is completed. Once physician notification was completed, the Nursing Supervisor would document this notification on the [MEDICATION NAME]/Anticoagulant Record. O. On October 12, 2013, the facility implemented a procedure by which the DON or designated Unit Manager would track the requisition of PT/INR laboratory tests until laboratory test results are received and physicians are notified of the results. This tracking will be conducted daily on an ongoing basis, and will be documented on the [MEDICATION NAME]/Anticoagulant Record Form. P. On October 13, 2013, the facility implemented a procedure by which the Administrator, DON, or designated Nursing Supervisor would conduct daily audits of the Laboratory Books and [MEDICATION NAME]/Anticoagulant Record to ensure that laboratory tests results were obtained and physicians were notified in a timely manner. Q. On October 13, 2013, the facility implemented a procedure by which the Administrator or DON would conduct sampled audits of the Laboratory Book, [MEDICATION NAME]/Anticoagulant Record, MARs, and physician's orders [REDACTED]. Areas of concern would be reported to the Quality Assessment and Performance Improvement (QAPI) Committee monthly by the Administrator for the Committee's review, modification, and Performance Improvement. R. On October 16, 2013, the facility implemented a procedure requiring that ongoing in-service education will be provided to all nursing staff on a quarterly and annual basis related to the policies and procedures for the ordering of laboratory tests, the documentation of laboratory testing results in the clinical record, and the process of notifying the physician of results in a timely manner. Also, nursing staff would be trained on the proper administration of anticoagulants, and other medications, in accordance with facility policies and procedures. Additionally, this new policy requires that all newly-hired nurses will be trained on these facility policies and procedures upon hire. Included in this procedure was the provision that staff conformance with medication administration and facility laboratory protocols would be tracked by the facility's QAPI Committee, who will then determine the need for additional training, based on staff performance. S. On October 16, 2013, the QAPI Committee met to discuss this Immediate Plan of Correction Implementation for the Removal of Immediate Jeopardy. The next scheduled QAPI Committee meeting is scheduled for October 24, 2013, for the review of these new procedures implemented by the facility regarding medication administration and laboratory procedures. Based on these corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice was removed on October 17, 2013. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. As of October 12, 2013, the facility implemented new procedures by which administrative staff would conduct daily MAR indicated [REDACTED]. On October 12, 2013, the facility had also developed and implemented a new [MEDICATION NAME]/Anti-coagulant Record Form to be utilized by supervisory nursing staff for the documentation of PT/INR orders, laboratory testing results, and physician notification. However, due to the newly-implemented status of these critical procedures regarding the supervisory nursing staffs' monitoring of anticoagulant order transcription accuracy and PT/INR order receipt and follow-up, as well as the newly-implemented forms to document this monitoring, nursing staffs' ongoing application with these new procedures, continued compliance could not be entirely assured as of the completion of this complaint survey. In addition, on October 16, 2013, the facility had instituted a new policy requiring that all newly-hired licensed nursing staff would receive training on the facility's policies and procedures related to laboratory testing, and the administration of resident medications, including anticoagulant drug therapy. However, this October 16, 2013, training procedure was implemented only two days prior to the exit date of this complaint survey, thus not allowing an adequate period of time to assess the facility's application and compliance. Also, the facility had implemented a procedure by which monitoring would be completed, by the Administrator or DON, of the facility's compliance with anticoagulant and laboratory testing policies and procedures, as reflected on the Laboratory Book, [MEDICATION NAME]/Anticoagulant Records, resident MARs, and physician's orders [REDACTED]. The results of this monitoring would then be reported to the QAPI Committee monthly for the Committee's review, evaluation, and ultimate determination of the need for potential policy/procedure modification. However, though the QAPI Committee had met on October 16, 2013, to discuss and review these new policies and procedures established by the facility, the QAPI Committee will not meet again until October 24, 2013, to begin the ongoing process of monitoring staffs' compliance with the new procedures. Thus, the Committee's ongoing process of facility procedural oversight could not be evaluated at the time of survey completion. Therefore, the non-compliance continues, but the scope and severity is reduced to a "D" level.

Based on record review and staff interview, facility administration failed to ensure that resident drug therapy and laboratory testing were provided in accordance with physicians' orders. This failure resulted in a pattern of medication errors affecting nine (9) residents (#1, #20, #21, #22, #24, #26, "A", "B", and "C"), for whom the facility failed to provide anticoagulant drug therapy, [MEDICATION NAME] drug therapy, cardiovascular drug therapy, and/or laboratory testing in accordance with physicians' orders, on the total survey sample of thirty-three (33) residents. Specifically, for Resident #26, who had [DIAGNOSES REDACTED]. Additionally, the facility failed to administer [MEDICATION NAME] medication to address the expressed pain of Residents "A" and "C". This resulted in a situation in which the facility's non-compliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility's Administrator was informed of the Immediate Jeopardy on October 16, 2013 at 11:25 a.m. The non-compliance related to the Immediate Jeopardy was identified to have existed as of September 13, 2013 (the date the facility failed to obtain a [MEDICATION NAME] Time/International Normalized Ratio (PT/INR) laboratory test for Resident #1, which was ordered as a repeat for a report of 09/11/2013 which had revealed high PT/INR levels of 39.2 and 4.34, respectively, and also then resumed the resident's [MEDICATION NAME] drug therapy with no order), continued through October 16, 2013, and was removed on October 17, 2013. The facility implemented a credible allegation of jeopardy removal related to the Immediate Jeopardy on October 16, 2013. The Administrator indicated that she had been unaware of issues involving medication administration, and had thus not made corrective actions to address these issues. The Administrator did indicate awareness of problems with laboratory services, but further acknowledged that the facility had failed to follow the corrective procedures which had been developed in response to these identified laboratory problems. An allegation of jeopardy removal was received on October 16, 2013. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on October 17, 2013, and the facility remained out of compliance at a lower scope and severity of "E" while the process of evaluating modifications of the medication administration and laboratory requisition systems continued. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the administration of resident medication and the facility's process for obtaining and reporting laboratory testing results. Observations were made of medication administration to assess staffs' conformance with physicians' medication orders. Findings include: Cross refer to F333. Based on observation, record review, and staff interview, the facility failed to ensure that Residents #1, #20, #21, #22, #24, #26, and "B" were free of significant medication errors involving anticoagulant/cardiovascular drug therapy, and/or laboratory testing related to drug therapy. Resident #26, who had [DIAGNOSES REDACTED]. Also, for Resident #1 who had [DIAGNOSES REDACTED]. [REDACTED]. Cross refer to F309. Based on record review and staff interview, the facility failed to ensure [MEDICATION NAME] medication administration, in conformance with physicians' orders, for two (2) residents ("C" and "Z"), thus failing to provide these residents with effective pain management. Residents "C" and "Z", for whom the facility failed to administer pain medication as ordered for expressed pain, continued to experience pain. During an interview with the Administrator conducted on 10/18/2013 at 1:00 p.m., the Administrator was questioned regarding the facility's processes of medication administration and laboratory testing. The Administrator stated that, prior to this complaint survey, she had not been aware of a significant pattern of medication administration errors involving resident medications. The Administrator acknowledged that the facility had not identified an issue related to the failure to routinely administer resident medications as ordered. The Administrator further acknowledged that due to the facility's failure to identify these significant problems related to the facility's system of medication administration and resulting medication errors, the facility had failed to develop and implement corrective actions to address this problem. However, the Administrator did acknowledge being aware of a problem with the facility's provision of laboratory services, with those issues having been identified in the past. She stated that the facility had been aware of this laboratory services issue since May of 2013. She stated that after discovery of this laboratory systems issue, interventions had been put into place, including an audit tool, which allowed for the tracking of laboratory orders and laboratory tests. However, the Administrator acknowledged that, although she though that this routine laboratory services monitoring was still being completed, she had since learned that facility staff had stopped utilizing the audit tool at some point. She acknowledged that the facility had failed to provide the planned monitoring. Based on the above, the facility's administration failed to maintain systems which ensured the accurate administration of resident medications, and the performance of resident laboratory testing, in accordance with physicians' orders. The failure resulted in a pattern of medication errors which involved Residents #1, #20, #21, #22, #24, #26, "A", "B", and "C". The Immediate Jeopardy was determined to have been removed on 10/17/2013, at which time the facility had presented and implemented an allegation of jeopardy removal with the following interventions: A. On October 5, 2013, the facility's DON and Assistant Director of Nursing (ADON) conducted audits on all residents receiving anticoagulant drug therapy to ensure that all residents had accurate medication orders and correct laboratory orders. B. On October 5, 2013, the DON, Unit Managers, and the Director of Education (DEQ) reviewed all physician's orders [REDACTED]. Physicians were notified of any discrepancies, and new physicians' orders were received as needed. C. On October 5, 2013, all facility medication carts were audited by the DON, Unit Managers, the DEQ, and the facility's pharmacy consultant to ensure that the correct dosages of all anticoagulant medications, and all other medications, were present. D. On October 5, 2013, the facility implemented a procedure by which the DON/DEQ/Unit Managers would review all physicians' telephone orders daily to ensure the accuracy of any changes related to resident anticoagulant drug therapy. The findings and noted errors or discrepancies will be documented on the Supervisor's Report. Physicians would be notified of any identified discrepancies. E. On October 10, 2013, the facility completed staff in-service training which stressed the importance of ensuring medication orders had been transcribed accurately and timely, in accordance with facility policies. As of that date, one-hundred (100) percent of all licensed nursing staff had received training. F. On October 10, 2013, the facility completed staff in-service training on ensuring new medication orders were provided to the pharmacy via facsimile in a timely manner, per facility policy and procedure. The medication administration policy and procedure were presented, as well as a specific discussion regarding [MEDICATION NAME] dosage administration, per physician's orders [REDACTED]. G. On October 10, 2013, the facility completed staff in-service training which covered the importance of informing physicians of PT/INR laboratory test results in a timely manner, per facility protocol and policy. As of that date, one-hundred (100) percent of all licensed nursing staff had received training. H. On October 10, 2013, the facility completed staff in-service training related to the signs and symptoms of bleeding for residents receiving anticoagulant drug therapy. As of that date, one-hundred (100) percent of all licensed nursing staff had received training. I. On October 11, 2013, the facility contracted with a new pharmacy provider. This pharmacy provider would aid the facility with ensuring that medication therapy was administered in conformance with physicians' orders and per facility policies and procedures. J. On October 12, 2013, the newly-contracted pharmacy provider company conducted audits to assess the conformance with the facility's policies and procedures regarding accurate resident physician's orders [REDACTED]. This was to ensure that the facility followed policies and procedures for the proper administration of medications. K. On October 12, 2013, the facility implemented a procedure by which the Administrator, DON, or designated Nursing Supervisor would review entries on resident MARs daily to ensure accuracy of transcribed anticoagulant orders. Findings would be documented on the Supervisor's Report, and physicians would be notified of any discrepancies. L. On October 12, 2013, the facility implemented a procedure by which the Administrator, DON, or designated Nursing Supervisor would review all Laboratory Books daily to ensure that PT/INR laboratory tests were logged correctly to ensure completion, and are also obtained in a timely manner per physicians' orders. M. On October 12, 2013, the facility developed and implemented a new form, the [MEDICATION NAME]/Anticoagulant Record Form, by which the DON or Unit Managers would document all PT/INR physicians' orders, the results of laboratory tests, and physician notification of laboratory test results. N. On October 12, 2013, the facility implemented a procedure by which the Administrator, DON, or designated Unit Manager would review all PT/INR laboratory results daily to ensure prompt notification to the physician is completed. Once physician notification was completed, the Nursing Supervisor would document this notification on the [MEDICATION NAME]/Anticoagulant Record. O. On October 12, 2013, the facility implemented a procedure by which the DON or designated Unit Manager would track the requisition of PT/INR laboratory tests until laboratory test results are received and physicians are notified of the results. This tracking will be conducted daily on an ongoing basis, and will be documented on the [MEDICATION NAME]/Anticoagulant Record Form. P. On October 13, 2013, the facility implemented a procedure by which the Administrator, DON, or designated Nursing Supervisor would conduct daily audits of the Laboratory Books and [MEDICATION NAME]/Anticoagulant Record to ensure that laboratory tests results were obtained and physicians were notified in a timely manner. Q. On October 13, 2013, the facility implemented a procedure by which the Administrator or DON would conduct sampled audits of the Laboratory Book, [MEDICATION NAME]/Anticoagulant Record, MARs, and physician's orders [REDACTED]. Areas of concern would be reported to the Quality Assessment and Performance Improvement (QAPI) Committee monthly by the Administrator for the Committee's review, modification, and Performance Improvement. R. On October 16, 2013, the facility implemented a procedure requiring that ongoing in-service education will be provided to all nursing staff on a quarterly and annual basis related to the policies and procedures for the ordering of laboratory tests, the documentation of laboratory testing results in the clinical record, and the process of notifying the physician of results in a timely manner. Also, nursing staff would be trained on the proper administration of anticoagulants, and other medications, in accordance with facility policies and procedures. Additionally, this new policy requires that all newly-hired nurses will be trained on these facility policies and procedures upon hire. Included in this procedure was the provision that staff conformance with medication administration and facility laboratory protocols would be tracked by the facility's QAPI Committee, who will then determine the need for additional training, based on staff performance. S. On October 16, 2013, the QAPI Committee met to discuss this Immediate Plan of Correction Implementation for the Removal of Immediate Jeopardy. The next scheduled QAPI Committee meeting is scheduled for October 24, 2013, for the review of these new procedures implemented by the facility regarding medication administration and laboratory procedures. Based on these corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice was removed on October 17, 2013. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. As of October 12, 2013, the facility implemented new procedures by which administrative staff would conduct daily MAR indicated [REDACTED]. On October 12, 2013, the facility had also developed and implemented a new [MEDICATION NAME]/Anti-coagulant Record Form to be utilized by supervisory nursing staff for the documentation of PT/INR orders, laboratory testing results, and physician notification. However, due to the newly-implemented status of these critical procedures regarding the supervisory nursing staffs' monitoring of anticoagulant order transcription accuracy and PT/INR order receipt and follow-up, as well as the newly-implemented forms to document this monitoring, nursing staffs' ongoing application with these new procedures, continued compliance could not be entirely assured as of the completion of this complaint survey. In addition, on October 16, 2013, the facility had instituted a new policy requiring that all newly-hired licensed nursing staff would receive training on the facility's policies and procedures related to laboratory testing, and the administration of resident medications, including anticoagulant drug therapy. However, this October 16, 2013, training procedure was implemented only two days prior to the exit date of this complaint survey, thus not allowing an adequate period of time to assess the facility's application and compliance. Also, the facility had implemented a procedure by which monitoring would be completed, by the Administrator or DON, of the facility's compliance with anticoagulant and laboratory testing policies and procedures, as reflected on the Laboratory Book, [MEDICATION NAME]/Anticoagulant Records, resident MARs, and physician's orders [REDACTED]. The results of this monitoring would then be reported to the QAPI Committee monthly for the Committee ' s review, evaluation, and ultimate determination of the need for potential policy/procedure modification. However, though the QAPI Committee had met on October 16, 2013, to discuss and review these new policies and procedures established by the facility, the QAPI Committee will not meet again until October 24, 2013, to begin the ongoing process of monitoring staffs' compliance with the new procedures. Thus, the Committee's ongoing process of facility procedural oversight could not be evaluated at the time of survey completion. Therefore, the non-compliance continues, but the scope and severity is reduced to an "E" level.

Based on record review, laboratory report review, Medication Regimen Review, and staff interview, the facility failed to ensure that the consultant pharmacist identified drug irregularities which resulted from the facility's failure to administer drug therapy as ordered, and/or the failure to obtain laboratory testing ordered in relation to drug therapy, for three (3) residents (#1, #24, and "C") who were receiving anticoagulant or analgesic medications, on the total survey sample of thirty-three (33) residents. For Resident #1, the facility failed to administer anticoagulant drug therapy and failed to perform laboratory testing as ordered by the physician. Rather, Resident #1 received daily anticoagulant drug therapy from 09/13/2013 through 10/03/2013, in the absence of the ordered laboratory test and in the absence of a physician's orders [REDACTED]. For Resident #24, the facility also failed to administer anticoagulant drug therapy as ordered. For Resident "C", the facility failed to administer analgesic drug therapy in accordance with physicians' orders and in response to the resident's expressed pain. This resulted in a situation in which the facility's non-compliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility's Administrator was informed of the Immediate Jeopardy on October 16, 2013 at 11:25 a.m. The non-compliance related to the Immediate Jeopardy was identified to have existed as of September 13, 2013 (the date the facility failed to obtain a Prothrombin Time/International Normalized Ratio (PT/INR) laboratory test for Resident #1, which was ordered as a repeat for a report of 09/11/2013 which had revealed high PT/INR levels of 39.2 and 4.34, respectively, and also then resumed the resident's Coumadin drug therapy with no order), continued through October 16, 2013, and was removed on October 17, 2013. The facility implemented a credible allegation of jeopardy removal related to the Immediate Jeopardy on October 16, 2013. The Administrator indicated that the facility had not had past awareness of significant issues involving medication administration. During a subsequent interview with the Administrator conducted on 10/18/2013 at 11:15 a.m., the Administrator stated that she had not been made aware of significant medication administration error issues, prior to this survey, and that there was no evidence to indicate that the facility's consultant pharmacist had identified this issue. An allegation of jeopardy removal was received on October 16, 2013. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on October 17, 2013, and the facility remained out of compliance at a lower scope and severity of "E" while the process of evaluating modifications of the medication administration and laboratory requisition systems continued. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the administration of resident medication and the facility's process for obtaining and reporting laboratory testing results. Observations were made of medication administration to assess staffs' conformance with physicians' medication orders. Findings include: 1. Record review for Resident #1 revealed that the current physician's orders [REDACTED]. A 09/11/2013 laboratory report documented a high Prothrombin Time (PT) of 39.2 and an elevated International Normalized Ratio (INR) of 4.34 for Resident #1. A 09/11/2013 Physician's Interim/Telephone Orders (PI/TO) specified to hold Coumadin therapy for two (2) days, repeat the PT/INR on 09/13/2013, and resume Coumadin therapy on 09/13/2013 if the INR was between 2.0 and 3.0. However, there was no evidence to indicate that the PT/INR laboratory test was done on 09/13/2013 for Resident #1 as ordered. Additionally, Resident #1's September and October 2013 MARs documented that daily Coumadin drug therapy was resumed on 09/13/13, and continued through 10/03/13, even though the INR test had not been done. Review of Resident #1's September 16, 2013 Medication Regimen Review (MRR) report revealed that, even though the resident had [DIAGNOSES REDACTED]. There was also no evidence to indicate that the pharmacist identified that the follow-up PT/INR test ordered to be completed on 09/13/2013 was not done, or that the resident's Coumadin drug therapy was resumed on 09/13/2013, without the INR laboratory test result or a physician's orders [REDACTED]. During an interview with the Administrator conducted on 10/18/2013 at 11:15 a.m., the Administrator acknowledged that the consultant pharmacist had failed to identify the irregularities related to the Coumadin drug therapy and laboratory testing. Cross refer to F333, example 2, for more information regarding Resident #1. 2. Record review for Resident "C" revealed that the September 2013 Physician order [REDACTED]. every six (6) hours as needed for pain, and specified the use of a Pain Scale of 0 - 10. However, Resident "C"'s September 2013 MAR indicated [REDACTED]. Despite the pattern of omission involving Resident "C"'s Acetaminophen/Hydrocodone medication ordered to address the resident's pain, review of the resident's September 16, 2013 MRR revealed no evidence to indicate that the facility's consultant pharmacist had identified this medication irregularity. During an interview with the Administrator conducted on 10/18/2013 at 11:15 a.m., the Administrator acknowledged that the consultant pharmacist failed to identify the drug irregularities referenced above. Cross refer to F309, example 1, for more information regarding Resident "C". 3. Record review for Resident #24 revealed an MDS of 08/20/2013 in which Section I - Active [DIAGNOSES REDACTED].[REDACTED] An August 2013 physician's orders [REDACTED]. daily. An 08/08/2013 PI/TO form then specified to change the dose of Coumadin to 3.5 mgs. daily. However, review of the resident's August 2013 MAR indicated [REDACTED]. dose on 08/07/2013, or the ordered Coumadin 3.5 mg. dose on 08/08/2013. Review of Resident #24's August 2013 MRR revealed that despite Resident #24 having [DIAGNOSES REDACTED]. anticoagulant drug therapy for two sequential days on 08/07/2013 and 08/08/2013. During an interview with the Administrator conducted on 10/18/2013 at 11:15 a.m., the Administrator acknowledged that the consultant pharmacist failed to identify the resident's drug irregularity involving Coumadin drug therapy referenced above. Cross refer to F333, example 7, for more information regarding Resident #24. In addition, during the interview with the Administrator conducted on 10/18/2013 at 11:15 a.m., as referenced above, the Administrator acknowledged that there was no evidence to indicate that the consultant pharmacist had identified the pattern of medication errors occurring in the facility. The Administrator also revealed that the facility had contracted with a new pharmacy services provider to provide pharmacy consultation with the facility. Based on the above, there was no evidence to indicate that the facility's consultant pharmacist had identified the significant medication errors for Resident #1 and Resident #24 involving anticoagulant drug therapy, and the significant medication error for Resident "C" involving analgesic drug therapy for pain management. There was also no evidence to indicate that the facility's consultant pharmacist had identified the pattern of medication errors which were occurring in the facility. The Immediate Jeopardy was determined to have been removed on 10/17/2013, at which time the facility had presented and implemented an allegation of jeopardy removal with the following interventions: A. On October 5, 2013, the facility's DON and Assistant Director of Nursing (ADON) conducted audits on all residents receiving anticoagulant drug therapy to ensure that all residents had accurate medication orders and correct laboratory orders. B. On October 5, 2013, the DON, Unit Managers, and the Director of Education (DEQ) reviewed all physician's orders [REDACTED]. Physicians were notified of any discrepancies, and new physicians' orders were received as needed. C. On October 5, 2013, all facility medication carts were audited by the DON, Unit Managers, the DEQ, and the facility's pharmacy consultant to ensure that the correct dosages of all anticoagulant medications, and all other medications, were present. D. On October 5, 2013, the facility implemented a procedure by which the DON/DEQ/Unit Managers would review all physicians' telephone orders daily to ensure the accuracy of any changes related to resident anticoagulant drug therapy. The findings and noted errors or discrepancies will be documented on the Supervisor's Report. Physicians would be notified of any identified discrepancies. E. On October 10, 2013, the facility completed staff in-service training which stressed the importance of ensuring medication orders had been transcribed accurately and timely, in accordance with facility policies. As of that date, one-hundred (100) percent of all licensed nursing staff had received training. F. On October 10, 2013, the facility completed staff in-service training on ensuring new medication orders were provided to the pharmacy via facsimile in a timely manner, per facility policy and procedure. The medication administration policy and procedure were presented, as well as a specific discussion regarding Coumadin dosage administration, per physician's orders [REDACTED]. G. On October 10, 2013, the facility completed staff in-service training which covered the importance of informing physicians of PT/INR laboratory test results in a timely manner, per facility protocol and policy. As of that date, one-hundred (100) percent of all licensed nursing staff had received training. H. On October 10, 2013, the facility completed staff in-service training related to the signs and symptoms of bleeding for residents receiving anticoagulant drug therapy. As of that date, one-hundred (100) percent of all licensed nursing staff had received training. I. On October 11, 2013, the facility contracted with a new pharmacy provider. This pharmacy provider would aid the facility with ensuring that medication therapy was administered in conformance with physicians' orders and per facility policies and procedures. J. On October 12, 2013, the newly-contracted pharmacy provider company conducted audits to assess the conformance with the facility's policies and procedures regarding accurate resident physician's orders [REDACTED]. This was to ensure that the facility followed policies and procedures for the proper administration of medications. K. On October 12, 2013, the facility implemented a procedure by which the Administrator, DON, or designated Nursing Supervisor would review entries on resident MARs daily to ensure accuracy of transcribed anticoagulant orders. Findings would be documented on the Supervisor's Report, and physicians would be notified of any discrepancies. L. On October 12, 2013, the facility implemented a procedure by which the Administrator, DON, or designated Nursing Supervisor would review all Laboratory Books daily to ensure that PT/INR laboratory tests were logged correctly to ensure completion, and are also obtained in a timely manner per physicians' orders. M. On October 12, 2013, the facility developed and implemented a new form, the Coumadin/Anticoagulant Record Form, by which the DON or Unit Managers would document all PT/INR physicians' orders, the results of laboratory tests, and physician notification of laboratory test results. N. On October 12, 2013, the facility implemented a procedure by which the Administrator, DON, or designated Unit Manager would review all PT/INR laboratory results daily to ensure prompt notification to the physician is completed. Once physician notification was completed, the Nursing Supervisor would document this notification on the Coumadin/Anticoagulant Record. O. On October 12, 2013, the facility implemented a procedure by which the DON or designated Unit Manager would track the requisition of PT/INR laboratory tests until laboratory test results are received and physicians are notified of the results. This tracking will be conducted daily on an ongoing basis, and will be documented on the Coumadin/Anticoagulant Record Form. P. On October 13, 2013, the facility implemented a procedure by which the Administrator, DON, or designated Nursing Supervisor would conduct daily audits of the Laboratory Books and Coumadin/Anticoagulant Record to ensure that laboratory tests results were obtained and physicians were notified in a timely manner. Q. On October 13, 2013, the facility implemented a procedure by which the Administrator or DON would conduct sampled audits of the Laboratory Book, Coumadin/Anticoagulant Record, MARs, and physician's orders [REDACTED]. Areas of concern would be reported to the Quality Assessment and Performance Improvement (QAPI) Committee monthly by the Administrator for the Committee's review, modification, and Performance Improvement. R. On October 16, 2013, the facility implemented a procedure requiring that ongoing in-service education will be provided to all nursing staff on a quarterly and annual basis related to the policies and procedures for the ordering of laboratory tests, the documentation of laboratory testing results in the clinical record, and the process of notifying the physician of results in a timely manner. Also, nursing staff would be trained on the proper administration of anticoagulants, and other medications, in accordance with facility policies and procedures. Additionally, this new policy requires that all newly-hired nurses will be trained on these facility policies and procedures upon hire. Included in this procedure was the provision that staff conformance with medication administration and facility laboratory protocols would be tracked by the facility's QAPI Committee, who will then determine the need for additional training, based on staff performance. S. On October 16, 2013, the QAPI Committee met to discuss this Immediate Plan of Correction Implementation for the Removal of Immediate Jeopardy. The next scheduled QAPI Committee meeting is scheduled for October 24, 2013, for the review of these new procedures implemented by the facility regarding medication administration and laboratory procedures. Based on these corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice was removed on October 17, 2013. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. As of October 12, 2013, the facility implemented new procedures by which administrative staff would conduct daily MAR indicated [REDACTED]. On October 12, 2013, the facility had also developed and implemented a new Coumadin/Anti-coagulant Record Form to be utilized by supervisory nursing staff for the documentation of PT/INR orders, laboratory testing results, and physician notification. However, due to the newly-implemented status of these critical procedures regarding the supervisory nursing staffs' monitoring of anticoagulant order transcription accuracy and PT/INR order receipt and follow-up, as well as the newly-implemented forms to document this monitoring, nursing staffs' ongoing application with these new procedures, continued compliance could not be entirely assured as of the completion of this complaint survey. In addition, on October 16, 2013, the facility had instituted a new policy requiring that all newly-hired licensed nursing staff would receive training on the facility's policies and procedures related to laboratory testing, and the administration of resident medications, including anticoagulant drug therapy. However, this October 16, 2013, training procedure was implemented only two days prior to the exit date of this complaint survey, thus not allowing an adequate period of time to assess the facility's application and compliance. Also, the facility had implemented a procedure by which monitoring would be completed, by the Administrator or DON, of the facility's compliance with anticoagulant and laboratory testing policies and procedures, as reflected on the Laboratory Book, Coumadin/Anticoagulant Records, resident MARs, and physician's orders [REDACTED]. The results of this monitoring would then be reported to the QAPI Committee monthly for the Committee ' s review, evaluation, and ultimate determination of the need for potential policy/procedure modification. However, though the QAPI Committee had met on October 16, 2013, to discuss and review these new policies and procedures established by the facility, the QAPI Committee will not meet again until October 24, 2013, to begin the ongoing process of monitoring staffs' compliance with the new procedures. Thus, the Committee's ongoing process of facility procedural oversight could not be evaluated at the time of survey completion. Therefore, the non-compliance continues, but the scope and severity is reduced to an "E" level.

Based on record review, staff interview, Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]#21, #22, #24, #26, #27, "B", "C", and "Z") who were receiving anticoagulant, cardiovascular and/or [MEDICATION NAME] medications, or were at risk for falls, on the total survey sample of thirty-three (33) residents. Specifically, for Residents #20, #21,#22, #24, and #26, the facility failed to administer anticoagulant drug therapy as ordered by the physician, as specified by the Care Plan. After failing to administer Resident #26's anticoagulant therapy as ordered, a laboratory report then documented significantly elevated [MEDICATION NAME] Time/International Normalized Ratio (PT/INR) results of 53.5 seconds and 6.53, respectively. For Resident #1, the facility failed to administer anticoagulant drug therapy and failed to perform laboratory testing as ordered by the physician, as specified by the Care Plan. For Resident "B", the facility failed to administer anticoagulant and cardiac drug therapy as ordered by the physician, as specified by the Care Plan. For Residents "C" and "Z", the facility failed to administer [MEDICATION NAME] drug therapy in accordance with physicians' orders, as specified by the Care Plan. This resulted in a situation in which the facility's non-compliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility's Administrator was informed of the Immediate Jeopardy on October 16, 2013 at 11:25 a.m. The non-compliance related to the Immediate Jeopardy was identified to have existed as of September 13, 2013 (the date the facility failed to obtain a [MEDICATION NAME] Time/International Normalized Ratio (PT/INR) laboratory test for Resident #1, which was ordered as a repeat for a report of 09/11/2013 which had revealed high PT/INR levels of 39.2 and 4.34, respectively, and also then resumed the resident's [MEDICATION NAME] drug therapy with no order), continued through October 16, 2013, and was removed on October 17, 2013. The facility implemented a credible allegation of jeopardy removal related to the Immediate Jeopardy on October 16, 2013. The Administrator indicated that the facility had not been aware, prior to this complaint survey, of significant issues involving medication administration, but did acknowledge the medication administration errors found as a result of this survey. The Administrator further acknowledged that, prior to this survey, the facility had not developed and implemented measures to address this problem involving a pattern of significant medication errors. However, the Administrator did acknowledged the facility's prior awareness of a problem related to laboratory testing, but stated that the facility had failed to conform with corrective procedures which had been initially developed to address this issue. The facility's failure to implement systems which ensured the accurate provision of drug therapy and laboratory services, in accordance with physicians' orders and resident Care Plans, resulted in the failure to administer anticoagulant drug therapy as ordered to Resident #1, Resident #20, Resident #21, Resident #22, Resident #24, and Resident #26, the failure to administer both anticoagulant and cardiovascular drug therapy to Resident "B" as ordered, the failure to administer pain medication to Residents "C" and "Z", as ordered, and the failure to obtain laboratory testing as ordered for Resident #1. An allegation of jeopardy removal was received on October 16, 2013. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on October 17, 2013, and the facility remained out of compliance at a lower scope and severity of "E" while the process of evaluating modifications of the medication administration and laboratory requisition systems continued. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the administration of resident medication and the facility's process for obtaining and reporting laboratory testing results. Observations were made of medication administration to assess staffs' conformance with physicians' medication orders. Findings include: 1. Record review for Resident #26 revealed a Minimum Data Set (MDS) of 08/20/2013 which documented, in Section I - Active Diagnoses, [MEDICAL CONDITION], Hypertension, and Diabetes Mellitus, and a physician's order of 09/11/2013 specified [MEDICATION NAME] Sodium ([MEDICATION NAME]) 5.5 mgs. each evening. Resident #26's Care Plan referenced the resident's anticoagulant drug therapy, and indicated as an Approach to administer the anticoagulant medication as ordered by the physician. an order written [REDACTED]. daily. A 09/19/13 Physician's Interim/Telephone Orders (PI/TO) also ordered a 5 mg. dose of [MEDICATION NAME]. However, Resident #26's September 2013 MAR indicated [REDACTED]. doses on 09/19/2013, 09/20/2013, 09/23/2013, and 09/24/2013, twice the actual 5 mg. daily dose of [MEDICATION NAME] that was ordered. A 09/25/2013 laboratory report for Resident #26 then documented a significantly elevated PT level of 53.5 seconds and a significantly elevated INR of 6.53. The Assistant Director of Nursing (ADON) acknowledged this error, during interview on 10/17/2013 at 3:00 p.m. Despite Resident #26 having a Care Plan Approach which specified to administer [MEDICATION NAME] as ordered, the facility administered two (2) daily 5 mg. doses of [MEDICATION NAME], equaling 10 mgs., to this resident, instead of the ordered daily dose of [MEDICATION NAME] 5 mgs., on four days between 09/19/ and 09/24/2013. The resident was then found to have significantly high PT/INR levels of 53.5 and 6.53, respectively. Cross refer to F333, example 1, for more information regarding Resident #26. 2. Resident #1's MDS assessment of 06/11/2013 documented diagnoses, in Section I - Active Diagnoses, which included Hypertension and [MEDICAL CONDITION], and the current Physician's Orders also documented [DIAGNOSES REDACTED]. Review of the Care Plan for Resident #1 revealed a Problem, originally dated 09/22/2011 and dated as reviewed/continued on 09/18/2013, which identified that Resident #1 was at risk for abnormal bleeding or bruising due to receiving [MEDICATION NAME]. This Care Plan reflected Approaches which specified to administer this anticoagulant medication as ordered by the physician, and to schedule laboratory work and report the results to the physician timely. A 09/11/2013 laboratory report for Resident #1 documented a high PT of 39.2 and an elevated INR of 4.34. A 09/11/2013, 4:00 p.m. PI/TO form specified to hold [MEDICATION NAME] 4 mg. for two (2) days, repeat the PT/INR on 09/13/2013, and to resume [MEDICATION NAME] 3.5 mg. therapy on 09/13/2013 if the INR level was between 2.0 and 3.0. However, even though this 09/11/2013, 4:00 p.m. PI/TO specified to hold [MEDICATION NAME] for 2 days, the September 2013 MAR indicated [REDACTED]. Additionally, there was no evidence to indicate that the PT/INR laboratory test, ordered to be repeated on 09/13/2013 for Resident #1 was done. Even though the 09/13/2013 PT/INR test was not done as ordered, the September and October 2013 MARs documented that on 09/13/2013, daily [MEDICATION NAME] drug therapy was resumed and continued through October 3, 2013. There was no evidence of an INR test result which the PI/TO had specified before [MEDICATION NAME] therapy was to be resumed, and no evidence of physician consultation regarding resumption of the drug therapy. During a 10/04/2013, 4:00 p.m. interview with the Director of Nursing (DON), the DON acknowledged that Resident #1's [MEDICATION NAME] therapy was resumed on 09/13/2013 without the INR laboratory test to support resumption of the drug. Based on the above, even though the Care Plan of Resident #1 specified that the resident receive [MEDICATION NAME] anticoagulant therapy and laboratory testing as ordered by the physician, the facility failed to hold the resident's [MEDICATION NAME] drug therapy on 09/11/2013 as ordered. The facility also failed to obtain a PT/INR laboratory test on 09/13/2013 as ordered, but then resumed [MEDICATION NAME] therapy on 09/13/2013, even though the order specified that this drug only be resumed based on results of the INR test result which the facility failed to obtain. Cross refer to F333, example 2, for more information regarding Resident #1. 3. Record review for Resident #22 revealed an MDS of 07/10/2013 which documented, in Section I - Active Diagnoses, Diabetes Mellitus and Hypertension. The September 2013 MAR for Resident #22 also documented [MEDICAL CONDITION] Fibrillation as a diagnosis, and a physician's order specified the anticoagulant [MEDICATION NAME] 4 mgs. daily. Resident #22's Care Plan, originally dated 06/03/2010, identified that the resident was at risk for bleeding/bruising/hemorrhage due to anticoagulant use. Approaches to address this bleeding risk specified to administer Resident #22's anticoagulant drug therapy as ordered by the physician, and to report laboratory results to the physician timely. A PI/TO of 09/25/13 for Resident #22 specified to hold [MEDICATION NAME] for two (2) days, and to obtain a PT/INR laboratory test on 09/27/13. The 09/27/13 laboratory report indicated a PT of 28.7 seconds and an INR of 2.87. A subsequent 10/02/2013 laboratory test documented a PT of 17.0 and a sub-therapeutic INR of 1.44. However, there was no evidence that the physician was notified timely, per the Care Plan, of the results of the 09/27/2013 and 10/02/2013 laboratory tests. Rather, evidence indicated that the physician was not notified until 10/07/13, as documented by dated initials on these laboratory reports. In addition, Resident #22's September and October 2013 MARs documented that [MEDICATION NAME] was held from 09/27/2013 through 10/03/2013 with no physician's order to hold the drug. A 10/04/2013 PI/TO form then again ordered daily [MEDICATION NAME] 4 mg. therapy, but the October 2013 MAR indicated [REDACTED]. During a 10/16/2013, 11:48 a.m. interview, the DON acknowledged that staff failed to administer Resident #22's [MEDICATION NAME] drug therapy as ordered, per the Care Plan. Based on the above, even though Resident #22's Care Plan specified to administer anticoagulant drug therapy as ordered by the physician, the facility held Resident #22's [MEDICATION NAME] therapy from 09/27/2013 through 10/03/2013, with no order, then failed to resume Resident #22's daily [MEDICATION NAME] drug therapy on 10/04/2013, as ordered. [MEDICATION NAME] therapy was not resumed until 10/06/2013. The facility also failed to notify the physician of 09/27/2013 and 10/02/2013 laboratory test results timely, per the Care Plan. Cross refer to F333, example 3, for more information regarding Resident #22. 4. Resident "B" MDS of 08/06/2013 documented diagnoses, in Section I - Active Diagnoses, which included Heart Failure and Hypertension, and the resident's October 2013 Physician's Orders documented an additional [DIAGNOSES REDACTED]. Resident "B"'s Care Plan documented a Problem, originally dated 08/12/2013, which indicated that the resident was at risk for abnormal bleeding/bruising due to [MEDICATION NAME], and included as an Approach to administer the anticoagulant as ordered by the physician. An additional Care Plan Problem for Resident "B", also dated 08/12/2013, indicated that the resident had the potential for decreased cardiac output related to a [DIAGNOSES REDACTED]. The current Physician's Orders for Resident "B" referenced above specified the administration of drugs which included the heart-failure drug Carvedilol 3.125 mgs. twice daily, and the anticoagulant drug [MEDICATION NAME] 5 mgs. daily. However, review of the October 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. During a 10/04/2013, 4:00 p.m. interview, the DON acknowledged that the [MEDICATION NAME] and Carvedilol doses for Resident "B" were not administered. Based on the above, even though Resident "B" had [DIAGNOSES REDACTED]. facility failed to administer these medications as ordered by the physician, per the Care Plan. Cross refer to F333, example 4, for more information regarding Resident "B". 5. Resident #20's MDS of 08/16/2013 documented diagnoses, in Section - Active Diagnoses, of [MEDICAL CONDITIONS], Diabetes Mellitus, [MEDICAL CONDITION] and Hypertension. The October 2013 Physician Orders form also documented a history of [MEDICAL CONDITION] with vessel graft, and orders for [MEDICATION NAME] 2 mgs. daily. Resident #20's Care Plan referenced a Problem, originally dated 08/22/2013, which identified that the resident was at risk for abnormal bleeding and bruising due to anticoagulant drug use. An Approach to address this resident's bleeding/bruising risk specified to administer the anticoagulant drug therapy as ordered by the physician. A PI/TO dated 10/07/13, timed at 1.23 p.m., specified to increase Resident #20's [MEDICATION NAME] dose to 2.5 mgs. However, the October 2013 MAR indicated [REDACTED]. at 5:00 p.m. on 10/07/2013, and also on 10/08/2013 and 10/09/2013, in error. During a 10/11/2013, 2:10 p.m. interview, the DON acknowledged that Resident #20 had not received [MEDICATION NAME] therapy as ordered, per the Care Plan. Based on the above, even though Resident #20 had [DIAGNOSES REDACTED].#20's Care Plan specified that anticoagulant drug therapy be given as ordered by the physician, staff failed to follow a physician's order of 10/07/2013 which specified that the [MEDICATION NAME] dose be increased to 2.5 mgs. Rather, staff administered only 2 mg. [MEDICATION NAME] doses on 10/07/2013, 10/08/2013 and 10/09/2013, in error. Cross refer to F333, example 5, for more information regarding Resident #20. 6. Record review for Resident #21 revealed an MDS of 09/24/2013 which documented, in Section I - Active Diagnoses, [DIAGNOSES REDACTED]. Physician's orders for Resident #21 included the anticoagulant drugs [MEDICATION NAME] 4 mgs. and Aspirin 81 mgs. daily. Resident #21's Care Plan listed a Problem, originally dated 02/16/2011, which identified that the resident was at risk for abnormal bleeding/hemorrhage/bruising due to anticoagulant use. Care Plan Approaches to address Resident#21's bleeding risk included to administer the resident's anticoagulant as ordered by the physician. However, even though a physician's order referenced on a 09/25/2013 laboratory report, received by the facility at 11:53 a.m., specified to hold Resident #21's [MEDICATION NAME] for two (2) days, the September 2013 MAR indicated [REDACTED]. During a 10/11/2013, 2:40 p.m. interview, the DON acknowledged that the 09/25/2013 [MEDICATION NAME] dose was not held, as ordered, per the Care Plan. Based on the above, despite Resident #21 having [DIAGNOSES REDACTED].#21's anticoagulant drug therapy as specified by the physician's order, as specified by the Care Plan. Cross refer to F333, example 6, for more information regarding Resident #21. 7. Record review for Resident #24 revealed an MDS of 08/20/2013 which documented, in Section I - Active Diagnoses, [MEDICAL CONDITION] and Hypertension, and the August 2013 MAR indicated [REDACTED]. A Care Plan entry for Resident #24 documented that the resident received anticoagulant drug therapy related to [MEDICAL CONDITION] Fibrillation, and an Approach specified to administer medication as ordered by the physician. A physician's order for Resident #24 specified a dose of [MEDICATION NAME] 3 mgs. daily, but the August 2013 MAR indicated [REDACTED]. dose being given on 08/07/2013 at 5:00 p.m. A 12:22 p.m., 08/08/2013 PI/TO for Resident #24 specified to discontinue the 3 mg. [MEDICATION NAME] dose, and to start [MEDICATION NAME] 3.5 mgs. daily. However, the August 2013 MAR indicated [REDACTED]. dose having been administered. During a 10/17/2013, 2:15 p.m. interview, the ADON acknowledged this [MEDICATION NAME] error for Resident #24 referenced above. Based on the above, despite Resident #24 having a [DIAGNOSES REDACTED]. Cross refer to F333, example 7, for more information regarding Resident #24. 8. Resident "C"'s MDS assessment of 07/09/2013 documented a [DIAGNOSES REDACTED]. A physician's order specified that Resident "C" was to receive the pain medication [MEDICATION NAME]-[MEDICATION NAME] 325 mgs/7.5 mgs. every six (6) hours as needed for pain, and also specified the use of a Pain Scale of 0 (no pain) through 10 (severe pain). The Care Plan for Resident "C" identified a Problem, originally dated 02/07/2013, indicating that the resident had the potential for alteration in comfort. This Care Plan identified multiple Approaches to address the resident's potential for pain, including to assess Pain Management every shift, and to medicate with the ordered medication. However, review of Resident "C"'s September 2013 MAR indicated [REDACTED]. Based on the above, even though the facility did assess Resident "C"'s pain, per the Care Plan, by utilizing the ordered Pain Scale, the facility failed to provide Pain Management as ordered, and as specified by the Care Plan, by failing to administer the resident's [MEDICATION NAME]/[MEDICATION NAME] pain medication as ordered, in accordance with the Pain Scale. The facility thus failed to provide effective pain management for Resident "C", in accordance with the Care Plan. Cross refer to F309, example #1, for more information regarding Resident "C". 9. Record review for Resident "Z" revealed an MDS of 08/13/2013 which documented a [DIAGNOSES REDACTED]. A physician's order for Resident "Z" specified the application of a [MEDICATION NAME] 75 mcg/hr patch every three days for limb pain. The Care Plan for Resident "Z" referenced a Problem indicating that the resident had pain and an alteration in comfort. An Approach to address this resident's pain was to administer the pain medications as ordered and requested. However, the September 2013 MAR for Resident "Z" documented that the [MEDICATION NAME]es had not been applied as scheduled and ordered on [DATE] and 09/19/2013. During a 10/11/2013, 11:40 a.m. interview, the DON acknowledged that [MEDICATION NAME]es were not applied for Resident "Z" on 09/16/2013 and 09/19/2013, as ordered. Based on the above, the facility failed to address Resident "Z"'s pain, per the Care Plan, by failing to administer the resident's pain medication as ordered, and as specified by the Care Plan. The facility thus failed to provide effective pain management for Resident "Z" as specified by the Care Plan. Cross refer to F309, example 2, for more information regarding Resident "Z". 10. Record review for Resident #27 revealed Care Plan entry of 07/12/2013 which indicated a Problem related to the resident being at risk for falls related to impaired mobility. Approaches to address this resident's fall-risk specified the application of a chair alarm. However, during a 10/18/2013, 1:45 p.m. observation, Resident #27 was seated in a wheelchair but with no chair alarm applied, per the Care Plan. During a 10/18/2013, 1:57 p.m. interview with Nurse "BB" and Nurse "CC", Nurse "CC" acknowledged that a chair alarm should be applied to the resident's wheelchair. Cross refer to F323 for more information regarding Resident #27. The Immediate Jeopardy was determined to have been removed on 10/17/2013, at which time the facility had presented and implemented an allegation of jeopardy removal with the following interventions: A. On October 5, 2013, the facility's DON and Assistant Director of Nursing (ADON) conducted audits on all residents receiving anticoagulant drug therapy to ensure that all residents had accurate medication orders and correct laboratory orders. B. On October 5, 2013, the DON, Unit Managers, and the Director of Education (DEQ) reviewed all Physician's Orders Forms and physician's telephone orders for all residents receiving anticoagulant drug therapy to ensure the accuracy of the medications ordered. Physicians were notified of any discrepancies, and new physicians' orders were received as needed. C. On October 5, 2013, all facility medication carts were audited by the DON, Unit Managers, the DEQ, and the facility's pharmacy consultant to ensure that the correct dosages of all anticoagulant medications, and all other medications, were present. D. On October 5, 2013, the facility implemented a procedure by which the DON/DEQ/Unit Managers would review all physicians' telephone orders daily to ensure the accuracy of any changes related to resident anticoagulant drug therapy. The findings and noted errors or discrepancies will be documented on the Supervisor's Report. Physicians would be notified of any identified discrepancies. E. On October 10, 2013, the facility completed staff in-service training which stressed the importance of ensuring medication orders had been transcribed accurately and timely, in accordance with facility policies. As of that date, one-hundred (100) percent of all licensed nursing staff had received training. F. On October 10, 2013, the facility completed staff in-service training on ensuring new medication orders were provided to the pharmacy via facsimile in a timely manner, per facility policy and procedure. The medication administration policy and procedure were presented, as well as a specific discussion regarding [MEDICATION NAME] dosage administration, per physician's orders. As of that date, one-hundred (100) percent of all licensed nursing staff had received training. G. On October 10, 2013, the facility completed staff in-service training which covered the importance of informing physicians of PT/INR laboratory test results in a timely manner, per facility protocol and policy. As of that date, one-hundred (100) percent of all licensed nursing staff had received training. H. On October 10, 2013, the facility completed staff in-service training related to the signs and symptoms of bleeding for residents receiving anticoagulant drug therapy. As of that date, one-hundred (100) percent of all licensed nursing staff had received training. I. On October 11, 2013, the facility contracted with a new pharmacy provider. This pharmacy provider would aid the facility with ensuring that medication therapy was administered in conformance with physicians' orders and per facility policies and procedures. J. On October 12, 2013, the newly-contracted pharmacy provider company conducted audits to assess the conformance with the facility's policies and procedures regarding accurate resident Physician's Orders Forms, medication cart content, and medication pass. This was to ensure that the facility followed policies and procedures for the proper administration of medications. K. On October 12, 2013, the facility implemented a procedure by which the Administrator, DON, or designated Nursing Supervisor would review entries on resident MARs daily to ensure accuracy of transcribed anticoagulant orders. Findings would be documented on the Supervisor's Report, and physicians would be notified of any discrepancies. L. On October 12, 2013, the facility implemented a procedure by which the Administrator, DON, or designated Nursing Supervisor would review all Laboratory Books daily to ensure that PT/INR laboratory tests were logged correctly to ensure completion, and are also obtained in a timely manner per physicians' orders. M. On October 12, 2013, the facility developed and implemented a new form, the [MEDICATION NAME]/Anticoagulant Record Form, by which the DON or Unit Managers would document all PT/INR physicians' orders, the results of laboratory tests, and physician notification of laboratory test results. N. On October 12, 2013, the facility implemented a procedure by which the Administrator, DON, or designated Unit Manager would review all PT/INR laboratory results daily to ensure prompt notification to the physician is completed. Once physician notification was completed, the Nursing Supervisor would document this notification on the [MEDICATION NAME]/Anticoagulant Record. O. On October 12, 2013, the facility implemented a procedure by which the DON or designated Unit Manager would track the requisition of PT/INR laboratory tests until laboratory test results are received and physicians are notified of the results. This tracking will be conducted daily on an ongoing basis, and will be documented on the [MEDICATION NAME]/Anticoagulant Record Form. P. On October 13, 2013, the facility implemented a procedure by which the Administrator, DON, or designated Nursing Supervisor would conduct daily audits of the Laboratory Books and [MEDICATION NAME]/Anticoagulant Record to ensure that laboratory tests results were obtained and physicians were notified in a timely manner. Q. On October 13, 2013, the facility implemented a procedure by which the Administrator or DON would conduct sampled audits of the Laboratory Book, [MEDICATION NAME]/Anticoagulant Record, MARs, and Physician's Order sheets twice a week for four (4) weeks, then weekly for four (4) weeks, then monthly. Areas of concern would be reported to the Quality Assessment and Performance Improvement (QAPI) Committee monthly by the Administrator for the Committee's review, modification, and Performance Improvement. R. On October 16, 2013, the facility implemented a procedure requiring that ongoing in-service education will be provided to all nursing staff on a quarterly and annual basis related to the policies and procedures for the ordering of laboratory tests, the documentation of laboratory testing results in the clinical record, and the process of notifying the physician of results in a timely manner. Also, nursing staff would be trained on the proper administration of anticoagulants, and other medications, in accordance with facility policies and procedures. Additionally, this new policy requires that all newly-hired nurses will be trained on these facility policies and procedures upon hire. Included in this procedure was the provision that staff conformance with medication administration and facility laboratory protocols would be tracked by the facility's QAPI Committee, who will then determine the need for additional training, based on staff performance. S. On October 16, 2013, the QAPI Committee met to discuss this Immediate Plan of Correction Implementation for the Removal of Immediate Jeopardy. The next scheduled QAPI Committee meeting is scheduled for October 24, 2013, for the review of these new procedures implemented by the facility regarding medication administration and laboratory procedures. Based on these corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice was removed on October 17, 2013. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. As of October 12, 2013, the facility implemented new procedures by which administrative staff would conduct daily MAR indicated [REDACTED]. On October 12, 2013, the facility had also developed and implemented a new [MEDICATION NAME]/Anti-coagulant Record Form to be utilized by supervisory nursing staff for the documentation of PT/INR orders, laboratory testing results, and physician notification. However, due to the newly-implemented status of these critical procedures regarding the supervisory nursing staffs' monitoring of anticoagulant order transcription accuracy and PT/INR order receipt and follow-up, as well as the newly-implemented forms to document this monitoring, nursing staffs' ongoing application with these new procedures, continued compliance could not be entirely assured as of the completion of this complaint survey. In addition, on October 16, 2013, the facility had instituted a new policy requiring that all newly-hired licensed nursing staff would receive training on the facility's policies and procedures related to laboratory testing, and the administration of resident medications, including anticoagulant drug therapy. However, this October 16, 2013, training procedure was implemented only two days prior to the exit date of this complaint survey, thus not allowing an adequate period of time to assess the facility's application and compliance. Also, the facility had implemented a procedure by which monitoring would be completed, by the Administrator or DON, of the facility's compliance with anticoagulant and laboratory testing policies and procedures, as reflected on the Laboratory Book, [MEDICATION NAME]/Anticoagulant Records, resident MARs, and Physician's Orders Sheets twice weekly for four weeks, then weekly for four weeks, then monthly. The results of this monitoring would then be reported to the QAPI Committee monthly for the Committee ' s review, evaluation, and ultimate determination of the need for potential policy/procedure modification. However, though the QAPI Committee had met on October 16, 2013, to discuss and review these new policies and procedures established by the facility, the QAPI Committee will not meet again until October 24, 2013, to begin the ongoing process of monitoring staffs' compliance with the new procedures. Thus, the Committee's ongoing process of facility procedural oversight could not be evaluated at the time of survey completion. Therefore, the non-compliance continues, but the scope and severity is reduced to an "E" level.

Based on record review, laboratory report review, Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]#1), who received [MEDICATION NAME] anticoagulant drug therapy, on the survey sample of thirty-three (33) residents. Specifically, Resident #1 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. However, the facility failed to obtain this repeat PT/INR laboratory test as ordered. This resulted in a situation in which the facility's non-compliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility's Administrator was informed of the Immediate Jeopardy on October 16, 2013, at 11:25 a.m. The non-compliance related to the Immediate Jeopardy was identified to have existed as of September 13, 2013 (the date the facility failed to obtain a [MEDICATION NAME] Time/International Normalized Ratio (PT/INR) laboratory test for Resident #1, which was ordered as a repeat for a report of 09/11/2013 which had revealed high PT/INR levels of 39.2 and 4.34, respectively, and also then resumed the resident's [MEDICATION NAME] drug therapy with no order), continued through October 16, 2013, and was removed on October 17, 2013. The facility implemented a credible allegation of jeopardy removal related to the Immediate Jeopardy on October 16, 2013. The Administrator acknowledged that the facility had been aware of problems related to the provision of laboratory services to residents, and further stated that corrective procedures had been put into place. However, the Administrator acknowledged that the facility had failed to consistently follow these corrective procedures, and had failed to monitor to ensure staff compliance, and thus issues with laboratory services had continued. The facility's failure to ensure a system which provided for the provision of laboratory services, in accordance with physicians' orders, resulted in the failure to obtain the PT/INR laboratory test as ordered for Resident #1. An allegation of jeopardy removal was received on October 16, 2013. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on October 17, 2013, and the facility remained out of compliance at a lower scope and severity of "D" while the process of evaluating modifications of laboratory requisition systems continued. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the facility's process for obtaining and reporting laboratory testing results. Resident records were reviewed to assess laboratory test requisition as ordered by the physician. Findings include: Record review for Resident #1 revealed the October 2013 physician's orders [REDACTED]. A 09/11/13 laboratory report for Resident #1 documented high PT/INR results of 39.2 and 4.34, respectively. A 09/11/2013 physician's orders [REDACTED]. There was no evidence to indicate that the repeat PT/INR test ordered for 09/13/2013 was done, but the September/October 2013 MARs documented continued [MEDICATION NAME] administration from 09/13/2013 through 10/03/2013. The Director of Nursing acknowledged the above during interview on 10/04/13 at 4:00 p.m. During an interview with the Administrator conducted on 10/18/2013 at 1:10 p.m., the Administrator acknowledged that the facility had been aware of an existing problem related to the facility's laboratory services system, further stating that interventions had been developed to correct and monitor these known laboratory problems. However, the Administrator further acknowledged that the system of monitoring for the effectiveness of the corrective actions had not been consistently maintained by facility staff. Based on the above, the facility failed to provide laboratory services, as ordered by the physician, which met the needs of Resident #1 who received [MEDICATION NAME] anticoagulant drug therapy and who had [DIAGNOSES REDACTED]. Cross refer to F333, example 2, for more information regarding Resident #1. The Immediate Jeopardy was determined to have been removed on 10/17/2013, at which time the facility had presented and implemented an allegation of jeopardy removal with the following interventions: A. On October 5, 2013, the facility's DON and Assistant Director of Nursing (ADON) conducted audits on all residents receiving anticoagulant drug therapy to ensure that all residents had accurate medication orders and correct laboratory orders. B. On October 5, 2013, the DON, Unit Managers, and the Director of Education (DEQ) reviewed all physician's orders [REDACTED]. Physicians were notified of any discrepancies, and new physicians' orders were received as needed. C. On October 5, 2013, all facility medication carts were audited by the DON, Unit Managers, the DEQ, and the facility's pharmacy consultant to ensure that the correct dosages of all anticoagulant medications, and all other medications, were present. D. On October 5, 2013, the facility implemented a procedure by which the DON/DEQ/Unit Managers would review all physicians' telephone orders daily to ensure the accuracy of any changes related to resident anticoagulant drug therapy. The findings and noted errors or discrepancies will be documented on the Supervisor's Report. Physicians would be notified of any identified discrepancies. E. On October 10, 2013, the facility completed staff in-service training which stressed the importance of ensuring medication orders had been transcribed accurately and timely, in accordance with facility policies. As of that date, one-hundred (100) percent of all licensed nursing staff had received training. F. On October 10, 2013, the facility completed staff in-service training on ensuring new medication orders were provided to the pharmacy via facsimile in a timely manner, per facility policy and procedure. The medication administration policy and procedure were presented, as well as a specific discussion regarding [MEDICATION NAME] dosage administration, per physician's orders [REDACTED]. G. On October 10, 2013, the facility completed staff in-service training which covered the importance of informing physicians of PT/INR laboratory test results in a timely manner, per facility protocol and policy. As of that date, one-hundred (100) percent of all licensed nursing staff had received training. H. On October 10, 2013, the facility completed staff in-service training related to the signs and symptoms of bleeding for residents receiving anticoagulant drug therapy. As of that date, one-hundred (100) percent of all licensed nursing staff had received training. I. On October 11, 2013, the facility contracted with a new pharmacy provider. This pharmacy provider would aid the facility with ensuring that medication therapy was administered in conformance with physicians' orders and per facility policies and procedures. J. On October 12, 2013, the newly-contracted pharmacy provider company conducted audits to assess the conformance with the facility's policies and procedures regarding accurate resident physician's orders [REDACTED]. This was to ensure that the facility followed policies and procedures for the proper administration of medications. K. On October 12, 2013, the facility implemented a procedure by which the Administrator, DON, or designated Nursing Supervisor would review entries on resident MARs daily to ensure accuracy of transcribed anticoagulant orders. Findings would be documented on the Supervisor's Report, and physicians would be notified of any discrepancies. L. On October 12, 2013, the facility implemented a procedure by which the Administrator, DON, or designated Nursing Supervisor would review all Laboratory Books daily to ensure that PT/INR laboratory tests were logged correctly to ensure completion, and are also obtained in a timely manner per physicians' orders. M. On October 12, 2013, the facility developed and implemented a new form, the [MEDICATION NAME]/Anticoagulant Record Form, by which the DON or Unit Managers would document all PT/INR physicians' orders, the results of laboratory tests, and physician notification of laboratory test results. N. On October 12, 2013, the facility implemented a procedure by which the Administrator, DON, or designated Unit Manager would review all PT/INR laboratory results daily to ensure prompt notification to the physician is completed. Once physician notification was completed, the Nursing Supervisor would document this notification on the [MEDICATION NAME]/Anticoagulant Record. O. On October 12, 2013, the facility implemented a procedure by which the DON or designated Unit Manager would track the requisition of PT/INR laboratory tests until laboratory test results are received and physicians are notified of the results. This tracking will be conducted daily on an ongoing basis, and will be documented on the [MEDICATION NAME]/Anticoagulant Record Form. P. On October 13, 2013, the facility implemented a procedure by which the Administrator, DON, or designated Nursing Supervisor would conduct daily audits of the Laboratory Books and [MEDICATION NAME]/Anticoagulant Record to ensure that laboratory tests results were obtained and physicians were notified in a timely manner. Q. On October 13, 2013, the facility implemented a procedure by which the Administrator or DON would conduct sampled audits of the Laboratory Book, [MEDICATION NAME]/Anticoagulant Record, MARs, and physician's orders [REDACTED]. Areas of concern would be reported to the Quality Assessment and Performance Improvement (QAPI) Committee monthly by the Administrator for the Committee's review, modification, and Performance Improvement. R. On October 16, 2013, the facility implemented a policy requiring that ongoing in-service education will be provided to all nursing staff on a quarterly and annual basis related to the policies and procedures for the ordering of laboratory tests, the documentation of laboratory testing results in the clinical record, and the process of notifying the physician of results in a timely manner. Also, nursing staff would be trained on the proper administration of anticoagulants, and other medications, in accordance with facility policies and procedures. Additionally, this new policy requires that all newly-hired nurses will be trained on these facility policies and procedures upon hire. Included in this procedure was the provision that staff conformance with medication administration and facility laboratory protocols would be tracked by the facility's QAPI Committee, who will then determine the need for additional training, based on staff performance. S. On October 16, 2013, the QAPI Committee met to discuss this Immediate Plan of Correction Implementation for the Removal of Immediate Jeopardy. The next scheduled QAPI Committee meeting is scheduled for October 24, 2013, for the review of these new procedures implemented by the facility regarding medication administration and laboratory procedures. Based on these corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice was removed on October 17, 2013. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. As of October 12, 2013, the facility implemented new procedures by which administrative staff would conduct daily MAR indicated [REDACTED]. On October 12, 2013, the facility had also developed and implemented a new [MEDICATION NAME]/Anticoagulant Record Form to be utilized by supervisory nursing staff for the documentation of PT/INR orders, laboratory testing results, and physician notification. However, due to the newly-implemented status of these critical procedures regarding the supervisory nursing staffs' monitoring of anticoagulant order transcription accuracy and PT/INR order receipt and follow-up, as well as the newly-implemented forms to document this monitoring, nursing staffs' ongoing application with these new procedures, continued compliance could not be entirely assured as of the completion of this complaint survey. In addition, on October 16, 2013, the facility had instituted a new policy requiring that all newly-hired licensed nursing staff would receive training on the facility's policies and procedures related to laboratory testing, and the administration of resident medications, including anticoagulant drug therapy. However, this October 16, 2013, training procedure was implemented only two days prior to the exit date of this complaint survey, thus not allowing an adequate period of time to assess the facility's application and compliance. Also, the facility had implemented a procedure by which monitoring would be completed, by the Administrator or DON, of the facility's compliance with anticoagulant and laboratory testing policies and procedures, as reflected on the Laboratory Book, [MEDICATION NAME]/Anticoagulant Records, resident MARs, and physician's orders [REDACTED]. The results of this monitoring would then be reported to the QAPI Committee monthly for the Committee ' s review, evaluation, and ultimate determination of the need for potential policy/procedure modification. However, though the QAPI Committee had met on October 16, 2013, to discuss and review these new policies and procedures established by the facility, the QAPI Committee will not meet again until October 24, 2013, to begin the ongoing process of monitoring staffs' compliance with the new procedures. Thus, the Committee's ongoing process of facility procedural oversight could not be evaluated at the time of survey completion. Therefore, the non-compliance continues, but the scope and severity is reduced to a "D" level.

Based on record review, staff interview, Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. For Resident #22, who had [DIAGNOSES REDACTED]. This resulted in a situation in which the facility's non-compliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility's Administrator was informed of the Immediate Jeopardy on October 16, 2013 at 11:25 a.m. The non-compliance related to the Immediate Jeopardy was identified to have existed as of September 13, 2013, continued through October 16, 2013, and was removed on October 17, 2013. The facility implemented a credible allegation of jeopardy removal related to the Immediate Jeopardy on October 16, 2013. The Administrator acknowledged past problems with the facility's provision of laboratory services, which had been identified, and also indicated that corrective procedures had been put into place. However, the Administrator acknowledged that the facility had failed to comply with these corrective procedures on an ongoing basis. An allegation of jeopardy removal was received on October 16, 2013. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on October 17, 2013, and the facility remained out of compliance at a lower scope and severity of "D" while the process of evaluating modifications of the laboratory requisition systems continued. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the facility's process for obtaining and reporting laboratory testing results. Observations were made of medication administration to assess staffs' conformance with physicians' medication orders. Findings include: Resident #22's September 2013 MAR indicated [REDACTED]. A 09/25/2013 Physician's Interim/Telephone Orders form specified to hold Resident #22's [MEDICATION NAME] for two (2) days, and ordered a PT/INR laboratory test to be done on 09/27/13. Resident #22's laboratory report of 09/27/2013 documented a high PT result of 28.7 seconds and an INR within the therapeutic range of 2.87. However, record review revealed no evidence to indicate the physician was notified of these 09/27/2013 PT/INR laboratory test results, which documented a high PT result of 28.7, until hand-written initials dated 10/07/2013 (10 days following receipt of the report by the facility) on the laboratory report documented physician notification on that date. Additionally, Resident #22's September and October 2013 MARs documented that the resident's daily [MEDICATION NAME] doses were held, with no physician's order, from 09/27/2013 through 10/01/2013. Then, a laboratory report dated 10/02/2013 documented a PT result of 17.0 seconds, and a sub-therapeutic INR result of 1.44 for Resident #22. A printed notation on this laboratory report documented that the report results had been electronically transmitted to the facility on [DATE] at 12:01 p.m. However, despite the facility being made aware, via this 10/02/2013 laboratory report, that Resident #22 had a sub-therapeutic INR (after [MEDICATION NAME] had been held for five (5) days with no order), there was no evidence to indicate that the physician was notified of the PT/INR laboratory test results on 10/02/2013. A hand-written notation dated 10/04/2013, written on this 10/02/2013 laboratory report, then documented an order to resume Resident #22's [MEDICATION NAME] 4 mg. drug therapy, thus representing a two (2) day delay in physician notification of the laboratory results which indicated a sub-therapeutic INR. During an interview on 10/16/2013 at 11:48 a.m., the Director of Nursing acknowledged the above. Based on the above, for Resident #22 who had [DIAGNOSES REDACTED]. The facility also failed to promptly notify the physician of 10/02/2013 PT/INR test results (which revealed a sub-therapeutic INR of 1.44), not providing physician notification until 10/04/2013, two (2) days after receipt. Cross refer to F333, example 3, for more information regarding Resident #22. The Immediate Jeopardy was determined to have been removed on 10/17/2013, at which time the facility had presented and implemented an allegation of jeopardy removal with the following interventions: A. On October 5, 2013, the facility's DON and Assistant Director of Nursing (ADON) conducted audits on all residents receiving anticoagulant drug therapy to ensure that all residents had accurate medication orders and correct laboratory orders. B. On October 5, 2013, the DON, Unit Managers, and the Director of Education (DEQ) reviewed all Physician's Orders Forms and physician's telephone orders for all residents receiving anticoagulant drug therapy to ensure the accuracy of the medications ordered. Physicians were notified of any discrepancies, and new physicians' orders were received as needed. C. On October 5, 2013, all facility medication carts were audited by the DON, Unit Managers, the DEQ, and the facility's pharmacy consultant to ensure that the correct dosages of all anticoagulant medications, and all other medications, were present. D. On October 5, 2013, the facility implemented a procedure by which the DON/DEQ/Unit Managers would review all physicians' telephone orders daily to ensure the accuracy of any changes related to resident anticoagulant drug therapy. The findings and noted errors or discrepancies will be documented on the Supervisor's Report. Physicians would be notified of any identified discrepancies. E. On October 10, 2013, the facility completed staff in-service training which stressed the importance of ensuring medication orders had been transcribed accurately and timely, in accordance with facility policies. As of that date, one-hundred (100) percent of all licensed nursing staff had received training. F. On October 10, 2013, the facility completed staff in-service training on ensuring new medication orders were provided to the pharmacy via facsimile in a timely manner, per facility policy and procedure. The medication administration policy and procedure were presented, as well as a specific discussion regarding [MEDICATION NAME] dosage administration, per physician's orders. As of that date, one-hundred (100) percent of all licensed nursing staff had received training. G. On October 10, 2013, the facility completed staff in-service training which covered the importance of informing physicians of PT/INR laboratory test results in a timely manner, per facility protocol and policy. As of that date, one-hundred (100) percent of all licensed nursing staff had received training. H. On October 10, 2013, the facility completed staff in-service training related to the signs and symptoms of bleeding for residents receiving anticoagulant drug therapy. As of that date, one-hundred (100) percent of all licensed nursing staff had received training. I. On October 11, 2013, the facility contracted with a new pharmacy provider. This pharmacy provider would aid the facility with ensuring that medication therapy was administered in conformance with physicians' orders and per facility policies and procedures. J. On October 12, 2013, the newly-contracted pharmacy provider company conducted audits to assess the conformance with the facility's policies and procedures regarding accurate resident Physician's Orders Forms, medication cart content, and medication pass. This was to ensure that the facility followed policies and procedures for the proper administration of medications. K. On October 12, 2013, the facility implemented a procedure by which the Administrator, DON, or designated Nursing Supervisor would review entries on resident MARs daily to ensure accuracy of transcribed anticoagulant orders. Findings would be documented on the Supervisor's Report, and physicians would be notified of any discrepancies. L. On October 12, 2013, the facility implemented a procedure by which the Administrator, DON, or designated Nursing Supervisor would review all Laboratory Books daily to ensure that PT/INR laboratory tests were logged correctly to ensure completion, and are also obtained in a timely manner per physicians' orders. M. On October 12, 2013, the facility developed and implemented a new form, the [MEDICATION NAME]/Anticoagulant Record Form, by which the DON or Unit Managers would document all PT/INR physicians' orders, the results of laboratory tests, and physician notification of laboratory test results. N. On October 12, 2013, the facility implemented a procedure by which the Administrator, DON, or designated Unit Manager would review all PT/INR laboratory results daily to ensure prompt notification to the physician is completed. Once physician notification was completed, the Nursing Supervisor would document this notification on the [MEDICATION NAME]/Anticoagulant Record. O. On October 12, 2013, the facility implemented a procedure by which the DON or designated Unit Manager would track the requisition of PT/INR laboratory tests until laboratory test results are received and physicians are notified of the results. This tracking will be conducted daily on an ongoing basis, and will be documented on the [MEDICATION NAME]/Anticoagulant Record Form. P. On October 13, 2013, the facility implemented a procedure by which the Administrator, DON, or designated Nursing Supervisor would conduct daily audits of the Laboratory Books and [MEDICATION NAME]/Anticoagulant Record to ensure that laboratory tests results were obtained and physicians were notified in a timely manner. Q. On October 13, 2013, the facility implemented a procedure by which the Administrator or DON would conduct sampled audits of the Laboratory Book, [MEDICATION NAME]/Anticoagulant Record, MARs, and Physician's Order sheets twice a week for four (4) weeks, then weekly for four (4) weeks, then monthly. Areas of concern would be reported to the Quality Assessment and Performance Improvement (QAPI) Committee monthly by the Administrator for the Committee's review, modification, and Performance Improvement. R. On October 16, 2013, the facility implemented a procedure requiring that ongoing in-service education will be provided to all nursing staff on a quarterly and annual basis related to the policies and procedures for the ordering of laboratory tests, the documentation of laboratory testing results in the clinical record, and the process of notifying the physician of results in a timely manner. Also, nursing staff would be trained on the proper administration of anticoagulants, and other medications, in accordance with facility policies and procedures. Additionally, this new policy requires that all newly-hired nurses will be trained on these facility policies and procedures upon hire. Included in this procedure was the provision that staff conformance with medication administration and facility laboratory protocols would be tracked by the facility's QAPI Committee, who will then determine the need for additional training, based on staff performance. S. On October 16, 2013, the QAPI Committee met to discuss this Immediate Plan of Correction Implementation for the Removal of Immediate Jeopardy. The next scheduled QAPI Committee meeting is scheduled for October 24, 2013, for the review of these new procedures implemented by the facility regarding medication administration and laboratory procedures. Based on these corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice was removed on October 17, 2013. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. As of October 12, 2013, the facility implemented new procedures by which administrative staff would conduct daily MAR indicated [REDACTED]. On October 12, 2013, the facility had also developed and implemented a new [MEDICATION NAME]/Anti-coagulant Record Form to be utilized by supervisory nursing staff for the documentation of PT/INR orders, laboratory testing results, and physician notification. However, due to the newly-implemented status of these critical procedures regarding the supervisory nursing staffs' monitoring of anticoagulant order transcription accuracy and PT/INR order receipt and follow-up, as well as the newly-implemented forms to document this monitoring, nursing staffs' ongoing application with these new procedures, continued compliance could not be entirely assured as of the completion of this complaint survey. In addition, on October 16, 2013, the facility had instituted a new policy requiring that all newly-hired licensed nursing staff would receive training on the facility's policies and procedures related to laboratory testing, and the administration of resident medications, including anticoagulant drug therapy. However, this October 16, 2013, training procedure was implemented only two days prior to the exit date of this complaint survey, thus not allowing an adequate period of time to assess the facility's application and compliance. Also, the facility had implemented a procedure by which monitoring would be completed, by the Administrator or DON, of the facility's compliance with anticoagulant and laboratory testing policies and procedures, as reflected on the Laboratory Book, [MEDICATION NAME]/Anticoagulant Records, resident MARs, and Physician's Orders Sheets twice weekly for four weeks, then weekly for four weeks, then monthly. The results of this monitoring would then be reported to the QAPI Committee monthly for the Committee ' s review, evaluation, and ultimate determination of the need for potential policy/procedure modification. However, though the QAPI Committee had met on October 16, 2013, to discuss and review these new policies and procedures established by the facility, the QAPI Committee will not meet again until October 24, 2013, to begin the ongoing process of monitoring staffs' compliance with the new procedures. Thus, the Committee's ongoing process of facility procedural oversight could not be evaluated at the time of survey completion. Therefore, the non-compliance continues, but the scope and severity is reduced to a "D" level.

Based on record review, staff interview, and resident interview, the facility failed to ensure the provision of effective pain management, by failing to administer [MEDICATION NAME] medications in conformance with physicians' orders, for two (2) residents ("C" and "Z"), on the total survey sample of thirty-three (33) residents. This resulted in harm for both Residents "C" and "Z", who had a history of [REDACTED]. However, the facility failed to administer pain medication as ordered for expressed pain, and these residents continued to experience pain. Findings include: 1. Record review for Resident "C" revealed a Quarterly Minimum Data Set (MDS) assessment with an Assessment Referenced Date of 07/09/2013 which documented, in Section C - Cognitive Patterns, that the resident's Brief Interview for Mental Status (BIMS) score was 14, thus indicating that the resident was cognitively intact. Section I - Active [DIAGNOSES REDACTED]. Further record review for Resident "C"' s revealed a physician's orders [REDACTED]. every six (6) hours as needed for pain. Another physician's orders [REDACTED]. Review of the September 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]" revealed that the resident was to be evaluated for pain every shift, as specified by the physician's orders [REDACTED]. As indicated in the physician's orders [REDACTED]. Resident "C" was then to receive doses of the pain medication [MEDICATION NAME]/[MEDICATION NAME] 325/7.5 mgs., as specified by the physician's orders [REDACTED]. During an interview with Registered Nurse (RN) "DD" conducted on 10/11/2013 at 1:55 p.m., Nurse "DD" was asked about the procedure utilized for the administration of pain medications. This nurse stated that she would ask a resident if he/she was experiencing pain, and if so, to assign a number to that pain. If the expressed pain level was 5 or below, the resident would initially be given a milder pain medication such as [MEDICATION NAME], and then receive a stronger medication if needed. It the expressed pain level was 6 or above, the stronger pain medication would be utilized. However, further review of Resident "C"'s September 2013 MAR indicated [REDACTED] - On 09/01/2013 at 10:30 p.m., Resident "C" had a documented pain level of 6, but there was no evidence to indicate that the resident received the dose of [MEDICATION NAME]/[MEDICATION NAME] as ordered for pain. - On 09/02/2013 at 10:30 p.m., the resident had a documented pain level of 5, but there was no evidence to indicate that the resident received the dose of [MEDICATION NAME]/[MEDICATION NAME] as ordered for pain, or any other medication for pain. - On 09/05/2013 at 10:30 p.m., the resident had a documented pain level of 7, but there was no evidence to indicate that the resident received the dose of [MEDICATION NAME]/[MEDICATION NAME] as ordered for pain. - On 09/09/2013 at 10:30 p.m., the resident had a documented pain level of 6, but there was no evidence to indicate that the resident received the dose of [MEDICATION NAME]/[MEDICATION NAME] as ordered for pain. - On 09/13/2013 at 10:30 p.m., the resident had a documented pain level of 6, but there was no evidence to indicate that the resident received the dose of [MEDICATION NAME]/[MEDICATION NAME] as ordered for pain. - On 09/14/2013 at 10:30 p.m., the resident had a documented pain level of 7, but there was no evidence to indicate that the resident received the dose of [MEDICATION NAME]/[MEDICATION NAME] as ordered for pain. - On 09/15/2013 at 10:30 p.m., the resident had a documented pain level of 5, but there was no evidence to indicate that the resident received the dose of [MEDICATION NAME]/[MEDICATION NAME] as ordered for pain, or a dose of any other pain medication. - On 09/16/2013 at 10:30 p.m., the resident had a documented pain level of 6, but there was no evidence to indicate that the resident received the dose of [MEDICATION NAME]/[MEDICATION NAME] as ordered for pain. - On 09/25/2013 at 10:30 p.m., the resident had a documented pain level of 5, but there was no evidence to indicate that the resident received the dose of [MEDICATION NAME]/[MEDICATION NAME] as ordered for pain, or a dose of any other pain medication. During an interview with Resident "C" conducted on 10/11/2013 at 1:45 p.m., Resident "C" stated that at times, when he/she had asked for pain medication due to pain, he/she had not received the pain medication as requested. The resident stated that he/she did not know why staff failed to administer the requested pain medication. Based on the above, despite Resident "C" having [DIAGNOSES REDACTED]. The facility thus failed to provide effective pain management, as specified by physician's orders [REDACTED]. 2. Record review for Resident "Z" revealed a Quarterly MDS having an Assessment Referenced Date of 08/13/2013 which documented a BIMS score of 15 in Section C - Cognitive Patterns, indicating that the resident was cognitively intact. This MDS also documented, in Section I - Active Diagnoses, that the resident had [DIAGNOSES REDACTED]. Resident "Z"' s September 2013 Physician order [REDACTED]. However, review of the September 2013 MAR for Resident "Z" revealed that while a [MEDICATION NAME] 75 mcg/hr patch had been applied on 09/13/2013 as ordered, this MAR indicated [REDACTED]. During an interview with Resident "Z" conducted on 10/16/2013 at 3:10 p.m., the resident was asked about the period of time during which the [MEDICATION NAME]es had not been applied as ordered. The resident stated that during that period of time, he/she had experienced pain, and had told nursing staff that he/she was having pain. However, the resident further stated that nursing staff had failed to address his pain, and had not offered an alternative to the pain patch. During an interview with the DON conducted on 10/11/2013 at 11:40 a.m., the DON acknowledged that on the dates of 09/16/2013 and 09/19/2013, [MEDICATION NAME]es had not been applied to Resident "Z", as specified by the physician's orders [REDACTED]. Based on the above, the facility failed to apply the [MEDICATION NAME]es, as ordered by the physician, to address Resident "Z"'s limb pain. The facility therefore failed to provide effective pain management for Resident "Z", and the resident experienced pain.