Every finding on record at Southern Tenn Medical Center SNF

Based on facility policy review, medical record review, and interviews, the facility failed to ensure 3 residents (Resident #4, Resident #11, and Resident #17) were offered the opportunity to formulate an advanced directive upon admission to the facility of 3 residents reviewed for advanced directives. The findings include: Review of the facility's undated policy titled, Advanced Directives, revealed .The facility will provide information to the resident/ resident representative on Advanced Directives and will assist the resident/ resident representative in formulating advanced care planning .Upon admission, the resident/ resident representative will be provided with written information concerning the right to .formulate an advanced directive if he or she chooses to do so .Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/ her family members and/ or his or her legal representative, about existence of any written advanced Directives .If the resident indicates that he or she had not established advanced directives, the facility staff will offer assistance in establishing advanced directives .Nursing staff or designee will document in the medical record the offer to assist and the resident's decision to accept or decline assistance . Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction, Diabetes Mellitus Type 2, and Muscle Weakness. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #4 scored a 13 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Review of the medical record for Resident #4 revealed no documentation of an advanced directive and no documentation the facility offered the resident an opportunity to formulate an advanced directive. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including Cirrhosis of the Liver, Diabetes, and Acute Respiratory Failure. Review of an admission MDS assessment dated [DATE], revealed Resident #11 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Review of the medical record for Resident #11 revealed no documentation of an advanced directive and no documentation the facility offered the resident an opportunity to formulate an advanced directive. Review of the medical record revealed Resident #17 was admitted to the facility on [DATE] with diagnoses including Urinary Tract Infection, Muscle Wasting, and Chronic Kidney Disease. Review of an admission MDS assessment dated [DATE], revealed Resident #17 scored of 12 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Review of the medical record for Resident #17 revealed no documentation of an advanced directive and no documentation the facility offered the resident or resident's representative an opportunity to formulate an advanced directive. During an interview on 9/3/2025 at 3:33 PM, the Director of Nursing (DON) confirmed there was no documentation in the medical records to indicate Resident's #4, Resident #11, and Resident #17 had an advance directive or documentation to reflect the facility had educated or offered for Resident #4, Resident #11, and Resident #17 to formulate an advanced directive. The DON further confirmed the facility had not provided education or the opportunity to formulate advanced directives to any of the residents in the facility for several months.

Based on medical record review and interviews the facility failed to provide the required Notice of Medicare Non-Coverage (NOMNC) and Advanced Beneficiary Notice (ABN) for 3 residents (Resident #3, Resident #5, and Resident #33) of 3 residents reviewed for beneficiary notification.The findings include: Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including Myocardial Infarction [Heart Attack] and Muscle Weakness. Review of a 5 day Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #3 scored a 4 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Review of a Nursing progress note for Resident #3 dated 8/26/2025, revealed .Patient left unit .to be discharged home, transferred out of unit .EMS [Emergency Medical Services] via stretcher . Review of the medical record for Resident #3, revealed no NOMNC or ABN had been provided to the resident or resident representative. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including Chronic Kidney Disease, Severe Protein Calorie Malnutrition, and Muscle Weakness. Review of an admission MDS assessment dated [DATE], revealed Resident #5 scored a 13 on the BIMS assessment which indicated the resident was cognitively intact. Review of a Nursing progress note for Resident #5 dated 8/29/2025, revealed . Patient discharged to home . Review of the medical record for Resident #5, revealed no NOMNC or ABN and been provided d to the resident. Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including Congestive Heart Failure and Muscle Weakness. Review of an admission MDS assessment dated [DATE], revealed Resident #33 scored a 14 on the BIMS assessment which indicated the resident was cognitively intact. Review of a Nursing progress note for Resident #33 dated 7/31/2025, revealed .Patient discharged to home with home health accompanied by spouse and son . Review of the medical record for Resident #33, revealed no NOMNC or ABN had been provided to the resident. During an interview on 9/3/2025 at 4:21 PM, the MDS Registered Nurse stated Resident #3, Resident #5, and Resident #33 had not been provided a NOMNC or an ABN. The MDS Registered Nurse further stated the staff had not provided ABNs to any residents in the facility for several months. The MDS Registered Nurse continued to state the staff had not provided any residents who received Medicare Part A skilled services while in the facility a NOMNC. During an interview on 9/4/2025 at 8:35 AM, the Administrator confirmed the facility failed to provide Resident #3, Resident #5, and Resident #33 with a NOMNC and ABN. The Administrator further confirmed the staff had not provided ABN to any residents in the facility for several months. The Administrator continued to confirm the staff had not provided a NOMNC to any residents who received Medicare Part A skilled services in the facility since 2024.

Based on job description review, facility policy review, medical record review, and interview, the facility failed to provide effective administrative leadership and oversight to ensure the required documentation was maintained or obtained related to Notice of Medicare Non Coverage (NOMNC) for 3 residents (Resident #3, Resident #5, and Resident #33), failed to maintain or obtain the required documentation related to Advanced Beneficiary Notices (ABN) for 3 residents (Resident #3, Resident #5, and Resident #33), failed to offer assistance with the formulation of Advanced Directives for 3 residents (Resident #4, Resident #11, and Resident #17), and had not documented staff or residents received education on COVID-19 vaccination for 5 residents (Resident #7, Resident #11, Resident #19, Resident #24, and Resident #32), and had not offered the COVID-19 vaccine to the staff since 2022.The findings include: Review of a Job Description Report for Post Acute/ Skilled Care Administrator dated 10/11/2024, revealed .Develops and implements Skilled Care goals, plans, and standards consistent with the clinical, administrative .requirements/ objectives of the organization .Directs and evaluates departmental operations .to achieve performance and quality control objectives .Plans and monitors staffing activities, including .orientating, evaluating, disciplinary actions, and continuing education . Review of a Job Description Report for Post Acute Director of Nursing (DON) dated 5/1/2025, revealed .Develops and implements .standards consistent with the clinical, administrative .requirements/objectives of the organization .Directs and evaluates departmental operations .to achieve performance and quality control objectives .Plans and monitors staffing, including .orientating, evaluating, disciplinary actions, and continuing education .ensures that the department operates in compliance .Coordinates and directs internal/ external audits .Integrates evidence-based practices into operations and clinical protocols .Assures quality of care by adhering to established best practices and standards .by the .Board of Nursing, and other governing agencies . Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including Myocardial Infarction [Heart Attack] and Muscle Weakness. Review of a 5 day Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #3 scored a 4 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Review of a Nursing progress note for Resident #3 dated 8/26/2025, revealed .Patient left unit .to be discharged home, transferred out of unit .EMS [Emergency Medical Services] via stretcher . Review of the medical record for Resident #3, revealed no NOMNC or ABN had been provided to the resident or resident representative. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including Chronic Kidney Disease, Severe Protein Calorie Malnutrition, and Muscle Weakness. Review of an admission MDS assessment dated [DATE], revealed Resident #5 scored a 13 on the BIMS assessment which indicated the resident was cognitively intact. Review of a Nursing progress note for Resident #5 dated 8/29/2025, revealed . Patient discharged to home . Review of the medical record for Resident #5, revealed no NOMNC or ABN had been provided to the resident. Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including Congestive Heart Failure and Muscle Weakness. Review of an admission MDS assessment dated [DATE], revealed Resident #33 scored a 14 on the BIMS assessment which indicated the resident was cognitively intact. Review of a Nursing progress note for Resident #33 dated 7/31/2025, revealed .Patient discharged to home with home health accompanied by spouse and son . Review of the medical record for Resident #33, revealed no NOMNC or ABN had been provided to the resident. During an interview on 9/3/2025 at 4:21 PM, the MDS Registered Nurse stated Resident #3, Resident #5, and Resident #33 had not been provided a NOMNC or an ABN. The MDS Registered Nurse further stated the staff had not provided ABNs to any of the residents in the facility for several months. The MDS Registered Nurse continued to state the staff had not provided any residents who received Medicare Part A skilled services while in the facility a NOMNC. During an interview on 9/4/2025 at 8:35 AM, the Administrator confirmed the facility failed to provide Resident #3, Resident #5, and Resident #33 with a NOMNC and ABN. The Administrator further confirmed the staff had not provided ABN to any residents in the facility for several months and was not aware the facility staff had not issued the required documents. The Administrator continued to confirm the staff had not provided a NOMNC to any residents who received Medicare Part A skilled services in the facility since 2024. Review of the facility's undated policy titled, Advanced Directives, revealed .The facility will provide information to the resident/ resident representative on Advanced Directives and will assist the resident/ resident representative in formulating advanced care planning .Upon admission, the resident/ resident representative will be provided with written information concerning the right to .formulate an advanced directive if he or she chooses to do so .Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/ her family members and/ or his or her legal representative, about existence of any written advanced Directives .If the resident indicates that he or she had not established advanced directives, the facility staff will offer assistance in establishing advanced directives .Nursing staff or designee will document in the medical record the offer to assist and the resident's decision to accept or decline assistance . Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction, Diabetes, and Muscle Weakness Review of an admission MDS assessment dated [DATE], revealed Resident #4 scored a 13 on the BIMS assessment which indicated the resident was cognitively intact. Review of the medical record for Resident #4 revealed no documentation of an advanced directive and no documentation the facility had offered the resident an opportunity to formulate an advanced directive. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including Cirrhosis of the Liver, Diabetes, and Acute Respiratory Failure. Review of an admission MDS assessment dated [DATE], revealed Resident #11 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Review of the medical record for Resident #11 revealed no documentation of an advanced directive and no documentation the facility had offered the resident an opportunity to formulate an advanced directive. Review of the medical record revealed Resident #17 was admitted to the facility on [DATE] with diagnoses including Urinary Tract Infection, Muscle Wasting, and Chronic Kidney Disease. Review of an admission MDS assessment dated [DATE], revealed Resident #17 scored of 12 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Review of the medical record for Resident #17 revealed no documentation of an advanced directive and no documentation the facility had offered the resident or resident representative an opportunity to formulate an advanced directive. During an interview on 9/3/2025 at 3:33 PM, the Director of Nursing (DON) confirmed there was no documentation in the medical records to indicate if Resident's #4, Resident #11, and Resident #17 had an advance directive or documentation to reflect the facility had educated or offered for Resident #4, Resident #11, and Resident #17 to formulate an advanced directive. The DON further confirmed staff had not provided education to any residents in the facility on their right to formulate an advanced directive for several months. Review of the facility's policy titled, Infection Prevention and Control Plan, effective 8/2023, revealed .Referral for assessment, potential testing, immunization .counseling as appropriate of hospital staff, independent practitioners .is providers when there is a risk of occupational exposure, or illness from an infectious disease that may put the population they serve at risk .continued education is provided to all staff .including their responsibilities in preventing the spread of infection . Review of the facility's policy titled, Managing COVID-19 Post PHE [Public Health Emergency], effective 3/2024, revealed .everyone 6 years and older should get 1 updated .vaccine, regardless of whether they've received any original COVID-19 vaccine .facility will ensure compliance with federal and state guidance for managing COVID-19 after the expiration of the Public Health Emergency .facility will encourage .staff, residents .to remain up to date with all recommended COVID-19 vaccine doses .staff and residents will be offered resources and counseled about the importance of receiving the COVID-19 vaccine .facility will provide education to resident/representative on the COVID-19 vaccination .will offer COVID-19 vaccinations to all residents .medical record will document the offering, acceptance/refusal and administration of the vaccination to the resident .facility will provide education on benefit of COVID vaccination to staff and will encourage staff to obtain vaccination . Review of the Centers for Disease Control and Prevention (CDC) documentation titled, COVID-19 Vaccination for Long-term Care Residents dated 6/11/2025, revealed .If you live or work in long-term care .you can help protect yourself and the people around you by getting your updated COVID-19 vaccine .CDC recommends an updated COVID-19 vaccine for most adults ages 18 years and older, including people who live and work in long-term care (LTC) .settings .CDC recommends everyone ages 65 years and older, including people who live and work in LTC settings, get 2 doses of an updated COVID-19 vaccine 6 months apart . Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including Urinary Tract Infection, Muscle Weakness, and Abnormal Gait. Review of an admission MDS assessment dated [DATE], revealed Resident #7 scored an 8 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Review of the medical record for Resident #7 revealed no documentation education on COVID 19 was provided or that the facility offered Resident #7 the COVID vaccination. Further review revealed there was no signed declination form in Resident #7's medical record. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnosis including Cirrhosis of Liver, Acute Respiratory Failure, and Diabetes. Review of an MDS assessment dated [DATE], revealed Resident #11 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Review of Resident #11's medical record revealed no documentation education on COVID 19 was provided or that the facility offered Resident #11 the COVID vaccination. Further review revealed there was no signed declination form in Resident #11's medical record. Review of the medical record revealed Resident #19 was admitted to the facility on [DATE] with diagnoses including Left Femur Fracture and Abnormal Gait. Review of an MDS assessment dated [DATE], revealed Resident #19 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Review of Resident #19's medical record revealed no documentation education on COVID 19 was provided or that the facility offered Resident #19 the COVID vaccination. Further review revealed there was no signed declination form in Resident #19's medical record Review of the medical record revealed Resident #24 was admitted to the facility on [DATE] with diagnoses including Dementia, Left Femur Fracture, Need for Assistance with Personal Care and Pain. Review of an MDS assessment for Resident #24 dated 8/22/2025, revealed the BIMS assessment had not been completed because the assessment was in progress. Review of Resident #24's medical record revealed no documentation education on COVID 19 was provided or that the facility offered Resident #24 the COVID vaccination. Further review revealed there was no signed declination form in Resident #24's medical record. Review of the medical record revealed Resident #32 was admitted to the facility on [DATE] with diagnoses including Myocardial Infarction [Heart Attack] and Unsteadiness on feet. Review of an MDS assessment for Resident #24 dated 8/31/2025, revealed the BIMS assessment had not been completed because the assessment was in progress. Review of the medical record for Resident #32 revealed no documentation education on COVID 19 was provided or that the facility offered Resident #32 the COVID vaccination. Further review revealed there was no signed declination form in Resident #32's medical record. During a medical record review and interview on 9/3/2025 at 3:00 PM, the Infection Preventionist (IP) stated the facility follows National Healthcare Safety Network and Centers for Disease Control recommendations. The IP provided resident vaccination information for Resident #7, #11, #19, #24, and #32. The IP stated COVID education had been provided to Resident #7, #11, #19, #24, and #32 and all declined the COVID vaccine. The IP stated she did not ask Resident #7, # 11, #19, #24, and #32 to sign a declination form or document the education had been provided because it was not required any longer. The IP stated she only documents education was provided to residents when they agree to the vaccine, then the education and vaccination are documented in the medical record. The IP stated she did not have any information on staff who had declined the COVID vaccine. The IP stated the facility has not offered education on covid vaccination or provide the COVID vaccine to staff in several years. She added the employee health nurse may be able to provide that information. During an interview on 9/4/2025 at 8:10 AM, the Employee Health Nurse stated she was not able to identify an employee who had declined the COVID vaccine or signed a declination form because the facility has not offered education on the COVID vaccine or had administered the COVID vaccines to the facility staff since 2022. During an interview on 9/4/2025 at 12:15 PM, the Human Resources Director confirmed the facility no longer offered COVID-19 education or the COVID-19 vaccine to the staff .it is no longer a requirement. During an interview on 9/4/2025 at 2:31 PM, the Administrator confirmed the facility had not provided the residents with the opportunity to formulate advanced directive, had not provided the residents with Advance Beneficiary Notices (ABN) or Notice of Medicare Non-Coverage (NOMNC), and had not documented the staff or residents had received education on the COVID-19 vaccine, and had not offered the COVID-19 vaccine to the staff. The Administrator confirmed the deficiencies had not been identified by staff at the facility and no action plans had been developed to correct the identified concerns.

Based on facility policy review, job description review, Quality Assurance Performance Improvement (QAPI) meeting minutes review, medical record review, and interview, the facility's leadership and QAPI Committee failed to identify, address and initiate corrective action plans for quality deficiencies to ensure the residents attained or maintained their highest practicable physical, functional, mental, and psychosocial well-being when the residents were not offered the opportunity to formulate advanced directives upon admission, were not provided Advance Beneficiary Notices (ABN) or Notice of Medicare Non-Coverage (NOMNC) documentation upon discharge, and had not documented the staff or residents received education on the COVID-19 vaccine for 5 residents (Resident #7, Resident #11, Resident #19, Resident #24, and Resident #32), and had not offered the COVID-19 vaccine to the facility's staff since 2022.The findings include: Review of a facility policy titled Quality Assurance Performance Improvement Committee [QAPI], dated 7/19/2025, revealed .The facility will maintain systems and processes to ensure that the Quality Assurance/ Performance Improvement Committee provides oversight and direction to the facility in identifying and addressing issues and/or risk and that responsive action plans for improvement and/or correction are implemented and monitored for identified outcomes .appropriate and reasonable efforts will be made, and resources provided to maintain compliance with applicable regulations for nursing facilities, and to meet needs of residents in a manner that promotes their physical, mental, and psychosocial well- being .The facility will maintain a QAPI committee consisting at a minimum of the director of nursing [DON]. The medical director .three members of the facilities staff .infection preventionist .QAPI committee meeting will be held at least quarterly or more often as necessary to fulfill the committee's responsibilities to identify and correct quality deficiencies effectively and/or to monitor quality improvement initiatives .The data will be reviewed with enough frequency to enable the committee to know if improvements or correction is needed or if previously identified opportunities are achieving desired outcomes . Review of a Job Description Report for Post Acute/ Skilled Care Administrator dated 10/11/2024, revealed .Develops and implements Skilled Care goals, plans, and standards consistent with the clinical, administrative .requirements/ objectives of the organization .Directs and evaluates departmental operations .to achieve performance and quality control objectives .Plans and monitors staffing activities, including .orientating, evaluating, disciplinary actions, and continuing education . Review of a Job Description Report for Post Acute Director of Nursing dated 5/1/2025, revealed .Develops and implements .standards consistent with the clinical, administrative .requirements/objectives of the organization .Directs and evaluates departmental operations .to achieve performance and quality control objectives .Plans and monitors staffing, including .orientating, evaluating, disciplinary actions, and continuing education .ensures that the department operates in compliance .Coordinates and directs internal/ external audits .Integrates evidence-based practices into operations and clinical protocols .Assures quality of care by adhering to established best practices and standards .by the .Board of Nursing, and other governing agencies . Investigation revealed the facility had failed to obtain an advanced directive or offer the opportunity to formulate an advanced directive for 3 of 3 sampled residents (Resident #4, #11, and #17). Investigation through record review and interview revealed the facility had failed to offer any resident or resident representative the opportunity to formulate and advanced directive for several months. The facility's QAPI Committee failed to identify a system was not in place to ensure the residents or resident representatives were provided with this opportunity. The facility's failure had been ongoing and had not been identified by the facility's leadership or QAPI Committee. Refer to F-578 Investigation revealed the facility failed to ensure the required NOMNC and ABN documentation was provided to the 3 of 3 resident's (Resident #3, #5, and #33) reviewed. Continued investigation through medical record review and interview revealed the facility's QAPI Committee failed to identify a system was not in place to ensure the appropriate notices were provided to any of the facility's residents or resident representatives for several months (an unknown period of time). The facility's failure had been ongoing and had not been identified by the facility's leadership or QAPI Committee. Refer to F-582 Investigation revealed the facility failed to ensure the Centers for Disease Control (CDC) recommendations were followed related to COVID-19 education and vaccination documentation and failed to follow the facility's policy related to COVID-19. The facility failed to document the offering of the COVID-19 vaccine to any of the facility's staff since 2022, failed to document the education provided or have COVID-19 vaccine declination documentation signed for 5 of 5 residents reviewed (Residents #7, #11, #19, #24, and #32). Investigation through medical record review and interview revealed the facility had failed to have any COVID-19 declination forms signed for any resident who declined and failed to document COVID-19 education was provided to those residents. The facility's failure had been ongoing and had not been identified by the facility's leadership or QAPI Committee. Refer to F-887 During an interview on 9/3/2025 at 3:33 PM, the Director of Nursing (DON) confirmed there was no documentation in the medical records to indicate if Resident's #4, Resident #11, and Resident #17 had an advance directive or documentation to reflect the facility had educated or offered for Resident #4, Resident #11, and Resident #17 to formulate an advanced directive. The DON further confirmed staff had not provided education to any residents in the facility on their right to formulate an advanced directive for several months (an unknown period of time). During an interview on 9/3/2025 at 4:21 PM, the MDS Registered Nurse stated Resident #3, Resident #5, and Resident #33 had not been provided a NOMNC or an ABN. The MDS Registered Nurse further stated the staff had not provided ABNs to any residents in the facility. The MDS Registered Nurse continued to state the staff had not provided any residents who received Medicare Part A skilled services while in the facility a NOMNC for several months. During an interview on 9/4/2025 at 8:35 AM, the Administrator confirmed the facility failed to provide Resident #3, Resident #5, and Resident #33 with a NOMNC and ABN. The Administrator further confirmed the staff had not provided ABN to any residents in the facility. The Administrator continued to confirm the staff had not provided a NOMNC to any residents who received Medicare Part A skilled services in the facility since 2024. During a medical record review and interview on 9/3/2025 at 3:00 PM, the Infection Preventionist (IP) stated the facility follows National Healthcare Safety Network and Centers for Disease Control recommendations. The IP provided resident vaccination information for Resident #7, #11, #19, #24, and #32. The IP stated COVID education had been provided to Resident #7, #11, #19, #24, and #32 and all declined the COVID vaccine (the IP was unable to provide the documentation to verify the information was provided). The IP stated she had not asked Resident #7, # 11, #19, #24, and #32 to sign a declination form or document the education had been provided because it was not required any longer. The IP stated she had only documented the education was provided to residents when the residents had agreed or consented to the vaccine, then the education and vaccination were documented in the medical record. The IP stated she did not have any information on the staff who had declined the COVID vaccine. The IP stated the facility has not offered education on covid vaccination or provided the COVID vaccine to the facility staff in several years. During an interview on 9/4/2025 at 8:10 AM, the Employee Health Nurse stated she was not able to identify an employee who had declined the COVID-19 vaccine or signed a declination form because the facility has not offered education on COVID vaccine or administered COVID vaccines to the staff since 2022. During an interview on 9/4/2025 at 12:15 PM, the Human Resources Director confirmed the facility no longer offered COVID-19 education or the COVID-19 vaccine to the staff .it is no longer a requirement. During an interview on 9/4/2025 at 2:31 PM, the Administrator stated the QAPI Committee consisted of the Interdisciplinary Team Including the Administrator, the Director of Nursing, the Infection Preventionist, the Medical Director, the Social Worker, the MDS Coordinator, and the Therapy Director. The Administrator stated the QAPI Committee met monthly to review and correct any deficient practices identified. The Administrator confirmed the facility had not provided the residents with the opportunity to formulate advanced directive, had not provided the residents with Advance Beneficiary Notices (ABN) or Notice of Medicare Non-Coverage (NOMNC), and had not documented the staff or residents had received education on the COVID-19 vaccine, and had not offered the COVID-19 vaccine to the staff. The Administrator confirmed the quality deficiencies had not been identified by the QAPI committee, was not included in the past 3 months of QAPI minutes, and no action plans had been developed to correct the identified concerns.

Based on medical record review , facility policy review, review of current Centers for Disease Control (CDC) recommendations and interviews the facility failed to document education was provided to residents and staff regarding COVID-19 vaccination, failed to document offering the COVID vaccine to residents and completing a declination form if the vaccine was declined, and failed to offer staff COVID-19 vaccines affecting all staff and 5 of 5 (Resident #7, #11, #19, #24 and #32) sampled residents reviewed. The findings include: Review of the facility's policy titled, Infection Prevention and Control Plan effective 8/2023, revealed .Referral for assessment, potential testing, immunization .counseling as appropriate of hospital staff, independent practitioners .is providers when there is a risk of occupational exposure, or illness from an infectious disease that may put the population they serve at risk .continued education is provided to all staff .including their responsibilities in preventing the spread of infection . Review of the facility's policy titled, Managing COVID-19 Post PHE [Public Health Emergency] effective 3/2024, revealed .everyone 6 years and older should get 1 updated .vaccine, regardless of whether they've received any original COVID-19 vaccine .facility will ensure compliance with federal and state guidance for managing COVID-19 after the expiration of the Public Health Emergency .facility will encourage .staff, residents .to remain up to date with all recommended COVID-19 vaccine doses .staff and residents will be offered resources and counseled about the importance of receiving the COVID-19 vaccine .facility will provide education to resident/representative on the COVID-19 vaccination .will offer COVID-19 vaccinations to all residents .medical record will document the offering, acceptance/refusal and administration of the vaccination to the resident .facility will provide education on benefit of COVID vaccination to staff and will encourage staff to obtain vaccination . Review of the Centers for Disease Control and Prevention (CDC) documentation titled, COVID-19 Vaccination for Long-term Care Residents dated 6/11/2025, revealed .If you live or work in long-term care .you can help protect yourself and the people around you by getting your updated COVID-19 vaccine .CDC recommends an updated COVID-19 vaccine for most adults ages 18 years and older, including people who live and work in long-term care (LTC) .settings .CDC recommends everyone ages 65 years and older, including people who live and work in LTC settings, get 2 doses of an updated COVID-19 vaccine 6 months apart .Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including Urinary Tract Infection, Muscle Weakness, and Abnormal Gait. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #7 scored an 8 on the Brief Interview for Mental Status (BIMS) assessment indicating the resident had moderate cognitive impairment. Review of Resident #7's medical record revealed no documentation education on COVID 19 was provided or that the facility offered Resident #7 the COVID vaccination. Further review revealed there was no signed declination form in Resident #7's medical record. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnosis including Cirrhosis of Liver, Acute Respiratory Failure, and Type 2 Diabetes. Review of an MDS assessment dated [DATE], revealed Resident #11 scored a 15 on the BIMS assessment indicating the resident was cognitively intact. Review of Resident #11's medical record revealed no documentation education on COVID 19 was provided or that the facility offered Resident #11 the COVID vaccination. Further review revealed there was no signed declination form in Resident #11's medical record. Review of the medical record revealed Resident #19 was admitted to the facility on [DATE] with diagnoses including Left Femur Fracture and Abnormal Gait.Review of an MDS assessment dated [DATE], revealed Resident #19 scored a 15 on the BIMS assessment indicating the resident was cognitively intact. Review of Resident #19's medical record revealed no documentation education on COVID 19 was provided or that the facility offered Resident #19 the COVID vaccination. Further review revealed there was no signed declination form in Resident #19's medical record Review of the medical record revealed Resident #24 was admitted to the facility on [DATE] with diagnoses including Dementia, Left Femur Fracture, Need for Assistance with Personal Care and Pain. Review of an MDS assessment for Resident #24 dated 8/22/2025, revealed the BIMS assessment had not been completed because the assessment was in progress. Review of Resident #24's medical record revealed no documentation education on COVID 19 was provided or that the facility offered Resident #24 the COVID vaccination. Further review revealed there was no signed declination form in Resident #24's medical record. Review of the medical record revealed Resident #32 was admitted to the facility on [DATE] with diagnoses including Myocardial Infarction [Heart Attack] and Unsteadiness on feet. Review of an MDS assessment for Resident #24 dated 8/31/2025, revealed the BIMS assessment had not been completed because the assessment was in progress. Review of Resident #32's medical record revealed no documentation education on COVID 19 was provided or that the facility offered Resident #32 the COVID vaccination. Further review revealed there was no signed declination form in Resident #32's medical record. During a medical record review and interview on 9/3/2025 at 3:00 PM, the Infection Preventionist (IP) stated the facility follows National Healthcare Safety Network and Centers for Disease Control recommendations. The IP provided resident vaccination information for Resident #7, #11, #19, #24, and #32. The IP stated COVID education had been provided to Resident #7, #11, #19, #24, and #32 and all declined the COVID vaccine. The IP stated she did not ask Resident #7, # 11, #19, #24, and #32 to sign a declination form or document education had been provided because it was not required any longer. The IP stated she only documents education was provided to residents when they agree to the vaccine, then the education and vaccination are documented in the medical record. The IP stated she did not have any information on staff who had declined the COVID vaccine. The IP stated the facility has not offered education on covid vaccination or provide the COVID vaccine to staff in several years. She added the employee health nurse may be able to provide that information. During an interview on 9/4/2025 at 8:10 AM, the Employee Health Nurse stated she was not able to identify an employee who declined the COVID vaccine or signed a declination form because the facility has not offered education on COVID vaccine or administered COVID vaccines to staff since 2022. During an interview on 9/4/2025 at 12:15 PM, the Human Resources Director confirmed the facility no longer offered COVID-19 education or the COVID-19 vaccine to the staff .it is no longer a requirement.

Based on facility policy review, medical record review, observation, and interviews, the facility failed to obtain a physician's order for the use of an indwelling urinary catheter [a tube inserted into the bladder that drains urine] for 1 resident (Resident #12) of 4 residents reviewed for the use of an indwelling catheter.The findings include: Review of the facility policy titled Foley Catheter, dated 10/2024, revealed .Insertion of .[an indwelling urinary] .catheter should only be used for appropriate indications .Indications should be documented by the physician in the .[indwelling urinary] .catheter order .indications, date of insertion, time of insertion, staff inserting, catheter type, size, and proper technique . Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including Pressure Ulcer of the Sacral Region and Urinary Tract Infection. Review of the baseline care plan for Resident #12 dated 8/23/2025, revealed the resident had an indwelling urinary catheter. Review of a Progress Note for Resident #12 dated 8/23/2025, revealed .Urinary catheter intact . Review of a Progress Note for Resident #12 dated 8/24/2025, revealed .Catheter in place . Review of Physicians Orders for Resident #12 dated 8/30/2025 to 9/3/2025, revealed Resident #12 did not have an order for the use of an indwelling urinary catheter. During an observation in Resident #12's room on 9/2/2025 at 1:11 PM, revealed an indwelling urinary catheter secured to bottom of the bed in a dignity bag. Review of a Progress Note for Resident #12 dated 9/3/2025, revealed .Catheter in place . During an observation in Resident #12's room on 9/3/2025 at 9:05 AM, revealed an indwelling urinary catheter secured to bottom of the bed in a dignity bag. During an observation in Resident #12's room on 9/4/2025 at 10:15 AM, revealed an indwelling urinary catheter secured to bottom of the bed in a dignity bag. During an interview on 9/4/2025 at 10:15 AM, Licensed Practical Nurse (LPN) A stated Resident #12 had an indwelling urinary catheter. During an interview on 9/4/2025 at 12:56 PM, the Director of Nursing (DON) confirmed there was not a physician's order for the indwelling urinary catheter for Resident #12. The DON stated it was her expectation that if a resident is admitted with an indwelling urinary catheter, staff obtain a physician's order for an indwelling urinary catheter.

Based on facility policy review, Centers for Disease Control and Prevention (CDC) guidance, observation, and interview, the facility failed to properly prevent COVID-19 (an infectious disease caused by the [CONDITION(S)]-CoV-2 virus) by failing to implement universal use of eye protection as part of Personal Protective Equipment (PPE) during resident care interactions in a community with high COVID-19 transmission which had the potential to result in COVID-19 transmission to all 11 residents in the facility. The findings include: Review of the facility's policy titled, Infection Prevention and Control Plan, revised 4/20/2021, showed .following objectives are in place to reduce or eliminate risks .appropriate use of personal protective equipment . Review of the facility's policy titled, Standard Operating Procedure, revised 6/15/2021, showed .Core Principles of COVID-19 Infection Prevention .Appropriate staff use of Personal Protective Equipment . Review of the CDC guidance titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated 2/22/2022, showed .The guidance applies to all U.S. settings where healthcare is delivered .IPC [infection prevention and control] (e.g. [example], use of source control, screening testing) are influenced by levels of [CONDITION(S)]-CoV-2 transmission in the community .Implement Source Control Measures .Source control refers to use of respirators or well-fitting facemasks .Implement Universal Use of Personal Protective Equipment for HCP .If [CONDITION(S)]-Cov-2 infection is not suspected in a patient presenting for care (based on symptom and exposure history), HCP [Healthcare Personnel] working in facilities located in counties with substantial or high transmission should also use PPE as described below .Eye protection (i.e. [that is], goggles or a face shield that covers the front and sides of the face) should be worn during all patient care encounters . Review of the CDC COVID Data Tracker on 7/10/2022 showed the facility was located in a county with high community COVID-19 transmission rate. During an observation on 7/11/2022 at 9:26 AM, Licensed Practical Nurse (LPN) #1 entered Resident #15's room and transferred the resident from the chair to the commode. LPN #1 wore a mask and gloves during the resident care interaction. During an interview on 7/11/2022 at 9:28 AM, LPN #1 confirmed she did not wear eye protection during the resident care interaction. The LPN stated staff wore eye protection .a few weeks ago .when the county rate was up . During an observation on 7/11/2022 at 10:13 AM, LPN #1 entered Resident #219's room for resident care. LPN #1 wore no eye protection as she leaned over the resident's bed. During an interview on 7/11/2022 at 10:15 AM, LPN #1 confirmed she was within 6 feet of Resident #219 without eye protection. LPN #1 stated the facility instructed the staff that only a mask and eye protection was required during resident care unless resident was in transmission based precautions. During an observation on 7/11/2022 at 10:40 AM, Occupational Therapist (OT) #1 provided therapy to Resident #168 in the resident's room. OT #1 wore a gown, gloves and N-95 mask during the resident care interaction. During an interview on 7/11/2022 at 10:57 AM, OT #1 confirmed no eye protection was worn during the resident care interaction with Resident #168. During an observation on 7/11/2022 at 10:50 AM, Resident #15 was seated in the chair next to the bed. The Infection Control Nurse entered the room, pulled the residents socks down and assessed the resident's bilateral lower extremities. The Infection Control Nurse wore a mask and gloves during the resident care interaction with no eye protection. During an interview on 7/11/2022 at 10:53 AM, outside Resident #15's room, the Infection Control Nurse stated PPE required for resident care interactions included gloves and a mask. The Infection Control Nurse confirmed she wore no eye protection during the resident care interaction with Resident #15. During an observation on 7/11/2022 at 11:27 AM, Physical Therapist (PT) #1 was observed in Resident #15's room providing therapy with only a surgical mask and gloves on during the resident care interaction. During an interview on 7/11/2022 at 11:50 AM, PT #1 confirmed no eye protection was worn during the resident care interaction with Resident #15. PT #1 was aware of what PPE was required by the therapy supervisor. During an interview on 7/13/2022 3:45 PM, the Infection Control Nurse stated the facility was located in a county with a high community COVID-19 transmission level, and staff were required to wear a mask and eye protection during all resident care interactions. The Infection Control Nurse confirmed staff were not wearing eye protection during resident care interactions and stated, I have told them to wear goggles. Further interview confirmed the facility followed CDC guidelines for PPE, and the Infection Control Nurse expected staff to wear a mask and eye protection during all resident care interactions due to the high community COVID-19 transmission level. The facility had not had a resident case of COVID-19 since 2/2022.

Based on review of the facility policy, medical record review, and interview, the facility failed to develop a comprehensive care plan that included person-centered interventions for 2 residents (Resident #8 and Resident #15) of 4 residents reviewed for comprehensive care plans. The findings include: Review of the facility's policy titled, Admissions, Transfers, and Discharges Skilled Care, with an effective date of 2/2022, showed .The facility will develop a person-centered plan of care to address patient needs and services, with input from the Patient/ Representative to ensure the needs and services are provided in accordance with resident choices and with consideration of cultural, ethnic, and spiritual preferences . Review of the facility's undated policy titled, Interdisciplinary Care Plan, showed .The result of the MDS [Minimum Data Set] assessment will be used to develop, review and revise the resident's comprehensive Plan of Care. The assessment will be conducted or coordinated through participation of all the interdisciplinary team members .A comprehensive, individualized interdisciplinary care plan will be developed as soon as possible after admission but not later than one week after completion of the MDS comprehensive assessment (which occurs within 14 days of admission for LTCF residents). Goals will be developed to help each resident achieve his/her optimal level of physical, mental, psycho-social functioning .DEVELOPMENT OF THE INDIVIDUALIZED CARE PLAN .Problem Identification: Each discipline will perform and assessment to identify pertinent problems that will require a specific plan .Short-term Goals: Each discipline will develop a short-term goal for each problem .Short-term goals will be stated in measurable and realistic terms which will be documented on the care plan .Time frames will be established for achievement .Interventions: Each discipline will develop an intervention for each goal and document the necessary intervention on the care plan .Resident care plan interventions will be individualized, based on each resident's needs and medical condition . Resident #8 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #8's comprehensive care plan dated 4/23/2022, showed the resident had a nutritional risk and was at risk for pain. The care plan had no documentation of person-centered individualized interventions for pain or nutritional risk for Resident #8. Review of Resident #8's 5-day MDS assessment dated [DATE], showed the resident was at risk for nutritional deficits and was at risk for pain. Section V of the assessment showed Resident #8 was triggered during the assessment for pain and nutritional risk. MDS Coordinator documented these areas would be care planned. During an interview on 7/13/2022 at 9:38 AM, the Director of Nursing (DON) confirmed Resident #8 had a nutritional risk and was at risk for pain. The DON confirmed Resident #8's comprehensive care plan did not include individualized person-centered interventions for pain or nutritional risk. Resident #15 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician's order dated 6/8/2022, showed .[MEDICATION(S)] [anti-depressant medication] .PO [by mouth] .20 MG [milligrams] .BID [twice daily] . Review of the Physician's order dated 6/9/2022, showed .[MEDICATION(S)] [MEDICATION(S)] [anti-psychotic medication] .PO .10 MG .BID . Review of the comprehensive care plan dated 6/9/2022, showed .Focus: SNF [Skilled Nursing Facility] Psychoactive Drug Monitor . The comprehensive care plan did not include Resident #15's use of psychoactive medications related to the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS assessment dated [DATE], showed Resident #15 had active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident received antipsychotic and antidepressant medications on all 7 days of the look back period. Resident #15's use of [CONDITION(S)] drugs would be care planned. During an interview on 7/13/2022 at 9:46 AM, the DON stated Resident #15 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15 received [CONDITION(S)] medications. The DON confirmed it was her expectation that Resident #15's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] #15. During an interview on 7/13/2022 at 1:49 PM, the MDS Coordinator confirmed Resident #15's admission MDS assessment was completed on 6/15/2022 and included the resident's mental health diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Section V of the assessment showed Resident #15's use of [CONDITION(S)] medications was triggered and included on the care plan. The MDS Coordinator confirmed she did not include Resident #15's mental health diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .I didn't know to do that .

Based on facility policy review, medical record review, and interview the facility failed to follow physician's orders for 1 resident (Resident #15) of 3 residents reviewed for insulin administration. The findings include: Review of the facility's policy titled, Medication Administration, with an effective date of 8/2021, showed .Medications may be administered to patients upon order of the medical staff or other individuals who have been granted clinical privileges to write such orders . Resident #15 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician's order dated 6/8/2022, showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician's order dated 6/10/2022, showed Resident #15 received a Diabetic Consistent Carbohydrate diet. Review of a physician's order dated 6/15/2022, showed .INSULIN [MEDICATION(S)] [long acting diabetic medication] .12 UNIT .SUBQ [subcutaneous] .DAILY .HOLD IF BLOOD SUGAR IS BELOW 110 . Review of the POC [Point of Care] Glucose results dated 6/17/2022 at 6:58 AM, showed Resident #15's blood sugar was 101. Review of the MEDICATION ADMINISTRATION SUMMARY dated 6/17/2022 at 8:53 AM, showed Resident #15 received 12 units of INSULIN [MEDICATION(S)]. Review of the POC Glucose results dated 6/18/2022 at 5:26 AM, showed Resident #15's blood sugar was 102. Review of the MEDICATION ADMINISTRATION SUMMARY dated 6/18/2022 at 8:11 AM, showed Resident #15 received 12 units of INSULIN [MEDICATION(S)]. Review of the POC Glucose results dated 6/19/2022 at 5:24 AM, showed Resident #15's blood sugar was 91. Review of the MEDICATION ADMINISTRATION SUMMARY dated 6/19/2022 at 9:09 AM, showed Resident #15 received 12 units of INSULIN [MEDICATION(S)]. During an interview on 7/13/2022 at 11:20 AM, the Director of Nursing (DON) stated Resident #15 was ordered to receive 12 units of Insulin [MEDICATION(S)] daily at 9:00 AM. The order was started on 6/15/2022 and was to be held for blood sugar lower than 110. Nurses were to use the blood sugar level obtained before breakfast to determine if Insulin [MEDICATION(S)] was to be given. It was the DON's expectation for physician's orders to be followed. The DON confirmed Resident #15's physician's order was not followed when Resident #15 received Insulin [MEDICATION(S)] on 6/17/2022 with a blood sugar of 101, 6/18/2022 with a blood sugar of 102, and 6/19/2022 with a blood sugar of 91. Resident #15 suffered no adverse consequences because of the insulin administration. During a telephone interview on 7/13/2022 at 2:26 PM, the Medical Director stated it was his expectation that physician orders were followed. The Medical Director was unaware that Resident #15 had received the Insulin [MEDICATION(S)] on 6/17/2022, 6/18/2022, and 6/19/2022 with a blood sugar lower than 110. If the nurse had notified him of the blood sugar result, he would have instructed the nurse to administer the medication. The medication was scheduled for 9:00 AM after breakfast and Insulin [MEDICATION(S)] is a long-acting insulin. Resident #15 had no adverse effects because of the insulin administration.

Based on Resident Assessment Instrument Manual 3.0 (RAI) record review, and interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 6 residents (Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7) of 16 residents reviewed for MDS assessments. The findings include: Review of the RAI Manual 3.0 dated 10/2019 showed .the comprehensive assessment is considered complete on the date the RN [Registered Nurse] Coordinator indicates completion of the admission assessment .Assuming the resident does not have any significant changes in status or is not discharged from the facility the next assessment schedule is the Quarterly assessment . Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's discharge MDS assessment dated [DATE], showed the resident was discharged from the facility on 1/14/2022. Review of the admission/5-day MDS assessment dated [DATE], showed Resident #2's admission/5-day MDS assessment was completed 3 days after the resident was discharged from the facility. Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's discharge MDS assessment dated [DATE], showed the resident was discharged from the facility on 1/17/2022. Review of the admission/5-day MDS assessment dated [DATE], showed Resident #3's admission/5-day MDS assessment was completed 2 days after the resident was discharged from the facility. Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #4's discharge MDS assessment dated [DATE], showed the resident had been discharged from the facility on 1/25/2022. Review of the admission/5-day assessment MDS assessment dated [DATE], showed Resident #4's admission/ 5-day MDS assessment was completed 1 day after the resident was discharged from the facility. Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident # 5's discharge MDS assessment dated [DATE], showed the resident had been discharged from the facility on 1/18/2022. Review of the admission/5-day MDS assessment dated [DATE], showed Resident #5's admission/5-day assessment had been completed 3 days after the resident had been discharged from the facility. Resident #6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #6's discharge MDS assessment dated [DATE], showed the resident had been discharged from the facility on 2/3/2022. Review of the admission/5-day MDS assessment dated [DATE], showed Resident #5's admission/5-day assessment had been completed 1 day after the resident had been discharged from the facility. Resident #7 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #7's discharge MDS assessment dated [DATE], showed the resident had been discharged from the facility on 2/17/2022. Review of the admission/5-day MDS assessment dated [DATE], showed Resident #5's admission/5-day assessment had been completed 4 days after the resident had been discharged from the facility. During an interview on 7/13/2022 at 11:11 AM, with the MDS Coordinator confirmed she had completed the discharge assessments on the actual date Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7 had been discharged from the facility and she had completed the admission/5-day assessments for each resident after the resident had been discharged from the facility.

Based on medical record review, and interview the facility failed to monitor behaviors and side effects for [MEDICAL CONDITION] medications for 1 resident (#116) of 5 residents reviewed for unnecessary medications. The findings include: Medical record review revealed Resident #116 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Physicians Orders revealed the following: 4/30/19- [MEDICATION NAME] (medication to treat depression) 50 milligrams (mg) po (by mouth) QHS (every night time) 4/30/19- Mirtazepine (medication to treat depression) 15 mg po Q HS Medical record review of the facility Psychoactive Drug Monitoring dated 5/4/19 and 5/5/19, revealed .Does the patient receive Psychoactive Drugs .N (No) . Observation and interview of Resident #116 on 5/6/19 at 12:55 PM, in the residents room revealed the resident was alert and oriented, sitting up in a recliner chair. Interview with the Director of Nursing on 5/8/19 at 9:05 AM, in the conference room confirmed Resident #116 did receive 2 [MEDICAL CONDITION] medications and the facility failed to monitor for side effects and behaviors for the antidepressant medications.

Based on medical record review and interview, the facility failed to complete and failed to submit the Minimum Data Sets (MDS) 14 days after completion for 4 residents (#1, #3, #10, #11) of 8 residents reviewed for MDS assessments. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident was discharged on [DATE] after a 5 day length of stay at the facility. Medical record review revealed 1 MDS assessment for the resident, coded as a 5 day SNF PPS (skilled nursing facility prospective payment system) Part A Discharge (End of Stay) Assessment with a Due Date of 3/9/18. Continued review of the 5 day MDS revealed it was signed by the MDS Licensed Practical Nurse (LPN) #1 on 5/1/18. Further review revealed the MDS Registered Nurse (RN) #1 documented the 5 day assessment was complete and ready for submission on 5/1/18. Continued review revealed the 7 day timeframe to complete the assessment after discharge was not met and the 14 day submission requirement after completion of assessment was not met. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident was discharged on [DATE] for a 21 day length of stay at the facility. Medical record review revealed a 5 day scheduled assessment with a Due Date of 3/31/18 was the initial MDS assessment. Continued review revealed the Care Area Assessment was included in the 5 day MDS. Further review revealed the MDS was signed as complete by LPN #1 and RN #1 on 4/25/18. Continued review revealed the Due Date of 3/31/18 to complete the assessment after 14 days in the facility was not met and the 14 day submission requirement after completion of the assessment was not met. Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident discharged on [DATE] after a 56 day length of stay at the facility. Medical record review revealed a 5 day scheduled assessment with a Due Date of 11/22/17 was the initial MDS assessment. Continued review revealed the Care Area Assessment was included in the 5 day MDS. Further review revealed the MDS was signed as complete by RN #1 on 12/7/17, 31 days after admission and 17 days after a 14 day comprehensive assessment was due. Continued review revealed the Due Date of 11/22/17 to complete the assessment after 14 days in the facility was not met and the 14 day submission requirement after completion of the assessment was not met. Medical record review revealed the 14 day scheduled assessment with a Due Date 11/29/17 was completed by RN #1 on 1/2/18. Continued review revealed the Due Date of 11/29/17 was not met and the 14 day submission requirement after completion of the assessment was not met. Medical record review revealed a 30 day scheduled assessment with a Due Date of 12/14/17 was not met. Continued review revealed the MDS areas LPN #1 was responsible for were completed on 5/16/18, and the 30 day MDS was not completed by RN #1. Medical record review revealed the SNF PPS Part A Discharge (End of Stay) Assessment, with a Due Date of 1/11/18 had not been completed by RN #1 as of 5/16/18. Continued review revealed the timeframe to complete the MDS within 7 days after the discharge (on 1/2/18) was not met, and the discharge MDS had not been submitted by the facility. Medical record review revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident discharged on [DATE] after a 17 day length of stay at the facility. Medical record review revealed a 5 day scheduled assessment with a Due Date of 1/4/18 was the initial MDS assessment. Further review revealed the MDS was signed as complete by RN #1 on 5/15/18, 4 months after completion was required. Continued review revealed the 14 day scheduled assessment with a Due Date of 1/18/18 was signed complete by RN #1 on 5/15/18, more than 3 months after completion was required. Interview with LPN #1, on 5/15/18 at 4:30 PM, in room [ROOM NUMBER] confirmed she was responsible for coordinating and completing the MDS assessments. Continued interview confirmed .not able to get the MDS work done for several months .pulled to cover the units . Interview with the Administrator on 5/16/18 at 9:50 AM, in room [ROOM NUMBER], confirmed staffing and software issues had contributed to the MDS assessments not being completed in the required CMS (Centers for Medicare/Medicaid Services) timeframes.

Based on medical record review, observation, and interview, the facility failed to provide a comprehensive care plan for 3 residents (#3, #10, and #114) of 3 residents reviewed with lengths of stay at the facility greater than 20 days. The findings included: Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident was discharged from the facility on 4/7/18 after a 21 day stay. Medical record review revealed a 5 day scheduled assessment was the initial Minimum Data Set (MDS) assessment. Continued review revealed the Care Area Assessment was included in the 5 day MDS. Continued review revealed the resident did not have a comprehensive care plan included in the closed medical record. Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident discharged from the facility on 1/2/18 after a 56 day stay. Medical record review revealed a 5 day scheduled assessment was the initial MDS assessment. Continued review revealed the Care Area Assessment was included in the 5 day MDS. Review continued and revealed the resident did not have a comprehensive care plan in the closed medical record. Medical record review revealed Resident #114 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation of the resident in his room on 5/14/18 at 11:10 AM, revealed he was lying in bed watching TV and did not offer any complaints. Interview with LPN #1, responsible for coordinating the comprehensive care plans, on 5/16/18 at 9:30 AM, in room [ROOM NUMBER], confirmed a comprehensive care plan was due on 5/12/18 and the present care plan, dated 5/10/18, did not address the resident's Care Assessment Areas for providing assistance with ADL's (Activities of Daily Living), to address being at risk for Dehydration, and to address being at high risk for Falls. Interview with the Director of Nurses on 5/16/18 at 11:30 AM, in room [ROOM NUMBER], revealed .the comprehensive care plans .haven't been doing from the Care Area Assessments.

Based on review of facility policies, observation and interview, the facility failed to ensure kitchen equipment, the dessert freezer and hood exhaust vents were clean and free from debris, and failed to properly air dry steam table pans, in 1 of 2 kitchens observed. The findings included: Review of the facility policy Sanitation Program Hazard and MGT. (Management) Prevention dated 4/98 revised 7/16 revealed .Maintain a clean, safe, and effective environment of care and to prevent the transmission of disease-caring organisms .Clean equipment, walls, floors, and storage areas routinely . Review of the facility policy Dishes and Silverware dated 4/98 revised 7/16 revealed .Keep clean utensils separate from dirty ones to avoid contamination .Clean the pots and pans .store them on a rack upside down after they are completely dry . Review of the facility policy Temperature Monitoring: Refrigerator/Cooling/Warming Equipment dated 5/98 revised 7/15 revealed .each department is responsible for cleaning food .refrigerators in their areas as needed . Observation with the Director of Dietary on 4/3/17 at 9:45 AM, in the kitchen revealed the following: a). 2 of 3 two inch ½ steam table pans stored wet b). 4 of 11 four inch ½ steam table pans stored wet c). 1 Steam kettle with dried debris on the outside and top rim d). 1 Grill with a buildup of black charred debris e). Exhaust hood vents with black and dusty debris f). 2 of 2 ovens with dried/burnt debris on the bottom and the doors g). 1 of 4 knives with dried food debris stored on clean utility rack Observation with the Director of Dietary on 4/3/17 at 10:10 AM, in the kitchen revealed a dessert freezer with ice build-up and black debris on the lid, seal, sides, and rim of the freezer. Observation on 4/4/17 at 2:30 PM, in the nourishment refrigerator revealed white flakey, dried debris covering the milk storage shelf. Interview with the Director of Dietary on 4/3/17 at 10:25 AM, in the kitchen confirmed the facility failed to ensure kitchen equipment, utensils, dessert freezer and hood exhaust vents were clean, sanitary, and free from debris. Continued interview confirmed 6 steam table pans were stored wet. Interview with the Director of Dietary on 4/4/17 at 2:35 PM, in the nourishment room confirmed the facility failed to maintain the nourishment refrigerator in a clean and sanitary manner.

Based on review of facility policy, observation, and interview, the facility failed to properly clean kitchen equipment and failed to properly store prepared food for one of one kitchen reviewed. The findings included: Review of facility policy, Sanitation Program Hazard & MGT(management) Prevention, reviewed 8/13, revealed "...clean equipment...routinely with the appropriate sanitizing compounds..." Review of facility policy, Leftovers, revised 11/05, revealed "...cold food for storage in the refrigerator...completely covered with plastic wrap, foil or container lid..." Observation with the Dietary Manager on 4/13/15 at 10:05 AM, in the kitchen, revealed dust particles were on the fan located over the kitchen door. Observation of a bakers rack, with the Dietary Manager on 4/13/15 at 10:25 AM, revealed cleaned dishes ready for use, with two of four metal muffin tins with dried food particles. Observation with the Dietary Manager on 4/13/15 at 10:30 AM, revealed a special function fixed grill with large dried brown food particles in between the grates. Observation with the Dietary Manager on 4/13/15 at 10:40 AM, revealed Cooler One had dust debris on the two cooling fans. Observation with the Dietary Manager on 4/13/15 at 10:45 AM, in Cooler Two, revealed dust debris was on the two cooling fans. Continued observation revealed an uncovered tray rack that contained the following uncovered food items: lettuce, tomatoes, cucumbers, onions, and a large bowl of ranch dressing. Interview with the Dietary Manager on 4/13/15 at 10:50 AM, in the kitchen, confirmed the facility failed to clean the fan, the two muffin tins, the fixed grill, the cooling fans in the two coolers, and failed to cover the food items. Further interview with the Dietary Manager and Cook #1 confirmed the fixed grill was used for grilling meats and was unsure of when it was last used or cleaned. Observation of Cooler 2 with the Dietary Manager, on 4/14/15 at 11:25 AM, in the kitchen, revealed dust debris was on the two cooling fans. Interview with the Dietary Manager on 4/14/15 at 11:25 AM, in the kitchen, confirmed the two cooling fans had dust debris and "...we are in heavy production..."

Based on medical record review and interview, the facility failed to develop a care plan to address Depression, Anxiety, and Urinary Tract Infection, for one (#14) of twenty residents reviewed. The findings included: Resident #14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed the resident was discharged on [DATE]. Medical record review of physician's orders [REDACTED]. Medical record review of a positive urine culture, received by the facility on January 31, 2014, revealed the causative organisms were [MEDICATION NAME] Faecium and Pseudomonas Aeruginosa, and the [MEDICATION NAME] were ordered to treat the Urinary Tract Infection. Medical record review of the Care Plan dated January 10, 2014, and reviewed on February 5, 2014, revealed no documentation the resident's Depression, Anxiety, or Urinary Tract Infection were addressed. Interview on February 11, 2014, at 2:10 p.m., with the Director of Nursing, in the nursing station, confirmed the care plan did not address the resident's Depression, Anxiety, or Urinary Tract Infection.

Based on medical record review, review of facility policy, and interview, the facility failed to maintain an accurate medical record for one resident (#37) of twenty residents reviewed. The findings included: Resident #37 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Admission assessment dated [DATE], revealed the resident had a "...pressure ulcer to the left third digit, at a stage two..." level. Further review of the assessment revealed a second skin problem identified as "redness to bilateral buttocks" at a stage one..." level. Further review revealed the sizes of these sites were not documented. Medical record review of the Weekly Pressure Ulcer Flow Sheet with the onset date of August 24, 2013, revealed a pressure ulcer to bilateral buttocks at a stage two level and no size was documented. Review of the facility policy entitled Pressure Ulcer Prevention and Management, revealed "...Upon admission every patient's skin integrity is assessed...document measurements of...and description of the wound bed..." Interview on February 11, 2014, at 10:39 a.m., in the social worker's office, with the Quality Management representative, confirmed the "...consensus was there was no pressure ulcer size documented..." and the medical record was not accurate.

Based on observation and interview, the facility failed to post nurse staffing information. The findings included: Observation on February 10, 2014, at 10:10 a.m., revealed the nurse staffing information was not posted. Interview on February 10, 2014, at 10:30 a.m., with Registered Nurse #1, in the hallway, confirmed the nurse staffing information for February 10, 2014, was not posted.

Based on observation, facility policy review, and interview, the facility failed to maintain the dumpster area appropriately. The findings included: Observation of the dumpster on February 10, 2014, at 1:55 p.m., with the Dietary Manager, revealed a one gallon open container of mayonaise open inside the dumpster, and the dumpster area had the following debris in the area around the dumpster: soiled gloves; an aluminum lid; paper; cardboard debris; and a plastic water bottle. Review of the faciliity's policy Trash and Grease removal, revised August 2013, revealed "...All trash must be in plastic trash bags..." Interview with the Dietary Manager, on February 10, 2014, at the time of the observation, confirmed the dumpster area was not properly maintained.

Based on observation and interview, the facility failed to provide sanitary storage of food and equipment and failed to maintain appropriate serving temperatures for food items on the tray line in kitchen #1 and failed to ensure a pest free environment in the dry storage area in kitchen #2. The findings included: Observation of the dietary department in kitchen #1 on August 27, 2012, from 10:30 a.m. until 11:15 a.m., revealed: 1. One six pound nine ounce can of Mandarin Oranges was dented and available for use; 2. One opened, plastic container of icing in the walk-in refrigerator, had an expiration date of August 22, 2012 and available for use; 3. Grapes uncovered, in a metal pan with water, stored in the walk- in refrigerator and available for use; 4. Frozen taco meat covered with broken plastic wrap and aluminum foil had an expiration date of June 25, 2012, and available for use; 5. Three containers of sausage balls in the walk in freezer had expiration dates of June 6, July 15, and July 5, 2012, and available for use; 6. Five pound container of thickener stored open on the shelf in the dry storage area and available for use; 7. A five pound bag of flour, unlabeled, stored open on the shelf, and available for use; 8. A two pound bag of almonds, unlabeled, stored open on the shelf and available for use; 9. Table mounted can opener had chunks of tomato stuck to it and available for use; 10. A large plastic container of sugar, unlabeled, and available for use; 11. A container of cocoa had a spoon inside and available for use; 12. A container of cinnamon had a spoon inside and available for use; 13. A piping bag full of icing, unlabeled, wrapped in clear plastic wrap and available for use; 14. A container of chicken fry had a scoop inside and available for use; 15. There was in excess of five flies in the kitchen; 16. Standing water in the dishwasher area of the kitchen and no Wet Floor sign present; 17. A walk- in refrigerator door was cracked open three inches for a minimum of 5 minutes; 18. Dishwasher final rinse was at sixty-five degrees instead of the required one hundred eighty degrees; 19. The sanitizer sink measured over 500 parts per million and was being used; 20. The stand- up meat slicer had particles of sliced meat and a build- up of food debris on the base, and available for use; 21. A cone shaped food strainer had a build-up of yellow food debris in the bottom of the strainer, and available for use; 22. The tray line had a build-up of food particles and debris under the entire line, and available for use; 23. A sheet pan had food particles and debris and available for use; 24. A spatula had a crusty build-up of food on the end of the blade and available for use; 25. Six tongs were stored in a container with food particles and debris in the bottom, and available for use. Interview with the dietary manager on August 27, 2012, at 11:15 a.m., in the dietary department, confirmed dented cans were to be removed from stock; all expired food items were to be disposed of on their expiration date; all open food in the walk in refrigerator was to be covered; all items stored after opening were to be closed and labeled with an expiration date; the table mounted can opener should have been cleaned after being used; all plastic containers used for storage were to be labeled with contents; no spoons or scoops were to be stored in containers with products; there were to be no flies in the kitchen ; a wet floor sign needed to be in the dishwasher room; the walk in refrigerator door should have been closed after being used; the dishwasher temperatures were not in acceptable ranges; the sanitizer sink was not in acceptable range; the stand up meat slicer was dirty and needed to be cleaned; the strainer, spatula, tongs, and sheet pan all needed to be cleaned; and the tray line needed to be taken apart and cleaned. Observation of food temperatures in the dietary department on August 27, 2012, between 11:15 a.m., and 11:30 a.m., on the tray line revealed: 1. Green beans at 131 degrees Fahrenheit; 2. Chicken patties at 134 degrees Fahrenheit. Interview with the dietary manager on August 27, 2012, at 11:30 a.m., in the dietary department, confirmed the temperatures of the food on the tray line had fallen below acceptable temperature limits since being placed on the steam table for service. Observation of food temperatures in the dietary department on August 28, 2012, between 11:15 a.m., and 11:30 a.m., on the tray line revealed: 1. Pork chops at 124 and 137 degrees Fahrenheit; Interview with the dietary manager on August 28, 2012, at 11:30 a.m., in the dietary department, confirmed the temperatures of the food on the tray line had fallen below acceptable temperature limits since being placed on the steam table for service. Observation on August 27, 2012 at 2:10 p.m., in the kitchen #2 dry storage area revealed the presence of ants on the dry storage shelving, located on the east wall of the room. Continued observation, revealed a line of ants entering the dry storage room through a penetration in the concrete floor beside the electrical conduits. Continued observation revealed an open cardboard case containing 16 sealed packets of four ounce maple syrup atop the shelf. Continued observation revealed ants were present on the outside of the case. Continued observation of the dry storage racks on the west wall of the dry storage room revealed multiple ants present on the shelving. Atop the shelving were two cardboard boxes containing sealed individual packs of sugar, and Splenda ( a sugar substitute). Continued observation revealed ants were also present on the outside surface of a sealed box which contained cases of sealed cereals. Interview with Dietary Manager #2 on August 27, 2012, at 2:15 p.m. in the dry storage room, confirmed the presence of ants on the shelving used to store dry goods which were available for resident use.

Based on medical record review, observation, interviews, review of facility policy, review of National Institutes of Health (NIH) reference, and review of facility nursing education, the facility failed to notify the physician of a therapeutic blood level to discontinue [MEDICATION NAME] (anticoagulant medicine which prolongs blood clotting time) therapy and failed to notify the physician of inability to obtain ordered laboratory tests for one resident (#2) receiving anticoagulation therapy of six residents reviewed receiving anticoagulation therapy. The facility's failure to ensure labs were obtained as ordered and laboratory results were called to the physician, which would allow the physician to adjust anticoagulation therapy and/or order additional laboratory tests, is likely to cause serious injury, harm, impairment, or death to resident #2 from uncontrolled bleeding related to extremely increased blood clotting times. The Administrator, Director of Nursing (DON), Chief Operating Officer (CEO), and Chief Nursing Officer (CNO) were notified of the Immediate Jeopardy on March 16, 2011, at 1:30 p.m., in the activities room. The Immediate Jeopardy was effective March 6, 2011, and is ongoing. The findings included: Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set, dated dated dated [DATE], revealed the resident's BIMS (Brief Interview Mental Status) score was 10 out of 15 (0=severe cognitive impairment and 15=no impairment) and the resident was independent with activities of daily living. Medical record review of the admission orders [REDACTED]. Medical record review of the MAR (Medication Administration Record) for February 1 through March 16, 2011, revealed the resident was receiving [MEDICATION NAME] 5000 units subcutaneously three times a day. Medical record review of a physician's progress note dated February 25, 2011, at 10:30 a.m., revealed, "...Alert, talkative, responsive, oriented. With little complaints of pain...status [REDACTED]. Medical record review of a physician's order dated February 25, 2011, revealed, "...INR (International Normalized Ratio - lab value for anticoagulation therapy to determine therapeutic range) every day. [MEDICATION NAME] 5 mg po (milligrams by mouth) every day." Medical record review revealed all the INR reports in the resident's medical record were obtained from the same laboratory with the following notation at the bottom of each report: "The American College of Chest Physicians conference recommends an INR of 2.0 to 3.0 for basic blood thinning needs. For patients who have a high risk of clot formation, they recommend a range of 2.5 to 3.5." Medical record review revealed the following INR lab results in the resident's medical record: February 26, 4:00 a.m. - 1.2; February 27, 4:35 a.m. - 1.2; and February 28 - no results. Medical record review of a physician's order dated March 1, 2011, revealed, "obtain labs BMP, CBC, PT/INR, Mg++ (Basic Metabolic Panel, Complete Blood Count, [MEDICATION NAME] Time/International Normalized Ratio, Magnesium)..." Medical record review revealed the labs were obtained on March 1, 2011, at 9:20 a.m., and the INR was 1.2. Medical record review of a physician's order dated March 1, 2011, revealed an order to increase the [MEDICATION NAME] to 7.5 mg every day. Medical record review revealed no laboratory reports for March 2, 2011, and an INR was obtained March 3, 2011, at 4:50 a.m., with a result of 1.7. Medical record review of a physician's progress note dated March 3, 2011, revealed, "...The patient clinically is doing well...INR 1.7...History of [MEDICAL CONDITIONS] now restarted back on [MEDICATION NAME] term anticoagulation with [MEDICATION NAME] patient clinically is doing better...Has been restarted back on [MEDICATION NAME] is still subtherapeutic...is on 7.5 mg. Will repeat PT and INR on 03/06/2011 and if INR is still low may need to go up again on (his/her) [MEDICATION NAME] dose..." Medical record review of a physician's order dated March 3, 2011, at 12:00 p.m., revealed, "PT/INR on 3/6/11 & (and) call (named physician - MD (medical doctor) #1) INR result." Medical record review revealed no laboratory reports for March 4 or 5, 2011, and an INR was obtained March 6, 2011, at 5:25 a.m., with a result of 2.5. Further review revealed no signatures or documentation on the lab results, and no documentation MD #1 was called with the INR results. Medical record review revealed no further written or verbal physician's orders or progress notes in the medical record and no laboratory reports for March 7-9, 2011, and no documentation MD #1 was called with the INR results. Medical record review revealed a laboratory report dated March 10, 2011, at 1:00 p.m., for a PTT (Partial [MEDICAL CONDITION] Time) with a result of 44 (reference range 23-35). Further review revealed a handwritten note on the report, "Called (named physician - MD #2) run PT INR," signed by an LPN (Licensed Practical Nurse) and dated March 10, 2011. Interview with the Director of Nursing and the Charge Nurse on March 15, 2011, at 8:15 a.m., at the nursing station, revealed they were unaware of why the lab obtained the PTT on March 10, 2011 because there was no physician order for [REDACTED]. Medical record review of a nursing note dated March 10, 2011, at 6:30 p.m., revealed, "Flushed PICC (peripherally inserted central line catheter) double lumen lines, able to admin IV (administer intravenous) antibiotics via lines but unable to draw labs from lines. No return." Medical record review revealed no results March 10, 2011, for the PT/INR. Medical record review revealed no laboratory results for March 11-14, 2011. Observation of the resident on March 14, 2011, at 1:45 p.m., revealed the resident was in a private room, sitting on the side of the bed. Further observation revealed the resident had a PICC in the right upper arm and a Wound Vac (negative pressure wound therapy system) to the left foot. Medical record review of a physician's order dated March 15, 2011, revealed, "...Discharge Home!" Medical record review and interviews with the Director of Nursing and the Charge Nurse, on March 15, 2011, at 8:15 a.m., at the nursing station, confirmed the physician ordered daily INRs on February 25, 2011, which were not obtained on February 28, March 2, March 4, March 5, or March 7-14, 2011, and the laboratory report for March 10, indicated a PT/INR was to be collected, and there were no results available. Further interviews confirmed documentation in the nursing notes for March 10, 2011, indicated the staff were unable to obtain labs from the resident's PICC line; but there was no documentation the physician was called or other attempts to obtain the blood had been made; the medical record did not contain documentation indicating why the labs had not been obtained; and no documentation of any physician notifications of laboratory values, or of labs not being obtained. Medical record review revealed there were no INR results between March 7-14, 2011. Medical record review revealed an INR collected March 15, 2011, at 5:30 p.m., with a result of 7.3 and "Critical (abnormal lab value which requires immediate attention) called to (extension and staff name)..." Medical record review of a physician's order dated March 15, 2011, at 7:45 p.m., revealed, "Hold discharge till (until) INR stable. PT daily. Stop [MEDICATION NAME], Hold [MEDICATION NAME]. Give Vit K (vitamin K for clotting reverses the effect of [MEDICATION NAME]) 10 mg (1 ml (milliliter)) sub Q (subcutaneous) now." Medical record review revealed an INR was obtained March 16, 2011, at 5:33 a.m., with a result of 9.4 and "Critical called..." Medical record review of a physician's order dated March 16, 2011, at 7:45 a.m., revealed 1 cc (cubic centimeters) Vitamin K Sub Q now." Medical record review of a physician's order dated March 16, 2011, at 9:00 a.m., revealed, "Fresh frozen plasma today - 1 unit (Fresh frozen plasma increases clotting; reverses the effect of [MEDICATION NAME]). INR every day call me results every day. CBC today. CMP today." Review of NCBI Bookshelf, a service of the National Library of Medicine, National Institutes of Health (NIH), revealed reversal of the [MEDICATION NAME] ([MEDICATION NAME]) toxicity or increased anticoagulation due to [MEDICATION NAME] ([MEDICATION NAME]) therapy include administration of vitamin K and [MEDICAL CONDITION] with fresh frozen plasma. Review of the facility's policy Physician Visits (no policy number), effective February 2001 and updated December 2006, revealed, "...Nursing staff will call or fax pertinent information i.e. (that is) lab, radiology reports to the physician as needed...If the resident experiences a change of condition between visits the charge nurse or designee will contact the physician with a report of resident's condition." Review of all education requirements nursing staff received in the last 12 months revealed an article titled "Going with the flow: [MEDICATION NAME] ([MEDICATION NAME]) What you and your patient need to know," from Nursing made Incredibly Easy! July/August 2004. Review of the article revealed, "...The patient's international normalized ratio (INR) is the key to determining if the [MEDICATION NAME] dose is adequate. An INR below 2.0 puts the patient at greater risk of [MEDICAL CONDITION]; when it's above 4.0, he has an increased risk of hemorrhage...Because [MEDICATION NAME] doesn't start working immediately-it may take up to 5 days to reach its [MEDICAL CONDITION] level-you can expect to give it in the acute care setting while the patient is still on [MEDICATION NAME]. Then, once the [MEDICATION NAME] INR reaches the therapeutic level, [MEDICATION NAME] is discontinued. Initially you'll monitor the INR daily, then every 2 to 3 days until its stable. Monitoring continues weekly for several weeks...The major complication of anticoagulant therapy is bleeding..." Medical record review and interviews with MD #2 on March 16, 2011, at 8:45 a.m., and 9:20 a.m., at the nursing station, confirmed the physician was the author of the order on February 25, 2011, to obtain daily INRs. Further interviews confirmed the physician was a member of a group of three physicians who rotated weekly to provide physician coverage for care of residents in the facility. Further interviews confirmed the physician had not been notified the facility had difficulty obtaining blood for the INRs and had not been notified of the laboratory results on March 6, 2011. Further interviews confirmed the first time the physician had been called regarding the resident's laboratory results or anticoagulation therapy was on March 15, 2011, when the facility notified the physician of an elevated INR of 7.3. Further interviews confirmed the physician had completed a full assessment of the resident on March 16, 2011, at 8:55 a.m., found no bruising or signs and symptoms of bleeding (risks related to elevated INR results), and the wound to the left foot was healing with no signs of bleeding. Further interviews confirmed the physician was aware the resident was receiving [MEDICATION NAME] and [MEDICATION NAME] daily, and the order for daily INRs were to monitor the resident's status. Further interviews confirmed MD #2 verified MD #1 saw the resident on March 1, 2011, when the resident's INR was 1.7. Further interviews confirmed the resident's INR on March 6, 2011, was 2.5 and "I would have stopped [MEDICATION NAME] at that point and continued [MEDICATION NAME]" Further interviews confirmed the [MEDICATION NAME] was not stopped and the resident was administered [MEDICATION NAME] and [MEDICATION NAME] daily after reaching the therapeutic level of 2.5 on March 6, 2011. Further interviews confirmed if an INR had been obtained before March 15, 2011 (daily or on March 10), "hopefully" the facility would have noticed the INR increase before it had reached a critical value of 7.3 and 9.4, requiring Vitamin K and fresh frozen plasma administration. Interview with the charge nurse on March 16, 2011, at 9:10 a.m., at the nursing desk, confirmed the physician group providing primary medical care to the resident consisted of three physicians, one of whom had been out of the state for a while, with the other two providing coverage. Further interviews confirmed staff is to call the house operator at any time to contact the physician providing coverage for the day. Observation and interview with the resident on March 16, 2011, at 10:00 a.m., revealed the resident was lying in bed with a family member present. During the interview, the resident confirmed MD #2 had talked with the resident that morning and explained the resident's "blood is too thin." Medical record review and interview with the charge nurse on March 16, 2011, at 10:30 a.m., at the nursing station, confirmed the only nursing notes in the medical record consisted of three notes wtritten on February 1, March 9, and March 10, 2011. Further interviews confirmed there was no documentation the physician was notified of the lab result on March 6, 2011, and there were no orders written related to anticoagulation therapy after March 3, 2011. Further interviews confirmed a level of 2.5 was therapeutic for anticoagulation therapy, indicating [MEDICATION NAME] was to be discontinued. Further interviews confirmed an INR was to be obtained on March 10, 2011, the lab was not obtained, and there was no documentation the physician was notified the lab could not be obtained. Interview with MD #1 on March 16, 2011, at 10:35 a.m., by phone, and medical record review and interview on March 16, 2011, at 12:50 p.m., at the nursing station, confirmed the physician wrote the order on March 3, to draw the INR on March 6, and MD #1 felt the order nullified the order to draw daily INRs. Further interviews confirmed the physician saw the resident on March 1; the resident was still subtherapeutic for anticoagulation therapy (therapeutic is 2.0 - 3.0), but was slowly rising; and the physician wanted to be notified of the results of the INR on March 6, three days later, to determine whether [MEDICATION NAME] needed to be discontinued or [MEDICATION NAME] increased. Further interviews confirmed standard protocol was to discontinue [MEDICATION NAME] once the resident reached a level of 2.0, and then to monitor the INR every three days. Further interviews confirmed the physician was never notified of the 2.5 INR result on March 6, and had the physician been notified, there would have been a verbal order to stop the [MEDICATION NAME] and draw another INR on March 9, 2011. Interviews with LPN #3, the Administrator, and the CNO (Chief Nursing Officer) on March 16, 2011, at 4:00 p.m., in the Activities Room, confirmed LPN #3 was aware the resident was receiving [MEDICATION NAME] therapy three times a day and [MEDICATION NAME] 7.5 mg every day. Further interviews confirmed the lab faxes reports daily and the nurses were to call the physician and inform of all laboratory results. Further interview confirmed the LPN stated MD #1 was notified of the 2.5 INR on March 6, 2011, and there were no new orders from the physician. Further interviews confirmed the LPN did not document on the lab report, nursing notes, or physician orders of the physician being notified of the lab result, the medications the resident was receiving or the physician stated no new orders. Further interviews confirmed documentation was not satisfactory to indicate why the INR was not obtained March 10, 2011, as requested on the lab result of the PTT, and no documentation the physician was made aware the lab had not been obtained as ordered. Interview with the CNO and the Administrator on March 16, 2011, at 4:10 p.m., in the activities room, confirmed the nursing staff was required to attend the annual skills day every year. Further interviews confirmed the article on [MEDICATION NAME] was part of the annual education and all staff had received education on standards for [MEDICATION NAME] therapy. Interviews with the Director of Nursing and Charge Nurse on March 15, 2011, at 8:15 a.m., MD #2 on March 16, 2011, at 8:45 a.m., the Charge Nurse on March 16, 2011, at 10:30 a.m., MD #1 at 12:50 p.m., at the nursing station, and the CNO on March 16, 2011, at 4:00 p.m., in the activities room, confirmed there was no documentation to indicate the physician was notified of lab results as ordered and did not notify the physician of difficulty in obtaining blood for labs.

Based on the survey results dated March 16, 2011, the facility failed to notify the physician of a therapeutic blood level to discontinue [MEDICATION NAME] (anticoagulant medicine which prolongs blood clotting time) therapy and failed to notify the physician of inability to obtain ordered laboratory tests for one resident (#2) receiving anticoagulation therapy of six residents reviewed receiving anticoagulation therapy. A revisit was conducted at Southern Tennessee Medical Center SNF on April 5, 2011, following acceptance of the Allegation of Compliance to remove the Immediate Jeopardy for F 157. The revisit revealed the corrective actions completed on April 1, 2011, removed the Immediate Jeopardy at F 157, but noncompliance continues at a "D" level for F 157, as evidenced by the findings at tag F 157. The findings included: The facility provided an acceptable Credible Allegation of Compliance with a compliance date of April 1, 2011. An onsite visit was completed on April 5, 2011, to validate compliance. The credible allegation was validated on April 5, 2011, at 3:30 p.m. Validation of the Credible Allegation of Compliance was accomplished through medical record review, observation, and interviews with licensed nurses, a physician, a pharmacist, and residents. The facility provided evidence of in-service and training records for all nursing staff, nurse aides, laboratory personnel, and pharmacy staff related to inability to complete diagnostic tests, management of anticoagulation (blood thinner) therapy, clinical test values reporting, communication and documentation, and 24 hour chart checks. Included in the validation process was review of facility tools used to document ongoing monitoring of obtaining lab work, physician notification, and chart audits. Interview with the two licensed nurses on the unit confirmed the nurses had received training and had taken a test on anticoagulation protocol, obtaining lab work, physician notification, and documentation. Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the physician's orders [REDACTED]. Medical record review revealed a physician's orders [REDACTED]. Medical record review revealed the PT/INR was completed daily; results reported daily to the physician; and [MEDICATION NAME] dosages adjusted by the physician based on PT/INR results. The facility remained out of compliance at a Scope and Severity level of "D", no actual harm with potential for minimal harm that is not immediate jeopardy. The facility will remain out of compliance until it provides an acceptable plan of correction to include continued monitoring to ensure the deficient practice does not recur and review of the facility's corrective measures by the Quality Assurance Committee.

Based on medical record review and interview, the facility failed to monitor and update the comprehensive care plan for one resident (#2) receving blood thinning medications of twelve residents reviewed. The facility's failure to monitor and update the plan of care to ensure staff were knowledgeable for monitoring and the delivery of care is likely to cause serious injury, harm, impairment or death to resident #2 from uncontrolled bleeding related to extremely increased blood clotting times. The Administrator, Director of Nursing (DON), Chief Operating Officer (CEO) were notified of the Immediate Jeopardy on March 16, 2011, at 1:30 p.m., in the activities room. The findings included: Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the resident's Interdisciplinary Plan of Care dated February 1, 2011, revealed, "Problem Potential for adverse effects from anticoagulant therapy [MEDICATION NAME] (blood thinning medication to prevent clots). Goal Patient will have no adverse effects...Monitor as ordered by MD..." Further review of the plan of care revealed no interventions had been put in place to address that the resident was receiving [MEDICATION NAME] (blood thinning medication) that was ordered on February 25, 2011 and a dosage increase of [MEDICATION NAME] that was ordered on March 1, 2011. A box located next to "PT INR" was empty and did not have a mark in the box to indicate the need to monitor PT INR as ordered by the physician. Medical record review and interview with the Charge Nurse on March 16, 2011, at 2:30 p.m. at the Nursing Station, confirmed the care plan had not been updated to reflect the resident's [MEDICATION NAME] therapy and did not indicate the necessity to monitor PT/INR as ordered by the physician.

Based on the survey results dated March 16, 2011, the facility failed to monitor and update the comprehensive care plan for one resident (#2) receving blood thinning medications of twelve residents reviewed. A revisit was conducted at Southern Tennessee Medical Center SNF on April 5, 2011, following acceptance of the Allegation of Compliance to remove the Immediate Jeopardy for F 280. The revisit revealed the corrective actions completed on April 1, 2011, removed the Immediate Jeopardy at F 280, but noncompliance continues at a "D" level for F 280, as evidenced by the findings at tag F 280. The findings included: The facility provided an acceptable Credible Allegation of Compliance with a compliance date of April 1, 2011. An onsite visit was completed on April 5, 2011, to validate compliance. The credible allegation was validated on April 5, 2011, at 3:30 p.m. Validation of the Credible Allegation of Compliance was accomplished through medical record review and interviews with licensed nurses. The facility provided evidence of in-service and training records for all nursing staff related to updating care plans. Included in the validation process was review of facility tools used to document ongoing monitoring of chart audits. Interview with two licensed nurses on the unit confirmed the nurses had received training and had taken a test on anticoagulation protocol and updating care plans. Medical record review revealed four residents (#1, #2, #4, and #6) were receiving anticoagulants and all care plans for the four residents indicated the name of the anticoagulant and the necessary monitoring required for each resident. The facility remained out of compliance at a Scope and Severity level of "D", no actual harm with potential for minimal harm that is not immediate jeopardy. The facility will remain out of compliance until it provides an acceptable plan of correction to include continued monitoring to ensure the deficient practice does not recur and review of the facility's corrective measures by the Quality Assurance Committee.

Based on medical record review, observation, interview, review of facility policy, review of National Institutes of Health (NIH) reference, and review of facility nursing education, the facility failed to provide necessary care to follow physician's orders for obtaining laboratory (labs) results and calling the physician with laboratory results for one resident (#2) receiving anticoagulation therapy of six residents reviewed receiving anticoagulation therapy. The facility's failure to ensure labs were obtained as ordered and laboratory results were called to the physician, which would allow the physician to adjust anticoagulation therapy and/or order additional laboratory tests, is likely to cause serious injury, harm, impairment, or death to resident #2 from uncontrolled bleeding related to extremely increased blood clotting times. The Administrator, Director of Nursing (DON), Chief Operating Officer (CEO), and Chief Nursing Officer (CNO) were notified of the Immediate Jeopardy on March 16, 2011, at 1:30 p.m., in the activities room. The Immediate Jeopardy was effective March 6, 2011, and is ongoing. F-309 represents Substandard Quality of Care. The findings included: Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set, dated dated dated [DATE], revealed the resident's BIMS (Brief Interview Mental Status) score was 10 out of 15 (0=severe cognitive impairment and 15=no impairment) and the resident was independent with activities of daily living. Medical record review of the admission orders [REDACTED]. Medical record review of the MAR (Medication Administration Record) for February 1 through March 16, 2011, revealed the resident was receiving [MEDICATION NAME] 5000 units subcutaneously three times a day. Medical record review of a physician's progress note dated February 25, 2011, at 10:30 a.m., revealed, "...Alert, talkative, responsive, oriented. With little complaints of pain...status [REDACTED]. Medical record review of a physician's order dated February 25, 2011, revealed, "...INR (International Normalized Ratio - lab value for anticoagulation therapy to determine therapeutic range) every day. [MEDICATION NAME] 5 mg po (milligrams by mouth) every day." Medical record review revealed all the INR reports in the resident's medical record were obtained from the same laboratory with the following notation at the bottom of each report: "The American College of Chest Physicians conference recommends an INR of 2.0 to 3.0 for basic blood thinning needs. For patients who have a high risk of clot formation, they recommend a range of 2.5 to 3.5." Medical record review revealed the following INR lab results in the resident's medical record: February 26, 4:00 a.m. - 1.2; February 27, 4:35 a.m. - 1.2; and February 28 - no results. Medical record review of a physician's order dated March 1, 2011, revealed, "obtain labs BMP, CBC, PT/INR, Mg++ (Basic Metabolic Panel, Complete Blood Count, [MEDICATION NAME] Time/International Normalized Ratio, Magnesium)..." Medical record review revealed the labs were obtained on March 1, 2011, at 9:20 a.m., the INR was 1.2, and handwritten at the bottom of the lab report was a note indicating the resident was on [MEDICATION NAME] 5 mg. Medical record review of a physician's order dated March 1, 2011, revealed an order to increase the [MEDICATION NAME] to 7.5 mg every day. Medical record review revealed no laboratory reports for March 2, 2011, and an INR was obtained March 3, 2011, at 4:50 a.m., with a result of 1.7. Medical record review of a physician's progress note dated March 3, 2011, revealed, "...The patient clinically is doing well...INR 1.7...History of [MEDICAL CONDITIONS] now restarted back on [MEDICATION NAME] term anticoagulation with [MEDICATION NAME] patient clinically is doing better...Has been restarted back on [MEDICATION NAME] is still subtherapeutic...is on 7.5 mg. Will repeat PT and INR on 03/06/2011 and if INR is still low may need to go up again on (his/her) [MEDICATION NAME] dose..." Medical record review of a physician's order dated March 3, 2011, at 12:00 p.m., revealed, "PT/INR on 3/6/11 & (and) call (named physician - MD (medical doctor) #1) INR result." Medical record review revealed no laboratory reports for March 4 or 5, 2011, and an INR was obtained March 6, 2011, at 5:25 a.m., with a result of 2.5. Further review revealed no signatures or documentation on the lab results, and no documentation MD #1 was called with the INR results. Medical record review revealed no further written or verbal physician's orders or progress notes in the medical record and no laboratory reports for March 7-9, 2011, and no documentation MD #1 was called with the INR results. Medical record review revealed a laboratory report dated March 10, 2011, at 1:00 p.m., for a PTT (Partial [MEDICAL CONDITION] Time) with a result of 44 (reference range 23-35). Further review revealed a handwritten note on the report, "Called (named physician - MD #2) run PT INR," signed by an LPN (Licensed Practical Nurse) and dated March 10, 2011. Interview with the Director of Nursing and the Charge Nurse on March 15, 2011, at 8:15 a.m., at the nursing station, revealed they were unaware of why the lab obtained the PTT on March 10, 2011 because there was no physician order for [REDACTED]. Medical record review of a nursing note dated March 10, 2011, at 6:30 p.m., revealed, "Flushed PICC (peripherally inserted central line catheter)double lumen lines, able to admin IV (administer intravenous) antibiotics via lines but unable to draw labs from lines. No return." Medical record review revealed no results on March 10, 2011, for the PT/INR. Medical record review revealed no laboratory results for March 11-14, 2011. Medical record review of the MAR for March, 2011, revealed the resident continued to receive [MEDICATION NAME] 5000 units three times a day and [MEDICATION NAME] 7.5 mg every day from March 3-14, 2011. Observation of the resident on March 14, 2011, at 1:45 p.m., revealed the resident was in a private room, sitting on the side of the bed. Further observation revealed the resident had a PICC in the right upper arm and a Wound Vac (negative pressure wound therapy system) to the left foot. Medical record review of a physician's order dated March 15, 2011, revealed, "...Discharge Home!" Medical record review and interviews with the Director of Nursing and the Charge Nurse, on March 15, 2011, at 8:15 a.m., at the nursing station, confirmed the physician ordered daily INRs on February 25, 2011, which were not obtained on February 28, March 2, March 4, March 5, or March 7-14, 2011, and the laboratory report for March 10, indicated a PT/INR was to be collected, and there were no results available. Further interviews confirmed documentation in the nursing notes for March 10, 2011, indicated the staff were unable to obtain labs from the resident's PICC line; but there was no documentation the physician was called or other attempts to obtain the blood had been made; the medical record did not contain documentation indicating why the labs had not been obtained; and no documentation of any physician notifications of laboratory values, or of labs not being obtained. Medical record review revealed there were no INR results between March 7-14, 2011. Interview with the Charge Nurse on March 15, 2011, at 8:30 a.m., at the nursing desk, confirmed the resident was to be discharged home on March 15, 2011. Medical record review revealed an INR collected March 15, 2011, at 5:30 p.m., with a result of 7.3 and "Critical (abnormal lab value which requires immediate attention) called to (extension and staff name)..." Medical record review of a physician's order dated March 15, 2011, at 7:45 p.m., revealed, "Hold discharge till (until) INR stable. PT daily. Stop [MEDICATION NAME], Hold [MEDICATION NAME]. Give Vit K (vitamin K for clotting reverses the effect of [MEDICATION NAME]) 10 mg (1 ml (milliliter)) sub Q (subcutaneous) now." Medical record review revealed an INR was obtained March 16, 2011, at 5:33 a.m., with a result of 9.4 and "Critical called..." Medical record review of a physician's order dated March 16, 2011, at 7:45 a.m., revealed 1 cc (cubic centimeters) Vitamin K Sub Q now." Medical record review of a physician's order dated March 16, 2011, at 9:00 a.m., revealed, "Fresh frozen plasma today - 1 unit (Fresh frozen plasma increases clotting; reverses the effect of [MEDICATION NAME]). INR every day call me results every day. CBC today. CMP today." Review of NCBI Bookshelf, a service of the National Library of Medicine, National Institutes of Health (NIH), revealed reversal of the [MEDICATION NAME] ([MEDICATION NAME]) toxicity or increased anticoagulation due to [MEDICATION NAME] ([MEDICATION NAME]) therapy include administration of vitamin K and [MEDICAL CONDITION] with fresh frozen plasma. Medical record review of the Interdisciplinary Plan of Care dated February 1, 2011, revealed, "Problem Potential for adverse effects from anticoagulant therapy [MEDICATION NAME]. Goal Patient will have no adverse effects...Intervention assess for: bruising, bleeding from gums, nosebleed, tarry stools, abdominal swelling, prolonged bleeding from a wound, coughing up blood, blood in emesis (vomiting), diarrhea, hematuria (blood in urine). Monitor as ordered by MD..." Further review revealed staff had not updated the plan to indicate the resident was receiving [MEDICATION NAME], and the empty box located next to "PT INR" did not have a mark in the box to indicate the need to monitor PT INR as ordered by the physician. Review of the facility's policy Physician Visits (no policy number), effective February 2001 and updated December 2006, revealed, "...Nursing staff will call or fax pertinent information i.e. (that is) lab, radiology reports to the physician as needed...If the resident experiences a change of condition between visits the charge nurse or designee will contact the physician with a report of resident's condition." Review of all education requirements nursing staff received in the last 12 months revealed an article titled "Going with the flow: [MEDICATION NAME] ([MEDICATION NAME]) What you and your patient need to know," from Nursing made Incredibly Easy! July/August 2004. Review of the article revealed, "...The patient's international normalized ratio (INR) is the key to determining if the [MEDICATION NAME] dose is adequate. An INR below 2.0 puts the patient at greater risk of [MEDICAL CONDITION]; when it's above 4.0, he has an increased risk of hemorrhage...Because [MEDICATION NAME] doesn't start working immediately-it may take up to 5 days to reach its [MEDICAL CONDITION] level-you can expect to give it in the acute care setting while the patient is still on [MEDICATION NAME]. Then, once the [MEDICATION NAME] INR reaches the therapeutic level, [MEDICATION NAME] is discontinued. Initially you'll monitor the INR daily, then every 2 to 3 days until its stable. Monitoring continues weekly for several weeks...The major complication of anticoagulant therapy is bleeding..." Medical record review and interviews with MD #2 on March 16, 2011, at 8:45 a.m., and 9:20 a.m., at the nursing station, confirmed the physician was the author of the order on February 25, 2011, to obtain daily INRs. Further interviews confirmed the physician was a member of a group of three physicians who rotated weekly to provide physician coverage for care of residents in the facility. Further interviews confirmed the physician had not been notified the facility had difficulty obtaining blood for the INRs and had not been notified of the laboratory results on March 6, 2011. Further interviews confirmed the first time the physician had been called regarding the resident's laboratory results or anticoagulation therapy was on March 15, 2011, when the facility notified the physician of an elevated INR of 7.3. Further interviews confirmed the physician had completed a full assessment of the resident on March 16, 2011, at 8:55 a.m., and found no bruising or signs and symptoms of bleeding, and the wound to the foot was healing with no signs of bleeding. Further interviews confirmed the resident could not be discharged home. Further interviews confirmed the resident required administration of Vitamin K on March 15, and repeated on March 16, 2011, and would have to receive fresh frozen plasma, to attempt to reverse the high INR results and reduce the risk of bleeding. Further interviews confirmed the physician was aware the resident was receiving [MEDICATION NAME] and [MEDICATION NAME] daily, and the order for daily INRs were to monitor the resident's status. Further interviews confirmed MD #2 verified MD #1 saw the resident on March 1, 2011, when the resident's INR was 1.7. Further interviews confirmed the resident's INR on March 6, 2011, was 2.5 and "I would have stopped [MEDICATION NAME] at that point and continued [MEDICATION NAME]" Further interviews confirmed the [MEDICATION NAME] was not stopped and the resident was administered [MEDICATION NAME] and [MEDICATION NAME] daily after reaching the therapeutic level of 2.5 on March 6, 2011. Further interviews confirmed if an INR had been obtained before March 15, 2011, "hopefully" the facility would have noticed the INR increase before it had reached a critical value of 7.3 and 9.4. Interview with the charge nurse on March 16, 2011, at 9:10 a.m., at the nursing desk, confirmed the physician group providing primary medical care to the resident consisted of three physicians, one of whom had been out of the state for a while, with the other two providing coverage. Further interviews confirmed staff is to call the house operator at any time to contact the physician providing coverage for the day. Observation and interview with the resident on March 16, 2011, at 10:00 a.m., revealed the resident was lying in bed with a family member present. During the interview, the resident confirmed MD #2 had talked with the resident that morning, and explained the resident's "blood is too thin." Medical record review and interview with the charge nurse on March 16, 2011, at 10:30 a.m., at the nursing station, confirmed the only nursing notes in the record consisted of three notes written on February 1, March 9, and March 10, 2011. Further interviews confirmed there was no documentation the physician was notified of the lab result on March 6, 2011, and there were no orders written related to anticoagulation therapy after March 3, 2011. Further interviews confirmed a level of 2.5 was therapeutic for anticoagulation therapy, indicating [MEDICATION NAME] was to be discontinued. Further interviews confirmed an INR was to be obtained on March 10, 2011, the lab was not obtained, and there was no documentation the physician was notified the lab could not be obtained. Interview with MD #1 on March 16, 2011, at 10:35 a.m., by phone, and medical record review and interview on March 16, 2011, at 12:50 p.m., at the nursing station, confirmed the physician wrote the order on March 3, to draw the INR on March 6, and MD #1 felt the order nullified the previous order for daily INRs. Further interviews confirmed the physician saw the resident on March 1, and the resident was still subtherapeutic for anticoagulation therapy (therapeutic is 2.0-3.0), but was slowly rising. Further interviews confirmed the physician wanted the resident to stay on the same dose of [MEDICATION NAME] and [MEDICATION NAME], because it took three days for [MEDICATION NAME] results to be reflected in the INR, and the physician wanted to be notified of the results of the INR on March 6, three days later, to determine whether [MEDICATION NAME] needed to be discontinued or [MEDICATION NAME] increased. Further interviews confirmed standard protocol was to discontinue [MEDICATION NAME] once the resident reached a level of 2.0, and then to monitor the INR every three days. Further interviews confirmed the physician was never notified of the 2.5 INR result on March 6, and had the physician been notified, there would have been a verbal order to stop the [MEDICATION NAME] and draw another INR on March 9, 2011. Further interviews confirmed the physician did not have standing orders, but always gave verbal orders to stop [MEDICATION NAME] and draw INRs every three days, once a patient reaches a level of 2.0. Interviews with LPN #3, the Administrator, and the CNO on March 16, 2011, at 4:00 p.m., in the Activities Room, confirmed LPN #3 was aware the resident was receiving [MEDICATION NAME] therapy three times a day and [MEDICATION NAME] 7.5 mg every day. Further interviews confirmed the lab faxed reports daily and the nurses were to call the physician and inform of all laboratory results. Further interview confirmed the LPN stated MD #1 was notified of the 2.5 INR on March 6, 2011, and there were no new orders from the physician. Further interviews confirmed the LPN did not document on the lab report, nursing notes, or physician orders of the physician being notified of the lab result, the medications the resident was receiving, or the physician stated no new orders. Further interviews confirmed documentation was not satisfactory to indicate why the INR was not obtained March 10, 2011, as requested on the lab result of the PTT, and no documentation the physician was made aware the lab had not been obtained as ordered. Interview with the CNO and the Administrator on March 16, 2011, at 4:10 p.m., in the activities room, confirmed the nursing staff was required to attend the annual skills day every year. Further interviews confirmed it was mandatory for all nursing; was offered at 19 different times; for staff who could not attend, the materials were available for review; and the department managers were responsible for ensuring all staff received the education. Further interviews confirmed the article on [MEDICATION NAME] was part of the annual education and the expectations were staff had received education on standards for [MEDICATION NAME] therapy. Interviews with the Director of Nursing and Charge Nurse on March 15, 2011, at 8:15 a.m., MD #2 on March 16, 2011, at 8:45 a.m., the Charge Nurse on March 16, 2011, at 10:30 a.m., MD #1 at 12:50 p.m., at the nursing station, and the CNO on March 16, 2011, at 4:00 p.m., in the activities room, confirmed labs were not obtained as ordered by the physician; nursing did not notify the physician of lab results as ordered; nursing did not notify the physician of difficulty in obtaining blood for labs; and [MEDICATION NAME] was not discontinued when the resident reached a therapeutic level, as indicated by anticoagulation therapy protocols.

Based on the survey results dated March 16, 2011, the facility failed to provide necessary care to follow physician's orders for obtaining laboratory (labs) results and calling the physician with laboratory results for one resident (#2) receiving anticoagulation therapy of six residents reviewed receiving anticoagulation therapy. A revisit was conducted at Southern Tennessee Medical Center SNF on April 5, 2011, following acceptance of the Allegation of Compliance to remove the Immediate Jeopardy for F 309. The revisit revealed the corrective actions completed on April 1, 2011, removed the Immediate Jeopardy at F 309, but noncompliance continues at a "D" level for F 309, as evidenced by the findings at tag F 309. The findings included: The facility provided an acceptable Credible Allegation of Compliance with a compliance date of April 1, 2011. An onsite visit was completed on April 5, 2011, to validate compliance. The credible allegation was validated on April 5, 2011, at 3:30 p.m. Validation of the Credible Allegation of Compliance was accomplished through medical record review, observation, and interviews with licensed nurses, a physician, a pharmacist, and residents. The facility provided evidence of in-service and training records for all nursing staff, nurse aides, laboratory personnel, and pharmacy staff related to inability to complete diagnostic tests, management of anticoagulation (blood thinner) therapy, clinical test values reporting, communication and documentation, and 24 hour chart checks. Included in the validation process was review of facility tools used to document ongoing monitoring of obtaining lab work, physician notification, and chart audits. Interview with the two licensed nurses on the unit confirmed the nurses had received training and had taken a test on anticoagulation protocol, obtaining lab work, physician notification, and documentation. Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the physician's orders revealed the resident was receiving [MEDICATION NAME] (anticoagulant) therapy. Medical record review revealed a physician's order dated March 21, 2011, for daily PT/INR ([MEDICATION NAME] and international normalized ratio). Medical record review revealed the PT/INR was completed daily; results reported daily to the physician; and [MEDICATION NAME] dosages adjusted by the physician based on PT/INR results. The facility remained out of compliance at a Scope and Severity level of "D", no actual harm with potential for minimal harm that is not immediate jeopardy. The facility will remain out of compliance until it provides an acceptable plan of correction to include continued monitoring to ensure the deficient practice does not recur and review of the facility's corrective measures by the Quality Assurance Committee.

Based on medical record review and interview, the facility failed to obtain laboratory tests as ordered by the physician for two residents, #2 who was on [MEDICATION NAME] and [MEDICATION NAME] ( blood thinning medications) and #8, of twelve residents reviewed. The facility's failure to ensure labs were obtained as ordered which would allow the physician to adjust anticoagulation therapy and/or order additional laboratory tests, is likely to cause serious injury, harm, impairment, or death to resident #2 from uncontrolled bleeding related to extremely increased blood clotting times. The Administrator, Director of Nursing (DON), Chief Operating Officer (CEO), and Chief Nursing Officer (CNO) were notified of the Immediate Jeopardy on March 16, 2011, at 1:30 p.m., in the activities room. The Immediate Jeopardy was effective March 6, 2011, and is ongoing. The findings included: Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Medical record review revealed no INR results for February 28, or March 2, 2011. Medical record review of a physician's orders [REDACTED]." Medical record review revealed no results for the ESR, BMP, or CBC. Medical record review revealed a verbal order signed by a Licensed Practical Nurse (LPN) and dated March 10, 2011 stating, "Called (named physician - MD #2) run PT INR,". Medical record review of a nursing note dated March 10, 2011, at 6:30 p.m., revealed, "Flushed PICC (peripherally inserted central line catheter) double lumen lines, able to admin IV (administer intravenous) antibiotics via lines but unable to draw labs from lines. No return." Medical record review revealed no results on March 10, 2011, for the PT/INR. Medical record review and interviews with the Director of Nursing and the Charge Nurse, on March 15, 2011, at 8:15 a.m., and 10:30 a.m., at the nursing station, confirmed the laboratory tests were not obtained as ordered. Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Interview with the Charge Nurse on March 16, 2011, at 10:45 a.m., at the nursing station confirmed the laboratory tests were not obtained as ordered.

Based on the survey results dated March 16, 2011, the facility failed to obtain laboratory tests as ordered by the physician for two residents, #2 who was on [MEDICATION NAME] and [MEDICATION NAME] ( blood thinning medications) and #8, of twelve residents reviewed. A revisit was conducted at Southern Tennessee Medical Center SNF on April 5, 2011, following acceptance of the Allegation of Compliance to remove the Immediate Jeopardy for F 502. The revisit revealed the corrective actions completed on April 1, 2011, removed the Immediate Jeopardy at F 502, but noncompliance continues at a "D" level for F 502, as evidenced by the findings at tag F 502. The findings included: The facility provided an acceptable Credible Allegation of Compliance with a compliance date of April 1, 2011. An onsite visit was completed on April 5, 2011, to validate compliance. The credible allegation was validated on April 5, 2011, at 3:30 p.m. Validation of the Credible Allegation of Compliance was accomplished through medical record review, observation, and interviews with licensed nurses, a physician, a pharmacist, and residents. The facility provided evidence of in-service and training records for all nursing staff, nurse aides, laboratory personnel, and pharmacy staff related to inability to complete diagnostic tests, management of anticoagulation (blood thinner) therapy, clinical test values reporting, communication and documentation, and 24 hour chart checks. Included in the validation process was review of facility tools used to document ongoing monitoring of obtaining lab work, physician notification, and chart audits. Interview with the two licensed nurses on the unit confirmed the nurses had received training and had taken a test on anticoagulation protocol, obtaining lab work, physician notification, and documentation. Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the physician's orders [REDACTED]. Medical record review revealed a physician's orders [REDACTED]. Medical record review revealed the PT/INR was completed daily; results reported daily to the physician; and [MEDICATION NAME] dosages adjusted by the physician based on PT/INR results. The facility remained out of compliance at a Scope and Severity level of "D", no actual harm with potential for minimal harm that is not immediate jeopardy. The facility will remain out of compliance until it provides an acceptable plan of correction to include continued monitoring to ensure the deficient practice does not recur and review of the facility's corrective measures by the Quality Assurance Committee.