Every finding on record at Royal Oak Nursing Center

Based on observations, interviews, and policy review, the facility failed to ensure isolation protocols were followed related to PPE (personal protection equipment) use and notifying visitors of infections, in two rooms (231 and 230) out of 15 rooms in hall 200.Findings included: On 02/02/2026 at 03:33 PM, room [ROOM NUMBER] was observed with a contact isolation sign on it, requiring gloves and a gown prior to room entry. There was no indication of whether the sign was for the resident in Bed A or the resident in Bed B. Staff A, Certified Nursing Assistant (CNA) and Staff B, CNA, were observed leaving room [ROOM NUMBER] B, without gloves and gowns after assisting a resident on Bed B's side, as the resident was in a wheelchair. Staff A and Staff B did not use hand hygiene after leaving room [ROOM NUMBER] B.On 02/02/2026 at 03:37 PM Staff A, CNA and Staff B, CNA, were observed re-entering room [ROOM NUMBER] B, without donning gloves and gowns, prior to entering the room. Staff A and Staff B made contact with a curtain divider in room [ROOM NUMBER], and the resident in room [ROOM NUMBER] B's wheelchair, shoulder, right hand, and wrist. Staff A and Staff B were observed leaving room [ROOM NUMBER] and made contact with a table in the hall that had multiple items on it.On 02/02/2026 at 03:40 PM, room [ROOM NUMBER] was observed with a contact isolation sign on the door. Staff A, CNA and Staff B, CNA, were observed entering room [ROOM NUMBER] without donning gloves or gowns. The contact precaution sign on the door did not reveal which resident it applied to. Staff A and Staff B exited room [ROOM NUMBER] and did not use hand hygiene between rooms.On 02/02/2026 at 03:36 PM, an interview was conducted with a family member of the resident in room [ROOM NUMBER] B. The family member explained not having been told anything about the contact isolation sign. The family member of the resident in room [ROOM NUMBER] B stated not knowing gloves and gown were required prior to entering room [ROOM NUMBER]. The family member stated after seeing the contact isolation sign on the door they may need to stop visitation. The family member confirmed they had not been notified or educated on appropriate PPE use prior to entering the room.On 02/02/2026 at 03:42 PM, an interview was conducted with Staff A, CNA and Staff B, CNA, after they were observed leaving room [ROOM NUMBER]. Staff A explained the contact sign on the door of room [ROOM NUMBER] was for Bed B. Staff A stated they assisted the resident in Bed B. Staff A pointed at the contact isolation sign on the door of room [ROOM NUMBER] and stated, I know everything about that. Staff A stated gown and gloves were not needed because only the hands of the resident in Bed B were touched without gloves. Staff A stated if the resident was being picked up during a transfer, then gloves should have been worn. Staff A stated she would have washed her hands afterwards. Staff A stated hand sanitizer had not been used between care contact in rooms [ROOM NUMBERS]. After reading a contact isolation sign on room [ROOM NUMBER]'s door, Staff A stated PPE should have been put on if contact had been made with a resident, not before entering the room.On 02/02/2026 at 03:59 PM, an interview was conducted with Staff C, Registered Nurse (RN), who stated for contact isolation signs, gloves and gown were required to be donned before entering the room. Staff C, RN stated after leaving a contact isolation room, hand hygiene should be used. Staff C stated all her aides knew how to use PPE and when to use it. Staff C stated, that's nursing 101 right there, or at least it should be.On 02/02/2026 at 04:55 PM, an interview was conducted with the Nursing Home Administrator (NHA), Director of Nursing (DON), and the Infection Preventionist (IP). The DON stated prior to entering a room with a contact isolation sign on it, staff should have put on gloves and gowns. The DON stated when the aides left the room, the gown and gloves should have been disposed of, and their hands should have been washed. The DON stated before the aides went to another room, the process should have been restarted. The DON stated if aides were going near residents, PPE would have been required. The DON stated if a curtain, or a resident's wheelchair was touched, gown and gloves would have been required. The DON stated if a resident's hands were touched, definitely, PPE was required. The DON stated every resident room and bathroom had hand hygiene. The DON stated a new procedure was required from space to space.Review of an undated facility policy titled, Infection Prevention and Control Program, revealed: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. Definitions: Staff includes all facility staff (direct and indirect care functions), contracted staff, consultants, volunteers, others who provide care and services to residents on behalf of the facility, and students in the facility's nurse aide training programs or from affiliated academic institutions. Policy Explanation and Compliance Guidelines:1. The designated Infection Preventionist is responsible for oversight of the program and serves as a consultant to our staff on infectious diseases, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases. 2. All staff are responsible for following all policies and procedures related to the program. 3. Surveillance:a. A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon a facility assessment and accepted national standards.b. The Infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility and reports surveillance findings to the facility's Quality Assessment and Assurance Committee.c. The RNs and LNs participate in surveillance through assessment of residents and reporting changes in condition to the residents' physicians and management staff, per protocol for notification of changes and in-house reporting of communicable diseases and infections. 4. Standard Precautions:a. All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services.b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures.c. All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE.d. Licensed staff shall adhere to safe injection and medication administration practices, as described in relevant facility policies.5. Isolation Protocol (Transmission-Based Precautions):a. A resident with an infection or communicable disease shall be placed on transmission-based precautions as recommended by current CDC guidelines.b. Residents on transmission-based precautions should be placed into a private/single room if available/appropriate, or are cohorted with residents with the same pathogen, or share a room with a roommate with limited risk factors, in accordance with national standards.c. Residents will be placed on the least restrictive transmission-based precaution for the shortest duration possible under the circumstances.d. When a resident on transmission-based precautions must leave the resident care unit/area, the charge nurse on that unit/area shall communicate to all involved departments the nature of the isolation and shall prepare the resident for transport in accordance with current transmission-based precaution guidelines.g. Visitors coming to visit a resident who is on transmission-based precautions or quarantine, will be informed by the facility of the potential risk of visiting and precautions necessary when visiting the resident.13. Resident/Family/Visitor Education and Screening:a. Residents, family members, and visitors are provided information relative to the rationale for the isolation, behaviors required of them in observing these precautions, and conditions for which to notify the nursing staff. d. Passive screening, such as signs, are posted in the facility to alert family members and visitors to adhere to handwashing, respiratory etiquette, and other infection control principles to limit spread of infection from family members and visitors. Photographic Evidence Obtained.

Based on observation, interview, and record review, the facility failed to ensure an assessment and documentation for discovered skin discolorations / bruising was performed for three (Residents #201, #6, and #19) of 22 sampled residents and failed to ensure wound dressings were dated and initialed for one (Resident #252) of 22 sampled residents. Findings included: 1. On 03/26/2024 at 9:15 a.m., Resident #201 was observed sitting in her wheelchair returning to her room from the shower. She was dressed and groomed for the day. Resident #201 had a dialysis catheter present in the left chest area. She had a urinary catheter. There was a discolored bruised area on her right upper arm. She stated it was from the IV (Intravenous line) at the hospital. She stated it was [NAME] and larger. She had been readmitted from the hospital on 03/19/2024. Review of Minimum Data Set, dated dated dated [DATE], Section C, Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) score of 14 or cognitively intact. Section G, Functional Abilities and Goals showed resident dependent for toileting, showering and dressing. Resident #201 was readmitted on [DATE] with an original admitted [DATE]. Review of the Admission record showed diagnoses included but not limited to metabolic encephalopathy, lumbar spina bifida with hydrocephalus and shunt placement, diabetes, paraplegia, hypertensive chronic kidney disease or End Stage Renal Disease including dialysis, obstructive hydrocephalus, adjustment disorder, neuromuscular dysfunction of the bladder, anemia, anxiety, Stage IV sacral pressure ulcer, and convulsions. Review of the Skin Observation dated 03/19/2024 showed Skin Integrity: existing pressure ulcer and other existing skin impairment. New bruise and / or existing bruise was blank. Review of the Skin Observation dated 03/26/2024 showed Skin Integrity: existing pressure ulcer and existing surgical incision. New bruise and / or existing bruise was blank. Review of the nursing progress notes dated 03/19/2024 had no documentation related to the right upper arm bruising. Review of Resident #201's skin integrity care plan showed she was at risk for recurrent skin ulcers and impaired skin integrity related to limited mobility, paraplegia, diagnosis of peripheral vascular disease and diabetes. She has a history of chronic scabs to her bilateral thighs, habit to pick them open sometimes. She sometimes has itching and scratches, opening areas on her arms and upper back. Interventions included but not limited to weekly skin checks as of 11/04/2021; observe for discoloration, shiny appearance of the skin as of 11/04/2021; observe resident's skin for abnormal changes as of 11/04/2021. An interview / observation on 03/27/2024 at 9:45 a.m. with the Director of Nursing (DON) verified there was a discolored / bruise area on Resident #201's right upper arm. Resident #201 stated to the DON that it was from the hospital, and it was bigger and [NAME] before. 2. On 03/25/2024 at 1:19 p.m., Resident #19 was observed sitting in a wheelchair in the hallway. She was dressed and groomed for the day. She was unable to answer screening questions. She had a noticeable discoloration / bruise on her hands and arms. Resident #19 was admitted on [DATE] and readmitted on [DATE]. Review of the Admission Record showed diagnoses included but not limited to Chronic Pulmonary Obstructive Disease (COPD), convulsions, diabetes, anemia, Stage II chronic kidney disease, and restless leg syndrome. Review of the MDS dated [DATE] showed a BIMS score of 01 or severe impairment. Section GG, Functional Abilities and Goals showed she was dependent for toileting and showering. Review of the Skin Observation dated 03/21/2024 showed skin intact. New bruise and / or existing bruise was blank. Review of the nursing progress notes showed no documentation related to discoloration / bruising of her hands and arms. Review of Resident #19's skin integrity care plan showed she was at risk for impaired skin integrity related to impaired mobility due to generalized weakness-incontinence. Interventions included but not limited to weekly skin checks as of 04/20/2021; use caution when transferring resident to avoid bumping skin against hard surfaces as of 02/08/2024; use geri sleeves to both upper extremities as tolerated to protect skin from injury as of 07/6/2021. 3. On 03/26/2024 at 1:25 p.m., Resident #6 was observed sitting in her wheelchair in the hallway. She was dressed and groomed for the day. She had discoloration and / or bruising noted on both of her hands and arms. Resident #6 was admitted on [DATE]. Review of the Admission Record showed diagnoses included but not limited to Chronic Pulmonary Obstructive Disease (COPD), dementia with other behavioral disturbance, atrial fibrillation, moderate protein-calorie malnutrition, anxiety, and anemia. Review of the MDS dated [DATE] showed a BIMS score of 06 or severe impairment. Section GG, Functional Abilities and Goals showed she was dependent for toileting and showering. Review of the Skin Observation dated 03/23/2024 showed skin intact. New bruise and / or existing bruise was blank. Review of the nursing progress notes showed no documentation related to discoloration / bruising of her hands and arms. Review of Resident #6's skin integrity care plan showed she was at risk for impaired skin integrity related to impaired mobility due to generalized weakness. Interventions included but not limited to weekly skin checks as of 10/24/2022. During an interview on 03/27/2024 at 12:00 p.m., Staff D, Licensed Practical Nurse (LPN) stated that if the staff found a new area on the skin, they were to document it in the progress notes. Staff D, LPN verified Resident #19 had 5 bruises on her right hand and arm and 4 bruises on her left hand and arm. Staff D, LPN verified Resident #6 had bruising on both of her hands and arms. Staff D, LPN stated Resident #201's bruising should have been documented in the progress notes when she obtained the discoloration or on her re-admission (paperwork) if she was readmitted with it. If a bruise / discoloration was found later, it should have been documented in the facility report. During an interview on 03/27/2024 at 12:31 p.m., the DON stated all new skin areas should be documented in the progress note and / or on a skin assessment. She stated the skin impairment needed to be an identified incident requiring the process of investigating the cause of the injury. The DON stated they may need to put something into place to prevent further injury. The DON reviewed Resident #201's medical record and confirmed nothing was documented regarding (her discoloration of her right arm) so the DON had a facility report completed. The DON stated she would have expected to see something about the bruise in the resident' chart. The DON reviewed Resident #19's record and stated there was no documentation regarding any skin issues i.e. bruises. The DON stated they should have done a progress note and a facility report which included notifying the family and physician. They also had to document monitoring of the area for 72 hours. The DON reviewed Resident #6's medical record and stated there was no documentation regarding bruising on her arms in the record. The DON asked the ADON (Assistant Director of Nursing) to evaluate the resident and document. During an interview with the Nursing Home Administrator (NHA) on 03/28/24 at 9:32 a.m. she stated, We do not have a policy regarding skin checks, it is a standard of care that we monitor the skin. 4. During an interview on 03/25/24 at 10:37 a.m., Resident # 252 stated, I have a leg wound and they never change it daily like my doctor wants them to. Resident #252 stated she saw a wound doctor every week, but the nurses were supposed to be changing the dressing daily and did not. Resident #252 stated my wound dressing wasn't changed over the weekend. An observation on 03/25/24 at 10:37 a.m., revealed Resident #252's right leg with a dry wound gauze like dressing held closed with tape. The dry wound dressing was not dated. Photographic evidence obtained. Review of the Admission Record showed Resident #252 was admitted to the facility on [DATE] with diagnoses included but not limited to multiple fractures of ribs, right side, subsequent encounter for fracture with routine healing, cellulitis of right lower limb, muscle weakness (generalized), and repeated falls. Review of the Medication Review Report revealed a physician order dated 03/15/24 that showed Cleanse ulcers to RLE [Right Lower Extremity]with NS [normal saline], apply xeroform then abd [army battle dressing] pads and wrap with kerlix. - every day shift every Mon, Wed, Fri for diabetic ulcers. The Treatment Administration Record (TAR) showed Resident #252 had received wound treatment on 03/15/24, 03/18/24, 03/20/24, 03/22/24, 03/25/24, and 03/27/24, per physician orders. During an interview on 03/27/24 at 10:35 a.m., Staff C Licensed Practical Nurse (LPN) stated that she was the wound nurse. Staff C stated that once wound treatment had been completed and the wound had been dressed All dressings you date and initial. During an interview on 03/27/24 at 10:50 a.m., the Director of Nursing (DON) stated that any wound dressing should be labeled and initialed when treatment was completed. Review of the facility's policy Dressings, Dry/Clean revised date September 2013 showed, Steps in the Procedure .10. Label tape and dressing with date and initials. Place on clean field. 41015

Based on observation, interview, and record review, the facility failed to ensure infection control practices and procedures were followed during medication administration for four (Residents #260, #259, #13 and #35) of seven sampled residents and one (Resident #84) of one sampled resident related to proper storing of a nebulizer mask. Findings included: 1. On 03/26/2024 at 8:35 a.m., Staff B, Licensed Practical Nurse (LPN) was observed passing medications to Resident #260. Staff B, LPN failed to perform hand hygiene after passing the medications. 2. On 03/26/2024 at 9:30 a.m., Staff B, LPN and the Regional Registered Nurse (RN) were observed passing medications to Resident #259 via a gastrostomy tube. Staff B moved the resident in his wheelchair, but did not hand sanitize prior to starting medication administration. Staff B touched the medication cart, her pen, her computer, dated the wrapper of the large syringe then started removing the medications from the medication cart. Staff B removed seven medications and placed them individually into medication cups. She placed the medication cups onto a Styrofoam barrier. Staff B crushed two medications and then turned and hand sanitized. Staff B then crushed four more medications. Staff B donned gloves and opened the medication in capsule form and poured it into the medication cup. Staff B did not hand sanitize after glove removal. Staff B removed an alcohol wipe from the medication cart and cleaned her stethoscope hanging around her neck. She then locked the medication cart and turned off the computer. Staff B had gathered a plastic cup and spoon from the medication cart. Staff B gathered the cup with a spoon in it, and the medications on the barrier and entered the room. Staff B entered the bathroom, poured water into the cup, washed her hands and applied gloves. Staff B was standing in the room and the Regional Registered Nurse (RRN) exited the room and brought a towel back in and laid it on the bed. The RRN then went around the bed and closed the blinds. RRN did not hand sanitize her hands. Staff B placed the Styrofoam barrier onto the towel on the bed. The RRN told Staff B she needed to place a barrier on the resident's lap under the g-tube. They removed the towel from the bed and placed it on the resident's lap. Staff B placed the Styrofoam barrier with the medications on it onto the bed. The RRN continued to hold the water cup with the spoon in it. Staff B opened the package the large syringe was in and used it to aspirate the g-tube. Staff B listened with the stethoscope as she infused air into the g-tube with the syringe. Staff B then flushed the g-tube with water. Staff B poured the first medication into the g-tube without putting any water into the medication cup and dissolving the medication. Staff then followed the pouring of the dry medication with water. Staff B with the assistance of RRN placed water into the remaining medication cups and poured them into the g-tube. Staff B did not consistently stir the medications after adding water before pouring them into the g-tube. Staff B flushed the g-tube with water after finishing the medication administration. Staff B went to the bathroom to rinse the syringe and throw away the plastic cup and spoon. Staff B removed her gloves and washed her hands. Staff B replaced the syringe into the dated plastic wrap and placed it onto the bedside table. RRN washed her hands. RRN coached Staff B throughout the procedure. 3. On 03/26/2024 at 10:55 a.m., Staff E, Registered Nurse (RN) was observed performing glucose monitoring for Resident #13. Staff E had placed the blood glucose meter, bottle of strips, lancet and alcohol wipe into a plastic cup. Staff E hand sanitized her hands and applied gloves in the resident's room. Staff E placed the plastic cup with the items inside of it onto the bedside table. Staff E removed the alcohol wipe and cleaned the left ring finger of the resident. Staff E removed the bottle of strips and removed one and placed it in the blood glucose meter. Staff E then closed the lid on the strips, set it on the bedside table and placed the blood glucose meter on top of it. Staff E placed a drop of blood on the strip and the results were 113. Staff E, using her gloved hands removed a pen from her pocket as well as a piece of paper and documented the blood sugar results on it. Staff E then replaced the pen and paper in her pocket. Staff E gathered the glucose monitor and placed it into the plastic cup and placed it in one of her pockets. Staff E placed the bottle of strips into her other pocket. Staff E removed her gloves and went into the resident's restroom to wash her hands. Staff E walked down the hallway to the medication room. Staff E applied gloves and removed a wipe from the blue top canister and wiped the blood glucose meter she had removed from the plastic cup. Staff E removed a second wipe and placed it around the blood glucose meter and placed it back into the cup she had used in the resident's room. Staff E removed her gloves but did not hand sanitize her hands in or upon leaving the medication room. Staff E was observed going down the hallway with another blood glucose meter set-up to another resident room. 4. On 03/26/2024 at 1:10 p.m., Staff A, LPN was observed administering 5 cc normal saline via Intravenous to Resident #35. Staff A hand sanitized and gathered the normal saline syringe, alcohol wipes and IV cap for the administration. Staff A applied gloves touched the overbed table, curtains and overbed table again. Staff A removed her gloves and reapplied gloves without hand sanitizing. Staff A cleaned the port and flushed the IV with the 5 cc of normal saline. She removed her gloves and washed her hands after the infusion. During an interview on 03/28/2024 at 12:49 p.m., the Director of Nursing (DON) stated hand hygiene was to be performed before starting to prepare medications, upon entering the resident's room with medications, they might need to hand sanitize while in the room and upon exiting the resident room. Staff E should not have taken a bottle of strips into the resident's room. Staff E should not have placed the clean blood glucose meter into the cup she had brought from the resident room. The DON shook her head when informed Staff E's pockets. The DON stated the medications should not be placed into the g-tube without being diluted with water because the medications could stick to the g-tube. Review of the facility's policy, Handwashing / Hand Hygiene, revised August 2019 showed this facility considers hand hygiene the primary means to prevent the spread of infections. 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 6. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: b. Before and after direct contact with residents; c. Before preparing or handling medications; d. Before performing any non-surgical invasive procedures; e. Before and after handling an invasive devices; i. After contact with a resident's intact skin; l After contact with objects (e.g. medical equipment) in the immediate vicinity of the resident; m. After removing gloves Review of the facility's policy, Administering Medications, revised April 2019 showed 25. Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. Review of the facility's policy, Blood Sampling - Capillary (Finger Sticks) revised September 2014 showed the purpose of this procedure is to guide the safe handling of capillary-blood sampling devices to prevent transmission of bloodborne diseases to residents and employees. General Guidelines: 1. Always ensure that blood glucose meters are intended for reuse are cleaned and disinfected between resident uses. Steps in the Procedure: 1. Perform hand hygiene. 2. Don gloves. 3. Place blood glucose monitoring device on clean field. 4. Place a new lancet and disposable platform on the spring-loaded finger-stick device. 5. Wipe the area to be lanced with an alcohol pledget. 6. obtain the blood sample, following the manufacturer's instructions for the device. 7. Discard the lancet and platform into the sharps container. 8. Following the manufacturer's instructions, clean and disinfect reusable equipment, parts, and / or device after each use. 9. Remove gloves, and discard into appropriate receptacle. 10. Perform hand hygiene. 11. Replace blood glucose monitoring device in storage area after cleaning. Review of the facility's policy, Enteral Tube Medication Administration, not dated showed the facility assures the safe and effective administration of enteral formulas and medications via enteral tubes. Procedure: Prepare one medication at a time. Put on examination gloves. Note: Medication administration via tube requires flushing with water at several steps in the procedure. Prepare medications for administration. 2. Crush each immediate-release tablets, one at a time, into a fine powder, and dissolve in at least 15 ml (or prescribed amount) of water. 3. Open each immediate release capsules, one at a time, crush contents into a fine powder, and dissolve in at least 15 ml (or prescribed amount) of water. Elevate the head of the bed. With gloves on, check for proper tube placement using air and auscultation only. Never check placement with water. Administer each medication separately and flush the tubing between each medication: 1. Place 15 ml (or prescribed amount) of water in syringe and flush tubing using gravity flow. Clamp tubing after the syringe is empty, allowing water to remain in the tube. 2. Pour dissolved/dilute medication in syringe and unclamp tubing, allowing medication to flow by gravity. 3. Flush tube with 15 ml (or prescribed amount) of water between each medication. Pinch tubing below the syringe tip when each volume of liquid clears the syringe to avoid excessive air from entering the stomach. This can cause discomfort and emesis. 4. Clamp tubing and detach syringe. Cleans reusable equipment per facility infection control. Perform hand hygiene. 41015 5. An observation on 03/25/24 at 10:00 a.m. revealed a nebulizer machine on the nightstand beside Resident #84's bed. The nebulizer mask was sitting on top of the nebulizer machine and left open to air. A clear bag was sitting underneath the nebulizer machine and not being used. Photographic evidence obtained. During an interview on 03/25/24 at 10:00 a.m., Resident #84 stated the nebulizer mask was not in the bag because he was physically unable to store it in the bag after his treatment. Resident #84 stated the nurse usually started the nebulizer treatment but then went out to take care of other residents. Resident #84 stated when the nebulizer treatments were finished I put it away myself. Resident #84 stated he would store the nebulizer mask in the bag if he physically could do so. A review of the Admission Record showed Resident #84 was admitted to the facility on [DATE] with diagnoses to include but not limited to Chronic Obstructive Pulmonary Disease (COPD) with (acute) exacerbation and unspecified asthma uncomplicated. Review of the Medication Review Report revealed a physician order dated 02/01/24 showed, Albuterol Sulfate Inhalation Nebulization Solution 1.25 MG [milligrams]/3 ML [milliliters] (Albuterol Sulfate)- 3 ml inhale orally via nebulizer every 4 hours as needed for shortness of breath. Review of Resident #84's care plan showed no focus, goals or interventions related to Resident #84's respiratory diagnoses of COPD or Asthma and no treatments that included a nebulizer breathing treatment. During an interview on 03/27/24 at 10:30 a.m., Staff B Licensed Practical Nurse (LPN) stated, all nebulizer masks should be placed in the bag for storage when not in use. During an interview on 03/27/24 at 11:40 a.m., the Director of Nursing (DON) stated nebulizer masks should have been placed in the bag after treatment. Review of the facility's policy Nebulizer- Administering Medications through a small volume (handheld) Nebulizer not dated revealed Store in plastic bag with the resident's name and the date on it.

Based on observation, record review, interview, and review of the facility's policy Self-Administration of Medications the facility failed to ensure two (Residents #84 and #262) out of 22 sampled residents were clinically appropriate to self-administer medications. Findings included: An observation on 03/25/24 at 10:00 a.m. revealed a nebulizer machine on the nightstand beside Resident #84's bed. The nebulizer mask was sitting on top of the nebulizer machine and left to open air. A clear bag was sitting underneath the nebulizer machine and not being used. Photographic evidence obtained. During an interview on 03/25/24 at 10:00 a.m. Resident #84 stated that the nebulizer mask was not in the bag because he was physically unable to store it in the bag after his treatment. Resident #84 stated the nurse usually started the nebulizer treatment but then went out to take care of other residents. Resident #84 stated when the nebulizer treatments are finished I put it away myself. Resident #84 stated staff did not stay the entire time while he received his breathing treatment. On 03/25/24 at 11:25 a.m., Resident #84 was observed sitting in bed and receiving a breathing treatment. Resident #84 was alone in his room and self-administering his breathing treatment with the nebulizer machine. A review of the Admission Record showed Resident #84 was admitted to the facility on [DATE] with diagnoses to include but not limited to Chronic Obstructive Pulmonary Disease (COPD) with (acute) exacerbation and unspecified asthma uncomplicated. Review of the Medication Review Report revealed a physician order dated 02/01/24 that showed, Albuterol Sulfate Inhalation Nebulization Solution 1.25 MG [milligrams]/3 ML [milliliters] (Albuterol Sulfate)- 3 ml inhale orally via nebulizer every 4 hours as needed for shortness of breath. There were no physician orders for self-administration of medications. Review of Resident #84's care plan showed no focus, goals or interventions related to Resident #84's respiratory diagnoses of COPD or Asthma, no treatments that included a nebulizer breathing treatment and no self-administration of medications. An observation on 03/25/24 at 10:14 a.m., revealed a medicine cup that contained four pills (one round orange colored pill, one round red colored pill, one round yellow colored pill and one white colored pill) that sat on Resident #262's bedside table. Photographic evidence obtained. During an interview on 03/25/24 at 10:14 a.m., Resident #262 stated, she usually takes the big ones first and then leisurely takes the other pills when she can. Resident #262 stated I cannot take a bunch of pills all at once, so the nurse leaves them for me to take. Resident #262 identified the pills in the medication cup as my morning meds. Review of the Admission Record showed Resident #262 was admitted to the facility on [DATE] with diagnoses to include but not limited to aftercare following joint replacement surgery, presence of right artificial knee, unilateral primary osteoarthritis, right knee and hypertensive heart disease without heart failure. Review of the Medication Review Report revealed no physician order for Resident #262 for self-administration of medications. Review of the care showed no focus, goal or interventions for Resident #262 for self-administration of medications. During an interview on 03/27/24 at 9:31 a.m., Staff B Licensed Practical Nurse (LPN) stated there were no Residents including Resident #84 and #262 that could self-administer their medications. During an additional interview on 03/27/24 at 10:30 a.m., Staff B LPN stated Resident #84 did have an order for nebulizer treatments, but the order was as needed (PRN) and he was able to let staff know when he needed a treatment. Staff B LPN stated that nebulizers do contain medication and are considered treatments nurses are to be present for when being administered. Staff B LPN stated that Resident #84 was alert and oriented so she did not always stand over Resident #84 when he was being administered his breathing treatment and stated sometimes, she would be near his door while he was being provided his nebulizer treatment. During an interview on 03/27/24 at 10:50 a.m., the Director of Nursing (DON) stated even though a nebulizer order was PRN it was a medication treatment so Residents cannot use it without a nurse presence. The DON confirmed there were no resident in the facility that were permitted to self-administer their own medications. The DON stated, no pills should be left at bedside. Review of the facility's policy Self-Administration of Medications revised date February 2021 revealed Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so 3. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. The decision that a resident can safely administer medications is reassessed periodically based on changes in the resident's medical and or decision-making status.

Based on observation, record review, interview, and review of the facility's policy Care Plans, Comprehensive Person-Centered the facility failed to develop a patient-centered care plan for one (Resident #84) out of twenty-two sampled residents related respiratory care and services. Findings included: An observation on 03/25/24 at 10:00 a.m., revealed a nebulizer machine on the nightstand beside Resident #84's bed. The nebulizer mask was sitting on top of the nebulizer machine and left to open air. A clear bag was sitting underneath the nebulizer machine and not being used. Photographic evidence obtained. During an interview on 03/25/24 at 10:00 a.m., Resident #84 stated the nebulizer mask was not in the bag because he was physically unable to store it in the bag after his treatment. Resident #84 stated the nurse usually started the nebulizer treatment but then went out to take care of other residents. Resident #84 stated when the nebulizer treatments were finished I put it away myself. Resident #84 stated staff did not stay the entire time while he received his breathing treatment. On 03/25/24 at 11:25 a.m., Resident #84 was observed sitting in bed and receiving a breathing treatment. Resident #84 was alone in his room and self-administering his breathing treatment with the nebulizer machine. A review of the Admission Record showed Resident #84 was admitted to the facility on [DATE] with diagnoses to include but not limited to Chronic Obstructive Pulmonary Disease (COPD) with (acute) exacerbation and unspecified asthma uncomplicated. Review of the Medication Review Report revealed physician orders as followed: - Albuterol Sulfate Inhalation Nebulization Solution 1.25 MG [milligrams]/3 ML [milliliters] (Albuterol Sulfate)- 3 ml inhale orally via nebulizer every 4 hours as needed for shortness of breath dated 02/01/24. - Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate)- 2 puff inhale orally every 4 hours as needed for shortness of breath FLUTICASONE-VILANT 200-25 MCG - 1 puff inhale orally one time a day for COPD dated 02/01/24. Review of Resident #84's care plan showed no focus, goals or interventions related to Resident #84's respiratory diagnoses of COPD or Asthma and no treatments that included an inhaler or nebulizer breathing treatments. During an interview on 03/27/24 at 11:40 a.m., the Director of Nursing (DON) stated it appears that we care planned everything under the sun except that. The DON confirmed Resident #84's care plan was not developed for his respiratory diagnoses, care, and treatment. Review of the facility's policy Care Plans, Comprehensive Person-Centered revised date March 2022 revealed, 1. The Interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 7. The comprehensive, person-centered care plan: .b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychological well-being.

Based on observation, interview, and record review, the facility failed to ensure that activities of daily living related to nail care were provided for one (Resident #9), out of five sampled residents. The findings include: On 3/25/2024 at 10:30 AM, Resident #9 was observed sitting in the hallway, just outside of his room. Resident #9 had food on the front of his gown, facial whiskers, and his hair was not combed. He was able to answer with head nods to yes/no questions. He responded with a negative (no) head nod when asked about liking the whiskers. He responded with a yes if preferred to be clean shaven. His hands were positioned on his lap. His fingers were curled under into the palm of his hands. He was able to open his fingers slightly to both hands. When this occurred, a foul odor was noted. His fingernails were dirty with brown and white substances underneath and his fingers were dirty. On 3/26/2024 at 8:55 AM, and 10:20 AM, Resident #9 was observed out of bed sitting in the wheelchair, his hands were resting in his lap. The resident's nails were dirty, long, and had a brown and white substance underneath the nails. Resident #9 had crumbs of food on his chest and in mustache. On 3/27/2024 at 12:30 PM, Resident #9 was observed sitting up in the wheelchair with a towel over his chest (being used as a clothing protector). The towel and resident's mustache, chin, and hands had food on them. His nails were still long, dirty, and had a foul odor. (Photographic Evidence Obtained). During an interview on 3/27/2024 at 1:12 PM, Staff H, Certified Nursing Assistant (CNA) and Staff F, CNA both stated utilizing the Kardex to know how to care for residents. Resident #9 was dependent on staff for all care. Resident #9 did not have any splints or skin problems on his buttocks. During an interview on 3/27/2024 at 9:40 AM, Staff G, CNA confirmed responsibility for Resident #9, and normally took care of the resident. Staff G confirmed Resident #9 needed assistance with all meals, bathing, hand hygiene, basically everything. Resident #9 did not have any splints or different care for his hands. Staff G stated Resident #9's buttocks did not have any skin concerns. During an interview on 3/27/2024 at 1:20 PM, Staff A, Licensed Practical Nurse (LPN) stated responsibility for the care of Resident #9. Staff A stated Resident #9 was dependent on staff for all Activities of Daily Living (ADLs). Staff A stated staff needed to clean his hands, wash his face, brush his teeth, provide nail care, et al. Staff A confirmed Resident #9 did not have splints or special care to his hands. Staff A, LPN stated Resident #9 did not have any skin concerns on his buttocks. During an interview on 3/27/2024 at 1:25 PM, the Director of Nursing (DON) confirmed Resident #9 was total care. The DON stated the CNAs should be assisting the resident with all care needs. The DON stated any nursing employee could soak and clean residents' nails. The DON observed Resident #9's fingernails and soiled clothing. The DON stated Resident #9 needed to be cleaned up and nails cleaned and trimmed. The DON stated if there was an order for a resident to have splints, then a care plan would be created. When an order was changed the expectation was for the care plan to be updated accordingly. When care changes the care plan should be updated at the same time, this would include excoriation to buttocks, as this is healed. A review of Resident #9's Admission Record revealed current admitted [DATE] with the following diagnosis: Alzheimer's Disease, Dementia without behavioral disturbance, Chronic Obstructive Pulmonary Disease (COPD), Right- and Left-hand contracture, Diabetes type 2, peripheral vascular disease (PVD), anxiety disorder and other co-morbidities. A Minimum Data Set (MDS) dated [DATE], revealed Resident #9 with a Brief Interview for Mental Status (BIMS) score of 1/15, which indicated severe cognitive impairment. The resident was coded to no behaviors. His functional abilities and goals revealed impairments on bilateral upper and lower extremities, dependent for all care. Review of Resident #9's Order Summary with an active date of 3/27/2024 showed no order for hand splints. Review of Resident #9's Care Plan revealed a care plan including the following: Focus of Contractures [Resident #9] has contracture of the right and left hands with a revision date of 2/11/2023. The interventions included but not limited to: Bilateral hand splint 3-4 hours at nights as tolerated. Alternate with rolled washed cloth as ordered. With a revision date of 10/14/2022. Provide routine skin care, wash and dry hands properly. Date initiated 10/14/2022. Focus area shows: [Resident #9] has an ADL self-care deficit and requires assistance with ADLS related to contractures, . revised on 4/3/2023. Interventions include but not limited to: hair and nail care as needed initiated on 7/21/2023. Contractures: The resident has contractures of both hands. Provide skin care to keep clean and prevent skin breakdown. Revised on 4/3/2023. Eating: Resident is an assist with meals, initiated on 9/28/2023. Focus Area: [Resident #9] has an excoriation to buttocks related to incontinence, revised on 4/10/2023. Review of the facility's policies and procedures with the subject of Fingernails/Toenails, Care of revised on February 2018. Purpose: the purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. General Guidelines: 1. Nail care includes daily cleaning and regular trimming. 4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. Steps in the Procedure: 3. Fill the wash basin 1/2 full of warm soapy water. 4. Allow the first hand or foot to soak in the warm soapy water for approximately 5 minutes. 5. Encourage the resident to exercise his or her fingers while they are soaking. 6. Rinse the hand or foot that has been in the soapy water with clear, warm water. 7. Dry the hand or foot with the towel. 8. Place the towel under the resident's dried hand or foot. 9. Place the second hand or foot in the soak basin. 10. Gently, remove dirt from around and under each nail with an orange stick. 11. Wipe the dirt from the orange stick with a paper towel. Discard the paper towel into the trash receptacle. 12. Do not trim nails below the skin line or cut the skin. 13. Trim fingernails in an oval shape and toenails straight across. 14. Smooth the nails with the nail file or emery board. Apply lotion as permitted. 15. Repeat the procedure for the second hand or foot. Reporting: 1. Notify the supervisor of the resident refuses the care. 2. Report other information in accordance with the facility policy and professional standards of practice.

Based on observation, record review, and interview, the facility failed to identify and educate staff of specific behaviors and triggers related to Post Traumatic Stress Disorder (PTSD) for one (Resident #77) of two sampled residents who had PTSD. Findings included: On 3/25/2024 at 2:25 p.m., Resident #77 was observed in the hallway leading from the therapy gym to the 200 hall. He was standing up and walking with therapy staff. Resident #77 was observed pleasant to speak with and was not presenting with any behaviors, pain, or discomfort. On 3/26/2024 at 11:15 a.m., Resident #77, while he was in his room, was interviewed with his permission. He expressed he was ordered and received psychotropic medications for several psychological diagnoses, and had taken those medications for many years. He felt the medications were working well, and also expressed, If I was not on these medications, I would not be the same as I am now. Resident #77 was asked if he had any type of history related to past trauma. He confirmed he did and he was seen by psychiatric services at least once a month and also saw a psychologist. Resident #77 was asked if he felt psychiatric services had been helping when it came to his past trauma. He said he felt the services were working but did not want to speak of what trauma/PTSD he had gone through. Resident #77 was not asked any further questions related to his past trauma/PTSD. Review of the medical record revealed Resident #77 was admitted to the facility on [DATE]. Review of the advance directives showed Resident #77 was his own responsible party. Review of the diagnosis sheet showed diagnoses to include but not limited to Post Traumatic Stress Disorder (PTSD) (onset 10/25/2023); Schizophrenia (onset 10/25/2023); Anxiety (onset 10/25/2023) Review of the current Minimum Data Set (MDS) Quarterly assessment, dated 1/31/2024, showed a Cognition/Brief Interview for Mental Status or BIMS score of 13 of 15, which indicated intact cognition. Mood - None documented as exhibited during this assessment period. Review of he most current Physician's Order Sheet (POS), dated for the month of 3/2024 showed the following but not limited to orders: (a) Beginning Order date of 10/27/2023: Observation; Behaviors. Observe for the following: 1. Itching, picking at skin; 2. Restlessness, agitation; 3. Hitting, kicking, physical aggression; 4. Spitting, biting; 5. Cussing, yelling; 6. Delusions, hallucinations, psychosis; 7. Refusing care; 8. Isolation, withdrawn, depression; 9. Wandering, pacing; 10. Insomnia; 11. Disorganized thinking; 12. Abnormal motor behaviors; 13. Negative symptoms, avoids eye contact, lacks facial expression, monotone; 0. No Behaviors. Every shift for monitoring non pharmacological interventions: 1. Diversion, redirection; 2. Activities, music; 3. Resident expressed feelings, 1-to-1 interactions; 4. Snack, drink; 5. Calming environment, relaxation techniques, aromatherapy; 6. Alternate staff member; 0- No behavior. There was no observation criteria for behaviors including specific past Trauma/PTSD listed in this Behavior observation order. Also, there were no other Trauma/PTSD behavior monitoring orders within the 3/2024 order sheet/treatment sheet. Review of the past and current Psychiatric notes/assessments revealed: (1) 10/31/2023 Psychiatric follow up assessment - History note - history anxiety and depression and schizoaffective disorder. Fall from home. Army Veteran, Past psychiatric history of PTSD, depression and substance abuse. Past Suicide attempt via drug overdose on psychiatric medications and past attempt of cutting himself past use of psychotropic medications. (2) 11/28/2023 Psychiatric follow up assessment - Notes - Past Suicide attempt via drug overdose on psychiatric medications and past attempt of cutting himself past use of psychotropic medications. Army Veteran, Past psychiatric history of PTSD, depression and substance abuse. Trauma history included serving in [name] war, war flashbacks. (3) 12/26/2023 Psychiatric follow up assessment - Notes - Past Suicide attempt via drug overdose on psychiatric medications and past attempt of cutting himself past use of psychotropic medications. Army Veteran, Past psychiatric history of PTSD, depression and substance abuse. Trauma history included serving in [name] war, war flashbacks. None of the above assessments from psychiatric services mentioned how Resident #77 would be assisted and further evaluated with relation to past Trauma/PTSD, specifically related to past suicidal attempt and war flashbacks. Review of the nurse progress notes dated from 10/30/2023 through to 3/28/2024 did not reveal any documentation related to Resident #77 presenting with any type of behaviors that may be triggered or related to past Trauma/PTSD. Review of the current care plans with a next review date of 5/2/2024 revealed the following but not limited to; Resident #77 is Pre Admission Screen Record Review (PASRR) positive MI/ID/DD related to Schizophrenia, PTSD, and with interventions in place. There was nothing related to specific interventions to either reduce or identify areas of past Trauma/PTSD. Resident #77 has a psychosocial well-being problem and actual related to history of anxiety, depression and psychotic, Chronic PTSD and Schizoaffective disorder, with interventions in place to include but not limited to: Monitor for changes in psychosocial well-being increased from baseline such as, but not limited to increased behaviors, sadness, irritability, anger, agitation, distress, crying, screaming, moaning, combativeness, fear, anxiety, withdraw, psychomotor retardation (slowed speech, thinking, and body movements; increased pauses before answering) self-isolation, change in appetite, etc. and notify social services/psych services and physician immediately for further intervention. (Date onset 10/26/2023). There was nothing related to specific interventions to either reduce or identify areas of past Trauma/PTSD. Resident #77 has history of Trauma related to history of sprained Left ankle. And has history of PTSD with interventions to include but not limited to: Staff to provide a trauma-informed care approach that involves understanding, recognizing and responding to the effects of all types of trauma; Recognizing the widespread impact and signs and symptoms of trauma in residents; and avoiding re-traumatization. (Date onset 10/26/2023). This care plan problem area did not reflect what specific type of PTSD/Trauma Resident #77 had, nor did the care plan problem area have interventions to reduce or identify behaviors specifically related to PTSD/Trauma. This care plan problem area was more related to trauma related to a sprained Left ankle. On 3/27/2024 at 11:20 a.m., an interview with Staff I, Certified Nursing Assistant (CNA) revealed she had Resident #77 on her assignment most days and she knew him and his care and services. Staff I also revealed she knew him well enough to know that he had not been presenting for awhile with any types of behaviors. Staff I revealed Resident #77 usually stayed in his room most of the day and came out when he was scheduled for rehabilitation therapy. She did not believe he participated in resident group activities. She also verified the resident had family visits at times. She said the resident had not had any behaviors in awhile that she could remember, but would report behaviors to the nurse if he exhibited any. Staff I was asked if she was aware if the Resident #77 had any past Trauma or Post Traumatic Stress Disorder (PTSD) behaviors that she might need to watch for. She revealed she did not believe that he did. She was asked if she was provided with any training or education related to residents having Trauma/PTSD. She said she did, but it might have been a long time ago. Staff I revealed the training was most likely basic and revealed how to identify certain behaviors and how to report them. Staff I confirmed she had never been educated on what PTSD/Trauma behavior or triggers to look out for and report when it came to Resident #77. On 3/27/2024 at 11:30 a.m., an interview with Staff B, Licensed Practical Nurse (LPN) revealed she had Resident #77 on her assignment on a daily basis and knew him and what his care expectations were. Staff B revealed Resident #77 stayed in his room most of the time and he usually only came out when he had therapy. She revealed he had electronic devices in his room, television shows to watch and had visits from family at times. Staff B revealed Resident #77 did not like to go to scheduled group activities, and he normally ate in his room for all three meals. Staff B said the resident had not had any documented behaviors during the past couple of months that she could remember, but he and his roommate would sometimes disagree with one another. They were really close roommate friends, and almost like family. Staff B said the resident could not remember the reason for his Trauma/PTSD and she did not know of what type of behaviors to look out for and report that were specifically related to his past Trauma/PTSD. She did not know what types of triggers would cause him to present with PTSD/Trauma behaviors. Staff B confirmed she had Trauma/PTSD education in the past, but was not made aware of what specific Trauma behaviors Resident #77 may or may not present with. Staff B also confirmed the floor CNAs were not aware of what specific behaviors of past Trauma to look out for and to report to her. On 3/27/2024 at 1:26 p.m., an interview with Staff J, Staff Developer revealed she was generally the person who was initially responsible for providing education and inservices related to Trauma/PTSD. She revealed initial training was provided to staff during their orientation process. Staff J also revealed the Director of Nursing and the Assistant Director of Nursing would also provide training related to PTSD/Trauma as need. Staff J provided a blank orientation packet that was provided to new staff which included a power point presentation. Page 17 of the power point presentation revealed two slides dedicated to Trauma informed care. The slides indicated how to generally observed, report and identify trauma in residents. There was a computer based website the staff had to watch to include review of the slides. Staff J said the PTSD/Trauma education was provided on a yearly basis to all staff. Staff J confirmed the DON, ADON, and psychiatric services were responsible for identifying, assessing, and monitoring residents for triggers and symptoms related to Trauma/PTSD, They were also responsible for passing down information to direct care staff related to specific behaviors related to Trauma/PTSD. A second interview with Staff J was conducted on 3/28/2024 at 8:30 a.m., and she provided the last facility wide Trauma/PTSD training, dated 7/25/2023. The training subject matter revealed; Trauma Informed Care, and was signed and dated by all direct care staff. Staff were provided with an informational Trauma Informed Care Handout. Staff J again could not speak to what triggers affected Resident #77 with regards to past Trauma/PTSD. She confirmed all staff should be aware of what type of behaviors to look for so they could be reported to the Nurse Manager, DON, and psychiatric services, in order to find ways to reduce those behaviors. Staff J confirmed Resident #77's medical record to include the Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not have a specific order or monitoring system for specific behaviors/triggers related to PTSD. On 3/28/2024 at 10:00 a.m., an interview with the Nursing Home Administrator and the DON confirmed though Resident #77 had care plans related to Trauma/PTSD behaviors, and orders for general behavior monitoring; there was no evidence in the medical record to include nurse progress notes, nursing quarterly assessments, and care plans that spoke to what type of past Trauma/PTSD he had. The DON confirmed the psychiatric assessments showed a note on 10/31/02023, 11/28/2023, and 12/26/2023 that the resident had a past history of trauma related to military war background. The DON said the information was not carried over to the current Trauma/PTSD care plan, nor were staff educated and inserviced on what types of triggers might induce those specific trauma behaviors. On 3/28/2024 at 11:00 a.m. the Nursing Home Administrator revealed the facility did not have a specific Trauma/PTSD policy and procedure. However, she provided a Behavioral Assessment, Intervention and Monitoring policy and procedure for review. She revealed this policy is used for residents who have Trauma/PTSD. The policy was last revised on March 2019 and revealed; 1. The facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with comprehensive assessment and plan of care. 2. Behavioral symptoms will be identified using facility-approved behavioral screening tools and the comprehensive assessment. 3. Residents who do not display symptoms of, or have not been diagnosed with, mental, psychiatric, psychosocial adjustment, substance abuse or Post Traumatic Stress Disorder (PTSD) will not develop behavioral disturbances that cannot be attributed to a specific clinical condition that makes the pattern unavoidable. General Guidelines; (1) Behavior is the response of an individual to a wide variety of factors. These factors may include medical, physical, functional, psychosocial, emotional, psychiatric, or environmental clauses. a. Behavior is regulated by the brain and is influenced by past experiences, personality traits, environment, and interactions with other people. b. Behavior can be a way for an individual in distress to communicate unmet needs, indicate discomfort, or express thoughts that cannot be articulated. (2) As part of the comprehensive assessment, staff will evaluate, based on input from the resident, family and caregivers, review of medical record and general observations: a. The resident's usual patterns of cognition, mood and behavior. b. The resident's typical or past responses to stress, fatigue, fear, anxiety, frustration and other triggers, and c. The resident's previous patterns of coping with stress, anxiety, and depression. (3) The nursing staff will identify, document, and inform the physician about specific details regarding change in an mental status, behavior, and cognition, including: a. Onset, duration, intensity and frequency of behavioral symptoms; b. Any recent precipitating or relevant factors or environmental triggers (e.g. medication changes, infection, recent transfer from hospital), and c. Appearance and alertness of the resident and related observations. Management - (1) The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm. a. Atypical behavior will be differentiated from behavior that is dangerous or problematic for the resident(s) or staff, or behavior that signals underlying distress. b. If the behavior is atypical but not problematic or dangerous and the resident does not appear to be in distress, then the IDT will monitor for changes but not necessarily intervene to normalize the behavior. (2) Interventions will be individualized and part of an overall care environment that supports physical, functional and psychosocial needs, and strives to understand, prevent or relieve the resident's distress or loss of abilities. (3) Interventions and approaches will be based on a detailed assessment of physical, psychological and behavioral symptoms and their underlying causes, as well as the potential situational and environmental reason s for the behavior. The care plan will include, as a minimum: (a) Frequency; (b) Intensity; (c) Duration; (d) Outcomes; (e) Location; (f) Environment; and (g) Precipitating factors or situations. Targeted and individualized interventions for the behavioral and/or psychosocial symptoms. The rational for the interventions and approaches; The rationale for the interventions and approaches; Specific and measurable goals for targeted behaviors; and How the staff will monitor for effectiveness of the interventions. Monitoring - IF the resident is being treated for altered behavior or mood, the IDT will seek and document any improvements or worsening in the individual's behavior, mood, and function.

Based on observation, interview, and record review the facility failed to provide supervision to prevent an unwitnessed exit from the facility for one resident (#1) of 3 residents sampled for elopement. On 08/23/22 at 3:20 a.m., Resident #1 walked out of the facility through a malfunctioning door in the dining room. Resident #1 wheeled himself approximately 300 feet from the building and abandoned his wheelchair behind a tree. Resident #1 ambulated another 300 feet sat on a bench outside the entrance of the neighboring facility. Findings included: A review of a Policy entitled Elopement Policy and Procedure with a revision date of 06/04/08 indicated the following: The facility expects to ensure the safety and protection of the residents assigned to their care. An elopement shall be defined as any resident who wanders outside the building and off the grounds, whether cognitively impaired or not. The parameters for which we consider an elopement as follows: Outside of fence that runs along the sides and back of property [facility name] at entrance of driveway. Under subsection entitled Procedure revealed . charge Nurse will provide staff with the following information: Resident's name, what they were wearing, last known location, and instruct staff to search the building & perimeter of the building up to [name of the road]. Charge Nurse or Designee will notify the Administrator, Director of Nursing, ADON, Social Services, and Maintenance Director immediately . under subsection entitled Department Head Assignments revealed .Upon location of resident, the nurse and/or doctor will evaluate resident for safety . On 09/06/22 at 8:03 a.m. a tour of the route Resident #1 may have taken was conducted with Staff A, Registered Nurse (RN), who was assigned to Resident #1. Staff A stated Resident #1 left the facility through the dining room double doors. Staff A stated the alarm on the door will alert the nurses at the nurses' station. Staff A stated if a resident with a wander monitoring device goes close to an alarmed door, it will set off the alarm. Staff A stated the nursing staff will figure out where the alarm is going off and rush to the sound to see what is going on. Staff A reported Resident #1 was able to get out because the alarm was not working at the time. Staff A stated Resident #1 traveled through the parking lot and put his wheelchair behind a tree across the parking lot from the facility. Staff A pointed to the spot behind the tree where the wheelchair was found. The tree was observed to be across the parking lot directly in front of the facility. An interview was conducted on 09/06/22 at 5:57 a.m. with Staff A, RN, Staff A stated Resident #1 was in his room the night of the incident and another resident at the end of the hall was asking for help. She stated she was helping the resident around 2:30-3:30 a.m. and was working with an agency aide that was assigned to the hall. Staff A stated before she went to help the resident, she saw Resident #1 in bed. She stated after she assisted the other resident, she was doing her rounds and did not see Resident #1 in bed. She stated usually Resident #1 gets out of bed himself and uses the bathroom. Staff A stated she knocked on the bathroom door, and after she did not hear an answer, she opened the door and Resident #1 was not in the bathroom. She stated she asked the aide if she had seen Resident #1, and she indicated she saw Resident #1 in his wheelchair in the doorway of his room. She stated her and the aide checked other rooms and all the bathrooms to see if maybe he got confused and went to another resident's bathroom. She stated the doors will alarm when a resident has a wander monitoring device, which Resident #1 had on at the time of the incident. Staff A stated the night Resident #1 left there was no alarm. She stated she went to look outside and came back for a flashlight, and the aide went looking in her car. Staff A stated she saw his wheelchair behind a tree in front of the facility near the parking lot. She stated it was as if the wheelchair was purposely placed there. She stated she found Resident #1 at the bus stop and the police came and helped them bring Resident #1 back to the facility. Staff A stated she completed a skin assessment and noted Resident #1 did not have any injuries and he was put on one-on-one supervision upon returning to the facility. She stated she contacted the Director of Nursing (DON) and Assistant Director of Nursing (ADON) after she returned to the facility. She stated the ADON reviewed the camera footage with her. She stated the footage, revealed on 08/23/22 at 3:20 a.m., Resident #1 was observed passing the nursing station and ducking down as he passed due to a nurse being there. She stated Resident #1 is alert and can be confused at times but has never indicated he wanted to leave the facility. She stated there are two double doors in the dining room, one of the alarms did not work on one of the doors. Staff A stated after the incident, the door was fixed to make sure both sides alarmed. She stated they did in-services since the incident. She stated Resident #1 was out of the facility for more than an hour the night of the incident. She stated she checks on her residents every two hours. A review of an admission record for Resident #1, revealed the resident was admitted to the facility on [DATE] with diagnoses to include unspecified dementia, [CONDITION(S)] [CONDITION(S)], [CONDITION(S)], urinary tract infection, depression, chronic [CONDITION(S)] with [CONDITION(S)], and difficulty walking. An admission Minimum Data Set (MDS) for Resident #1 dated 07/25/22, indicated in Section C: Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 99, unable to complete the interview. The assessment of mental status revealed Resident #1 had memory problems related to short term and long-term recall. Cognitive skills assessment revealed Resident #1 was severely impaired when related to daily decision making. Section E0900 related to wandering was checked 1, indicating behavior of this type occurred 1-3 days. The assessment showed the wandering impact places the resident at significant risk of getting to a potentially dangerous place. The assessment E1100 further revealed the behavior had gotten worse. Section G: Functional Skills, indicated Resident #1 required extensive assistance for bed mobility and transfers. Resident #1 was not assessed for walking independently. Section G0600 showed the resident uses a wheelchair for mobility. A progress note dated 08/23/22 showed , all the rooms were searched on station 1 and 2, and he [Resident #1] was nowhere to be found. Resident's wheelchair was found behind a tree, but the resident was not there. Resident had a wander guard on his left ankle which did not set off the alarm when he eloped. 911 activated, searching conducted. Resident was found sitting at the bus stop outside the facility next door. Police brought resident back to the facility. Resident was put on 1:1 supervision post elopement. Resident is stable, no visible injury observed during assessment. Vitals WNL (within normal limits). MD (Medical doctor) and family notified. Resident was discharged back to his previous placement, a secured unit on 8/25/22. A multidisciplinary care conference note dated 7/26/22 under nursing summary showed: Resident is being observed for elopement risk due to wandering and impaired cognition. Discharge goal is to return to community memory care unit. An interview was conducted on 09/06/22 at 11:23 a.m., with the ADON / Risk Manager. The ADON stated staff noticed when doing rounds, he [Resident #1] was not in his room around 3:30 a.m. and immediately started the search. She stated he was last observed at approximately 3 a.m. The ADON stated staff searched in house could not locate the resident and started the elopement process, searching outside. At about 3:45 a.m., the law enforcement was called. She stated the police found the resident sitting on a bench down the street. The ADON stated they saw in the camera the resident going through the dining room and went out through one of the doors that did not alarm. The ADON stated, our maintenance revealed the alarm door had been tampered with. Camera shows he was looking to see where the staff was and then he left. The door did not alarm. The ADON stated per maintenance, the alarm was armed but failed to activate on one side due to a loose connection on the door sensor. The ADON stated Resident #1 went around the building and could be seen on the cameras at the front of the building, in his wheelchair propelling himself away from the facility. She stated the camera did not capture him from there. The ADON stated Resident #1 must have walked to the bus stop because his wheelchair was found abandoned behind a tree in front of the facility. The ADON stated Resident #1 would ambulate on short distances and would normally hold on to surfaces. The ADON stated she would not consider him a safe walker. The ADON reports the staff called 911 and after about 45 minutes the resident was escorted back to the facility. She stated the resident was assessed for injuries, and none were noted. She stated Resident #1 was immediately placed on 1:1 supervision and a psychiatric evaluation was ordered. The ADON stated Resident #1 was transferred back to a memory unit because he said he would leave again. The ADON stated Resident #1 had not verbalizing wanting to leave prior to the elopement. An elopement assessment for Resident #1 conducted on 07/21/22 showed the resident is not alert. The Wandering / elopement history indicated resident wanders but has never eloped. Resident is actively exit-seeking, with a plan to put a wander guard on patient. Patient's safety can be maintained through an electronic device. Resident #1 scored 12.0, indicating at risk for elopement. An elopement assessment conducted on 08/24/22, day after Resident #1 eloped indicated the following: Resident scored 16.0, indicating significant elopement risk. The assessment summary stated resident recently eloped and is at risk for recurrence due to expressed desire to return to his prior place of residence. An interview was conducted on 09/06/22 at 8:33 a.m. with the Director of Maintenance (DOM). The DOM stated he was notified there was an elopement that happened over the weekend. He stated they checked the door where the resident went out. He stated there was loose wiring on the right door and that was why the door did not alarm. The DOM indicated one of the wires on the dining room emergency exit door was loose and he cut the end of the wire due to it being frayed. He stated prior to the incident, they were checking the doors weekly and previously the door would alarm. He stated he was not sure why the door was not working at that point in time. The DOM stated the changes they have implemented since the elopement were daily checks on the doors and they repaired that specific alarm on the door. The DOM stated he checked every door for alarms to go off, and there were no work orders prior to the elopement on any doors that were not in working order. A review of a document entitled Daily Exterior Door Audit revealed on 08/23/22 the Dining Room Exit was latching properly, but there was no alarm sounding. The document further revealed under the subsection entitled Comments: Loose Connection - Repaired 08/23/22 Completed . On 09/06/22 at 11:58 a.m. an interview was conducted with Staff B, Physical Therapy Assistant (PTA) and Staff C, Occupational Therapist (OT). Staff B reviewed the admission physical therapy assessment and stated Resident #1's plan of care was to work on standing dynamics, balance, bed mobility and use of a two-wheel walker. On admission, he could only ambulate 25 feet safely, with a walker and with supervision. At discharge, he was ambulating at 250 feet, supervised with a rolling walker. Staff C stated Resident #1 ambulated about 600 feet during the elopement. Staff B said, this is not a safe ambulation distance, he definitely needed supervision. He cannot and should not walk unsupervised. Staff B said, he was definitely at a significant risk of falling and injuring himself. Staff C said, Resident #1 was not a safe walker at the time he eloped, and at the time discharged . An interview was conducted on 09/06/22 at 6:17 a.m. with Staff D, Certified Nurse's Aide (CNA), stating she was working the night Resident #1 left. She stated another aide, an agency CNA, she does not know her name had asked her at 3:30 a.m. if she had seen Resident #1. She stated after she finished charting, she helped the aide and nurses look for him. She stated they found him at the bus stop. She stated Resident #1 was nice and never expressed wanting to leave. She stated the night Resident #1 left there were two CNAs and three nurses on duty. She said usually there are three aides and two nurses. Staff D stated the police brought Resident #1 back and she was not sure if he was wearing his shoes. She stated she and the agency aide cleaned him up. She stated she checks on the residents frequently, about every two hours. An interview was conducted on 09/06/22 at 6:31 a.m. with Staff E, CNA. She stated she worked the night Resident #1 left. She stated she worked the back hall with two other aides. She stated they looked for him [Resident #1] because he wanders the hall, and they checked other resident rooms because he tends to be confused at times. She stated a nurse called 911. She said they looked for him for about an hour. She stated she checks rooms a lot especially if a resident is at a fall risk or a wander risk. She stated the procedure for elopement is to alert the nurses, who then tells the aides what to do. A Care Plan for Resident #1 initiated 07/21/22 revealed a focus area as follows: Resident #1 exhibits behaviors. Resident ambulates and likes to wander aimlessly. Resident has independent locomotion in wheelchair and wanders towards the exit sometimes, Resident is forgetful and exhibit poor safety awareness, at risk for elopement, resident requires a wander guard, left lower leg placement. Interventions initiated on 07/21/22 indicated to alert staff of resident's wandering behavior and elopement risk, apply wander guard, check wander guard for functioning every Monday and Thursday on night shift, check wander guard placement every shift, observe resident's whereabouts frequently for exit seeking behavior, offer redirections when the resident is seeking unattended exit. An intervention initiated on 08/23/22 shows to provide one to one supervision when exhibiting exit seeking behaviors. A review of progress notes dated 07/15/22 showed Resident arrived at [name of facility] nursing center from acute care and was admitted for weakness for PT/OT to regain strength to return to memory care. Resident was pleasantly confused. A plan of care note dated 07/26/22 showed to continue safety due to forgetfulness and confusion. A progress note dated 08/24/22 showed Resident #1 continued to be on observation due to recent elopement and was discharging to a secured unit on 08/25/22. An interview was conducted with Staff G, Licensed Practical Nurse (LPN) on 09/06/22 at 6:26 a.m. Staff G stated she was working the night Resident #1 eloped. She stated Resident #1 snuck out the dining room door, and he left his wheelchair behind the double tree out front. She stated when it was discovered he left, they did a facility wide search, and went outside to look for him. She stated she looked for Resident #1 for 30 minutes and could not find him and returned to the facility. She stated the police brought him back about an hour later. She stated Resident #1 had a wander monitoring device on but the door he went out did not alarm. She stated the door had been fixed since the incident. She stated she checks on residents every two hours. On 09/06/22 at 12:03 p.m. an interview was conducted with the ADON and the DON. They stated a skin assessment was conducted on Resident #1 when they brought him back on 8/23/22 at 5:10 a.m., no impairment was noted. The DON stated Resident #1 reported no falls occurred during the time he was missing. The DON stated they called the police and filed a report. The DON stated they filed a report with Department of Children and families (DCF) and DCF closed the case and did not substantiate. On 09/06/22 at 1:04 p.m., an interview was conducted with the DON and the Nursing Home Administrator (NHA). They stated they took the elopement to Quality Assurance and Performance Improvement (QAPI). They stated they spoke to the Medical Director on the phone who could not attend in person. The NHA stated they conducted a root cause analysis, audited care plans, and looked for wandering behaviors for all residents that would call for an assessment. They stated they updated and identified 8 residents that needed wander guards and confirmed functionality for all wander guards. The DON said, the immediate action was to fix the door. It was the root cause of the system failure. The DON stated staff education began immediately and is on-going. The NHA stated elopement drills were not conducted because we identified the problem was with the door and not staff performance. The DON reported an elopement drill was done about a month prior to the elopement. Review of a facility policy titled, Wandering and Elopements, revised March 2019, indicated the following: The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Under policy interpretation and implementation, if identified at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. If an employee observes a resident leaving the premises, he/she should attempt to prevent the resident from leaving in a courteous manner, get help from other staff members in the immediate vicinity if necessary and instruct another staff to inform the charge nurse or director of nursing services that a resident is attempting to leave or has left the premises.

Based on observations, interviews, and record reviews, the facility failed to ensure a medication administration error rate of less than 5%. A total of 34 administration opportunities were observed with 16 medication errors for three (Resident #70, Resident #72, and Resident #240) of six residents observed for medication administration, resulting in a medication administration error rate of 47.06%. Findings included: A review of Resident #70's Medical Record revealed that Resident #70 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #70's Physician's Orders revealed the following: - An order, dated 11/11/2021, for Insulin [MEDICATION(S)] Solution subcutaneously before meals and at bedtime as per sliding scale: 151 - 200 = 2 units. A review of Resident #70's Care Plan revealed a problem, dated 11/24/2021, that Resident #70 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation of medication administration was conducted on 01/13/2022 at 10:55 AM for Resident #70 with Staff E, Licensed Practical Nurse (LPN). After performing a blood glucose check for Resident #70 and obtaining a result of 186, Staff E prepared Resident #70's insulin for administration. Staff E gathered Resident #70's Insulin [MEDICATION(S)] pen and attached a needle to the tip of the insulin pen. Staff E dialed 2 units on the insulin pen's dosage selector, gathered an alcohol wipe, and entered Resident #70's room for insulin administration. Staff E did not prime the insulin pen needle with insulin prior to dialing 2 units on the dosage selector. Staff E donned clean gloves, cleansed Resident #70's upper left arm with an alcohol wipe and administered insulin before doffing the gloves and exiting the room. A review of Resident #72's Medical Record revealed that Resident #72 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #72's Physician's Orders revealed the following: - An order, dated 12/01/2021, for [MEDICATION(S)] KwikPen Solution subcutaneously before meals and at bedtime as per sliding scale: 201 - 250 = 4 units. A review of Resident #72's Care Plan revealed a problem, dated 12/13/2021, that Resident #72 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation of medication administration was conducted on 01/13/2022 at 11:02 AM for Resident #72 with Staff E, LPN. After performing a blood glucose check for Resident #72 and obtaining a result of 209, Staff E prepared Resident #72's insulin for administration. Staff E gathered Resident #72's [MEDICATION(S)] KwikPen and attached a needle to the tip of the insulin pen. Staff E dialed 4 units on the insulin pen's dosage selector. Staff E did not prime the insulin pen needle with insulin prior to dialing 4 units on the dosage selector. Staff E donned clean gloves, cleansed Resident #72's right lower abdomen with an alcohol wipe, and administered insulin before doffing the gloves and disposing the needle into a sharps container. An interview was conducted following the observation with Staff E. Staff E stated that she had training related to insulin pens at other facilities but was never told that the insulin pen needles required priming before dialing the dose and administering it to the resident. Staff E also stated that she did not know the procedure for priming an insulin pen needle. A review of Resident #240's Medical Record revealed that Resident #240 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #240's Physician's Orders revealed the following orders: - An order, dated 01/07/2022, for Acidophilus 1 capsule by mouth one time a day at 08:00 AM. - An order, dated 01/07/2022, for Vitamin C 2000 milligrams (mg) by mouth one time a day at 09:00 AM. - An order, dated 01/07/2022, for Benadryl 25 mg by mouth one time a day at 09:00 AM. - An order, dated 01/07/2022, for Calcium-Vitamin D 600 mg-400 mg by mouth one time a day at 09:00 AM. - An order, dated 01/09/2022, for [MEDICATION(S)] Q-10 200 mg by mouth one time a day at 08:00 AM. - An order, dated 01/09/2022, for [MEDICATION(S)] 1000 micrograms (mcg) by mouth one time a day at 08:00 AM. - An order, dated 01/09/2022, for [MEDICATION(S)] (HCl) 60 mg by mouth two times a day at 08:00 AM and 05:00 PM. - An order, dated 01/07/2022, for [MEDICATION(S)] 40 mg by mouth two times a day at 09:00 AM and 05:00 PM. - An order, dated 01/07/2022, for [MEDICATION(S)] 4 mg by mouth two times a day at 09:00 AM and 05:00 PM. - An order, dated 01/09/2022, for Multivitamin Tablet 1 tablet by mouth one time a day at 09:00 AM. - An order, dated 01/07/2022, for Omeprazole 20 mg by mouth two times a day at 08:00 AM and 04:00 PM. - An order, dated 01/07/2022, for [MEDICATION(S)] 99 mg by mouth one time a day at 08:00 AM. - An order, dated 01/07/2022, for [MEDICATION(S)] 150 mg by mouth three times a day at 09:00 AM, 02:00 PM, and 09:00 PM. - An order, dated 01/07/2022, for Red Yeast Rice Extract 600 mg by mouth one time a day at 09:00 AM. An observation of medication administration was conducted on 01/13/2022 at 11:37 AM for Resident #240 with Staff D, Registered Nurse (RN). Staff D gathered the following medications to administer to Resident #240: - Acidophilus 1 capsule by mouth. - Vitamin C 2000 mg by mouth. - Benadryl 25 mg by mouth. - Calcium-Vitamin D 600 mg-400 mg by mouth one time a day at 09:00 AM. - [MEDICATION(S)] Q-10 200 mg by mouth. - [MEDICATION(S)] 1000 mcg by mouth. - [MEDICATION(S)] HCl 60 mg by mouth. - [MEDICATION(S)] 40 mg by mouth. - [MEDICATION(S)] 4 mg by mouth. - Multivitamin Tablet 1 tablet by mouth. - Omeprazole 20 mg by mouth. - [MEDICATION(S)] 99 mg by mouth. - [MEDICATION(S)] 150 mg by mouth. - Red Yeast Rice Extract 600 mg by mouth. Staff D performed hand hygiene, donned Personal Protective Equipment (PPE) and entered Resident #270's room. Staff D administered medications to Resident #270 at 11:50 AM and exited the room. An interview was conducted following the observation with Staff D. Staff D stated that medications would normally be given within an hour before to an hour after the scheduled time of the medication and if medications were to be administered late, the resident's physician would be notified after the medication pass was completed. An interview was conducted on 01/14/2022 at 6:09 PM with the facility's Director of Nursing (DON). The DON stated that he would expect that anyone with a nursing license should know that an insulin pen needle needed to be primed with 2 units of insulin and a drop should be seen at the tip of the needle before administration. If the needle to the insulin pen is not primed then the pen will deliver less insulin than ordered. The DON also stated that medications should be administered within one hour before to one hour after the scheduled administration time unless the physician's order specified otherwise. If the nurse was not able to meet the required timeframe, the resident's physician should be notified prior to the administration in cases any changes are needed to the order. A telephone interview was conducted on 01/18/22 at 5:00 PM with the facility's Consultant Pharmacist (CP). The CP stated that they conducted monthly visits to the facility and a consultant nurse also conducted medication administration audits once every quarter. The CP also stated that he reminds nursing staff that the insulin pens needed to be primed prior to administration in order to deliver an accurate dose. If the insulin pen was not primed, the resident may not be administered an accurate dose. The CP stated that medications being administered late was a universal problem and that it is mostly related to nursing staff shortage throughout the industry. A review of the facility policy titled Insulin Administration, revised September 2014 revealed under the section titled Preparation that nursing staff will have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery system(s) prior to their use. A review of the facility policy titled Adverse Consequences and Medication Errors, revised in April 2014 revealed under the section titled Policy Interpretation and Implementation, that a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's order, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. The policy also revealed examples of medication errors, including wrong time and failure to follow manufacturer instructions and/or accepted professional standards. A review of the facility policy titled Administering Medications, revised in December 2012 revealed under the section titled Policy Statement that medications shall be administered in a safe and timely manner, and as prescribed. The policy also revealed under the section titled Policy Interpretation and Implementation that medications must be administered in accordance with the orders, including any required time frame and that medications must be administered within one (1) hour of their prescribed time, unless otherwise specified. A review of the manufacturers instructions for the [MEDICATION(S)] (insulin [MEDICATION(S)]) [MEDICATION(S)] indicated the following steps under the section titled Priming your [MEDICATION(S)] FlexTouch Pen: - Turn the dose selector to select 2 units. - Hold the Pen with the needle pointing up. Tap the top of the Pen gently a few times to let any air bubbles rise to the top. - Hold the Pen with the needle pointing up. Press and hold in the dose button until the dose counter shows 0. The 0 must line up with the dose pointer. - A drop of insulin should be seen at the needle tip. If you do not see a drop of insulin, repeat the steps no more than 6 times. If you still do not see a drop, change the needle.

Based on observations, interviews, and record reviews, the facility failed to ensure assistance with Activities of Daily Living (ADL) for dependent residents was provided for six (Resident #17, #26, #27, #21, and #78) of 33 sampled residents. Findings included: A review of Resident #17's Medical Record revealed that she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident #17's Care Plan revealed a problem, revised on 01/14/2022, that she had poor intake by mouth and was at risk for weight loss/dehydration. Interventions included to provide super foods as indicated, provide diet per order, and provide a home made chocolate milkshake two times daily. Resident #17's Care Plan also revealed a problem, initiated 10/06/2020, that she required maximal direction with daily decision making. Interventions included to observe for changes in the resident's cognitive and communications status and have Speech Language Pathology (SLP) evaluation and treatment as needed. A review of Resident #17's Minimum Data Set (MDS) Assessment, dated 10/07/2021, revealed under Section C - Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 2, which indicated severe cognitive impairment. An observation was conducted on 01/12/2022 at 11:52 AM of Resident #17 during the lunch meal. She was observed in bed with the head of the bed elevated and a meal tray in front of her on the bedside table. Resident #17 was observed talking to herself, had frequent and sporadic arm movements, and did not appear to be able to feed herself. She was observed knocking her meal tray into her bed and onto the floor. At 12:06 PM, facility staff was observed cleaning up the meal tray that Resident #17 spilled and exiting the room. Resident #17 was not provided another meal tray and was not observed being assisted with the lunch meal. An observation was conducted on 01/12/2022 at 5:43 PM of Resident #17 during the dinner meal. Staff A, Certified Nursing Assistant (CNA) was observed bringing in a dinner tray for Resident #17, turning the light on, and exiting the room. An observation inside of the resident's room at 5:56 PM revealed her meal tray was set up, uncovered, on her bedside table and out of her reach. She was observed laying flat in the bed and was not provided assistance with the dinner meal. An observation was conducted at 6:48 PM of Staff A, CNA collecting the tray of Resident #17's roommate and putting it on the meal cart. Staff A, CNA did not collect Resident #17's tray and did not provide assistance with Resident #17's dinner meal. Staff A, CNA was observed collecting other resident trays in the unit hallway. An interview was conducted on 01/12/2022 at 6:51 PM with Staff A, CNA. She stated she was not sure if she collected Resident #17's tray when she entered her room and stated that she was going to check to see if the tray was collected. Staff A was observed taking Resident #17's dinner tray out of the room and putting it back onto the meal cart. An interview was conducted with Staff A following the observation. Staff A stated Resident #17 was no longer able to feed herself due to an increase in her hand and arm movements and was able to feed herself up until a couple of weeks ago. Staff A addressed she did not assist Resident #17 with her dinner meal and did not attempt to assist the resident because she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted on 01/14/2022 at 07:55 AM with the facility's Certified Dietary Manager (CDM). The CDM stated that he was not informed by facility staff that Resident #17 needed assistance with her meals. He said the CNA staff should be communicating any changes in the resident's ability to feed themselves to the nurse so it could be addressed. An interview was conducted on 01/14/2022 at 2:36 PM with Staff B, Licensed Practical Nurse (LPN). Staff B stated Resident #17 had some decline in her functioning over the last week and was more agitated and anxious then usual. Staff B also stated that the nurse should be notified by the CNA staff of any decline in resident functioning so they could be assessed and the proper referrals and notifications could be made. A review of Resident #17's Meal Intake Record from 12/30/2021 to 01/14/2022 revealed that Resident #17 had an intake of 0% to 25% of meals for 31 of 40 recorded meals and refused 9 of 40 recorded meals. A telephone interview was conducted on 01/14/2022 at 3:18 PM with the facility's Registered Dietician (RD). The RD stated that any drastic change in a resident's intake should be communicated to the CDM and herself to assess the cause for the decreased intake. Decreased intake could be related to dysphagia, decreased appetite, infection, depression, an overall decline, or a decreased ability to feed themselves. The RD also stated that she was at the facility on 01/10/2022 and staff did not inform her that Resident #17 had a change in her ability to feed herself. A review of Resident #17's annual Nutritional Assessment, dated 10/07/2021, revealed that the resident's meal intake varied from 25% to 76% at meal times and she required encouragement for meal and supplement intake. The Nutritional Assessment also revealed under the section titled Nutrition Goals that Resident #17 had goals to consume all/most supplements, tolerate diet, and improve meal intake 75% for 2 of 3 daily meals. An interview was conducted on 01/14/2022 at 6:28 PM with the facility's Director of Nursing (DON) and Nursing Home Administrator (NHA). The DON stated that the CNA or nursing staff share observations of residents during meal times and refer them to therapy if any changes were identified. CNA staff were expected to notify the nurse if a resident was not able to feed themselves or had had a change in their functional ability. CNA staff would also be expected to provide assistance with meals as needed. The DON stated he was notified that Resident #17 had recently needed more assistance with meals and even though she refused meals he would still expect the CNA staff to attempt to provide assistance to the resident at meal times. A review of the facility policy titled Assistance with Meals, revised in July 2017 revealed under the section titled Policy Statement that residents shall receive assistance with meals in a manner that meets individual needs of each resident. The policy also revealed under the section titled Resident requiring full assistance that resident who cannot feed themselves will be fed with attention to safety, comfort, and dignity. Photographic evidence obtained. 2. An observation of dependent roommates (Resident's #26 and #27) on 1/13/22 at 8:30 a.m. revealed: Resident #27 laying on her bed sideways (head closest to the door and feet toward the window) with her legs crossed and feet hanging over the right side of the bed just above her soiled brief that was lying on the floor mat. Resident #27 was observed without clothes, a brief, or covers. Her brief was on the floor mat and covers were toward the foot of the bed. Her water cup was observed on the bedside table with the paper still covering the top of the straw. Resident #26 was observed lying on her back on an air mattress with her mouth wide open . The head of the bed was elevated and her tube feeding was infusing at 75 ml per hour. The residents' room was observed from the conference room. Staff E, LPN was observed going in twice to provide medication to Resident #26 and #27 around 9:30 a.m. on 1/13/22. An interview with Staff E, on 1/13/22 at 10:10 a.m., confirmed she did not cover Resident #27 or alert the CNA that the resident was without clothes and had a soiled brief on the floor. Resident #26 and #27 were observed on 1/13/22 at 10:45 a.m., in the same position with Resident #27 still uncovered without clothes and the soiled brief under her feet on the floor mat. Resident #27's water cup remained the same with paper covering the straw. An observation of Resident #26 and #27 on 1/13/22 at 11:40 a.m., revealed Resident #26 still lying on her back with her mouth wide open and head of bed elevated. Resident #27 was observed in a fetal position without clothes or covers and her feet were hanging over the soiled brief on the floor. Her blankets were observed toward the foot of the bed. Her tray table was observed with the water cup untouched and the straw covered with paper at the top. Meal trays were observed coming down the 300 hallway at 11:41 a.m. on 1/13/22. Staff I, CNA was getting the trays ready to deliver. He stated he last checked on Resident #27 about 45 minutes ago and was unable to say if she was clothed or wearing a brief. He said he did not offer her water at that time and said she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with Staff H, CNA on 1/13/22 at 12:16 p.m. She stated she was taking care of Resident #26 and last checked on her a while ago. Staff H could not say if she observed the roommate (Resident #27) and what state she was in when she went into the room. Staff H, stated she needed to complete peri care on Resident #26 and would do that soon with [Staff I] and then walked away. On 1/13/22 at 1:24 p.m., Staff H and Staff I were observed walking into Resident #26's room with supplies. Resident #26 was lying on her back with her mouth wide open. A white incontinence pad was observed saturated with dark yellow urine and a white brief was observed saturated from front to back with dark yellow urine. Staff H, said, oh wow as she removed the saturated brief and incontinence pad. Resident #26 was observed with stool stuck to her bottom. Staff H cleaned the stool with a soapy wash cloth at least 4 times leaving some stool on the residents bottom. Staff H, CNA confirmed she did not apply the brief and was unaware the resident was wearing a brief as this was the first time she changed the resident today. Staff H finished cleaning the resident and applied a blue incontinence pad without a brief under the resident. Staff H and Staff I applied lotion to the resident without removing the soft boots on both feet. Both staff members stated they never remove the boots to apply lotion or clean the resident that the nurse did that. Resident #26 was then positioned on her right side facing the window and covered up. Resident #26 was admitted [DATE] for diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the MDS dated [DATE], under Section C a BIMS revealed a score of 99 which indicated the resident was unable to be assessed. Section G for functional status revealed the resident needed extensive assistance of two plus persons for mobility and personal hygiene . A review of the care plan focus area for activities of daily (ADL) living status revealed the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included assisting resident with repositioning in bed, initiated on 7/24/19. Resident required assist of two for all incontinence care, initiated on 1/18/20. Resident needed staff to provide pericare, initiated on 7/24/19. Resident needed two staff to move her up in bed using a draw sheet as indicated, initiated on 7/24/19. A review of the task sheet for toilet use dated 1/13/22, revealed the resident was totally dependent using full staff performance at 5:56 a.m. and 9:21 a.m. The task sheet for bowel continence dated 1/13/22 revealed at 5:56 a.m. and at 2:59 p.m., Resident #26 was incontinent of large loose stool and incontinent of urine. Resident #27 was admitted on [DATE] for diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the MDS dated [DATE], under Section C a BIMS revealed a score of 5 which indicated severe cognitive impairment. Section G for functional status revealed for bed mobility and toileting the resident needed extensive assistance of two plus persons for physical assist. Dressing, personal hygiene and eating required extensive assistance of one person physical assist. A review of the care plan focus area for activities of daily living revealed the resident had decreased ability to participate with her ADL care related to generalized weakness and impaired cognition and mobility. She required assist of two for bathing and incontinence care due to her repetitive behaviors initiated 2/20/18. Interventions included resident needed staff to assist her with dressing, initiated on 4/26/18. Resident liked to disrobe and preferred a fetal position in bed, initiated on 10/17/19. Provide resident with incontinence checks and pericare, initiated on 4/26/18. Provide level of assistance as needed for each meal. Offer to assist resident with her meals. Resident would ask for snacks at a later time if she did not feel like eating her meal, initiated on 4/26/18. Resident was incontinent of bowel and bladder, resident used briefs when she was out of bed, initiated on 4/26/18. A review of the task list for nutrition and number of times fluids were offered for 1/13/22, included only 5:55 a.m. with fluid offered 3 times. The task list was printed on 1/13/22 at 4:55 p.m. The task list for bowel continence and urinary continence dated 1/13/22, revealed the resident was incontinent at 5:56 a.m. and 10:36 p.m. A review of the Kardex revealed Resident #27 had a tendency to turn sideways in bed. Reposition when necessary and as tolerated. Required floor mats to both sides of bed when resident was in bed. Provide privacy and then redirection when resident began to disrobe to maintain her dignity. Provide resident with incontinence checks and pericare. Resident was incontinent of bowel and bladder, resident used briefs when she was out of bed. Encourage resident to drink fluids throughout each shift. During an interview on 1/13/22 at 4:29 p.m. with the Director of Nursing (DON), he stated his expectation would be to check and change the resident every 2 hours and stated he believed in his staff and they would not leave a resident for a long period of time but stated he would verify by surveillance. The DON confirmed soft boots should be removed by aides to wash and apply lotion and the nurse would apply any treatments. During an interview with the DON on 1/13/22 at approximately 7:00 p.m., he brought in a piece of paper with handwritten times and stated management reviewed the facility surveillance and the longest time between staff entering Resident #26's and #27's room was one hour and fifty-eight minutes. The DON stated he was unable to say if the staff provided care for Residents #26 or #27 and fluids for Resident #27 as he only looked at people entering the resident's room. The DON confirmed that any aides entering the room should have offered resident #27 water and provided care for a resident that was without clothes and removed the soiled brief that was on the floor. 3. On 01/11/22 at 1:10 p.m., an observation was made of Resident #21. He was lying in bed, watching the television. His facial hair, mustache & beard was not groomed. On 01/12/22 at 11:15 a.m. an observation was made of Resident #21. He was lying in bed, watching television. Facial hair remained ungroomed. On 01/13/22 at 11:16 a.m. an observation was made of Resident #21. He was lying in bed, watching television. Facial hair remained ungroomed. On 01/14/22 at 12:35 p.m. an observation was made of Resident #21. He was lying in bed, facial hair remained ungroomed. Staff G, Certified Nursing Assistant (CNA) was called into the room and asked when the resident would be shaved. Staff G walked to the side of the bed and slightly kneeled down to be at eye level with Resident #21. She asked if he wanted to be shaved. He nodded his head up & down, to indicate Yes. Staff G asked him if he wanted his mustache shaved, he shook his head from side to side, to indicate No. Staff G asked the resident if he only wanted his beard shaved, he nodded his head up & down, to indicate Yes. Staff G stated that she would shave him right away. On 01/14/22 at 4:28 p.m., an interview was conducted with the Assistant Director of Nursing (ADON) regarding ADL care related to shaving. She stated the residents should be shaved as needed or as requested according to their preference. Her expectation was that CNA's would offer the residents a shave daily, while they were providing care. She would not expect the CNA's to wait until a resident's shower day to offer a shave since they may require one in between those times. A review of Resident #21's Admission Record revealed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the current MDS assessment dated [DATE] revealed a BIMS score of 07, which indicated Resident #21 had severe cognitive impairment. Further review of the MDS assessment Section G, Functional Status, indicated the resident required extensive assistance of at least one person to use the toilet, bathe, eat, dress & perform personal hygiene activities. He also had functional limitation in range of motion with impairment on both sides of the upper & lower extremities. Review of Resident #21's most recent care plan dated 07/19/21, revealed a focus area for ADL's related to a functional deficit due to generalized weakness, impaired mobility, and impaired cognition. Goals were to have daily needs met to maintain safety, comfort, and dignity through next review date (10/28/22). Interventions included but not limited to resident needed staff to wash him up, dress him in the morning, and offer to shave him daily. On 01/11/22 at 1:07 p.m., an interview was conducted with Resident # 78. He was asked if he preferred to have the facial hair that was observed on his face. Resident #78 stated that he would have liked to have it cut but understood that the staff did not have time to shave him. He had not said anything about it because he did not like to complain. On 01/12/22 at 11:15 a.m. Resident #78 was observed in bed. He had not received a shave; his facial hair was observed in the same manner as the day prior. On 01/13/22 at 11:25 a.m. Resident #78 was observed in bed. He had not received a shave; his facial hair was observed in the same manner as the day prior. A review of Resident #78's Admission Record revealed he was admitted to the facility on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the current MDS assessment dated [DATE], revealed a BIMS score of 13, which indicated Resident #78 was cognitively intact. Further review of the MDS assessment Section G, Functional Status, indicated Resident #78 required extensive assistance of at least one person to use the toilet, bathe, dress & perform personal hygiene activities. Resident #78 also had functional limitation in range of motion with impairment on one side of the upper extremities. Review of Resident #78's most recent Care Plan dated 12/16/21, revealed a focus area for ADLs related to assistance needed with oral hygiene, toileting hygiene, personal hygiene, etc. Goals were for Resident #78 to have daily needs met to maintain safety, comfort, and dignity through next review date (03/16/22). Interventions included but not limited to assist resident with oral care and encourage him to participate by washing face, hands, and areas that can be reached. On 01/14/22 at 4:28 p.m., an interview was conducted with the Assistant Director of Nursing (ADON) regarding ADL care related to shaving. She stated that the residents should be shaved as needed or as requested according to their preference. She expected the CNA's to offer the residents a shave daily, when they were providing care. Review of facility policy for activities of daily living, supporting dated March 2018, 2001 Med-pass, inc, page 5 and 6 revealed: Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living. Resident who are unable to care out activities of daily living independently will receive services necessary to maintain good nutrition, grooming, and personal and oral hygiene. 2. Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene, b. mobility, c. elimination, d. dining and e. communication. Review of facility policy for activities of daily living, dressing and undressing the resident, revised 2010, Med-pass 2001, page 53 and page 54, revealed: The purpose of this procedure are to assist the resident as necessary with dressing and undressing and to promote cleanliness. 7. Residents who may need some assistance with dressing and undressing include: d. A confused resident who may need assistance in putting on clothing properly.

Based on observation, interview, and record review, the facility failed to ensure one (Resident #84) of 25 resident beds was inspected to ensure the frame and mattress were compatible with the resident's height to ensure safety from his feet hanging over the end of the bed. Findings Included: Observation on 1/11/22 at 10:00 a.m., revealed Resident #84 sitting up in bed with his feet to his heels hanging off the end of the bed. The resident stated he was 6 foot 2 inches and his heels always hung off the end of the bed. The bed was observed without a foot board, bed extender, or side rails. Observation on 1/13/22 at 8:54 a.m. revealed Resident #84 sitting up in bed with his feet hanging over the end of the bed. The resident stated he never had a footboard that he could remember or extender on his mattress. During an interview with the Maintenance Director on 1/13/22 at 8:55 a.m., he stated the nurses were responsible to ensure the residents height and weight fit the bed. He walked into the residents room and stated, Wow he does not have a foot board or extender on his bed. We will have to fix that. He confirmed the resident should have an extender and foot board on his bed and stated he would go and get one. During an interview with the ADON on 1/13/22 at 9:00 a.m., she confirmed the residents are checked by the nurses to see if they fit the mattress and are safe in the bed. The ADON walked into the residents room and stated, He is too tall for his bed and does not look comfortable. She said she needed to check into why he did not have a footboard or mattress extender. During an interview with Staff I, CNA on 1/13/22 at 9:09 a.m., he confirmed the resident needed assistance to sit up in bed and stated his feet hung over the bed because he was too tall and his feet would rub the footboard. During an observation of Resident #84 on 1/13/22 at 10:38 a.m., the resident was lying in bed with the foot board and extender attached to the bed and his feet did not come close to the footboard. During an interview on 1/13/22 at 11:35 a.m., the Maintenance Director stated they did monthly bed checks for rails and safety but the nurses were responsible for making sure the resident beds fit the resident. Resident #84 was admitted on [DATE] and readmitted on [DATE]. He had diagnoses to include [CONDITION(S)] and [CONDITION(S)] following cerebral infarction affecting left dominant side. A review of the MDS Section G dated 12/17/21 revealed the resident needed extensive assistance with two plus persons for bed mobility and was totally dependent on staff for transfers. A review of the Brief Interview for Mental Status (BIMS) revealed a score of 12 which indicated moderate cognitive impairment. Review of the care plan revealed a focus area for activities of daily living. The resident had a deficit in his ability to perform ADL's at his usual level, initiated on 7/26/19. Interventions included assistance of two staff to move him up in bed using a draw sheet, initiated on 7/26/19. During an interview with the DON on 1/13/22 at 4:00 p.m., he stated that the resident had moved from the door bed to the window bed then back to the door bed. The bed extender did not move with him because it made the bed too long. The resident would push his feet against the foot board and that would give him the possibility of a wound. The DON went on to say that without the extender he was able to float his heels by letting his feet hang off the end of the bed. Review of facility policy revealed Bed safety revised December 2007, 2001 Med-Pass, pages 3 and 4, revealed: 1. The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, and freedom of movement. 2. To try to prevent injuries from the beds and related equipment (including the frame and mattress) the facility shall promote the following approaches: b. the review shall consider situations that could be caused by the resident's weight, movement or bed position.

Based on interviews and record reviews, the facility failed to ensure proper monitoring of [CONDITION(S)] medication was implemented for one (Resident #239) of six residents sampled for Unnecessary Medications. Findings included: A review of Resident #239's Medical Record revealed that Resident #239 was admitted to the facility on [DATE] with a diagnosis of dementia. A review of Resident #239's Physician's Orders revealed the following orders: - An order, dated 01/08/2022, for [MEDICATION(S)] 5 milligrams (mg) by mouth in the morning for anxiety. - An order, dated 12/22/2021, for [MEDICATION(S)] [MEDICATION(S)] (HCl) 25 mg by mouth at bedtime for sundowning behavior. Resident #239's Physician's Orders did not reveal orders for monitoring of side effects or behaviors related to use of [MEDICATION(S)] or [MEDICATION(S)] HCl. An interview was conducted on 01/14/2022 at 1:26 PM with the facility's Director of Nursing (DON). The DON stated that Resident #239 was put on [MEDICATION(S)] and [MEDICATION(S)] HCl due to restlessness and sundowning behaviors and was followed up by psychiatric services. Residents that received [CONDITION(S)] medications would have monitoring orders in place for behaviors and side effects. The DON addressed that Resident #239 did not have orders in place for monitoring of behaviors or side effects related to use of [MEDICATION(S)] or [MEDICATION(S)] HCl. The DON stated that he would expect either the nurse entering the medication order or the Unit Managers to enter the orders for behavioral monitoring and side effect monitoring for [CONDITION(S)] medication use. An interview was conducted on 01/18/2022 at 5:00 PM with the facility's Consultant Pharmacist (CP). The CP stated that he would recommend monitoring for certain medications and that he would expect to see side effect monitoring and behavioral monitoring for any antipsychotic medication use. The CP also stated that the electronic charting system that the facility used had a way to monitor side effects and behaviors related to certain medication usage.

Based on observation, interview, and review of the employee orientation and training handbook, the facility failed to ensure one of four nurses working on 1/13/22 from the 3:00 p.m. to 11:00 p.m. shift was trained and competent using the electronic medical record to ensure resident safety regarding medication and treatment administration. Findings Included: During an interview with Staff J, RN agency nurse on 1/13/22 at 4:55 p.m., she confirmed today was her first day working in the building. Staff J confirmed she was not trained on the facility computer system and never had an in-service to find, document, and ensure medications and treatments were completed as ordered. Staff J confirmed Resident #26 was in need of wound care that was not completed during the day. She said she was unable to access the computer system to find where and what type of wound care to provide. Staff J stated she was just figuring out how to find the medications for the resident and document they were given. Staff J attempted to find the resident and the treatments needed but was unsuccessful and stated she would have to find someone to help her navigate the system and find the treatments. Staff J stated she was given infection control information and notified if the facility had Covid but that was the only training she received prior to the start of her shift. During an interview with the Assistant Director of Nursing (ADON) on 1/13/22 at 5:56 p.m., she stated that agency nurses were trained on infection control when they enter the building. The training did not include what type of computer system was used to document and provide medications and treatments, as it was a system that was widely used. The ADON stated she never thought to ask the agency staff if they were familiar with the electronic medical record prior to their shift and went to Staff J to begin the training process. During an interview with the ADON on 1/13/22 at 6:18 p.m., she stated she was training the nurse on quick tips to use the computer but did not have three hours to provide the education needed. During an interview with the Director of Nursing (DON) on 1/13/22 at 6:36 p.m., he confirmed Staff J was not familiar with the electronic medical record as she only worked at a hospital and it would take a minute to teach the system as it was not easy to learn for those that had never used it. During an interview with the ADON on 1/13/22 at 6:55 p.m., she confirmed the staffing coordinator was now providing the staffing agencies with the type of electronic medical record and required the staff to know how to use the system prior to being assigned at the facility. Review of the Clinical Employee Orientation & Training handbook completed on December 21, 2021 for Staff J revealed the training and orientation packet did not include computer training or orientation. Review of the employee new hire (agency) education packet did not reveal any computer training.

Based on interviews and record reviews, the facility failed to ensure wanderguard functioning and placement was properly and consistently documented for one (Resident #239) of two residents sampled for wanderguards. Findings included: A review of Resident #239's Medical Record revealed that Resident #239 was admitted to the facility on [DATE] with a diagnosis of dementia. A review of Resident #239's Care Plan revealed a problem, dated 12/31/2021, that Resident #17 exhibited behaviors of wandering, had independent locomotion in her wheelchair, wandered toward exits, was forgetful, confused, and exhibited poor safety awareness, was at risk for elopement, and required a wanderguard. Interventions included to apply a wanderguard, check the wanderguard for functioning every Monday and Thursday on night shift, and check wanderguard placement on Resident #239's right ankle every shift. A review of Resident #239's Minimum Data Set (MDS) assessment, dated 12/28/2021 revealed under Section C - Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 5, which indicated severe cognitive impairment. Resident #239's MDS assessment also revealed under Section P - Restraints and Alarms, that Resident #239 used a wander/elopement alarm on a daily basis. A review of Resident #239's Physician's Orders revealed an order, dated 12/22/2021 to check wanderguard and placement every shift. A review of Resident #239's Physician's Orders did not reveal an order to check Resident #239's wanderguard for functioning. A review of Resident #239's Treatment Administration Record (TAR) for January 2022 revealed the following documentation for the order to check wanderguard and placement every shift: - No documentation recorded on the 7 AM to 3 PM shift on 01/07/2022. - No documentation recorded on the 3 PM to 11 PM shift on 01/01/2022. - No documentation recorded on the 11 PM to 7 AM shift on 01/03, 01/04, 01/10, or 01/11/2022. An observation was conducted on 01/14/2022 at 1:12 PM of Resident #239 propelling herself in her wheelchair. Resident #239 was observed propelling herself toward the front entrance of the facility with another resident. Resident #239 was redirected by facility staff without difficulty. Resident #239 was observed to have a wanderguard bracelet to her right ankle. An interview was conducted on 01/14/2022 at 1:21 PM with Staff C, Certified Nurses Aide (CNA). Staff C, CNA stated that Resident #239 would normally propel herself in her wheelchair around the building and would sometimes head toward the entrance of the facility after family visits. Staff C, CNA also stated that Resident #239 was easily redirected by staff and that she had a wanderguard bracelet that the nurse would check. An interview was conducted on 01/14/2022 at 1:26 PM with the facility's Director of Nursing (DON). The DON stated that wanderguards were normally checked for functioning twice weekly and that placement of wanderguards should be verified every shift. The DON addressed that Resident #239 did not have an order in place to check the functioning of her wanderguard and stated that the order should have been put into place. The DON also addressed that documentation related to the functioning of Resident #239's wanderguard was missing from the TAR and stated that he would expect the nursing staff to complete required documentation in the TAR and verify the placement as ordered.

Based on observations, record review, and interviews the facility did not ensure that controlled substances schedule II-V were stored in permanently affixed compartments in one of two medication rooms sampled during the performance of the facility task of Medication Storage and Labeling. Findings included: On 10/14/2020 at 2:35 p.m., the unit manager (UM) for 100 and 200 hall accommodated the observation of the locked medication storage room located behind the nurse's station. The UM unlocked a drawer that contained an Emergency Drug Kit (EDK) that contained controlled substances scheduled II-V. Medications were in a small plastic box closed with plastic tie wraps. The plastic box was not permanently affixed and could be easily removed from the drawer. The UM then unlocked the refrigerator which contained an EDK that contained refrigerated medications not limited to [MEDICATION NAME] 2 mg/ml ([MEDICATION NAME]) (quantity 4) a schedule IV medication, and [MEDICATION NAME] (quantity 1), a schedule IV medication. Medications were in a small plastic box closed with tie wraps that were not permanently affixed and could easily be removed from the refrigerator. The UM was not aware that schedule II-V medications must be stored in a permanently affixed compartment. On 10/14/2020 at 3:10 p.m., the Director of Nursing (DON) revealed that she also was unaware of the requirement for storage in a permanently affixed compartment for schedule II-V medications. She stated that she thought that if schedule II-V medications were stored behind two locks that was enough. A review of the facility policy titled Medication Storage In The Facility ID2: Controlled Substance Storage with a revised date of August 2014 revealed: B. Schedule (II-V) medications and other medications subject to abuse or diversion are stored in a permanently affixed, (double locked) compartment separate from all other medications or per state regulation C. Controlled-substances that require refrigeration are stored within a locked box within the refrigerator. This box must be attached to the inside of the refrigerator. On 10/15/2020 at 9:30 a.m., a telephone interview with the Consultant Pharmacist revealed that his opinion was that if the controlled substances were stored behind two locks in a separate container that was enough. When asked about refrigerated controlled substances, he stated that it has also been an issue and very difficult to comply with. He stated that traditionally what the facility was doing has been an accepted practice. He continued on to state, the way that facility is doing it meets the intent of the regulation. Photographic evidence was obtained.

Based on observation, interview, and policy review the facility failed to ensure two of two reusable face shields were disinfected for the required contact time noted for the type of disinfecting wipes used on one unit (200 hall) of one unit utilized as a quarantined COVID-19 unit. Findings included: At 10:09 a.m. on 5/13/20, a tour was conducted of the facility. The tour revealed nine resident rooms on the 200-hall (rooms 217, 219, 221, 226, 227, 229, 228, 230, 231) with signage that indicated the residents residing in the rooms were under droplet precautions. The signs on the doors to the nine resident rooms included laminated instructions for the donning and doffing of Personal Protective Equipment (PPE). At 11:20 a.m., an observation was made of Staff B, Certified Nursing Assistant (CNA), dressed in a gown, face mask, gloves, and face shield enter resident room [ROOM NUMBER] with a meal tray. Staff B exited room [ROOM NUMBER] with a face shield in hand. The staff member was not wearing the gown previously seen wearing when entering the room. Staff B went to the isolation caddy in between rooms [ROOM NUMBERS] and removed a wipe from a yellow disinfecting wipe container. The staff member wiped the face shield and began waving the shield back and forth at waist level. At the same time an additional observation revealed Staff A, CNA set a meal tray on an over-the-bed table outside of room [ROOM NUMBER]. The Staff A was wearing two face masks, donned a gown, a face shield and gloves, picked up the tray, and entered room [ROOM NUMBER]. Staff A left room [ROOM NUMBER] without the gown and with the face shield in hand. Staff A went to the isolation caddy near room [ROOM NUMBER], removed a wipe from the same yellow disinfecting canister, wiped the face shield, and waved it back and forth. Staff A, CNA and Staff B, CNA were both interviewed immediately following the observations. Staff A stated the face shield was to be wet for four minutes. The staff members continued to wave the respective face shields back and forth during the interview. Staff A stated that sometimes she washes the face shield with soap and water in the residents' room. The observation indicated more meal trays to be delivered. A review of the Brand Name Disinfecting Wipes container included the following instructions disinfect: (Photographic Evidence Obtained) - Allow to remain wet for four (4) minutes. - Allow surface to air dry. At 11:44 a.m., the Staff Developer was observed highlighting the instructions for disinfecting on a container of Brand Name Disinfecting Wipes on the 200-hall. At 1:50 p.m., the Director of Nursing stated the contact time for Brand Name Disinfecting wipes was four (4) minutes and her expectation was for staff to clean the face shields and keep it wet for four (4) minutes. The policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, dated 2001 and revised July 2014, indicated, Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC (Center of for Disease Control and Prevention) recommendations for disinfection and the OSHA (Occupational Safety and Health Administration) Bloodborne Pathogens Standard. The policy identified reusable items are cleaned and disinfected or sterilized between residents (e.g. stethoscopes, durable medical equipment). A review of the CDC guidelines for, Cleaning and Disinfecting Your Facility, (https://www.cdc.gov/coronavirus/2019-ncov/community/disinfecting-building-facility.html), revealed: Disinfect *Recommend use of EPA-registered household disinfectantexternal icon. Follow the instructions on the label to ensure safe and effective use of the product. Many products recommend: o Keeping surface wet for a period of time (see product label). o Precautions such as wearing gloves and making sure you have good ventilation during use of the product. An untitled an undated bullet-point document was received from the facility which indicated equipment (was) to be cleaned before and after use and between each patient use.

Based on observations, interviews and record reviews the facility failed to follow their policy and procedure for handwashing, use of gloves and disinfection of shared resident equipment on 1(isolation unit) of 2 units. Findings included: A review of the facility policy titled Handwashing/Hand Hygiene revised on August 2015 read as follows Policy Statements: The facility considers hand hygiene the primary means to prevent the spread of infections. 7. Use an alcohol-based hand rub containing at least 62% alcohol or alternatively soap and water for the following situations: b. before and after direct contact with residents l. After contact with medical equipment in the immediate vicinity of the resident m. After removing gloves n. Before and after entering isolation precautions settings 9. The use of gloves does not replace handwashing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare associated infections. A review of the facility policy title Cleaning and Disinfection of Resident- Care Items Equipment revised on July 2014 read as follows. Policy Statement: Resident care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA blood-borne pathogen standard. 3. Durable medical equipment must be cleaned and disinfected before use by another resident. 4. Reusable resident care equipment will be decontaminated and/or sterilized between residents according to manufacturer's instructions. 5. Only equipment that is designated reusable shall be used by more than one resident. 6. Single use items will be discarded after a single use. An observation was conducted on 4/16/2020 at 1:18 p.m., on the 200 hall (hall identified as the facility isolation hall) Staff A, Housekeeping was observed coming out of room [ROOM NUMBER] with her blue gloves on. Staff A went to her cart and proceeded to move to the next room. An interview was conducted with Staff A said, Yes, I should have removed my gloves and washed my hands after leaving the room. An interview was conducted on 4/16/2020 at 1:20 p.m., with Staff B, Certified Nurse's Aide (CNA) who said, Yes, we are to remove our gloves and wash our hands before leaving a resident's room. An observation was conducted on 4/16/2020 at 1:22 p.m., Staff C, CNA walked into a resident's room took the residents temperature, then walked out of the resident's room without washing her hands. Staff C, CNA walked the thermometer over to a wire basket on the wall and placed the un-cleaned thermometer in the basket. An interview was conducted on 4/16/2020 at 1:24 with Staff D, Nurse on the floor who said, I had Staff C, CNA go and take the residents temperature quickly. I am sure she put it back and planned to go back and clean it later. A second observation was conducted on 4/16/2020 at 1:30 p.m., on the 200 hall a thermometer sitting on a bed side table out in the hallway. (photographic evidence was obtained). Staff D, nurse confirmed it should be cleaned and put back where it belongs. I expect the thermometer to be cleaned after each resident use. Yes, staff should wash their hands after leaving a residents room and after removing their gloves.

Based on observation, record & policy review, and interviews the facility failed to ensure the Interdisciplinary Team assessed one resident (#13) out of 31 sampled residents observed during the mandatory task of Medication Administration for the self-administration of medications. Findings included: The policy titled, Self-Administration of Medications, dated 2001 and revised (MONTH) (YEAR), stated resident have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. The policy titled, Administering Medications through a Small Volume (Handheld) Nebulizer, dated 2001 and revised (MONTH) 2010, stated in the section, Steps in the Procedure, #16: Remain with the resident for the treatment. Resident #13 was admitted [DATE], per the Admission Record, & readmitted on [DATE] and 1/4/19. The electronic clinical record included [DIAGNOSES REDACTED]. The review of the clinical record did not indicate a current Minimum Data Set (MDS). During the mandatory task of Medication Administration on 1/15/19 at 10:50a.m., Staff Member A, Registered Nurse (RN) was observed taking a vial of [MEDICATION NAME]-[MEDICATION NAME] 0.5-3mg/3mL (milligram/milliliter) from a brown pouch in the bottom drawer of the medication cart. Staff Member A gathered a package containing nebulizer tubing and mask then entered Resident #13's room. Staff Member A attached new nebulizer tubing and mask to the nebulizer machine sitting next to Resident #13 and dispensed the vial into the nebulizer cup, placed nebulizer mask on Resident #13, and turned on machine, aerosol was observed coming from mask. Staff Member left resident room. The mandatory task continued with Staff Member A obtaining blood glucose results from two other residents. At 11:13a.m., Surveyor entered Resident #13's room and observed nebulizer mask on the bedside table next to resident. The nebulizer machine was off and no aerosol was observed emitting from the mask. At 11:17a.m., Staff Member A entered Resident #13's room, educated resident that there was still medication in the nebulizer cup and encouraged resident to finish the medication. Staff Member A replaced mask on Resident #13's face, turned machine on, and left the room. At 11:20a.m., Staff Member A stated resident doesn't leave the mask on for the full 3-5 minutes so has to go back to resident and confirm all the medication was administered. When posed the question about how long a nebulizer normally takes to administer, Staff A stated 3-5 minutes, unless you know something else. The nebulizer machine could be heard shutting off from three rooms away. An observation was made of the nebulizer machine was off, the residents meal tray was sitting on bedside table, and resident was observed opening cover to red dessert bowl. At 11:24a.m., Staff Member A entered room, confirmed all the medication was administered, disposed of tubing and mask, wash hands, and returned to the medication care outside of a residents room three doors away from Resident #13's room. Staff Member A removed a bottle of insulin from the medication cart, drew up the insulin, returned vial of insulin to the bottle, and entered a resident's room in back of cart. During an interview on 1/15/19 at 3:31p.m., Staff Member A stated she was behavioral trained and not used to administering all the medications but should have stayed with the resident while the nebulizer was running to make sure the resident received all the medication. The staff member stated pharmacy had been called and was informed nebulizers take longer than 3-5minutes and should stay with resident during medication administration. The review conducted of Resident #13's physician orders on 1/15/19 at 11:52a.m., revealed no physician order for [REDACTED].> Admit/Readmit Screener Bladder & Bowel Screener Braden scale for predicting pressure sore risk Fall Risk Screener Elopement Risk form Pain observation Tool Smoking Safety Review Baseline Care Plan The electronic record did not indicate a Medication Self-Administration Safety Screen was completed prior to the observation conducted on 1/15/19 at 10:50a.m., of Resident #13 self-administering [MEDICATION NAME]-[MEDICATION NAME] 0.5-3mg/3mL inhalation solution. Photographic evidence of a Medication Self-Administration Safety Screen was obtained on 1/15/19 at 12:02p.m., the unlocked screen was dated 1/15/19 at 11:54a.m., and indicated a score To Be Determined. The Safety screen instructions stated, Complete this assessment prior to resident initiating self-administration of medication and with any medication order changes.

Based on observation, interview and record review, the facility failed to have the wound care physician assess a new pressure ulcer for one (Resident #41) of two sampled residents with a new wound found on December, 21,2018. The wound care physician evaluated wounds every Monday. As of (MONTH) 17, 2019, the resident had not been evaluated. As of (MONTH) 14, 2019, the wound care nurse documented the wound as getting worse. During observation of wound care for one (Resident #41) of one sampled resident, the facility failed to provide wound care to prevent infection for Resident #41. Findings Included: During an interview with staff member E, LPN (wound care nurse) on 1/17/19 at 10:04 a.m., Staff member E, stated the wound care physician came in last week and staff member E, did not have Resident #41 looked at since his wound was almost healed. Staff member E, stated, Resident #41's wound is getting worse now and has not seen the wound care physician although he had an order. Staff member E, stated, she only did wounds on Monday for 8 hours, when the wound care physician comes in the facility. If the wound care physician did not come in she stated she would complete the wound measurements and evaluate if the treatment needed to be changed. Staff member E, stated that she had not had any formal training on wound care. During an interview with the Director of Nursing (DON) on 1/17/19 at 11:05 a.m. she stated, she she wants a wound healed in three weeks and since Resident #41's wound was not healing she had the primary physician sign an unavoidable wound document. The DON stated the facility was doing everything they could and the wound was not healing but could not confirm Resident #41 was evaluated by the primary physician or the wound care physician related to the wound. The DON stated that the wound care nurse wound have the physician information on when the resident was assessed by the wound care physician. The DON confirmed the wound care physician should have seen Resident #41 on 12/24/18, 12/31/18, or 1/7/19. During medication administration across the hall from Resident #41 on 1/16/19 at 9:34 a.m., the resident was yelling out, My butt hurts, I want to go to bed. The resident was observed sitting up to a chair. During an interview with Resident #41 on 1/16/19 at 4:30 p.m. the resident stated he was having pain on his bottom. Resident #41 was observed on an air mattress sitting up in the bed. During wound care observation on 01/16/19 at 10:56 a.m. with staff member D, LPN, the nurse washed her hands, donned gloves, cleaned the tray table with bleach wipes, doffed gloves and washed her hands. Staff member D set up a barrier, placed 4x4's, 3 medication cups with 4x4's and sprayed saline into three medication cups, cotton tipped applicators and dry dressing. The nurse washed hands, donned gloves, rolled the resident to his left side. The resident was lying without a brief on a disposable moisture barrier pad drifting in and out of sleep (snoring), the soiled dressing removed, the nurse doffed gloves, washed hands. When the nurse left to wash her hands the resident rolled to his back with the wound exposed lying on the moisture barrier, the nurse donned gloves, rolled the resident back to his left side, cleaned the wound with normal saline, dried the wound, the resident rolled to his back on the pad again, the nurse doffed her gloves and washed her hands. The nurse donned gloves rolled the resident back to his left side, applied [MEDICATION NAME] with a cotton tipped applicator. Two open areas were observed on the coccyx with the nurse applying [MEDICATION NAME] to the top wound only, the nurse let the resident roll back on the moisture barrier with the wound and [MEDICATION NAME] touching the barrier. The nurse doffed gloves and washed her hands. The nurse donned gloves and applied the dressing. The nurse cleaned up and covered the resident then doffed gloves and tied up the clear garbage bag and washed her hands. During an interview with staff member D, LPN on 1/16/19 at 11:15 a.m., the nurse stated that she would use assistance if she felt it was needed but this time she did not. Review of the physician order, dated 12/21/18, found Resident #41 for a wound care consult for care and services to evaluate and treat. Review of the physician order [REDACTED]. Review of the physician order [REDACTED]. Review of the physician order, dated 1/16/19, revealed a phone order for Silver [MEDICATION NAME] Cream 1% apply to coccyx topically every shift for Deep tissue injury (DTI) with normal saline then apply silver [MEDICATION NAME] and dry dressing, change everyday. Review of nursing Progress notes, dated 12/21/18, revealed the resident with buttocks red/pink with small open area in the middle. Spots of purple noted around area. Resident denied pain. Applied cream to buttocks. Opti foam dressing in place. Review of the weekly wound observation form, dated 12/21/18, revealed the resident with air mattress ordered. Stage 2 noted to coccyx 2cmx0.5cmx0.1cm. Peri wound stage 1 extending 4cm to the left of the wound and 1.5 cm to the right of the wound. The wound was facility acquired on 12/21/18 as a stage II with [MEDICATION NAME] tissue present, dry without drainage. The current treatment plan was to cleanse open area on coccyx with normal saline. Apply hydrogel to wound. Skin prep periwound, and apply [MEDICATION NAME]. Change daily. Refer to wound care. signed by LPN. Review of the weekly wound observation form, dated 12/24/18, revealed the resident with coccyx wound SDTI (suspected Deep tissue injury) measuring 5cm x 5cm, treatment of [REDACTED]. No change in wound. Signed staff member E, LPN, wound care nurse. Review of the weekly wound observation, dated 1/10/19, revealed the resident with stage II coccyx wound with granulation tissue present with serosanguinous scant amount measuring 1.2cm x 0.2 cm x 0.1 cm, improving with [MEDICATION NAME] cream treatment. Signed staff member E, LPN, wound care nurse. Review of the weekly Wound care observation, dated 1/14/19, revealed the resident with stage II coccyx wound, worsening with granulation tissue with serosanguinous drainage measuring 2.2 cm x 1.8 cm x 0.1 cm. with silver [MEDICATION NAME] with dry dressing. Signed staff member E, LPN, wound care nurse. Review of the Minimum Data Set, dated dated [DATE], with a Brief Interview of Mental Status (BIMS) of 12. The resident has extensive assistance with two plus persons for physical assistance. Review of unavoidable skin breakdown dated 1/10/19 revealed the resident with hemoglobin of 11.5, immobility, chronic [MEDICAL CONDITION], generalized weakness, chronic bowel incontinence, [MEDICAL CONDITION] disease, obsese, with bilateral [MEDICAL CONDITION], limited range of motion. The page is signed and dated by the nurse on 1/10/19 and the physician via fax with the fax dated 1/10/19 at 1:51 p.m. Review of the record revealed the last date the physician observed the resident was on 12/19/18. Review of the Wound Report dated 1/14/19 revealed Resident #41 with the wound worsening with 100% granulation. Review of the policy and procedure for Pressure Ulcers/Skin Breakdown- Clinical Protocol from Nursing Services Policy and procedure Manual for Long-Term Care revised (YEAR), 3 pages revealed: 3: The staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. 4. The physician will assist the staff to identify the type and characteristics of an ulcer. 5. The physician will help identify and define any complications related to pressure ulcers. Treatment and Management- 1. The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings, and application of topical agents. 2. The physician will help identify medical interventions related to wound management; Monitoring - 1. During resident visits, the physician will evaluate and document the progress of wound healing - especially for those with complicated, extensive, or poorly-healing wounds. 2. the physician will guide the care plan as appropriate, especially when the wounds are not healing as anticipated or new wounds develop despite existing interventions.

Based on record review, and interview the facility failed to assure one (#13) of five sampled residents for skin conditions or pressure ulcers out of a total sample of 31 residents received weekly skin assessments. Findings included: A review of Resident #13's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED] A review of the physician orders [REDACTED].#13 had bilateral lower extremity wounds. A review of the electronic assessments did not indicate a weekly summary with skin was completed on Tuesday, 1/8/19 or Tuesday, 1/15/19. The electronic record did not indicate the nurses' note, completed on 1/8 or 1/15/19 included a skin assessment for Resident #13. During an interview on 1/16/19 at 2:01 p.m., Staff Member B, Registered Nurse Unit Manager (RN), stated notes on the wounds should be on the assessment tab. She stated the wound care nurse does monitoring once a week and the nurses document the skin assessment for Resident #13 on Tuesdays. Staff Member B stated Resident #13's skin assessment should have been documented on 1/8 and 1/15. The staff member reviewed the electronic record and confirmed there was no skin assessments from the nurses on the 8th or 15th. Staff Member B stated she would be checking with the nurse, who was in the facility, as to why the skin assessment was not completed and would have the nurse do late entry's from the 8th and 15th. At 6:36 p.m. on 1/16/19, Staff Member C/Assistant Director of Nursing (ADON) stated all residents were to have a weekly skin assessment done and the assessments were a quality of care issue. An undated bulletin obtained from the facility's nursing training folder stated, Attention Nurses: Skin Evaluation Protocol Nurses will complete a full skin assessment: 1. On admission/readmit 2. Scheduled weekly assessment 3. PRN Complete weekly skin assessment/admit skin screener in (electronic record system) and report new skin issues to MD and responsible party. Document communications in progress notes. Thank you. DON

Based on review of resident records, interviews of facility staff, interviews with the Physician/Medical Director, and interviews with the Director of Nurses (DON), the facility failed to follow physician's order [REDACTED].#3, #4, and #14). These significant mediation error actions potentially contributed to the death of one of the three (#3) residents. The Death Certificate for resident #3 stated GI Bleed (gastrointestinal) was an underlying cause of death for resident #3. The medication errors and related administration of anticoagulants along with insufficient monitoring of lab values for clotting status resulted in findings of immediate jeopardy. The immediate jeopardy was removed on [DATE] at 4:30 p.m. and the scope and severity was reduced to a D. Findings include: Per the facility face sheet for resident #3, she was initially admitted to the facility on [DATE], after a hospitalization . The face sheet revealed 15 [DIAGNOSES REDACTED]. A copy of a Do Not Resuscitate (DNR) order was found on the record. It was signed by the resident and the physician on [DATE]. Review of the physician's order [REDACTED]. " Review of the hospital physician ' s notes, dated [DATE] at 4:45 p.m., revealed that resident #3 had a chief complaint of shortness of breath for three days with mild chest pain. The diagnostic data section revealed a scan was performed and showed a " high probability for acute embolism (blood clot) in the left upper lobe. " The assessment and plan section revealed that the resident was receiving [MEDICATION NAME] and had been started on [MEDICATION NAME] 5 mg daily. Item number two stated the resident had [MEDICAL CONDITIONS], " persistent, with mild symptoms. " The hospital physician also noted a history of [MEDICAL CONDITION] and acknowledged the DNR order. Review of the facility medical record revealed that resident #3 returned to the facility on [DATE] at around 7:00 p.m. The admission orders [REDACTED]. " A telephone ordered, dated [DATE] at 12:30 p.m., stated to call the physician with the results of the [MEDICATION NAME] Time (PT/INR, clotting) lab values of that date. The results were reported to the facility as PT : >106, verified by repeat Reference Range: 7XXX,[DATE].8 INR: >10.4 Reference Range: 0XXX,[DATE].3 The lab report contained a hand written notation, no time, stating to HOLD [MEDICATION NAME] and repeat in the morning ([DATE]). [DATE] PT/INR: PT: 44.0, verified by repeat; INR 4.3. A physician's order [REDACTED]. [DATE] PT/INR: PT: 35.6; INR 3.5. A physician noted on the lab report, no time, that the resident was seen and [MEDICATION NAME] was reduced to 2.5 mg daily. [DATE] PT/INR: PT 87.2, verified by repeat; INR 8.5. Physician noted on the lab report, no time, to hold the [MEDICATION NAME] and repeat the labs. [DATE] PT/INR: PT 56.5, verified by repeat; INR 5.5. Physician noted on the lab report [MEDICATION NAME] to continue on hold until next INR. [DATE] a Complete Blood Count (CBC) was done. The results were: White blood count (WBC) 18.2; Reference Range 4XXX,[DATE].9 Platelets (PLT) 498; Reference Range ,[DATE] On [DATE] PT/INR: PT 19.4; INR 1.9. The physician noted on the lab report, no time noted, that [MEDICATION NAME] 2.5 mg daily was restarted. On [DATE] a laboratory report stated that the resident tested positive for the bacteria ,[MEDICAL CONDITION].. Difficile (C.Diff) toxin (a diarrhea producing toxin in the bowel). A note on the lab sheet, dated [DATE], stated the physician was aware of the results and [MEDICATION NAME] medication was to continue. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the October , 2010 lab values for resident #3 revealed PT/INR testing on ,[DATE]; ,[DATE]; ,[DATE]; ,[DATE]; ,[DATE]; and [DATE]. Documentation in the medical record revealed that the physician was contacted and orders were received each time. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On [DATE] the PT: 15.1 and the INR was 1.5. The physician increased the [MEDICATION NAME] to 2 mg daily. The MAR indicated [REDACTED] On [DATE] the lab results were: PT: 22.7; INR 2.2. The lab report contained a hand written note that stated the physician visited and orders were noted. On [DATE] the physician progress notes [REDACTED]. He noted one bowel movement per day. There was no mention of bloody movements. On [DATE] a monthly nursing summary report revealed that the resident was alert with occasional confusion and forgetfulness. Page two stated she was noncompliant with the diabetic diet. She was 64 inches tall and weighed 170 pounds. Continued review revealed that the resident required the assistance of one person for daily care. She was described as continent. Page six of the summary stated " no loose stools in the past few weeks. " On [DATE] an A1C lab for diabetes was reported as: 7.6; Reference range: 4XXX,[DATE].0. On [DATE] a second physician visited the resident in the facility. The physician wrote in the progress note that the resident had four loose stools since the morning, no time specified on the note, and that it " smells like [DIAGNOSES REDACTED]. " Under the Plan section he wrote: Stool for C.Diff; [MEDICATION NAME] 2 mg daily; Metrogyl ([MEDICATION NAME]) 500 mg three time daily (used to treat a C.Diff infection), and Lactobacillus, one capsule twice daily. On [DATE] the lab results were: PT: 30.5; INR 2.8. The Lab report stated that the INR therapeutic range was 2.0 to 3.0. The physician noted on the lab report, to continue the present dose of [MEDICATION NAME], 2 mg. On [DATE] a Nurse Practitioner progress note stated that the resident had a low-grade fever and vomiting. The assessment stated that the resident had " crackles right lung base. " Intravenous medications were ordered. The labs of that day were: PT: 32.1; INR 3.0. The lab report contained a hand written note to continue [MEDICATION NAME] 2 mg. On [DATE] the Nurse Practitioner visited the resident. The notes stated that the resident had " a few crackles " in the right lung base. Under the Impression section, item #3, she stated " [MEDICAL CONDITION] Embolism. On [MEDICATION NAME]. INR 3.0 today " . Item #6 stated a history of [DIAGNOSES REDACTED]. There was no documentation of bloody stools. On [DATE] at 12:45 p.m. the facility received a printed lab report with the following lab values: PT: 60.7, Verified by repeat INR: 6.7 On [DATE] at 1:30 p.m., a physician visited resident #3. He stated that the resident had four loose bowel movements since that morning. He stated that the resident had a right lower lobe lung infiltrate and was currently receiving antibiotics. He noted the history of diabetes (DM), [MEDICAL CONDITION] (CKD) stage 3, and a [MEDICAL CONDITION] infection. The following orders were obtained: 1. [MEDICATION NAME] ([MEDICATION NAME]): HOLD until next PT INR results (scheduled for [DATE]); 2. Breathing exercises with Acxupella three time daily; 3. Discontinue the [MEDICATION NAME] the five day course; 4. Watch for number of bowel movements and inform. . On [DATE] the order to HOLD the [MEDICATION NAME] until the next PT/INR was NOT transcribed to the MAR by nurse #1, a Licensed Practical Nurse (LPN). On [DATE] at 5:00 p.m. the MAR indicated [REDACTED]. On [DATE] at 5:00 p.m. the MAR indicated [REDACTED]. On [DATE] at 9:00 p.m. the nurse ' s notes stated that the resident was incontinent. There was no documentation of bloody stools. On [DATE] at 5:00 p.m. the MAR indicated [REDACTED]. On [DATE] at 2:00 p.m. the nurse ' s notes stated that the loose stools continued. There was no mention of blood in the stool. On [DATE], no time specified, the Nurse Practitioner visited. She stated in the note that the staff reported the resident had one loose stool that morning with a question of blood and mucus observed. The exam revealed the abdomen to be " soft, benign, with vague complaints of discomfort. " Under the topic of Plan, the documentation stated: [DIAGNOSES REDACTED] toxin A/B and continue current management. At [DATE] at 1:10 p.m. a telephone order was written for Pepto-Bismol, 30 cc every hour as needed for diarrhea, not to exceed eight doses. The MAR indicated [REDACTED]. On [DATE] at 1:00 p.m. the nurse ' s notes stated loose stools continued. There was not mention of blood present. On [DATE] at 5:00 p.m. the MAR indicated rectal bleeding " by nurse #5, an LPN. On [DATE] at 7:00 p.m. the nurses notes stated " dark, loose maroon colored stool. " The physician was called. The note stated " otherwise stable. " This note was recorded by nurse #5, an LPN. [DATE] at 8:00 p.m. another nurse wrote that she attempted to call the physician two times and was awaiting a return call. She noted that the resident had a poor appetite, low fluid intake, the skin warm and dry, and the temperature was 97.7. There was no further documentation regarding physician contact. There were no telephone orders regarding this contact. On [DATE] at 5:00 p.m. the MAR indicated rectal bleeding. " There was no documentation in the nurse ' s notes for this shift. On [DATE], 11 p.m. to 7 a.m. shift, the nurses notes stated that the resident continued to have loose stools. The vital signs were noted to be changed (no values recorded) and the resident complained of " not feeling well. " The oxygen saturation level was 96%. There was no documentation that the physician was notified. On [DATE] at 11:45 a.m. the nurse ' s note stated she called the physician. The nurse ' s note does not state why. On [DATE] at 11:50 a.m. the nurses notes stated that the doctor on call, identified as the first initial of his last name only, was contacted and Stat orders for lab work were ordered. The order included: 1. Complete Blood Count, CBC 2. Basic Metabolic Panel, BMP. There was no order for a PT/INR. On [DATE] at 12:10 p.m. the nurses notes revealed that LPN #2 recorded that the resident continued to have blood in her stool and had a small amount of bloody emesis (vomit). On [DATE] at 2:23 p.m. the lab reported a stool sample tested positive for [DIAGNOSES REDACTED]icile toxin. On [DATE] at 5:00 p.m. the MAR indicated rectal bleeding. " On [DATE] at 10:30 p.m. the nurse ' s notes stated that the CBC and BMP lab results were reported and attempts were made to contact the physician at 7:00 pm., 8:00 p.m., 8:45 p.m., and 10 p.m. There was no documentation of attempts to notify the DON of the concerns regarding the physician contact. There was no documentation of blood in the stool. On [DATE] at 10:40 p.m. the physician called and was informed of the lab values: The CBC revealed several abnormal levels including: WBC=21.6, Platelets=670; reference range ,[DATE] BUN-50; reference range ,[DATE]. The following orders were received: 1. [MEDICATION NAME] 500 mg three times daily 2. IV fluids of Normal Saline at 100 cc per hour for 24 hours. On [DATE] at 11:00 p.m., the nurse ' s notes stated the IV was started. On [DATE] at 2:00 a.m. the nurse ' s note stated the resident was weak but alert. There was no documentation of bloody stools. On [DATE] at 7:45 a.m. nurse #1 wrote that the resident was found " in a pool of blood from the rectal area. " The physician and family were called. Emergency Medical Services was called to send the resident to the hospital. There was no time in the note regarding the transfer time. The Assistant Director of Nurses later stated she was notified of the transfer but received no follow up information. She stated she was informed of the resident ' s death on [DATE] around 7:00 a.m. On [DATE] at 8:20 a.m. the nurse ' s notes stated that the facility was informed by the family that the resident had died . Record review of the Emergency Medical Services (EMS) record, obtained from the hospital, revealed that the ambulance arrived at the facility on [DATE] at 7:56 a.m., nine minutes after notification by the facility. The Nature of the Call was recorded as: Respiratory Distress. The Chief Complaint was listed as: Respiratory Distress, Severe. The airway was noted as: " Partially obstructed-Blood. " Breathing was labored. Blood/Fluid loss was estimated at less than 100 cc. The report stated that IV fluid and oxygen were administered prior to arrival (PTA), recorded as 7:30 a.m. At 8:01 a.m. the resident had a blood pressure of 60/ and a pulse of 63, weak. Respirations were recorded as 30 and fatigued. The EKG (a heart monitor) monitor showed a normal sinus rhythm. Per the EMS record, at 8:09, the pulse was 55, weak and irregular and respirations were absent. The monitor showed a heart Arrhythmia. Per the EMS narrative section, the monitor showed a heart rhythm became " agonal " (per the Taber ' s Dictionary: related to death) at arrival to the hospital. There was no documentation of continued rectal bleeding on the EMS record. Review of the hospital emergency room , Initial Assessment Form, obtained from the hospital, the Brief Assessment section stated that the resident was " found by the nursing home staff hemorrhaging from the rectum and mouth. " The resident was in an agonal cardiac rhythm and not breathing upon arrival. The assessment stated the resident was a " no code with papers. " The Chief Complaint stated: [MEDICAL CONDITION] pre-hospital. The exam timed at 8:13 a.m. stated that the resident had a high INR and continued to receive [MEDICATION NAME] at the facility. There was no documentation on the ER record of the presence of blood. The Clinical Impression was: DOA, dead on arrival. The physician pronounced the time of death as 8:15 a.m. On [DATE], at around 2:00 p.m., an interview with the Director of Nurses (DON) revealed that she became aware of a medication error related to [MEDICATION NAME] not being held and the death of resident #3 on [DATE] at about 8:30 a.m. She stated that nurse #1 was on duty on [DATE] and that she reported to the DON that she was taking the record apart (resident #3) when she noticed that the order of [DATE] to hold [MEDICATION NAME] were not transcribed to the MAR. She initially stated that she did not find the order. The DON then showed her the order that she had written on [DATE]. Nurse #1 was terminated on [DATE]. The DON stated that she then began the adverse incident investigation. She stated that nurse #2, who gave [MEDICATION NAME] on ,[DATE] and [DATE], was terminated also. Nurse #4, a night nurse responsible for the 24 hour chart check was terminated two days later for not catching the error. The DON stated that the attending physician for resident #3 is also the Medical Director for the facility. He was informed on [DATE], around midmorning. She stated he immediately came to the facility and discussed it with her, the ADON, the Risk Manager and the Nursing Home Administrator. The DON stated that on [DATE] all licensed staff was educated on anticoagulant therapy, lab values and signs/symptoms of side effects. She provided a sign in sheet with all licensed staff except two nurses. One of the two nurses worked once every six weeks and had been notified by phone to report to work early to have the education prior to coming on duty. The second nurse worked every other weekend and was informed to report early on the next scheduled day. She had not worked since [DATE]. On [DATE] and [DATE] interviews with the physician/medical director revealed that he had been the attending physician for resident #3. He stated he was on vacation the week of [DATE] but he consulted with the other physicians in the practice and everyone was aware of the multiple co morbidities of the resident. He stated he was unaware of the facility failure to hold the [MEDICATION NAME] until he was informed on [DATE], midmorning, by the DON. He stated he came to the facility to evaluate the record and the error. He was aware of the termination of three nurses. The physician stated he signed the Death Certificate and provided a copy on [DATE]. He stated the primary cause of death was: 1. Multiple Medical Problems of Aged. Secondary underlying issues were: 2. GI Bleed; [DIAGNOSES REDACTED], [MEDICAL CONDITION], diabetes (DM), [MEDICAL CONDITION] (CAD) and [MEDICAL CONDITION] CKD. On [DATE] the Death Certificate for resident #3 was reviewed by the physician and this surveyor. The physician confirmed that GI Bleed was listed as a secondary underlying medical issue. The physician further stated, on [DATE], that the resident had not received [MEDICATION NAME] during the three days prior to the bleeding event. He stated it was difficult to state what impact the three additional doses of [MEDICATION NAME] would have had on the outcome. He called his office and spoke with his partners during the interview of [DATE], and the physicians and nurse practitioner stated the facility did not verbalize concerns about rectal bleeding, but just the diarrhea. The physicians in the practice, including the nurse practitioner, stated to him that they did not have knowledge of the three additional doses of [MEDICATION NAME] and were treating resident #3 for the [DIAGNOSES REDACTED]icile [MEDICAL CONDITION] and lung infection. He stated he spoke with the pharmacy on [DATE] and requested the following: A preprinted MAR indicated [REDACTED]. A preprinted area on the MAR indicated [REDACTED] A laminated information sheet regarding anticoagulants to be place on the MAR for each resident. The physician stated that a sample MAR indicated [REDACTED]. Per the facility face sheet, resident #14 was admitted to the facility on [DATE]. The admitting [DIAGNOSES REDACTED]. Review of the MAR for November, 2010 revealed the resident received: [MEDICATION NAME] ([MEDICATION NAME]) 2.5 mg daily at 5:00 p.m. Review of the lab reports for resident #14 included the following: [DATE] PT: 24.9 INR: 2.2 No new orders written on the bottom of the report. [DATE] PT: 56.2, verified by repeat INR: 6.1. Therapeutic range listed as 2.0 to 3.0. The bottom of the lab slip contained a hand written note stating: " [DATE] [MEDICATION NAME] on hold till INR <3 " . It was signed, but illegible. On [DATE] at 12:00 p.m. the nurse ' s notes stated the physician was notified and a telephone order was received to hold [MEDICATION NAME] 2.5 mg until the INR was less than (<) 3. The note stated " PT/INR scheduled to be rechecked Thursday [DATE]. [DATE] at 12:00 p.m., a telephone physician's order [REDACTED].<3. PT/INR scheduled to be rechecked on Thursday [DATE]. " A review of the MAR for [DATE] revealed the [MEDICATION NAME] was held on [DATE], [DATE], and [DATE]. The [MEDICATION NAME] was documented as given [DATE], [DATE], [DATE], [DATE], and [DATE]. There was no documentation of lab results for a PT/INR for [DATE]. [DATE] lab report revealed: PT: 29.0 INR: 2.6 A hand written note on the report stated the results were called to the Physician ' s Assistant (PA). No new orders were obtained. [DATE] PT: 24.4 INR: 2.1 no new orders. [DATE] PT: 24.2 INR: 2.1 no new orders. Review of the MAR for December, 2010 revealed all doses of [MEDICATION NAME], 2.5 mg, 5:00 p.m. was documented as given. On [DATE] at 11:10 a.m. an interview with the nurse caring for the resident on [DATE] revealed she was unaware of the labs not being done on [DATE]. She checked the calendar and found that [DATE] was a holiday and only stat labs were to be done. She then stated she did not inform the physician of that finding. She stated she was unaware until now that the [MEDICATION NAME] was restarted on [DATE] without the labs ordered by the physician. She said at the time she wrote the order she thought that the resident received routine, twice weekly PT/INR levels and Thursday, [DATE] would have been the next test. The nurse and the DON confirmed that the labs for PT/INR were not drawn on [DATE], and the physician was not notified. The nurse and the DON confirmed that [MEDICATION NAME] ([MEDICATION NAME]) 2.5 mg, daily at 5:00 p.m., was restarted on [DATE] without laboratory results or a physicians order to do so. The nurse received a written discipline from the DON on [DATE] and the physician was informed of the error. The physician ordered PT/INR labs twice weekly on Monday and Thursday. Per the facility face sheet resident #4 was admitted to the facility on [DATE]. The admitting [DIAGNOSES REDACTED]. A review of the facility record revealed the resident was transferred to the hospital on [DATE]. The history and physical, dated [DATE], revealed the resident was [AGE] years old, had generalized weakness, and a cough. The plan included obtaining an MRI of the brain. On [DATE] a hospital consult physician ' s report stated the resident had a generalized [MEDICAL CONDITION] disorder. The neurological exam revealed the resident was confused, disoriented and required the assistance of three to walk a couple of steps. A CT scan of the head and an MRI of the brain revealed no acute event. Under the section of Plan, the physician consult wrote: #5: " Okay to continue [MEDICATION NAME] for [MEDICAL CONDITION] Fibrillation (a heart arrhythmia) since there is no acute stroke. " Per the face sheet, the resident returned to the facility on [DATE]. On [DATE], a Do Not Resuscitate (DNR) order was signed by the proxy and the physician. [DATE] a physician telephone order stated: " Accept transfer orders; PT/INR every Monday and Thursday. " [DATE] at 7:45 a.m. a physician telephone order stated, " [MEDICATION NAME] ([MEDICATION NAME]) 2.5 mg po, QD (daily). " A review of the MAR indicated [REDACTED]. [DATE] a lab reported the following: PT: 32.9 Reference range: 11XXX,[DATE].9 INR: 3.1 Reference range: 0XXX,[DATE].2 INR Therapeutic range 2.0 - 3.0. [DATE] at 10:26 a.m. a lab reported the following: PT: 36.9 INR: 3.9 A hand written notation at the bottom of the lab report stated: [DATE] " [MEDICATION NAME] decreased (indicated by downward arrow) to 2.0. The numbers were written over and the initial note was 2.5. The note was not signed nor time specific. On [DATE], [MEDICATION NAME] ([MEDICATION NAME]) 2.5 mg 5:00 p.m. dose was recorded as given by LPN # 4. On [DATE], a physician telephone order, no time specified, stated to decrease the [MEDICATION NAME] to 2.0 mg daily at 5:00 p.m. The Registered Nurse signed the order. On [DATE] and [DATE] [MEDICATION NAME] 2.0 mg was recorded as given at 5:00 p.m. [DATE] review of the nurse ' s notes revealed an entry at 8:30 p.m. that stated an order was received to decrease the [MEDICATION NAME] to 2.0 mg at 5 p.m. daily. The note was signed by the RN, charge nurse. There was no documentation regarding what time the physician was contacted regarding the abnormal lab values. [DATE] at 9:00 p.m. the LPN #4 note stated that the resident was resting well and in no distress or pain. On [DATE] at 1:00 p.m. the nurse ' s notes stated that the resident ' s bruises to the body remain. There was no documentation of bloody stools or urine. On [DATE] at 3:00 p.m. the nurse ' s notes stated that the resident was resting quietly and refused to eat breakfast. Lunch intake was 20%. On [DATE] at 5:00 p.m. the nurse ' s notes stated that the aide was unable to hear the blood pressure. The physician was called. At 6:00 p.m. the PA returned the call and requested the resident be sent to the hospital for evaluation. The note stated that the family wanted comfort measures only (CMO). The PA was informed of the resident ' s declining condition. The note further stated that the oxygen saturation was 88%. On [DATE] and [DATE] the MAR indicated [REDACTED]. On [DATE] nurse ' s notes, no time specified, stated resident took no meds on that day, there were no complaints of pain, and the staff provided comfort measures only. The note stated that the resident was incontinent. There was no mention of blood in the stool. On [DATE] at 12:01 a.m. the nurse ' s notes revealed that she was called to the room to find the resident had no pulse or respirations. The physician was notified. The family was notified. On [DATE] at 1:40 a.m. the nurse noted that the body was released to the funeral home. On [DATE] at around 2:00 p.m. the nurse caring for the resident (LPN #4) stated that she was on duty on [DATE] and administered [MEDICATION NAME] 2.5 mg. She stated that after the medication was given she became aware of the elevated clotting lab values after the medication was given. She stated she spoke with the Physician ' s Assistant (PA) after the medication was given and he was aware of the increased dose of [MEDICATION NAME] 2.5 mg given on [DATE]. The LPN stated that the PA stated to begin the decreased dose of [MEDICATION NAME] 2.0 mg. She did not write the order to start the dose change on [DATE]. On [DATE] at around 10:00 a.m. an interview was conducted with the Physician Assistant (PA), via telephone. The PA stated he was aware of the resident receiving [MEDICATION NAME] 2.5 mg on [DATE]. He stated he gave the order to begin the decreased dose on [DATE]. He stated he did not think it affected the resident ' s demise. He stated there was no indication of bleeding prior to her death. On [DATE] at around noon, the DON stated that nurse LPN #4 received a written reprimand for giving a [MEDICATION NAME] dose after the facility received elevated blood values and not writing the telephone order to start [MEDICATION NAME] 2.0 mg on [DATE]. The DON stated that the following measures were enacted after the medication error was investigated: Corrective Action: 1. Discipline: Terminated three employees from [DATE] to [DATE]. There were three nurses who received written warnings for poor performance from [DATE] to [DATE]. 2. Education: DON gave [MEDICATION NAME] usage in-service on [DATE] with discussion of Bleeding and side effects related to INR ' s and [MEDICATION NAME] dose. All licensed staff attended, except two nurse who work part time. They will receive the in-service prior to the next scheduled shift. They have been informed by phone. 3. Pharmacy changes: Medication Administration Records (MAR) are being changed , effective [DATE], and reprinted to include a space for the " INR level " just above the sign out portion on the MAR indicated [REDACTED]. 4. Pharmacy will preprint stop dosing perimeters to not give medication when INR is greater than 3.0. 5. Standing Orders will be written on the charts of patients receiving [MEDICATION NAME], to stop medication for INR above 3.0, effective [DATE]. 6. [MEDICATION NAME] Policy: was re-written by the Medical director and Director of Nurses, [DATE]. 7. Education to nurses on [DATE] included transcribing all physicians ' orders with correct date, time and nurses initials of who wrote the order. 8. Medical Director consulted with staff and pharmacy, on [DATE]. 9. Medical Director has provided personal cell phone numbers to the nurses and will follow up with the answering service to increase better communication with the physician/physician assistant/nurse practitioner. 10. Assistant Director of Nurses created new perimeters for MD access with time specific guidelines to notify facility administration, effective [DATE]. 11. DON/designee will conduct monthly QA on 24-hour chart checks to ensure that orders were carried through as written, begun on [DATE]. On [DATE] and [DATE] observation and interviews with four random medication nurses, by two nurse surveyors, revealed that all four nurses, LPNs, received education and training related to administration and monitoring of lab values for anticoagulant therapy. Each nurse demonstrated several current resident MAR, on the medication carts. The documents reflected the following: 1. The MARs reflected areas for documentation of the lab values for coagulation testing. Blocks were identified for routine testing days, specific to each resident, for the month of December, 2010. 2. A laminated information sheet was found in front of each MAR indicated [REDACTED]. 3. Laboratory thresholds and Do Not Give guidelines were written in the block, next to the anticoagulant order, effective [DATE]. All corrective actions since the event have been initiated and the scope and severity of F 333 was reduced to D on [DATE] at 4:30 p.m.

Based on medical record review, review of training materials, review of facility policy related to [MEDICATION NAME] ([MEDICATION NAME]) use, and interview with facility staff, it was determined that administration failed to provide resource management to meet the needs of three (#3, #4, & #14) of the sixteen sampled residents who were prescribed [MEDICATION NAME] ([MEDICATION NAME]) for anticoagulation therapy. Administration did not ensure the direct functions and operations of the facility were in accordance with current safety regulations governing medication administration for residents in long term care facilities. The failure by administration was related to not implementing and developing complete policies, procedures, and training for the use of [MEDICATION NAME] ([MEDICATION NAME]) , and failure to assure that staff was educated to monitor for adverse side effects related to anticoagulant medication usage. The administration failed to ensure that staff implemented the training received, led to neglect of three residents (#3, #4, and #14). Resident (#3) experienced massive bleeding and ultimately expired after receiving three doses of [MEDICATION NAME] that should have been put on hold per the physician's order [REDACTED]. The facility staff administered an anticoagulant with disregard to the physician's order [REDACTED]. These actions resulted in findings of immediate jeopardy, which was removed on [DATE] at 4:30 p.m. and the severity and scope was reduced to a D. Findings Include: 1. Review of the job description for the Nursing Home Administrator (NHA), received from the facility on [DATE], revealed: Administrative Responsibilities related to the Patients read as follows: " Maintain and implement programs of patient education and rehabilitation for the promotion of mental attitude and physical health. " Administrative Responsibilities related to the Medical Staff read as follows: " Work with medical staff, local Health Services and all those concerned with or responsible for rendering professional and medical service to provide the best possible care to all patients. " In addition, Administrative Responsibilities related to Nursing Service reads as follows: Assist the Director of Nursing Service to organize, evaluate and maintain the respective nursing service to insure nursing care which meets the standards of patient care. Keep informed regarding patients ' condition and care. Keep informed regarding unusual incidents pertaining to patients. " On [DATE] at around 2:00 p.m., an interview with the NHA revealed she was informed, on [DATE] around 9:00 a.m., of a significant medication error occurring prior to the death of resident #3. She stated that the Director of Nurse (DON) informed her of the occurrence and that the Medical Director was coming to the facility. The NHA stated she was informed of the details of the resident ' s transfer to the hospital on [DATE]. She stated she was not called by the staff on [DATE] and was unaware of the details regarding finding the resident in a pool of blood on [DATE]. The NHA stated that she had no prior knowledge of the any events related to the care and services of resident #3. Review of the medical record and the events related to resident #3 was conducted by two surveyors with the NHA. The medical record for resident #3 was reviewed on [DATE] at around 2:00 p.m. with the NHA. The review revealed: On [DATE] at 7:45 a.m. nurse #1 wrote that the resident was found " in a pool of blood from the rectal area. " The physician and family were called. The note did not specify the time the physician was called but stated " PCP (primary care physician) on call had not returned call." Emergency Medical Services, per the family request, was called to transport the resident to the hospital. There was no time on the note regarding the transfer time. On [DATE] at 8:10 a.m., the same nurse recorded in the notes that the hospital called due to not being able to reach the family. On [DATE] at 8:15 a.m., the nurse recorded in the notes that the family was called and were instructed to call the hospital. On [DATE] at 8:20 a.m. the nurse ' s notes stated that the family notified the facility that the resident had " passed away. " On [DATE] at 11:10 a.m., the nurse ' s notes stated that the PCP returned the call and was notified of the resident ' s death. On [DATE] , at around 2:00 p.m. , the NHA (Nursing Home Administrator) stated she was unaware of the development of the nurse finding the resident in a pool of blood on [DATE] at 7:45 a.m. and the subsequent death of the resident within one hour of the discovery of the pool of blood. She stated she was not called on [DATE] and remained uninformed of the situation until [DATE], at around 8:30 a.m., when the DON informed her. She also stated she was unaware of staff having difficulty with physicians calling back. She acknowledged that a part of her job description read in part: Page 4, Nursing Services: " Keep informed regarding patients ' condition and care. Keep informed regarding unusual incidents pertaining to patients. " She stated she was not informed regarding the care and services, changing condition, and unusual incidents relating to resident #3. During an interview on [DATE] at 09:22 a.m., the Assistant Director of Nurses (ADON) stated that she was notified of the transfer, but, received no follow up information. She stated she was on call for that weekend and the staff was expected to inform the on call supervisor of any unusual occurrences. She stated the call came just prior to her going to church, early in the morning of [DATE]. She stated she was only informed of the hospital transfer and not of the resident ' s death. She did not receive a second call on [DATE] regarding the death of resident #3. She stated she was informed of the death on [DATE] around 7:00 a.m. She stated she would have expected the nurse to call and inform her of the resident ' s death and this was not done. She stated she had no further contact with the facility on [DATE]. She stated that it was not unusual for a resident to require hospital evaluation. The ADON stated she did not call the Nursing Home Administrator. Review of the closed record for resident #3 with the NHA revealed: On [DATE], no time specified, the physician progress notes [REDACTED]. There was no documentation of rectal bleeding or bloody stools. The physician wrote the plan was: Continue PT; [MEDICATION NAME] ([MEDICATION NAME]) 2 mg daily; INR on Mondays. On [DATE] the nursing monthly summary stated, " No loose stools in the past few weeks. " On [DATE], no time specified, a physician visited the resident in the facility. The physician progress notes [REDACTED]. Diff. " Under the Plan section the physician wrote: Stool for C.Diff; [MEDICATION NAME] 2 mg daily; Metrogyl ([MEDICATION NAME]) 500 mg three times daily (used to treat a C.Diff infection), and Lactobacillus (for diarrhea), one capsule twice daily. On [DATE] the lab results were: PT: 30.5; INR 2.8. The lab report stated that the INR therapeutic range was 2.0 to 3.0. The physician noted on the lab report, to continue the present dose of [MEDICATION NAME], 2 mg. A physician ' s telephone order was faxed to the facility confirming [MEDICATION NAME] 2 mg daily. On [DATE], a Nurse Practitioner progress note, no time specified, stated that the resident had a low-grade fever and vomiting. The assessment stated that the resident had " crackles right lung base. " Intravenous medications were ordered. The labs of that day were: PT: 32.1; INR 3.0. The lab report contained a hand written note to continue [MEDICATION NAME] 2 mg. On [DATE], the Nurse Practitioner visited the resident. The notes stated that the resident had " a few crackles " in the right lung base. Under the Impression section, item #3, she stated, " [MEDICAL CONDITION] Embolism. On [MEDICATION NAME]. INR 3.0 today " . Item #6 stated a history of [DIAGNOSES REDACTED]. There was no documentation of bloody stools. On [DATE] at 12:45 p.m., the facility received a printed lab report with the following lab values: PT: 60.7, Verified by repeat (Reference Range 11XXX,[DATE].9) INR: 6.7 (Reference Range 0XXX,[DATE].2) On [DATE] at 1:30 p.m., a physician visited resident #3. He stated that the resident had four loose bowel movements since that morning. He stated that the resident had a right lower lobe lung infiltrate, (a drawing on the progress note stated the location of the " fine crackles " of the right lung) and was currently receiving antibiotics. The following orders were obtained: 1. [MEDICATION NAME] ([MEDICATION NAME]): HOLD until next PT INR results (scheduled for [DATE]); 2. Breathing exercises with Acxupella three times daily; 3. Discontinue the [MEDICATION NAME] the five day course; 4. Watch for number of bowel movements and inform. On [DATE] the order to HOLD the [MEDICATION NAME] until the next PT/INR was NOT transcribed to the MAR by nurse #1, a Licensed Practical Nurse (LPN). On [DATE] at 5:00 p.m., the MAR indicated [REDACTED]. On [DATE] at 5:00 p.m., the MAR indicated [REDACTED]. On [DATE] at 9:00 p.m., the nurse ' s notes stated that the resident was incontinent. There was no documentation of bloody stools. On [DATE] at 5:00 p.m., the MAR indicated [REDACTED]. On [DATE] at 2:00 p.m. the nurse ' s notes stated that the loose stools continued. There was no mention of blood in the stool. On [DATE], no time specified, the Nurse Practitioner visited. She stated in the note that the staff reported the resident had one loose stool that morning with a question of blood and mucus observed. The exam revealed the abdomen to be " soft, benign, with vague complaints of discomfort. " On [DATE] at 1:00 p.m. the nurse ' s notes stated loose stools continued. There was no mention of blood present. On [DATE] at 5:00 p.m. the MAR indicated rectal bleeding " by nurse #5, an LPN. On [DATE] at 7:00 p.m., the nurse ' s notes stated, " dark, loose maroon colored stool. " The physician was called. The note stated, " Otherwise, stable. " This note was recorded by nurse #5, an LPN. [DATE] at 8:00 p.m., another nurse wrote that she attempted to call the physician two times and was awaiting a return call. She noted that the resident had a poor appetite, low fluid intake, the skin warm and dry, and the temperature was 97.7. There was no further documentation regarding physician contact. There were no telephone orders regarding this contact. On [DATE] at 5:00 p.m., the MAR indicated rectal bleeding. " There was no documentation in the nurse ' s notes for this shift. On [DATE], 11 p.m. to 7 a.m. shift, the nurses notes stated that the resident continued to have loose stools. The vital signs were noted to be changed (no values recorded) and the resident complained of " not feeling well. " The oxygen saturation level was 96%. There was no documentation that the physician was notified. On [DATE] at 11:45 a.m., the nurse ' s note stated she called the physician. The nurse ' s note does not state why. On [DATE] at 11:50 a.m. the nurses notes stated that the doctor on call, identified as the first initial of his last name only, was contacted and Stat orders for lab work were received. On [DATE] at 12:10 p.m. the nurses notes revealed that LPN #2 recorded that the resident continued to have blood in her stool and had a small amount of bloody emesis (vomit). On [DATE] at 2:23 p.m., the lab reported a stool sample tested positive for [DIAGNOSES REDACTED]icile toxin. On [DATE] at 5:00 p.m., the MAR indicated rectal bleeding. " On [DATE] at 10:30 p.m. the nurse ' s notes stated that the CBC and BMP lab results were reported and attempts were made to contact the physician at 7:00 pm., 8:00 p.m., 8:45 p.m., and 10 p.m. There was no documentation of attempts to notify the DON of the concerns regarding the physician contact. There was no documentation of blood in the stool. On [DATE] at 10:40 p.m. the physician called and was informed of the lab values. The following orders were received: [MEDICATION NAME] 500 mg three times daily and Intravenous Fluids of Normal Saline at 100 cc per hour for 24 hours. On [DATE] at 2:00 a.m., the nurse ' s note stated the resident was weak but alert. There was no documentation of bloody stools. On [DATE], at around 2:00 p.m., an interview with the Director of Nurses (DON) revealed that she became aware of a medication error related to [MEDICATION NAME] not being held and the death of resident #3 on [DATE] at about 8:30 a.m. She stated that nurse #1 was on duty on [DATE] and that she reported to the DON that she was taking the record apart (resident #3) when she noticed that the order of [DATE] to hold [MEDICATION NAME] was not transcribed to the MAR. Nurse #1 was terminated on [DATE]. The DON stated that nurse #2, who gave [MEDICATION NAME] on ,[DATE] and [DATE], was terminated also. Nurse #4, a night nurse responsible for the 24 hour chart check was terminated two days later for not catching the error. The DON stated that the attending physician for resident #3 is also the Medical Director for the facility. He was informed on [DATE], around midmorning. She stated he immediately came to the facility and discussed it with her, the ADON, the Risk Manager and the Nursing Home Administrator. The DON stated that, on [DATE] all licensed staff was educated on anticoagulant therapy, lab values and signs/symptoms of side effects. She provided a sign in sheet with all licensed staff except two nurses. One of the two nurses worked once every six weeks and had been notified by phone to report to work early to have the education prior to coming on duty. The second nurse worked every other weekend and was informed to report early on the next scheduled day. She had not worked since [DATE]. The NHA was present at this interview with the DON and stated she was aware of the events regarding the termination of three nurses who failed to provide care and services as ordered by the physician for resident #3. On [DATE] and [DATE] interviews with the physician/medical director revealed that he had been the attending physician for resident #3. He stated he was on vacation the week of [DATE] but he consulted with the other physicians in the practice and everyone was aware of the multiple co morbidities of the resident. He stated he was unaware of the facility failure to hold the [MEDICATION NAME] until he was informed on [DATE], midmorning, by the DON. He stated he came to the facility to evaluate the record and the error. He was aware of the termination of three nurses. The physician stated he signed the Death Certificate and provided a copy on [DATE]. He stated the primary cause of death was: 1. Multiple Medical Problems of Aged. Secondary underlying issues were: 2. GI Bleed; [DIAGNOSES REDACTED], [MEDICAL CONDITION], diabetes (DM), [MEDICAL CONDITION] (CAD) and [MEDICAL CONDITION] CKD. On [DATE] the Death Certificate for resident #3 was reviewed by the physician and the surveyor. The physician confirmed that GI Bleed was listed as a secondary underlying medical issue. On [DATE], the physician consulted with his partners and the nurse practitioner in his practice and said the facility did not verbalize concerns about rectal bleeding, but just the diarrhea. The physicians in the practice, including the nurse practitioner, stated to him that they did not have knowledge of the three additional doses of [MEDICATION NAME] and were treating resident #3 for the [DIAGNOSES REDACTED]icile [MEDICAL CONDITION] and lung infection. He stated he spoke with the pharmacy on [DATE] and requested the changes: A preprinted MAR indicated [REDACTED]. A preprinted area on the MAR indicated [REDACTED]. The physician stated that a sample MAR indicated [REDACTED]. The NHA stated she was aware of these changes requested by the medical director and had approved them to begin as soon as possible [DATE]. 2. Per the facility face sheet, resident #14 was admitted to the facility on [DATE]. The admitting [DIAGNOSES REDACTED]. Review of the MAR for November, 2010 revealed the resident received: [MEDICATION NAME] ([MEDICATION NAME]) 2.5 mg daily at 5:00 p.m. Review of the lab reports for resident #14 included the following: [DATE] PT: 56.2, verified by repeat INR: 6.1. Therapeutic range listed as 2.0 to 3.0. The bottom of the lab slip contained a hand written note stating: " [DATE] [MEDICATION NAME] on hold till INR <3." It was signed, but illegible. On [DATE] at 12:00 p.m., the nurse ' s notes stated the physician was notified and a telephone order was received to hold [MEDICATION NAME] 2.5 mg until the INR was less than (<) 3. The note stated " PT/INR scheduled to be rechecked Thursday [DATE]. [DATE] at 12:00 p.m., a telephone physician's order [REDACTED].o. daily is to be held until INR is <3. PT/INR scheduled to be rechecked on Thursday [DATE]. " A review of the MAR for [DATE] revealed the [MEDICATION NAME] was held on [DATE], [DATE], and [DATE]. The [MEDICATION NAME] was documented as given [DATE], [DATE], [DATE], [DATE], and [DATE]. There was no documentation of lab results for a PT/INR for [DATE]. [DATE] lab report revealed: PT: 29.0 INR: 2.6 A hand written note on the report stated the results were called to the Physician ' s Assistant (PA). No new orders were obtained. On [DATE] at 11:10 a.m. an interview with the nurse caring for the resident on [DATE] revealed she was unaware of the labs not being done on [DATE]. She checked the calendar and found that [DATE] was a holiday and only stat labs were to be done. She then stated she did not inform the physician of that finding. She stated she was unaware until now that the [MEDICATION NAME] was restarted on [DATE] without the labs ordered by the physician. She said at the time she wrote the order she thought that the resident received routine, twice weekly PT/INR levels and Thursday, [DATE] would have been the next test. The nurse and the DON confirmed that the labs for PT/INR were not drawn on [DATE], and the physician was not notified. The nurse and the DON confirmed that [MEDICATION NAME] ([MEDICATION NAME]) 2.5 mg, daily at 5:00 p.m., was restarted on [DATE] without laboratory results or a physicians order to do so. The NHA stated on [DATE], that she was unaware of this order for clotting lab values not being done on [DATE]. She was also unaware of the medication for anticoagulation being restarted by a nurse on [DATE], without lab values and an order to restart from the physician. 3. Per the facility face sheet, resident #4 was admitted to the facility on [DATE]. The admitting [DIAGNOSES REDACTED]. A review of the facility record revealed the resident was transferred to the hospital on [DATE]. The history and physical, dated [DATE], revealed the resident was [AGE] years old, had generalized weakness, and a cough. The plan included obtaining a MRI of the brain. On [DATE], a hospital consult physician ' s report stated the resident had a generalized [MEDICAL CONDITION] disorder and a CT scan of the head and an MRI of the brain revealed no acute event. Per the face sheet, the resident returned to the facility on [DATE]. On [DATE], a Do Not Resuscitate (DNR) order was signed by the proxy and the physician. [DATE] at 7:45 a.m. a physician telephone order stated, " [MEDICATION NAME] ([MEDICATION NAME]) 2.5 mg p.o., QD (daily). " A review of the MAR indicated [REDACTED]. [DATE] at 10:26 a.m. a lab reported the following: PT: 36.9 INR: 3.9 A hand written notation at the bottom of the lab report stated: [DATE] " [MEDICATION NAME] decreased (indicated by downward arrow) to 2.0. The numbers were written over the initial value of 2.5. The note was not signed nor time specific. On [DATE], a physician telephone order, no time specified, stated to decrease the [MEDICATION NAME] to 2.0 mg daily at 5:00 p.m. The Registered Nurse in charge signed the order. On [DATE], [MEDICATION NAME] ([MEDICATION NAME]) 2.5 mg 5:00 p.m. dose was recorded as given by LPN # 4. The nurse ' s notes of [DATE] revealed an entry at 8:30 p.m. that stated an order was received to decrease the [MEDICATION NAME] to 2.0 mg at 5 p.m. daily. The note was signed by the RN, charge nurse. There was no documentation regarding what time the physician was contacted regarding the abnormal lab values. On [DATE] at 1:00 p.m., the nurse ' s notes stated that the resident ' s bruises to the body remain. There was no mention before or after this entry regarding bruises. There was no documentation of bloody stools or urine. On [DATE] at 5:00 p.m., the nurse ' s notes stated that the aide was unable to hear the blood pressure. The physician was called. At 6:00 p.m. the PA returned the call and requested the resident be sent to the hospital for evaluation. The nurse ' s note stated that the family wanted comfort measures only (CMO). The PA was informed of the resident ' s declining condition. On [DATE] at 12:01 a.m. the nurse ' s notes revealed that she was called to the room to find the resident had no pulse or respirations. The physician was notified. The family was notified. On [DATE] at 1:40 a.m. the nurse noted that the body was released to the funeral home. On [DATE] at around 2:00 p.m. the nurse caring for the resident (LPN #4) stated that she was on duty on [DATE] and administered [MEDICATION NAME] 2.5 mg. She stated that after the medication was given she became aware of the elevated clotting lab values after the medication was given. She stated she spoke with the Physician ' s Assistant (PA) after the medication was given and he was aware of the increased dose of [MEDICATION NAME] 2.5 mg given on [DATE]. The LPN stated that the PA stated to begin the decreased dose of [MEDICATION NAME] 2.0 mg. She did not write the order to start the dose change on [DATE]. On [DATE] at around 10:00 a.m. an interview was conducted with the Physician Assistant (P.A.), via telephone. The PA verified the information provided by LPN #4. He stated the resident showed no indication of bleeding prior to her death. On [DATE] and [DATE] observation and interviews with four random medication nurses, by two nurse surveyors, revealed that all four nurses, LPNs, received education and training related to administration and monitoring of lab values for anticoagulant therapy. Each nurse demonstrated several current resident MAR, on the medication carts. The NHA stated on [DATE] at around 2:00 p.m. that she was unaware of the three physician order [REDACTED]. She stated that she was apprised of the details regarding resident #3 but was not aware of the errors related to residents #4 and #14 until the surveyors discussed the findings with her. She also was unaware of nursing staff not notifying nursing administration with concerns regarding physician contacts. She stated the DON and ADON had provided numbers to call after hours with concerns. She verified her job description required her to be responsible for " all services, professional and business " regarding the operation of the facility. The DON stated that the following measures were enacted after the medication error was investigated: Corrective Action: 1. Discipline: Terminated three employees from [DATE] to [DATE]. There were three nurses who received written warnings for poor performance from [DATE] to [DATE]. 2. Education: DON gave [MEDICATION NAME] usage in-service on [DATE] with discussion of Bleeding and side effects related to INR ' s and [MEDICATION NAME] dose. All licensed staff attended, except two nurses who work part time. They will receive the in-service prior to the next scheduled shift. They have been informed by phone. 3. Pharmacy changes: Medication Administration Records (MAR) are being changed , effective [DATE], and reprinted to include a space for the " INR level " just above the sign out portion on the MAR indicated [REDACTED]. 4. Pharmacy will preprint stop dosing perimeters to not give medication when INR is greater than 3.0. 5. Standing Orders will be written on the charts of patients receiving [MEDICATION NAME], to stop medication for INR above 3.0, effective [DATE]. 6. [MEDICATION NAME] Policy: was re-written by the Medical director and Director of Nurses, [DATE]. 7. Education to nurses on [DATE] included transcribing all physicians ' orders with correct date, time and nurses initials of who wrote the order. 8. Medical Director consulted with staff and pharmacy, on [DATE]. 9. Medical Director has provided personal cell phone numbers to the nurses and will follow up with the answering service to increase better communication with the physician/physician assistant/nurse practitioner. 10. Assistant Director of Nurses created new perimeters for MD access with time specific guidelines to notify facility administration, effective [DATE]. 11. DON/designee will conduct monthly QA on 24-hour chart checks to ensure that orders were carried through as written, begun on [DATE]. All corrective actions since the event were verified as having been completed or in place and the scope and severity of F 490 was reduced to D on [DATE] at 4:30 p.m.

Based on record review and interviews with the Medical Director, the Director of Nurses (DON), the Assistant Director of Nurses (ADON) and a Physician ' s Assistant (PA) the facility staff failed to notify the attending medical practitioner of significant changes that required a need to significantly alter the medication regime, prevent adverse outcomes, and manage the deteriorating condition for two of 16 residents (#3, #14). The failure by the staff to notify the physician of bloody stools, continuing for three days or more (#3), three additional doses of [MEDICATION NAME] (an anticoagulant) given past a physician ordered " Hold " (#3), and laboratory specimens not obtained or monitored in a timely fashion (#14) resulted in the physician having an incomplete clinical picture of the residents status during anticoagulation treatment at the facility. These actions resulted in findings of immediate jeopardy, which was removed on [DATE] at 4:30 p.m. and the severity and scope was reduced to a D. Findings Include: Per the face sheet, resident #3 was readmitted to the facility on [DATE] after hospitalization for a [MEDICAL CONDITION] Embolism (blood clot in the lungs). The face sheet listed multiple other co morbidities including: [MEDICAL CONDITION], Dementia, and [MEDICAL CONDITION], Late effects of a stroke, [MEDICAL CONDITION], stage 3, Diabetes, a prior [MEDICAL CONDITION], Hypertension, and Diverticulitis of the colon (inflammation). Review of the physician's order [REDACTED]. Oxygen two liters by nasal canual as needed Insulin 5 units three times daily with meals and sliding scaled coverage [MEDICATION NAME], 44 units at bedtime [MEDICATION NAME] two tablets by mouth three times daily for [MEDICAL CONDITION] diarrhea. [MEDICATION NAME] 500 mg three times daily for 21 days, end date [DATE] (antimicrobial for C.Diff diarrhea) [MEDICATION NAME] ([MEDICATION NAME]), 2 mg, daily at 5:00 p.m. (anticoagulant to prevent clots) Laboratory: [MEDICATION NAME] Time (PT)/International Normalized Ratio (INR) testing on Mondays for medication titration of anticoagulant therapy. On [DATE], no time specified, a nurse practitioner note stated that the resident had crackles in the right lung base. The findings stated that the abdomen was soft and benign. The assessment was: Pneumonia. Intravenous Antibiotics were ordered. There was no documentation of bloody stools. On [DATE], no time specified, a physician visited the resident. The note stated the right lung base had a " few crackles " and the abdomen was soft. Under Impression, item #3, the physician wrote " [MEDICAL CONDITION] Embolism, on [MEDICATION NAME], INR 3.0 today " . Item 6 stated " H/O (history of) C.Diff [MEDICAL CONDITION] " . There was no mention of bloody stools. On [DATE] at 1:30 p.m. a physician visited the resident. The progress note stated that the resident had " loose BM since a.m. (total of 4). The physician noted the elevation of the INR, 6.7 (Therapeutic range 2.0 to3.0). He wrote that the right lower lung had fine crackles. There was no documentation of bloody stools. He wrote under the item Plan: Hold [MEDICATION NAME] ([MEDICATION NAME]). Breathing exercises with Acxupella three times daily. Discontinue the [MEDICATION NAME] the five day course. " Watch for no. (number) of BMs and inform " . On [DATE] at 1:30 p.m. the physician wrote an order: [MEDICATION NAME] Hold until next PT/INR results. A review of the [DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. [DATE] [MEDICATION NAME] 2mg was recorded as given by nurse #2 at 5:00 p.m. [DATE] [MEDICATION NAME] 2mg was recorded as given by nurse #2 at 5:00 p.m. [DATE] [MEDICATION NAME] 2 mg was recorded as given by nurse #3 at 5:00 p.m. A review of the Nurses notes from [DATE] to [DATE] revealed the following information: [DATE], 12:00 noon, no mention of bloody stools or any diarrhea. [DATE], 9:00 p.m., " occ (asional) incontinent, c/o (complained of) nausea. Appetite poor, " There was no documentation of bloody stools or any diarrhea. [DATE] at 2:00 p.m. the nurse wrote: " nausea with plus sign results from medication ...loose stools continues " . There was no mention of bloody stools. [DATE], no time specified, the Nurse Practitioner (ARNP) visited the resident. The progress note stated, history of[DIAGNOSES REDACTED]. Staff reported resident had " 1 loose stool this morning with a? (question mark) of blood and mucus " . The assessment revealed the resident ' s abdomen was " soft, benign, with vague complaints of discomfort. The plan indicated to obtain a stool sample for the C.Diff toxin and continue current management. The nurses notes dated [DATE], at 1:00 p.m., stated " loose stools continue " ' There was no documentation of blood in the stool. At 8:00 p.m., the notes stated, the resident had three " blood colored BMs " . The physician was called. There was no documentation regarding the outcome of the physician ' s call. On [DATE], at 7:00 p.m., (a late entry) the nurses note stated the resident had a dark loose, maroon colored stool. [DATE] The MAR indicated Rectal Bleeding " . Per the nurse ' s notes dated [DATE], 11:00p.m. to 7:00 a.m. shift, no time specified, the nurses note stated that the resident " cont to have loose stools " . The note stated that the vital signs were changing but no numbers were recorded. The physician was not called. [DATE] the MAR indicated rectal bleeding " . The nurses notes dated [DATE] at 11:45 a.m., stated the physician was called. It did not state why. At 11:50 a.m., the nurses notes stated the physician called back and orders were received for Stat (urgent) lab work: Complete Blood Count (CBC) and Basic Metabolic Panel (BMP). A PT/INR was not ordered. 12:10 p.m. the notes stated the resident continued to have blood in her stool and a small amount of blood in the emesis (vomit). She continued to have no oral intake. There was no documentation indicating the physician was informed of the bloody stools. [DATE] the MAR indicated rectal Bleeding " . The nurse ' s notes dated [DATE], at 7:00 p.m., recorded that the lab results were in and several attempts were made to call the physician. At 10:40 p.m. the physician ordered oral medication, [MEDICATION NAME] 500mg three times daily (for C.Diff) and intravenous fluids for 24 hours. There was no documentation for nineteen hours regarding bloody stools. There was no documentation that the physician was informed of the bloody stools. The nurse ' s notes dated [DATE], at 7:45 a.m., stated that the resident was " found in a pool of blood from the rectal area " . The note stated that the resident was sent to the hospital, no time specified. Per the nurse ' s note dated [DATE], at 8:20 a.m., the family informed the facility that the resident had died . On [DATE], at around 11:00 a.m., the DON reviewed the nurse ' s notes from [DATE] to [DATE] and confirmed that the nurses did not record the frequency, amount or color of the rectal bleeding/bloody stools. She verified that the notes do not reflect that the physicians were informed of the bleeding/bloody stools. She stated she was informed of the failure to transcribe the order to Hold [MEDICATION NAME] on [DATE], after the resident had died . She stated that she began the investigation into the error at that time. She stated that corrective action was begun on [DATE] to prevent further errors. All licensed staff was reeducated regarding administration and documentation of status with [MEDICATION NAME] administration. On [DATE], [DATE] and [DATE] interviews with the Medical Director for the facility revealed that he was the attending physician for resident #3. He stated he was informed by the facility, on [DATE], of a [MEDICATION NAME] medication error regarding resident #3. He stated at that time, midmorning of [DATE], he was told that the order to Hold [MEDICATION NAME] 2 mg, written on [DATE], was not transcribed to the MAR. He was then informed that the resident received three extra doses, ,[DATE], ,[DATE], and [DATE]. He stated he was then informed of the termination of three nurses regarding the errors. During the interview of [DATE], the physician consulted his two physician partners and the ARNP in the practice by telephone. He stated that no one in the practice had been informed by the facility staff about concerns of rectal bleeding or bloody stools. He stated the resident had a history of [REDACTED]. He also stated that the resident was having lung crackles and they were concerned about a recurrence of a blood clot in the lungs. He stated that she was medically complex. He stated all of the physicians and the ARNP were unaware of the three additional doses of [MEDICATION NAME] given past the order to hold on [DATE] until they were informed by him on [DATE]. He stated that had they been aware of the bloody stools, rectal bleeding or the medication error, they would have ordered a PT/INR test along with the other lab work on [DATE]. He stated that since they were unaware, this test was not ordered. The physician stated several times during these interviews that he and his partners were not notified of the significant changes of the resident ' s status in the days leading up to her death. Review of the face sheet for resident #14,, revealed that she was [AGE] years old and was admitted to the facility on [DATE]/ The admitting [DIAGNOSES REDACTED]. Review of the Laboratory reports for resident #14 revealed a lab test dated [DATE] with the following results: PT: 56.2, verified by repeat Reference Range: 11XXX,[DATE].9. INR: 6.1 (Reference Range 0.8 - 1.2.)A notation on the lab report stated " [MEDICATION NAME] on hold til INR <3.0 " . It was initialed by the nurse. A physician ' s telephone order dated [DATE], at around 12:00 p.m., stated the following: 1. [MEDICATION NAME] ([MEDICATION NAME]) 2.5 mg po (oral) daily is to be held until INR is <(less than symbol) 3. 2. PT/INT scheduled to be rechecked Thursday [DATE]. Review of the MAR for resident #14 revealed that [MEDICATION NAME] 2.5 mg was held on ,[DATE], ,[DATE], and [DATE]. [MEDICATION NAME] 2.5 mg at 5:00 p.m. was restarted on [DATE] and continued with daily administration through [DATE], the end of the month of November, 2010. Review of the laboratory reports for November, 2010 revealed NO report for [DATE]. Review of the physician's order [REDACTED]. On [DATE] at 11:10 a.m. an interview with the nurse caring for the resident revealed that she was the nurse who wrote the order to hold the [MEDICATION NAME] until the lab testing of [DATE]. She initially stated she could not find the lab. She then checked the calendar and confirmed that [DATE] was a holiday and the lab calendar stated Stat (urgent) only labs would be done. She then confirmed that the [MEDICATION NAME] was restarted on [DATE] without an order to do so. The nurse stated she thought that the resident was on twice weekly lab testing, Monday and Thursday and that was why she thought the next test would be Thursday. She stated she should have checked the lab book first because the Physician ' s Assistant that gave the order stated to hold [MEDICATION NAME] until the next INR test was below 3.0. The next test was scheduled for [DATE]. The nurse stated she was unaware of the error until this time when the surveyor requested a copy of the [DATE] lab results. On [DATE], at around noon, the DON was informed of the missed lab order and that [MEDICATION NAME] was restarted without an order to do so. She stated she was unaware of the situation until this time. The DON reviewed the medical record and stated that the [DATE] INR was 2.6. She confirmed that [MEDICATION NAME] was given from ,[DATE] to [DATE] without an order to do so. On [DATE] at 12:00 p.m. the nurse placed a call to the P.A. to inform him of the error. She recorded in the nurses notes that the P.A. changed the testing to twice weekly for resident #14. The nurse stated she was aware of the side effects of [MEDICATION NAME] and that none were observed with this resident. On [DATE] at around 2:00 p.m. the DON reviewed the corrective action after the medication error related to resident #3. She consulted the ADON and stated the following: 1. Three nurses were terminated from [DATE] to [DATE]. 2. Three nurses received written warnings for poor performance from [DATE] to [DATE]. 3. The DON presented an in-service Education on [DATE] regarding Anticoagulant therapy and side effect monitoring. Bleeding and laboratory values were discussed. All licensed staff were required to attend. Two nurses that work part time, have not attended but have been informed by phone that they must receive the education prior to working the next scheduled shift. 4. Effective [DATE] the pharmacy has been instructed to print a space on the MAR for the lab values related to clotting. This area is to be just above the sign out portion of the MAR for the anticoagulant medications so that the nurse will be aware of the lab values at the time of administration. 5. Pharmacy will preprint Stop parameters for anticoagulants so that the nurse will be informed to not give the medication if the INR test exceeds a designated threshold prescribed by the physician. 6. Standing orders will be written by the physician on the charts of the residents receiving anticoagulants, to stop administration if the INR exceeds 3.0. 7. The [MEDICATION NAME] administration policy was rewritten by the DON and the Medical Director, effective [DATE]. 8. The Education program of [DATE] included correct documentation expectations including: physician's order [REDACTED]. 9. The Medical Director consulted with the staff and the pharmacy on [DATE], the time of the discovery of the error. 10. The Medical Director has provided personal cell phone numbers to the nursing staff to assure a timely response to calls with resident concerns. He stated concerns with the answering service had been addressed prior to [DATE]. 11. The ADON created new perimeters for MD access time specific guidelines to notify facility administration , effective [DATE]. 12. DON or designee will conduct monthly QA on 24 hour chart checks to ensure that all orders were carried through as written, begun on [DATE]. On [DATE] and [DATE] during the morning and afternoon shifts, observation and random interviews with four medication nurses by two nurse surveyors revealed that all four nurses stated they received education and training related to administration and monitoring of lab values for anticoagulant therapy. Each nurse showed the surveyors current MARs with updated guidelines for stopping or holding the anticoagulant, a laminated side effect sheet in front of each MAR, and a designated place on the MAR for recording the lab values for clotting studies. All corrective actions since the event were verified as having been completed or in place and the scope and severity of F157 was reduced to a D on [DATE] at 4:30 p.m.

Based on review of resident records, interviews of facility staff, interviews with the Physician/Medical Director, and interviews with the Director of Nurses (DON), the facility failed to provide care while maintaining professional standards of practice related to the safe administration of anticoagulants ([MEDICATION NAME] ([MEDICATION NAME])), the monitoring of blood laboratory findings, and the disregard of physician's order [REDACTED].#3, #4, and #14) of 16 residents sampled . These actions potentially contributed to massive bleeding and the ultimate death of resident #3. The failure to maintain standards of practice caused medication errors related to administration of anticoagulants along with insufficient monitoring of lab values for clotting status and resulted in findings of immediate jeopardy. The immediate jeopardy was removed on December 17, 2010 at 4:30 p.m. and the scope and severity was reduced to a D. Per the Florida Statutes, Chapter 464 Nursing Part I Nurse Practice Act (ss 464.001-461.027): "(3)(a) 'Practice of Professional Nursing' means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based on applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to": 1. The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others. 2. The administration o medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments. 3. The supervision and teaching of other personnel in the theory and performance of any of the above acts. "(3) (b) 'Practice of practical nursing' means the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirm and the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist." Findings include: Per the facility face sheet for resident #3, she was initially admitted from the hospital to the facility on [DATE]. The face sheet revealed 15 [DIAGNOSES REDACTED]. Review of the physician's order [REDACTED]. " Review of the hospital physician ' s notes, dated 09/09/10 at 4:45 p.m., revealed a chief complaint of shortness of breath for three days with mild chest pain. The diagnostic data section revealed a scan was performed and showed a " high probability for acute embolism (blood clot) in the left upper lobe. " Review of the nurses notes dated 09/12/2010, the resident returned to the facility on [DATE] at around 7:00 p.m. The admission orders [REDACTED]. Per the laboratory report dated 11/22/10, at 12:45 p.m., the PT/INR results were as follows: PT: 60.7, Verified by repeat and INR: 6.7. On 11/22/10 at 1:30 p.m., a physician visited the resident. He stated that the resident had four loose bowel movements since that morning. He stated the resident had a right lower lobe lung infiltrate and was currently receiving antibiotics. He noted the history of diabetes (DM), [MEDICAL CONDITION] (CKD) stage 3, and a [MEDICAL CONDITION] infection and ordered [MEDICATION NAME] ([MEDICATION NAME]): HOLD until next PT INR results (scheduled for 11/29/10). Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 11/22/10 at 5:00 p.m. the MAR indicated [REDACTED]. On 11/23/10 at 5:00 p.m. the MAR indicated [REDACTED]. On 11/24/10 at 5:00 p.m. the MAR indicated [REDACTED]. On 11/25/10 at 5:00 p.m. the MAR indicated rectal bleeding " by nurse #5, an LPN. On 11/26/10 at 5:00 p.m. the MAR indicated rectal bleeding. " On 11/27/10 at 5:00 p.m. the MAR indicated rectal bleeding. " Per the nurse ' s notes dated 1/23/10, at 9:00 p.m., the resident was incontinent. There was no documentation of bloody stools. On 11/24/10, at 2:00 p.m., the nurse ' s notes stated that the loose stools continued. There was no mention of blood in the stool. . On 11/25/10 at 1:00 p.m. the nurse ' s notes stated loose stools continued. There was not mention of blood present. On 11/25/10 at 7:00 p.m. the nurses notes stated " dark, loose maroon colored stool. " The physician was called. The note stated " otherwise stable. " This note was recorded by LPN #5. 11/25/10 at 8:00 p.m. another nurse wrote that she attempted to call the physician two times and was awaiting a return call. She noted that the resident had a poor appetite, low fluid intake, the skin warm and dry, and the temperature was 97.7. There was no further documentation regarding physician contact. There were no telephone orders regarding this contact. On 11/26/10, 11 p.m. to 7 a.m. shift, the nurses notes stated that the resident continued to have loose stools. The vital signs were noted to be changed (no values recorded) and the resident complained of " not feeling well. " The oxygen saturation level was 96%. There was no documentation that the physician was notified. On 11/27/10 at 11:45 a.m. the nurse ' s note stated she called the physician. At 11:50 a.m. the nurse ' s notes stated that the doctor on call was contacted and Stat orders for lab work for a Complete Blood Count (CBC) and a Basic Metabolic Panel (BMP) were received. At 12:10 p.m. the nurses notes revealed that LPN #2 recorded that the resident continued to have blood in her stool and had a small amount of bloody emesis (vomit). At 2:23 p.m. the lab reported a stool sample tested positive for [DIAGNOSES REDACTED]icile toxin. At 10:30 p.m. the nurse ' s notes stated that the CBC and BMP lab results were reported and attempts were made to contact the physician at 7:00 pm., 8:00 p.m., 8:45 p.m., and 10 p.m. There was no documentation of attempts to notify the DON of the concerns regarding the physician contact. There was no documentation of blood in the stool. At 10:40 p.m. the physician called and was informed of the lab values. The orders received were as follows: [MEDICATION NAME] 500 mg three times daily and IV fluids of Normal Saline at 100 cc per hour for 24 hours. On 11/28/10 at 2:00 a.m. the nurse ' s note stated the resident was weak but alert. There was no documentation of bloody stools. On 11/28/10 at 7:45 a.m. nurse #1 wrote that the resident was found " in a pool of blood from the rectal area. " The physician and family were called. Emergency Medical Services was called to send the resident to the hospital. There was no time in the note regarding the transfer time. Review of the hospital emergency room records, obtained from the hospital, the resident was " found by the nursing home staff hemorrhaging from the rectum and mouth. " The resident was in an agonal cardiac rhythm and not breathing. The exam timed at 8:13 a.m. stated that the resident had a high INR and continued to receive [MEDICATION NAME] at the facility. There was no documentation on the emergency room record of the presence of blood. The Clinical Impression was: DOA, dead on arrival. The physician pronounced the time of death as 8:15 a.m. On 11/08/10 a second physician visited the resident in the facility. The physician wrote in the progress note that the resident had four loose stools since the morning, no time specified on the note, and that it " smells like [DIAGNOSES REDACTED]. " Under the Plan section he wrote: Stool for [DIAGNOSES REDACTED]; [MEDICATION NAME] 2 mg daily; Metrogyl ([MEDICATION NAME]) 500 mg three time daily (used to treat a [DIAGNOSES REDACTED] infection), and Lactobacillus, one capsule twice daily. Per the Nurse Practitioner progress note dated 11/15/2010, the resident had a low-grade fever and vomiting. The assessment stated that the resident had " crackles right lung base. " Intravenous medications were ordered. The labs of that day were: PT: 32.1; INR 3.0. The lab report contained a hand written note to continue [MEDICATION NAME] 2 mg. On 11/16/10 the Nurse Practitioner visited the resident. The notes stated that the resident had " a few crackles " in the right lung base. Under the Impression section, item #3, she stated " [MEDICAL CONDITION] Embolism; On [MEDICATION NAME]. INR 3.0 today " . Item #6 stated a history of [DIAGNOSES REDACTED]. There was no documentation of bloody stools. On 11/24/10, no time specified, the Nurse Practitioner visited. She stated in the note that the staff reported the resident had one loose stool that morning with a question of blood and mucus observed. The exam revealed the abdomen to be " soft, benign, with vague complaints of discomfort. " Under the topic of Plan, the documentation stated: [DIAGNOSES REDACTED] toxin A/B and continue current management. On 12/15/10 and 12/17/10 interviews with the physician/medical director revealed that he had been the attending physician for resident #3. He stated he was on vacation the week of 11/22/10 but he consulted with the other physicians in the practice and everyone was aware of the multiple co morbidities of the resident. He stated he was unaware of the facility failure to hold the [MEDICATION NAME] until he was informed on 11/29/10, midmorning, by the DON. He stated he came to the facility to evaluate the record and the error. He was aware of the termination of three nurses. The physician stated he signed the Death Certificate and provided a copy on 12/17/10. He stated the primary cause of death was: Multiple Medical Problems of Aged. The secondary underlying issues were: [MEDICAL CONDITION] (GI Bleed); [DIAGNOSES REDACTED], [MEDICAL CONDITION], Diabetes Mellitus (DM), [MEDICAL CONDITION] (CAD) and [MEDICAL CONDITION] CKD. He called his office and spoke with his partners during the interview of 12/17/10, and the physicians and nurse practitioner stated the facility did not verbalize concerns about rectal bleeding, but just the diarrhea. The physicians in the practice, including the nurse practitioner, stated to him that they did not have knowledge of the three additional doses of [MEDICATION NAME] and were treating resident #3 for the [DIAGNOSES REDACTED]icile [MEDICAL CONDITION] and lung infection. On 12/15/10, at around 2:00 p.m., an interview with the Director of Nurses (DON) revealed that she became aware of a medication error related to [MEDICATION NAME] not being held and the death of resident #3 on 11/29/10 at about 8:30 a.m. She stated that nurse #1 was on duty on 11/29/10 and that she reported to the DON that she was taking the record apart (resident #3) when she noticed that the order of 11/22/10 to hold [MEDICATION NAME] were not transcribed to the MAR. She initially stated that she did not find the order. The DON then showed her the order that she had written on 11/22/10. Nurse #1 was terminated on 11/29/10. The DON stated that she then began the adverse incident investigation. She stated that nurse #2, who gave [MEDICATION NAME] on 11/22 and 11/23/10, was terminated also. Nurse #4, a night nurse responsible for the 24 hour chart check was terminated two days later for not catching the error. The DON stated that the attending physician for resident #3 is also the Medical Director for the facility. He was informed on 11/29/10, around midmorning. She stated he immediately came to the facility and discussed it with her, the ADON, the Risk Manager and the Nursing Home Administrator. The DON stated that on 12/01/10 all licensed staff was educated on anticoagulant therapy, lab values and signs/symptoms of side effects. She provided a sign in sheet with all licensed staff except two nurses. One of the two nurses worked once every six weeks and had been notified by phone to report to work early to have the education prior to coming on duty. The second nurse worked every other weekend and was informed to report early on the next scheduled day. She had not worked since 12/01/10. Per the face sheet dated 01/30/2009 for resident #14, she was admitted to the facility on [DATE]. The admitting [DIAGNOSES REDACTED]. Review of the MAR for November, 2010 revealed the resident received [MEDICATION NAME] ([MEDICATION NAME]) 2.5 mg daily at 5:00 p.m. A laboratory report dated 11/22/10 revealed a PT of 56.2, verified by repeat and an INR of 6.1. Therapeutic range for the INR was listed as 2.0 to 3.0. The bottom of the lab slip contained a hand written note stating: " 11/23/10 [MEDICATION NAME] on hold till INR <3 " . It was signed, but illegible. On 11/22/10 at 12:00 p.m. the nurse ' s notes stated the physician was notified and a telephone order was received to hold [MEDICATION NAME] 2.5 mg until the INR was less than (<) 3. The note stated " PT/INR scheduled to be rechecked Thursday 11/25/10. A telephone physician's order [REDACTED].<3. PT/INR scheduled to be rechecked on Thursday 11/25/10. " A review of the MAR for 11/22/10 revealed the [MEDICATION NAME] was held on 11/22/10, 11/23/10, and 11/24/10. There was no documentation of lab results for a PT/INR for 11/25/10. But, the [MEDICATION NAME] was documented as given 11/25/10, 11/26/10, 11/27/10, 11/28/10, and 11/29/10. On 12/17/10 at 11:10 a.m. an interview with the nurse caring for the resident on 11/22/10 revealed she was unaware of the labs not being done on 11/25/10. She checked the calendar and found that 11/25/10 was a holiday and only stat labs were to be done. She then stated she did not inform the physician of that finding. She stated she was unaware until now that the [MEDICATION NAME] was restarted on 11/25/10 without the labs ordered by the physician. She said at the time she wrote the order she thought that the resident received routine, twice weekly PT/INR levels and Thursday, 11/25/10 would have been the next test. The nurse and the DON confirmed that the labs for PT/INR were not drawn on 11/25/10, and the physician was not notified. Per the facility face sheet resident #4 was admitted to the facility on [DATE]. The admitting [DIAGNOSES REDACTED]. On 11/20/10, at 7:45 a.m., a physician telephone order stated, " [MEDICATION NAME] ([MEDICATION NAME]) 2.5 mg po, QD (daily). " On 11/24/10, at 10:26 a.m., a lab reported the following: PT: 36.9 and INR 3:9. A hand written notation at the bottom of the lab report stated: 11/24/10 " [MEDICATION NAME] decreased (indicated by downward arrow) to 2.0. The numbers were written over and the initial note was 2.5. The note was not signed nor time specific. A review of the nurse ' s notes dated 11/24/2010, at 8:30 p.m., revealed an entry that stated an order was received to decrease the [MEDICATION NAME] to 2.0 mg at 5 p.m. daily. The note was signed by the RN, charge nurse. There was no documentation regarding what time the physician was contacted regarding the abnormal lab values. Per the review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. 11/24/10 at 9:00 p.m. the LPN #4 note stated that the resident was resting well and in no distress or pain. On 11/25/10 at 1:00 p.m. the nurse ' s notes stated that the resident ' s bruises to the body remain. There was no documentation of bloody stools or urine. On 11/26/10 at 3:00 p.m. the nurse ' s notes stated that the resident was resting quietly and refused to eat breakfast. Lunch intake was 20%. On 11/26/10 at 5:00 p.m. the nurse ' s notes stated that the aide was unable to hear the blood pressure. The physician was called. At 6:00 p.m. the PA returned the call and requested the resident be sent to the hospital for evaluation. The note stated that the family wanted comfort measures only (CMO). The PA was informed of the resident ' s declining condition. The note further stated that the oxygen saturation was 88%. On 11/27/10 and 11/28/10 the MAR indicated [REDACTED]. On 11/28/10 nurse ' s notes, no time specified, stated resident took no meds on that day, there were no complaints of pain, and the staff provided comfort measures only. The note stated that the resident was incontinent. There was no mention of blood in the stool. On 11/29/10 at 12:01 a.m. the nurse ' s notes revealed that she was called to the room to find the resident had no pulse or respirations. The physician was notified. The family was notified. On 11/29/10 at 1:40 a.m. the nurse noted that the body was released to the funeral home. On 12/16/10 at around 2:00 p.m. the nurse caring for the resident (LPN #4) stated that she was on duty on 11/24/10 and administered [MEDICATION NAME] 2.5 mg. She stated that after the medication was given she became aware of the elevated clotting lab values after the medication was given. She stated she spoke with the Physician ' s Assistant (PA) after the medication was given and he was aware of the increased dose of [MEDICATION NAME] 2.5 mg given on 11/24/10. The LPN stated that the PA stated to begin the decreased dose of [MEDICATION NAME] 2.0 mg. She did not write the order to start the dose change on 11/25/10. On 12/17/10 at around 10:00 a.m. an interview was conducted with the P.A. via telephone. The PA stated he was aware of the resident receiving [MEDICATION NAME] 2.5 mg on 11/24/10. He stated he gave the order to begin the decreased dose on 11/25/10. He stated there was no indication of bleeding prior to her death. Per an interview with the Director of Nurses on 12/16/2010, at approximately 12:00 p.m., the following measures were enacted after the medication errors were investigated: Corrective Action: 1. Discipline: Terminated three employees from 11/29/10 to 12/01/10. There were three nurses who received written warnings for poor performance from 12/01/10 to 12/17/10. 2. Education: DON gave [MEDICATION NAME] usage in-service on 12/01/10 with discussion of Bleeding and side effects related to INR ' s and [MEDICATION NAME] dose. All licensed staff attended, except two nurse who work part time. They will receive the in-service prior to the next scheduled shift. They have been informed by phone. 3. Pharmacy changes: Medication Administration Records (MAR) are being changed , effective 12/01/10, and reprinted to include a space for the " INR level " just above the sign out portion on the MAR indicated [REDACTED]. 4. Pharmacy will preprint stop dosing perimeters to not give medication when INR is greater than 3.0. 5. Standing Orders will be written on the charts of patients receiving [MEDICATION NAME], to stop medication for INR above 3.0, effective 12/01/10. 6. [MEDICATION NAME] Policy: was re-written by the Medical director and Director of Nurses, 12/01/10. 7. Education to nurses on 12/01/10 included transcribing all physicians ' orders with correct date, time and nurses initials of who wrote the order. 8. Medical Director consulted with staff and pharmacy, on 11/29/10. 9. Medical Director has provided personal cell phone numbers to the nurses and will follow up with the answering service to increase better communication with the physician/physician assistant/nurse practitioner. 10. Assistant Director of Nurses created new perimeters for MD access with time specific guidelines to notify facility administration, effective 12/17/10. 11. Nurse Consultant will provide additional educational in-service on documentation in January, 2011. 12. Electronic MAR indicated [REDACTED]. 13. DON/designee will conduct monthly QA on 24-hour chart checks to ensure that orders were carried through as written, begun on 12/16/10. 14. Pharmacy Consultant will plan to conduct focused review of medication interactions on all residents on anticoagulant therapy. All corrective actions since the event have been initiated and the scope and severity of F 333 was reduced to D on 12/17/10 at 4:30 p.m.

Based on record review and interviews, the facility failed to meet the needs of three of 16 residents (#3, #4, and #14) on anticoagulant therapy by neglecting to carry out physician orders [REDACTED]. The facility ' s failures resulted in errors of the administration of anticoagulant therapy after a physician ordered the medication be held, related to laboratory findings significantly outside therapeutic range. One of the three sampled residents (#3) died three days after receiving three doses of the anticoagulant medication in error, thereby, potentially contributing to the resident ' s death by [MEDICAL CONDITION] and other co-morbidities. These actions resulted in findings of immediate jeopardy, which was removed on [DATE] at 4:30 p.m. and the severity and scope was reduced to a D. Findings include: 1. Resident # 3 was originally admitted to the facility on [DATE], according to the medical record facesheet, following a hospitalization , and died on [DATE], per a hospital emergency department record of that date. Continued review of the hospital emergency room records disclosed that the resident was " found by the nursing home staff hemorrhaging from the rectum and mouth." The resident was in an agonal cardiac rhythm and not breathing. The assessment stated the resident was a " no code with papers." The Chief Complaint stated: [MEDICAL CONDITION] pre-hospital. The exam, timed at 8:13 a.m., stated that the resident had a high INR and continued to receive [MEDICATION NAME] at the facility. The Clinical Impression was: DOA, dead on arrival. The physician pronounced the time of death as 8:15 a.m. on [DATE]. Review of the November, 2010 medication administration record for Resident #3 provided the following treatment regime: 1. [MEDICATION NAME] 10mg. p.r.n.; 2. [MEDICATION NAME] 500 mg. p.o. T.I.D. for a total of 21 days (Initiated [DATE]); 3. [MEDICATION NAME] 2 mg. p.o. q.d. ([DATE]); 4. [MEDICATION NAME] Tab 1 mg (Gen EQ of [MEDICATION NAME]), one tablet p.o. daily, (order changed [DATE]); 5. [MEDICATION NAME], inject 44 units sub-cut at bedtime; 6. Glimepiride Tab 2 mg., on table p.o. every morning; 7. Milk of Magnesia Susp, 30 ml. by mouth daily as needed; 8. [MEDICATION NAME]/[MEDICATION NAME] SOL, one vial via nebulizer four times daily as needed; 9. [MEDICATION NAME] 0.25 mg. tab, one tablet by mouth three times daily as needed (changed [DATE]); 10. Tylenol 325 mg tab, two tablets by mouth every four hours as needed; 11. [MEDICATION NAME] Tab 25 mg (D/C); The November, 2010 Medication Administration record also included handwritten orders which had been transferred from the physician's order [REDACTED]. p.o. T.I.D., Lactobacillus ([DATE]) one tab p.o. B.I.D., [MEDICATION NAME] 500 mg. IV q 12 hours x two days, then, [MEDICATION NAME] 500 mg. p.o. B.I.D. twelve hours x 2 days, [MEDICATION NAME] 25 mg. p.o. q six hours p.r.n. n/v,[MEDICATION NAME] mg. B.I.D. x 5 days, and [MEDICATION NAME] 10 mg. p.o. q.d. Missing from the November, 2010 Medication Administration Record, however, was an [DATE] " [MEDICATION NAME] HOLD till next PT/INR results " which was scheduled for [DATE], per the November, 2010 Treatment Record. On [DATE] at 1:30 p.m., a physician visited resident #3. He stated that the resident had four loose bowel movements since that morning. He stated that the resident had a right lower lobe lung infiltrate and was currently receiving antibiotics. He noted the history of diabetes (DM), [MEDICAL CONDITION] (CKD) stage 3, and a [DIAGNOSES REDACTED] infection. Prior to the physician ' s visit of [DATE], the facility had received a printed lab report at 12:45 p.m. with the following lab values: PT: 60.7, Verified by repeat INR: 6.7 The following plan was: 1. [MEDICATION NAME] ([MEDICATION NAME]): HOLD until next PT INR results (scheduled for [DATE]); 2. Breathing exercises with Acupella three times daily; 3. Discontinue the [MEDICATION NAME] the five day course; 4. Watch for number of bowel movements and inform. On [DATE], during an interview with the attending physician at 3:12 p.m., it was revealed that the facility staff did not communicate to the physician concerns about blood in the stools. On [DATE] the physician order [REDACTED].#1, an LPN. On [DATE] at 5:00 p.m., the MAR revealed [MEDICATION NAME] 2 mg. was given by nurse #2, an LPN. On [DATE] at 5:00 p.m. the MAR revealed [MEDICATION NAME] 2 mg. was given by nurse #2, an LPN. On [DATE] at 9:00 p.m., the nurse ' s notes stated that the resident was incontinent. There was no documentation of bloody stools. On [DATE] at 5:00 p.m., the MAR revealed [MEDICATION NAME] 2 mg. was given by nurse #3, an LPN. Current [DIAGNOSES REDACTED]. Review of a September, 2010 hospital admission physician ' s notes, dated [DATE] at 4:45 p.m., revealed that resident #3 had a chief complaint of shortness of breath for three days with mild chest pain. The Diagnostic Data section revealed a scan was performed and showed a " high probability for acute embolism (blood clot) in the left upper lobe. " The Assessment and Plan section revealed that the resident was receiving [MEDICATION NAME] and had been started on [MEDICATION NAME] 5 mg daily. Item number two stated the resident had [MEDICAL CONDITION] (C.Diff) [MEDICAL CONDITION], " persistent, with mild symptoms." The hospital physician also noted a history of [MEDICAL CONDITION]. Following the September, 2010 hospitalization , Resident #3 returned to the facility on [DATE] at around 7:00 p.m. The admission orders [REDACTED]. The physician's order [REDACTED].#3 was free from potential harm. On [DATE] a monthly nursing summary report revealed that the resident was alert, with occasional confusion and forgetfulness. She was described as continent. Page six of the summary stated " no loose stools in the past few weeks." The summary details documented areas of concern that required careful monitoring to prevent physical harm including nursing monitoring of the coagulation status. On [DATE], another physician visited the resident in the facility. The physician wrote in the progress note, no time specified, that the resident had four loose stools since the morning, and that it " smells like [DIAGNOSES REDACTED]. " Under the Plan section he wrote: Stool for C.Diff; [MEDICATION NAME] 2 mg daily; Metrogyl ([MEDICATION NAME]) 500 mg three time daily (used to treat a C.Diff infection), and Lactobacillus, one capsule twice daily. On [DATE] a Nurse Practitioner progress note stated that the resident had a low grade fever and vomiting. The assessment stated that she had " crackles right lung base." Intravenous medications were ordered. On [DATE], no time specified, the Nurse Practitioner visited the resident. The notes stated that the resident had " a few crackles " in the right lung base. Under the Impression section, item #3, she stated " [MEDICAL CONDITION] Embolism, on [MEDICATION NAME]. INR 3.0 today." Item #6 stated a history of [DIAGNOSES REDACTED]. There was no documentation of bloody stools. On [DATE] at 3:10 p.m., the attending physician stated to this surveyor that all three physicians in his practice and the Advanced Nurse Practitioner (ARNP) were concerned at this point about the lung status. He stated that resident #3 had a recent history of a blood clot in the lungs and required careful management to prevent another clot. During an interview on [DATE], between ,[DATE] p.m., the DON confirmed that the facility staff administered three additional doses of [MEDICATION NAME], an anticoagulant. She stated that the facility was unaware of the error on [DATE]. On [DATE] at 2:00 p.m., the nurse ' s notes stated that the loose stools continued. There was no mention of blood in the stool. On [DATE], no time specified, the Nurse Practitioner visited. She stated in the note that the staff reported that the resident had one loose stool that morning with a question of blood and mucus observed. The exam revealed the abdomen to be " soft, benign, with vague complaints of discomfort. " Under the topic of Plan, the documentation stated: [DIAGNOSES REDACTED] toxin A/B and continue current management. On [DATE] the attending physician called the nurse practitioner and confirmed that she was unaware of any concern regarding frank blood in the stool. He stated that the N.P. was aware of the [MEDICAL CONDITION] related to C.Diff infection and was unaware that the [MEDICATION NAME] was not held as ordered. At [DATE] at 1:10 p.m., a telephone order was written for Pepto-Bismol, 30 cc every hour as needed for diarrhea, not to exceed eight doses. The MAR revealed no documentation of the administration of Pepto-Bismol. On [DATE] at 1:00 p.m., the nurse ' s notes stated loose stools continued. There was no mention of blood present. On [DATE] at 5:00 p.m., the MAR revealed that [MEDICATION NAME] 2 mg. was held due to " rectal bleeding " by nurse #5, an LPN. On [DATE] at 7:00 p.m. the nurses notes stated " dark, loose maroon colored stool. " The physician was called. The note stated " otherwise stable. " This note was recorded by nurse #5, an LPN. The nurse did not record vital signs or indications of possible physical harm related to an error of anticoagulant therapy. [DATE] at 8:00 p.m., another nurse wrote that she attempted to call the physician times two and was awaiting a return call. She noted that the resident had a poor appetite, low fluid intake, the skin warm and dry, and the temperature was 97.7. There was no further documentation regarding physician contact. There were no telephone orders regarding this contact. On [DATE] at 5:00 p.m., the MAR revealed nurse #5 held the [MEDICATION NAME] again due to " rectal bleeding. " There was no documentation in the nurse ' s notes for this shift. On [DATE], 11 p.m. to 7 a.m. shift, the nurses notes stated that the resident continued to have loose stools. The vital signs were noted to be changed (no values recorded) and the resident complained of " not feeling well. " The oxygen saturation level was 96%. There was no documentation that the physician was notified about concerns of possible harm. On [DATE] at 11:45 a.m., the nurse ' s note stated she called the physician. The nurse ' s note does not state why. On [DATE] at 11:50 a.m., the nurses notes stated that the doctor on call, identified as the first initial of his last name only, was contacted and Stat orders for a Complete Blood Count (CBC) and a Basic Metabolic Panel (BMP) were ordered. On [DATE] at 12:10 p.m., the nurse ' s notes revealed that nurse LPN #2 recorded that the resident continued to have blood in her stool and had a small amount of bloody emesis (vomit). On [DATE] at 2:23 p.m., the lab reported a stool sample tested positive for [DIAGNOSES REDACTED]icile toxin. On [DATE] at 5:00 p.m., the MAR revealed that nurse LPN #5 held the [MEDICATION NAME] due to " rectal bleeding. " On [DATE] at 10:30 p.m., the nurse ' s notes stated that the CBC and BMP lab results were reported and attempts were made to contact the physician at 7:00 pm., 8:00 p.m., 8:45 p.m., and 10 p.m. There was no documentation of attempts to notify the DON of the concerns regarding the physician contact. There was no documentation of blood in the stool. On [DATE] at 10:40 p.m., the physician called and was informed of the lab values. And orders were received for [MEDICATION NAME] 500mg three times daily and IV fluids of Normal Saline at 100 cc per hour for 24 hours. On [DATE] at 2:00 a.m., the nurse ' s note stated the resident was weak but alert. There was no documentation of bloody stools. On [DATE] at 7:45 a.m., nurse #1 wrote that the resident was found " in a pool of blood from the rectal area. " The physician and family were called. EMS was called to send the resident to the hospital. There was no time in the note regarding the transfer time. On [DATE], the ADON stated she was notified of the hospital transfer on [DATE] at around 8:30 a.m. but received no follow up information. She stated that she would have expected a call if the resident had died . She had no further contact with the facility on [DATE]. She stated she was informed of the resident ' s death on [DATE] around 7:00 a.m. On [DATE] at 8:20 a.m. the nurse ' s notes stated that the facility was informed by the family that the resident had died . On [DATE], at around 2:00 p.m., an interview with the DON revealed that she became aware of a medication error related to [MEDICATION NAME] not being held and the harm contributing to death of resident #3 on [DATE] at about 8:30 a.m. She stated that nurse #1 was on duty on [DATE] and that she reported to the DON that she was taking the record apart (resident #3) when she noticed that the order of [DATE] to hold [MEDICATION NAME] was not transcribed to the MAR. She initially stated that she did not find the order. The DON then showed her the order that she had written on [DATE]. Nurse #1 was terminated on [DATE]. The DON stated that she then began the adverse incident investigation. She stated that nurse #2, who gave [MEDICATION NAME] on [DATE] and [DATE], was also terminated. Nurse #4, a night nurse responsible for the 24 hour chart check, was terminated two days later for not catching the error. The DON stated that the attending physician for resident #3 was also the Medical Director for the facility. He was informed of the medication error on [DATE], around midmorning. She stated he immediately came to the facility and discussed it with her, the Assistant Director of Nurses (ADON), the Risk Manager and the Nursing Home Administrator (NHA). The DON stated that on [DATE] all licensed staff was educated on anticoagulant therapy, lab values and signs/symptoms of side effects. She provided a sign in sheet with all licensed staff except two nurses. One of the two nurses worked once every six weeks and had been notified by phone to report to work early to have the education prior to coming on duty. The second nurse worked every other weekend and was informed to report early on the next scheduled day. She had not worked since [DATE]. On [DATE] and [DATE], interviews with the physician/medical director revealed that he had been the attending physician for resident #3. He stated he was on vacation the week of [DATE] but he consulted with the other physicians and the Nurse Practitioner in the practice and everyone was aware of the multiple co morbidities of the resident. He stated he was unaware of the facility ' s failure to hold the [MEDICATION NAME] until he was informed on [DATE], midmorning, by the DON. He stated that he then came to the facility to evaluate the record and the error. He was aware of the termination of three nurses. The physician stated he signed the Death Certificate and provided a copy on [DATE]. He stated the primary cause of death was: 1. Multiple Medical Problems of Aged. Secondary underlying issues were: 2. GI Bleed; [DIAGNOSES REDACTED], [MEDICAL CONDITION], diabetes (DM), [MEDICAL CONDITION] (CAD) and [MEDICAL CONDITION] CKD. He further stated, on [DATE], that the resident had not received [MEDICATION NAME] during the three days prior to the bleeding event. He called his office and spoke with his partners during the interview of [DATE], and the physicians and nurse practitioner stated the facility did not verbalize concerns about rectal bleeding, but just the diarrhea. The physician reviewed the nurse ' s notes from [DATE] to [DATE] and stated that the notes did not indicate concerns regarding bloody stools or rectal bleeding. He again stated that all of the physician ' s in the practice and the Nurse Practitioner were concerned about [MEDICAL CONDITION] related to [MEDICAL CONDITION] and the lung status presented concerns of another [MEDICAL CONDITION] (blood clot). The physician stated that the physicians in the practice, including the nurse practitioner, stated to him on [DATE], that they did not have knowledge of the three additional doses of [MEDICATION NAME] and were treating resident #3 for the [DIAGNOSES REDACTED]icile [MEDICAL CONDITION] and lung infection. He stated he was unable to determine the effect of the three additional doses of [MEDICATION NAME] might have had on the resident ' s death. 2. Per the facility face sheet, resident #14 was admitted to the facility on [DATE]. The admitting [DIAGNOSES REDACTED]. Review of the MAR for November, 2010 revealed the resident received: [MEDICATION NAME] ([MEDICATION NAME]) 2.5 mg daily at 5:00 p.m. Review of the lab reports for resident #14 included the following: [DATE] Lab Report: PT: 56.2, verified by repeat. INR: 6.1. Therapeutic range listed as 2.0 to 3.0. The bottom of the lab slip contained a hand written note stating: " [DATE] [MEDICATION NAME] on hold till INR <3 " . It was signed, but illegible. Per the he nurse ' s notes dated [DATE], at 12:00 p.m., the physician was notified and a telephone order was received to hold [MEDICATION NAME] 2.5 mg until the INR was less than (<) 3. The note stated, " PT/INR scheduled to be rechecked Thursday [DATE]. " [DATE] at 12 noon, a telephone physician's order [REDACTED].<3. PT/INR scheduled to be rechecked on Thursday [DATE]. " Review of the MAR for [DATE] revealed that the [MEDICATION NAME] was held on [DATE], [DATE], and [DATE]. The [MEDICATION NAME] was documented as given [DATE], [DATE], [DATE], [DATE], and [DATE]. There was no documentation of lab results for a PT/INR for [DATE]. [DATE] lab report revealed: PT: 29.0 INR: 2.6. A hand written note on the report stated the results were called to the PA. No new orders were obtained. On [DATE] at 11:10 a.m. an interview with the nurse caring for the resident on [DATE] revealed that she was unaware of the labs not being done on [DATE]. She checked the calendar and found that [DATE] was a holiday and that only stat labs were to be done. She then stated she did not inform the physician of that finding. She stated she was unaware, until now, that the [MEDICATION NAME] was restarted on [DATE] without the labs as ordered by the physician. She stated that at the time she wrote the order she thought that the resident received routine, twice weekly PT/INR levels and Thursday, [DATE] would have been the next test. The nurse and the DON confirmed that the labs for PT/INR were not drawn on [DATE], per the telephone order, and the physician was not notified. The nurse and the DON confirmed that [MEDICATION NAME] ([MEDICATION NAME]) 2.5 mg, daily at 5:00 p.m., was restarted on [DATE] without the labs or a physicians order to do so. The resumption of anticoagulation medication in the presence of unknown lab values for coagulation studies, on [DATE], subjected the resident to possible physical harm. The nurse received a written discipline from the DON on [DATE] and the physician was informed of the error. On [DATE] the physician ordered PT/INR labs twice weekly on Monday and Thursday. 3. Per the facility face sheet resident #4 was admitted to the facility on [DATE]. The admitting [DIAGNOSES REDACTED]. Review of the facility record revealed that the resident was transferred to the hospital on [DATE]. The history and physical, dated [DATE], revealed that the resident was [AGE] years old, had generalized weakness, and a cough. The plan included obtaining an MRI of the brain. On [DATE] a hospital consult physician ' s report stated that the resident had a generalized [MEDICAL CONDITION] disorder. The neurological exam revealed the resident was confused, disoriented, and required the assistance of three to walk a couple of steps. A CT scan of the head and an MRI of the brain revealed no acute event. Under the section of Plan, the physician consult wrote: #5: " Okay to continue [MEDICATION NAME] for [MEDICAL CONDITION] Fibrillation (a heart arrhythmia) since there is no acute stroke. " Per the face sheet, the resident returned to the facility on [DATE]. On [DATE] A Do Not Resuscitate (DNR) order was signed by the proxy and the physician. On [DATE] a physician telephone order read, " Accept transfer orders; PT/INR every Monday and Thursday. " On [DATE] at 7:45 a.m. a physician telephone order read, " [MEDICATION NAME] ([MEDICATION NAME]) 2.5 mg po, QD (daily). Review of the MAR revealed that the order was transcribed and given on [DATE], [DATE], [DATE], and [DATE]. [DATE] at 10:26 a.m. a lab reported the following: PT: 36.9 INR: 3.9 A hand written notation at the bottom of the lab report stated: [DATE] " [MEDICATION NAME] decreased (indicated by downward arrow) to 2.0 " . The numbers were written over the initial value of 2.5. The note was not signed, nor time specific. On [DATE] [MEDICATION NAME] ([MEDICATION NAME]) 2.5 mg 5:00 p.m. dose was recorded on the MAR as given by LPN # 4. Administration of the prior, higher, dose of an anticoagulant, in the presence of elevated coagulation lab values, subjected the resident to the possibility of serious physical harm. Per a physician telephone order dated [DATE], no time specified, stated to decrease the [MEDICATION NAME] to 2.0 mg daily at 5:00 p.m. The Registered Nurse in charge signed the order. Per review of the nurse ' s notes dated [DATE], at 8:30 p.m., stated an order was received to decrease the [MEDICATION NAME] to 2.0 mg at 5 p.m. daily. The note was signed by the RN, charge nurse. There was no documentation regarding what time the physician was contacted regarding the abnormal lab values. [DATE] at 9:00 p.m. the LPN #4 note stated that the resident was resting well and in no distress or pain. [DATE] at 1:00 p.m. the nurse ' s notes stated that the resident ' s bruises to the body remain. There was no further documentation of the bruises before or after this note. There was no documentation of bloody stools or urine. Per the MAR, on [DATE] and [DATE] [MEDICATION NAME] 2.0 mg was recorded as given at 5:00 p.m. Per the nurse ' s notes dated [DATE], at 3:00 p.m., the resident was resting quietly and refused to eat breakfast. Lunch intake was 20%. The nurse ' s notes dated [DATE], at 5:00 p.m., stated that the aide was unable to hear the blood pressure. The physician was called. At 6:00 p.m. the PA returned the call and requested the resident be sent to the hospital for evaluation. The note stated that the family wanted comfort measures only (CMO). The PA was informed of the resident ' s declining condition. The note further stated that the oxygen saturation was 88%. On [DATE], at 12:01 a.m., the nurse ' s notes revealed that she was called to the room to find the resident had no pulse or respirations. The physician was notified. The family was notified. On [DATE], at 1:40 a.m., the nurse noted that the body was released to the funeral home. On [DATE] at around 2:00 p.m., the nurse caring for the resident (LPN #4) stated that she was on duty on [DATE] and administered [MEDICATION NAME] 2.5 mg at 5:00 p.m. She stated that after the medication was given she became aware of the elevated clotting lab values. She stated she spoke with the Physician ' s Assistant (PA) after the medication was given and he was aware that the dose of [MEDICATION NAME] 2.5 mg was given on [DATE]. The LPN stated that the P.A. stated to begin the decreased dose of [MEDICATION NAME] 2.0 mg, on [DATE]. She did not write the order to start the dose change on [DATE]. On [DATE], at around 10:00 a.m., the P.A. was contacted by telephone. This writer spoke with him and was informed that he was aware the resident received [MEDICATION NAME] 2.5 mg on [DATE]. He stated he gave the order to begin the decreased dose on [DATE]. He stated he did not think it affected the resident ' s demise. He stated there was no indication of bleeding prior to her death. On [DATE], around 12:00 p.m., the DON stated that nurse LPN #4 received a written reprimand for giving a [MEDICATION NAME] dose after the facility received elevated blood values and not writing the telephone order to start the reduced dose of [MEDICATION NAME] 2.0 mg on [DATE]. The DON confirmed the medication error subjected the resident to possible harm. The DON stated that the following measures were enacted after the medication error was investigated: Corrective Action: 1. Discipline: She stated she terminated three nurse employees from [DATE] to [DATE]. There were three additional nurses who received written warnings for poor performance from [DATE] to [DATE]. 2. Education: DON gave [MEDICATION NAME] usage in-service on [DATE] with discussion of bleeding and side effects related to PT/INR lab values and [MEDICATION NAME] dose. All licensed staff attended, except two nurse who work part time. They will receive the in-service prior to the next scheduled shift. They have been informed by phone. 3. Pharmacy changes: Medication Administration Records (MAR) were changed , effective [DATE], and reprinted to include a space for the " INR level " just above the sign out portion on the MAR so the nurse would know the INR level at the time the next dose is due. 4. Pharmacy will preprint Stop Dose perimeters to not give anticoagulant medication when INR is greater than 3.0. 5. Standing Orders will be written on the charts of patients receiving [MEDICATION NAME], to stop medication for INR above 3.0, effective [DATE]. 6. [MEDICATION NAME] Administration Policy was re-written by the Medical director and Director of Nurses, [DATE]. 7. Education to nurses on [DATE] included transcribing all physicians ' orders with correct date, time and nurses initials of who wrote the order. 8. Medical Director consulted with staff and pharmacy, on [DATE]. 9. Medical Director has provided personal cell phone numbers to the nurses and will follow up with the answering service to increase better communication with the physician/physician assistant/nurse practitioner. 10. The Assistant Director of Nurses created new perimeters for MD access with time specific guidelines to notify facility administration, effective [DATE]. 11. The DON/designee will conduct monthly QA on 24-hour chart checks to ensure that orders were carried through as written, begun on [DATE]. On [DATE] and [DATE] interviews by two nurse surveyors revealed that, four random nurses were aware of the new guidelines for administration and monitoring of anticoagulant medications. All four nurses, LPNs, demonstrated to the surveyors that the MAR had been revised as of [DATE], to reflect an area for documentation of the lab values directly on the MAR. Each nurse showed a laminated information sheet, in the MAR notebook section for each resident receiving anticoagulant therapy. Stop and Do Not Administer perimeters were written in the MAR block for the anticoagulant. All corrective actions have been initiated and the scope and severity of F 224 was reduced to " D " on [DATE] at 4:30 p.m.