Every finding on record at Stoneridge Health Care, LLC

Based on policy review, medical record review, observation, and interview, the facility failed to monitor water temperatures to ensure the environment was free from accident hazards when hot water temperatures ranging from 131 degrees Fahrenheit (F) to 134 degrees F were found in 6 of 17 (Resident #4, #7, #14, #15, #20, #23, #26, #27, and #30) occupied resident bathrooms, with no documentation of temperatures being monitored from 11/26/2025 though 3/15/2026. The findings include: 1. Review of the facility policy titled, Accident and Hazard Prevention Policy, dated 1/1/2026, revealed .A systematic process shall be in place to identify, evaluate, and correct environmental hazards on an ongoing basis . 2. Review of the undated Maintenance Director's job description revealed .Ensures the facility remains in compliance with all federal, state and local regulations .Ensures .monitors compliance .Maintains a safe .environment free of objects/situations that could cause harm .to residents, families, visitors, and associates .Performs regular safety inspections of the facility and documents the findings . 3. Review of the (named supplier) Invoice dated 3/16/2026, revealed .RESPONDED TO CALL OF HOT WATER ISSUES. CLEANED THE MIXING VALVE. REMOVED BAD CASING GASKET. FURNISHED AND INSTALLED A NEW CASING GASKET. SET TEMPERATURE TO 110*. OPERATING PROPERLY. NO LEAKS . 4. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Acute and Chronic Respiratory Failure, Anxiety, and Depression. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) assessment score of 15, which indicated Resident #4 was cognitively intact. Resident #4 required supervision for personal hygiene and partial assistance with toilet transfers. During an interview on 3 /15/2026 at 10:35 AM, Resident #4 was asked if the water was hot when she used it. Resident #4 stated .I can't go in there because I can't walk alone .They will get me water to wash up if I need it .I haven't had any problems . Observation in Resident #4's bathroom on 3/15/2026 at 12:12 PM, revealed the water temperature in Resident #4's sink with a reading of 132 degrees F. 5. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Legal Blindness, Dementia, Major Depressive Disorder, and Anxiety. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 15 which indicated Resident #27 was cognitively intact. Resident #27 was independent with personal hygiene and required supervision for toilet transfer. Observation in Resident #27's bathroom on 3/15/2026 at 10:47 AM, revealed the water temperature in Resident #27's sink with a reading of 132 degrees F. During an interview on 3/17/2026 at 10:55 AM, Resident #27 stated that she does not go to the bathroom because she has a bedside commode and that she had not had a problem with the water temperature. 6. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE], with diagnoses including Atherosclerotic Heart Disease, Hemiplegia and Hemiparesis, Anxiety, and Major Depressive Disorder. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 11, which indicated Resident #7 was moderately cognitively impaired. Resident #7 was dependent on staff for toileting and hygiene. Review of the medical record revealed Resident #30 was admitted to the facility on [DATE], with diagnoses including Alzheimer's, Legal Blindness, Hearing Loss Bilateral, and Dementia. Review of the quarterly MDS assessment dated [DATE], revealed Resident #30 was unable to be evaluated for a BIMS score due to severely impaired cognition. Resident #30 required maximal assist for toileting and personal hygiene. Observation in Resident #7 and #30's shared bathroom on 3/15/2026 at 10:48 AM, revealed the water temperature in the sink with a reading of 134 degrees F. During an interview on 3/17/2026 at 10:50 AM, Resident #7 stated she doesn't get out of bed and that she only gets bed baths. Resident #7 was asked if she has ever had an issue with the water temperature neither being too hot or too cold, and she stated No. No interview could be conducted with the Resident #30 as she was asleep each time she was approached for an interview. 7. Review of the medical record revealed Resident #26 was admitted to the facility on [DATE], with diagnoses including Malignant Neoplasm of Brain, Schizophrenia, Bipolar, and Hypertension. Review of the admission MDS assessment dated [DATE], revealed a BIMS score was not attempted due to Resident #26 was severely cognitively impaired. Resident #26 was dependent on staff for personal hygiene and required substantial assist for toilet transfers. Observation in Resident #26's bathroom on 3/15/2026 at 10:55 AM, revealed the water temperature in Resident #26's sink with a reading of 133 degrees F. During an interview on 3/15/2026 at 2:26 PM, the Director of Nursing (DON) was asked how Resident #26 was bathed. The DON stated, .the CNA gives her baths .this resident does not use her bathroom at all . 8. Review of the medical record revealed Resident #14 was admitted to the facility on [DATE], with diagnoses including Dementia, Anxiety, Benign Prostatic Hyperplasia, and Depression. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score was not attempted due to Resident #14 was severely cognitively impaired. Resident #14 was dependent on staff to perform personal hygiene and toilet transfers. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE], with diagnoses including Epilepsy, Dementia, Depression, Hypertension, and Anxiety. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 5, which indicated Resident #15 was severely cognitively impaired. Resident #15 was dependent on staff for toilet transfers. Observation in Resident #14 and #15's shared bathroom on 3/15/2026 at 12:12 PM, revealed the water temperature in the sink with a reading of 134 degrees F. During an interview on 3/15/2026 at 1:48 PM, Resident #15 was asked if he uses his bathroom. Resident #15 stated he does not use the bathroom in his room. During an interview on 3/15/2026 at 2:26 PM, the Director of Nursing (DON) was asked how Resident #14 was bathed. DON stated, .he gets assistance from the CNA and staff .goes to the shower room . The DON was asked how Resident #15 was bathed, and she stated, .Hospice baths him, he does not use his restroom . 9. Review of the medical record revealed Resident #20 was admitted to the facility on [DATE], with diagnoses including Chronic Kidney Disease, Need for Assistance with Personal Care, and Hypertension. Review of the admission MDS assessment dated [DATE], revealed a BIMS assessment score of 15, which indicated Resident #20 was cognitively intact. Resident #20 required substantial assistance with personal hygiene and transfer to the toilet. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE], with diagnoses including Displaced Fracture of Lateral Condyle of Left Tibia, Chronic Obstructive Pulmonary Disease, and Epilepsy. Review of the admission MDS assessment dated [DATE], revealed a BIMS assessment score of 13, which Resident # 23 was cognitively intact. Resident #23 required partial assistance for personal hygiene and was dependent for toileting. Observation in Resident #20 and #23's shared bathroom on 3/15/2026 at 12:12 PM, revealed the sink's water temperature was 132 F. During an interview on 3/15/2026 at 2:30 PM, Resident #20 was asked if she had ever had any problems with the water being too hot in her bathroom. Resident #20 stated .I don't even go in there .I wear a brief . When asked if the water had ever been too hot during personal care, Resident #20 stated .Oh no . During an interview on 3/15/2026 at 3:15 PM, Resident #23 was asked if she had any problems with the water being too hot in her bathroom. Resident #23 stated .I can't use the bathroom .the cast on my leg makes it too hard to get in there .if I need to wash my hands, they bring me a washcloth . During an interview on 3/16/2026 at 4:44 PM, the Executive Director/Maintenance Supervisor was asked how often water temperatures should be checked. The Executive Director/Maintenance Supervisor stated, .Weekly .I have someone here working on the plumbing now and changing out the mixing valve and to make sure the system is working properly . During an interview on 3/17/2026 at 7:45 AM, the Executive Director/Maintenance Supervisor was asked how water temperatures should be maintained. The Executive Director/Maintenance Supervisor stated he should do weekly checks in random rooms and different hallways. During an interview on 3/17/2026 at 3:27 PM, the Administrator was asked how often water temperatures should be checked. The Administrator stated, .We don't have a policy on that . The Administrator was asked how water temperatures should be monitored and she replied .We will be doing daily checks for the next 7 days and then weekly after that .

Based on policy review, medical record review, observation, and interview, the facility failed to ensure medications were properly stored and secured when medications were found unsecured and unattended in 2 of 17 (Resident #2 and #25) resident occupied rooms reviewed and when a treatment cart was left unsecured and unattended. The findings include: 1. Review of the facility policy titled, Medication Storage Policy, dated 11/2026, revealed .Purpose.To ensure medications are stored safely and securely in accordance with CMS (Centers for Medicare and Medicaid Services) regulations for long-term care facilities.All medications will be stored in a safe, secure, and properly maintained environment to protect residents and maintain medication integrity.All medications must be stored in locked medication carts, medication rooms, or medication refrigerators when not in use.Medication rooms, carts, and refrigerators must remain locked when not directly in use.Controlled Substances must be secured in a double-locked system according to federal and state regulations. Review of the facility policy titled, Narcotic Storage Policy, dated 11/2026, revealed .All narcotic and controlled medications will be stored, secured, and accounted for to prevent loss, diversion, or unauthorized access.All controlled substances must be stored in a double-locked system within the medication cart or medication room.Controlled substances must remain secured when not in direct use. 2. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], with diagnoses including Displaced Intertrochanteric (the area between the greater and lesser trochanters (a large bony prominence on the upper femur (thigh bone) of the proximal (toward the center of the body) femur) Fracture of Left Femur, Non-Pressure Chronic Ulcer of Other Part of Left Foot, Non-Pressure Chronic Ulcer of Other Part of Right Foot, and Osteoarthritis. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #2 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment, which indicated Resident #2 was cognitively intact and received scheduled and prn (as needed) pain medication regimen. Review of the Physician Order dated 2/21/2026, revealed Potassium Chloride ER (extended release) Tablet Extended Release 20 MEQ (milliequivalent).1 tablet by mouth one time a day. Review of the Physician Order dated 3/4/2026, revealed HYDROcodone (a Schedule II controlled medication used for pain management) -Acetaminophen Oral Tablet 5-325 MG (milligram).Give 1 tablet by mouth every 12 hours as needed for pain . During an observation and interview in Resident #2's room on 3/15/2026 at 11:19 AM, 2 white pills, one broken in half, were observed in a small clear medication cup on the resident's over bed table. Resident #2 was asked what the medications were in the cup. Resident #2 stated I was taking them and felt sick. The one that is broke in half is potassium, the other is hydrocodone. During an observation and interview in Resident #2's room on 3/15/2026 at 11:25 AM, Licensed Practical Nurse (LPN) A verified the medications in the medication cup on the resident's over bed table were potassium and Hydrocodone. LPN A was asked if medications should be left at bedside unsecured and unattended. LPN A stated, No. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Type 2 Diabetes, and Pressure Ulcer of Right Heel. Review of the significant change MDS assessment dated [DATE], revealed Resident #6 scored a 12 on the BIMS assessment, which indicated Resident #6 was moderately cognitively impaired and was noted for 1 unstageable pressure ulcer with pressure ulcer/injury care. Review of the Physician Order dated 3/6/2026, revealed Cleanse right heel with wound cleanser and pat dry. Apply [Named prescription-only topical medication used to debride chronic skin ulcers] to wound bed followed with [Named antibacterial foam dressing]. Cover with ABD [abdominal] pad and secure with rolled gauze and tape.one time a day. Observation at the Treatment Cart on 3/16/2026 at 1:37 PM, revealed LPN F removed the following supplies from the Treatment Cart in the hallway across from Resident #6's room: (Named prescription-only topical medication used to debride chronic skin ulcers), rolled gauze, ABD pad, sterile gauze sponges, (Named) wound wash, (Named antibacterial foam dressing), and tape. At 1:52 PM, LPN F and the Director of Quality Assurance entered Resident #6's room with the supplies and performed wound care for the resident with the Treatment Cart unlocked, unsecured, and unattended, with the key in the lock in the hallway. The Treatment Cart was left out of sight of facility staff during wound care treatment. During an observation and interview at the Treatment Cart on 3/16/2026 at 2:01 PM, LPN F was asked if she had left the treatment cart unlocked. LPN F stated, Yes. LPN F was asked should it had been left unlocked when out of sight. LPN F stated, No, it shouldn't have . 3. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE], with diagnoses including Dementia, Chronic Allergic Conjunctivitis (inflammation of the thin and clear layer that covers the white surface of the eye), and Dry Eye Syndrome of Bilateral Lacrimal (tear) Glands. Review of the significant change MDS assessment dated [DATE], revealed Resident #25 scored a 7 on the BIMS assessment, which indicated Resident #25 was severely cognitively impaired. Review of the Physician Orders revealed no order for allergy relief eye drops. Observation in Resident #25's room on 3/15/2026 at 11:28 AM, revealed an opened box with Resident #25's name written on it containing a bottle of allergy relief eye drops on the nightstand. During an observation and interview in Resident #25's room on 3/15/2026 at 11:35 AM, the eye drops remained on the nightstand. LPN A stated, The resident's daughter leaves those here. LPN A was asked if over the counter medications should be left unsecured and unattended in a resident's room. LPN A stated, No. During an interview on 3/17/2026 at 1:09 PM, the Director of Nursing (DON) was asked how medications should be stored. The DON stated, In the cart or in a locked area. The DON was asked who should have access to medications. The DON stated, Only the charge nurses and the pharmacist, if he is here. The DON was asked if medications should be left at bedside unsecured and unattended. The DON stated, Not pills. The DON was asked how narcotics and controlled substances should be stored. The DON stated, Double locked. The DON was asked if having medications unsecured and unattended at bedside could create an opportunity for another resident to take the medication. The DON stated, Absolutely. The DON was asked if the treatment cart should be left unlocked, unsecured, and unattended on the hallway. The DON stated, No. The DON was asked if leaving a treatment cart unlocked, unsecured, and unattended on the hall could create an opportunity for a resident to take something out of it or ingest something that is stored in it. The DON stated, Yes.

Based on facility policy review, medical record review, facility documentation review, and interviews, the facility failed to refund 4 Residents (Resident #4, Resident #5, Resident #6, and Resident #8) of 6 residents reviewed, for refunds of resident trust accounts within 30 days of discharge. The facility failed to monitor resident trust fund balances, so no resident goes over the $2000.00 balance limit for 1 (Resident #4) out of 6 discharged residents reviewed for trust fund balances. The findings include: Review of facility policy titled, Resident Trust Fund Refund Accounts Receivable, dated ,d+[DATE], ,d+[DATE], revealed, .The Facility must ensure accurate and timely, refunds within individual state regulations .Resident Trust Fund Refunds are usually issued due to either the resident was discharged .and return is not anticipated, or due to the resident expired. The facility must refund the Resident Trust Fund money of discharged or deceased residents according to the time frames and procedures of the individual state (TN [Tennessee] - within 30 days of discharge or expiration) . Review of facility policy titled, Resident Trust Funds Accounts Receivable, dated ,d+[DATE], ,d+[DATE], ,d+[DATE], revealed, .It is the policy of this facility to ensure that all resident trust accounts are maintained according to state regulations .The facility must refund the resident trust fund money of discharged or deceased residents according to the time frames and procedures of the individual state (TN - within 30 days of discharge or expiration) .Monitor closely that no Medicaid resident goes over their $2,000.00 limit per state guidelines . Review of facility policy titled, Resident trust Fund General Compliance, dated [DATE], revealed, .Resident Trust fund accounts shall be kept separate from the facility's operating accounts .The facility must refund the resident trust fund money of a discharged or deceased resident according with 30 days of discharge or resident death . Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses which included Personal history of Traumatic Brain Injury, Torticollis, Other conduct disorders, and Essential (primary) Hypertension. Resident #4 was discharged from the facility on [DATE]. Review of the Resident Trust Fund Statement, dated [DATE] to [DATE], for Resident #4 revealed: Date: [DATE] Balance: $2,901.00 Date: [DATE] Balance: $2,413.90 Date: [DATE] Balance: $2,984.02 Date: [DATE] Balance: $2,161.06 Date: [DATE] Balance: $3,248.36 Date: [DATE] Balance: $3,437.77 Date: [DATE] Balance: $2,238.89 Date: [DATE] Balance: $3,522.61 Date: [DATE] Balance: $3,476.74 Date: [DATE] Balance: $3,748.89 Date: [DATE] Balance: $3,183.03 (Resident #4 discharged on [DATE]) Date: [DATE] Balance: $475.51 (53 days after Resident #4 discharge date ) Date: [DATE] Balance: $1,266.58 (84 days after Resident #4 discharge date ) Date: [DATE] Balance: $2,068.83 (114 days after Resident #4 discharge date ) Date: [DATE] Balance: $51.91 (145 days after Resident #4 discharge date ) Date: [DATE] Balance: $843.95 (177 days after Resident #4 discharge date ) Date: [DATE] Balance: $10.04 (206 days after Resident #4 discharge date ) Date: [DATE] Balance: $802.44 (210 days after Resident #4 discharge date ) Date: [DATE] Balance: $1,594.44 (241 days after Resident #4 discharge date ) Date: [DATE] Balance: $802.44 (269 days after Resident #4 discharge date ) Date [DATE] Balance: $792.19 (300 days after Resident #4 discharge date ) Date: [DATE] Account Closed - Check 1398 Amount $1,610.19 - Balance $0 The Resident Trust Fund Statement, for Resident #4, dated [DATE] to [DATE], revealed twelve (12) months the trust fund balance exceeded the $2000.00 state guideline limit. The facility did not refund the trust fund balance until 302 days after Resident #4's discharge date of [DATE]. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Other Acute Osteomyelitis, Right Ankle and Foot, Acquired Absence of Right Great Toe, Methicillin Resistant Staphylococcus Aureus Infection causing diseases classified elsewhere, Essential (primary) Hypertension, and Cellulitis, unspecified. Resident #5 was discharged from the facility on [DATE]. Review of the Resident Trust Fund Statement, dated [DATE] to [DATE] for Resident #5 revealed; Date: [DATE] Balance: $558.73 Date: [DATE] Balance: $558.75 (Resident #5 discharged on [DATE]) Date: [DATE] Balance: $404.20 (34 days after Resident #5 discharge date ) Date: [DATE] Balance: $434.06 (73 days after Resident #5 discharge date ) Date: [DATE] Balance: $464.09 (104 days after Resident #5 discharge date ) Date: [DATE] Balance: $526.58 (134 days after Resident #5 discharge date ) Date: [DATE] Balance: $526.61 (165 days after Resident #5 discharge date ) Date: [DATE] Balance: $556.64 (196 days after Resident #5 discharge date ) Date: [DATE] Balance: $616.25 (225 days after Resident #5 discharge date ) Date: [DATE] Balance: $556.65 (230 days after Resident #5 discharge date ) Date: [DATE] Ending Balance: $526.65 (319 days after Resident #5 discharge date ) The facility did not refund the trust fund balance for Resident #5 within the 30 days of discharge date of [DATE]. Resident #4's trust fund still had a balance of $524.18 on [DATE] (342 days after discharge date ). Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses which included Cerebral Infarction, unspecified, Hemiplegia, unspecified affecting left nondominant side, Secondary Hypertension, and Chronic Ischemic Heart Disease. Resident #6 was discharged from the facility on [DATE]. Review of the Resident Trust Fund Statement, dated [DATE] to [DATE], for Resident #6 revealed; Date: [DATE] Balance: $292.72 Date: [DATE] Deposit $200.00 Balance: $461.50 (Resident #6 discharged on [DATE]) Date: [DATE] Check 1396-: $460.13 - Balance: $1.37 (25 Days after Resident #6 discharge) Date: [DATE] Account Closed - Check 1400 Amount $1.37 - Balance $0 The facility did not refund the trust fund balance until [DATE], 62 days after Resident #6's discharge date of [DATE]. Review of an email from Family Member #1 to facility's Social Services Director (SSD), dated [DATE] at 8:53 AM Eastern Standard Time (EST), revealed, .I need assistance with a few things. Could you [SSD] help me please .I [Family Member #1] sent a $200 check to him [Resident #6] the week before he [Resident #6] was removed from your facility. Can you [SSD] give me [Family Member #1] the status of that check . Review of an email from Family Member #1 to facility's SSD dated [DATE] at 12:58 PM EST revealed, .Please let me [Family Member #1] know about the mo [money] why from dad's account and where his things could have ended up . Review of an email from Family Member #1 to facility's SSD, dated [DATE] at 7:36 PM EST, revealed, .I've [Family Member #1] requested a response regarding my Dad's [Resident #6] money .I [Family Member #1] would appreciate a statement of account showing when the check I [Family member #1] sent for $200 for his [Resident #6] personal expenditures was refunded to him [Resident #6] and where it was mailed. It was mailed to you [facility] the week before he [Resident #6] was kicked out of your facility . Review of an email from facility's SSD to Family Member #1 dated [DATE] at 4:05 PM EST revealed, .I have included with this email a statement from his account. Our business office manager cut a check and gave it to our receptionist who then put it in the mail to the address listed on the statement. The check number was #1396 and it was put in the mail the week of the 8th-12th. I am not sure why you have not received this. We had major snow on Monday the 15th and below average temps in the area, so it is possible that mail was stalled . Review of the medical record revealed, Resident #8 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses which included Sepsis, unspecified organism, Unspecified Dementia, unspecified severity, with behavioral disturbance, Pain, unspecified, Vascular Dementia, unspecified severity, with psychotic disturbance, and Impaired Fasting Glucose. Resident #8 was discharged from the facility on [DATE]. Review of the Resident Trust Fund Statement, dated [DATE] to [DATE], for Resident #8 revealed; Date: [DATE] Balance: $819.73 Date: [DATE] Balance: $1,119.85 (Resident #8 discharged on [DATE]) Date: [DATE] Balance: $0.00 (25 Days after Resident #8 discharge date ) Date: [DATE] Balance: $1,119.85 (176 days after Resident #8 discharge date ) Date: [DATE] Balance: $1,120.08 (181 days after Resident #8 discharge date ) Date: [DATE] Account Closed - check #1399 Amount $1,120.08 - Balance $0.00 The facility did not refund the trust fund balance until [DATE], 185 days after Resident #8's discharge date of [DATE]. Review of the facility's Open Balance Report, dated [DATE], with the Business Office Manager's (BOM) handwritten dispositions of resident's accounts revealed; Resident discharge date Disposition Balance -[DATE] Resident #9 [DATE] Family finding where to send $248.01 Resident #8 [DATE] POA (power of attorney) hasn't processed $1,119.85 Resident #7 [DATE] In Process $42.44 Resident #5 [DATE] Working with SS [Social Security] $524.07 Resident #4 [DATE] Facility hasn't requested change $792.00 Resident #6 [DATE] In Process $460.13 The facility's Open Balance Report, dated [DATE], revealed resident accounts open past 30 days after residents' discharge date s. Review of the facility's Open Balance Report, dated [DATE], revealed; Resident #5 discharge date : [DATE] Balance: $524.18 The facility's Open Balance Report, dated [DATE], revealed Resident #5's trust fund account was open 343 days after Resident #5 was discharged from the facility. During an observation and interview in the BOM's office, on [DATE] at 4:10 PM, the BOM presented a facility document titled, Open Balance Report, dated [DATE], which listed 11 resident trust funds with 6 residents on the report with discharge date s. The BOM was asked to provide dispositions of the 6 discharged residents' trust fund accounts. Observed the BOM writing comments, about the account status, on the Open Balance Report, dated [DATE]. The BOM stated Resident #8's POA hasn't processed the check. The BOM stated Resident #4 was discharged from the facility on [DATE] and admitted to another facility that needs to request the direct deposit from social security be transferred. The BOM stated they can only write and send the checks, they cannot make the family or POA cash them within 30 days of discharge. When residents transfer to another facility it is up to the receiving facility to request the direct deposits be transferred from social security to the receiving facility. The BOM stated trust fund accounts are usually closed and refunds sent within 30 days of a resident's discharge from the facility. The BOM was asked about the balance limits on resident trust funds. The BOM stated Resident Trust Funds have a $2000.00 balance limit per state guideline and facility policy. The BOM stated, .Resident Trust Funds are to be monitored to not exceed $2000.00 . During a telephone interview on [DATE] at 10:55 AM, Family Member #1 stated Resident #6 was her (Family Member #1) father and was discharged from the facility in [DATE] not sure of the exact date. Family Member #1 stated had recently sent emails to the facility Social Services Director requesting a trust fund account statement for Resident #6 and disposition of a $200 check Family Member #1 had sent to the facility a week before Resident #6 was discharged . Family Member #1 stated, I haven't received the trust fund statement or refund from the facility. Family Member #1 checked the mail while on the phone with this surveyor. Family Member #1 stated a letter post marked [DATE], with no return address, was received. Inside the letter was a Resident Trust Fund Statement for Resident #6, dated [DATE] through [DATE], with a discharge date of [DATE], and check #1396 dated [DATE] for the amount $460.13, a refund of the trust fund balance. During an interview on [DATE] at 5:05 PM, the Administrator stated, The policy states the facility must refund the resident trust fund money of a discharged or deceased resident within 30 days in the State of Tennessee. The Administrator and the BOM were shown the Open Balance Report, dated [DATE] and was asked if the residents on the list were refunded in 30 days. The Administrator responded It is a state rule, and the rules are made almost impossible for facilities to meet. There are a lot of factors that we cannot control. The Administrator was shown the email from Family Member #1 dated [DATE] and was asked if she was aware of it. The Administrator stated, Yes that resident was discharged three months ago. The Administrator and the BOM were asked why the trust fund refund check for Resident #6 dated [DATE], had been received by Family Member #1 during a phone interview on [DATE] with the envelope post marked [DATE]. The BOM responded, I originally sent it out in [DATE], and it was just returned a couple weeks ago. I put it in another envelope with the correct address and mailed it I think the second week of [DATE]. The BOM was asked if the original envelope it was mailed in was kept. The BOM stated, No I think I threw it away.

Based on review of facility policy, medical record review, facility's Grievance Log review, facility email review, and interview, the facility failed to follow the policy to document and investigate a grievance for 1 resident (Resident #6) of 6 residents reviewed for grievances. The findings include: Review of the facility policy titled COMPLAINT MANAGEMENT: OPPORTUNITY FOR IMPROVEMENT, dated 9/1/2017, revealed, .It is the policy of this facility to document and investigate all concerns and complaints .The resident, their representatives, advocates, or interested family members may file a concern or complaint .All reported complaints/concerns will be responded to orally and in writing no longer than 5 working days after being reported .The responsibility for investigating concerns and complaints is assigned to the Social Services department at the facility .Upon receipt of a concern/complaint, the Social Services Director will begin by sending a letter to the person who has reported the complaint or concern acknowledging the receipt of the complaint or concern .Then the Social Services Director will begin by conducting an investigation into the incident. A copy of the report will be given to the department head from which the complaint refers to .The report will include .Date and time report filed, Date, time, and location incident took place, Name of witnesses or others involved, Account by person filing concern/complaint as to what occurred .The resident or person acting on behalf of the resident will be informed of the findings upon completion of the investigation as well as any corrective actions recommended orally and in writing no later than five days after the complaint or concern was made . Review of the medical record revealed, Resident #6 was admitted to the facility on [DATE] with diagnoses which included Cerebral Infarction, unspecified, Hemiplegia, unspecified affecting left nondominant side, Secondary Hypertension, and Chronic Ischemic Heart Disease. Resident #6 was discharged from the facility on 11/13/2023. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated moderate cognitive impairment. Review of the facility grievance log dated 9/1/2023 through 1/26/2024 revealed blank pages with .No Complaints . written at the top of 9/2023 through 12/2023 logs and .1/26/2024 No Complaints at this time . written across the top of the January 2024 log. The facility failed to document the specific concern/grievance from Resident #6's Family Member #1 sent to facility by email dated 1/11/2024 per the facility's policy that stated, . the policy of this facility to document and investigate all concerns and complaints . Review of an email from Family Member #1 to facility's Social Services Director (SSD) dated 1/11/2024 at 8:53 AM, Eastern Standard Time (EST), revealed, . I need assistance with a few things. Could you [SSD] help me please .I sent a $200 check to him [Resident #6] the week before he [Resident #6] was removed from your facility. Can you [SSD] give me the status of that check .his [Resident #6] wallet was not returned in the items released to his sister and her friend. Those also should have been released to me and not them. They [Resident #6's sister and friend] are in no way responsible for his [Resident #6] care .there were so many items that I had given to him [Resident #6] that were not returned. I just want you [SSD] to know that there is a very real problem with people taking things that aren't theirs in your facility. Whether it's employees or accidentally given to another patient, it's so unacceptable. Their things are all they have and to lose them so frequently is very heartbreaking .do you [SSD] have his [Resident #6] Choices coordinator information? He [Resident #6] has been accepted in Chattanooga and they need that information .since his [Resident #6] wallet was not returned, he [Resident #6] now has no identification, no SS [Social Security] card and no way of being identified. The new coordinator stated that it is standard procedure for every facility to have copies of those on hand. Could you [SSD] please send me the copies that you have on file? This is the most urgent need we have currently .The behavioral issues dad [Resident #6] was displaying ended up being related to medications he [Resident #6] was on while there. Those have been adjusted to the proper dosage and he [resident #6] hasn't had a single episode since. I just thought someone there should know it was related to medication, not a mental break . The facility did not acknowledge receipt of this complaint to the complainant per facility policy that states .Upon receipt of a concern/complaint, the Social Services Director will begin by sending a letter to the person who has reported the complaint or concern acknowledging the receipt of the complaint or concern . Review of an email from Family Member #1 to facility's SSD dated 1/16/2024 at 12:58 PM EST revealed, .Please let me [Family Member #1] know about the mo [money] why from dad's account and where his things could have ended up . Review of an email from Family Member #1 to facility's SSD dated 1/20/2024 at 7:36 PM EST revealed, . I've [Family Member #1] requested a response regarding my Dad's [Resident #6] money and personal items twice. I understand you [SSD] feel he is no longer your problem, but ignoring this request for information is both unprofessional and disrespectful. If I [Family Member #1] don't hear back within five business days, I'll [Family member #1] be forced to file a complaint with the police and the BBB [Better Business Bureau]. I [Family Member #1] would appreciate a statement of account showing when the check I [Family member #1] sent for $200 for his [Resident #6] personal expenditures was refunded to him [Resident #6] and where it was mailed. It was mailed to you [facility] the week before he [Resident #6] was kicked out of your facility. I [Family member #1] would also like to request that someone explain where all of my dad's [Resident #6] personal items have disappeared to. As well as his [Resident #6] wallet, including his ID, his social security card and health insurance cards. This is so unacceptable and unprofessional. I knew that theft was a regular issue there [the facility] but this is just unbelievable. Additionally, his [Resident #6] items should NEVER have been released to anyone but me [Family member #1] or my brother. His [Resident #6] sister and her friend should not have been allowed to leave with his [Resident #6] personal items. Please respond by Friday . The facility did not acknowledge receipt of this complaint to the complaint per facility policy that stated, . All reported complaints/concerns will be responded to orally and in writing no longer than 5 working days after being reported .The responsibility for investigating concerns and complaints is assigned to the Social Services department at the facility .Upon receipt of a concern/complaint, the Social Services Director will begin by sending a letter to the person who has reported the complaint or concern acknowledging the receipt of the complaint or concern . Review of an email from the facility's SSD to Family Member #1 to Facility SSD dated 1/23/2024 at 4:05 PM EST, revealed, .I have been trying to interview and talk to all the people involved in your dad's belongings and business affairs, I should have sent you an email letting you know that I was trying to find out the answers for you . During an interview in the administration building office with the SSD on 1/5/2024 at 12:15 PM the SSD stated there were no formal complaints, and .everything is logged including any verbal complaints. During a phone interview on 1/26/2024 at 10:15 PM, Family Member #1 stated Resident #6 was her [Family Member #1] father, was admitted in 2022, and had been discharged from the facility in November of 2023. Family Member #1 was unsure of exact discharge date . Family Member #1 stated after Resident #6 was sent to the hospital Family Member #1 called the facility and did not receive a return call. Family Member #1 had concerns about Resident #6's belongings, account balance, and wallet with identification cards and stated she had emailed the SSD on 1/11/2024 and didn't receive a response until 1/23/2024. Family Member #1 stated the SSD still had not resolved the concerns of Resident #6's belongings. During an interview in the office of the Director of Nursing (DON) on 1/30/2024 at 2:30 PM, when asked about the facility's policy on grievances or concerns, the DON stated anyone, staff, resident, or family member can file a grievance. The DON stated if residents are unable to complete the form staff are to assist residents completing the form. The DON stated that some examples of grievances include missing property, being treated unfairly, and lack of care. When asked when a grievance should be documented the DON stated the process is to fill out a grievance form immediately, notify the SSD, and begin investigating the concern. During an observation and interview in room [ROOM NUMBER] with SSD on 1/26/2024 at 2:35 PM, the SSD was asked for the January 2024 Grievance Log. The SSD presented a blank Grievance Log dated January 2024. The SSD was asked if the facility had received any grievances from any family members this month? The SSD stated No. The SSD was asked to note that on the January 2004 Grievance Log. The SSD wrote 1/26/2024- No Complaints at this time. The SSD was asked if a resident/family member stated I can't find mom's sweater what is your process. SSD stated, We all pitch in and find it. Between the laundry, CNAs, and social services we find it. If we don't find the items, then it is put on the grievance log and goes to the Administrator. The Administrator is the head of the grievance committee. A grievance form is then completed and sent to the appropriate department head for resolution. We tell families up front not to bring valuables or family heirlooms or anything of sentimental value due to people coming in you don't have control over. The SSD stated they have a locked drawer in the administration building for resident valuables such as wallets, and jewelry. Upon further interview the SSD stated The minute I get a concern I try to resolve it. If I am unable to resolve it, then I fill out a grievance and depending on the concern I forward it to the appropriate department supervisor. The supervisor then must tell how it will be fixed. During an interview in the Administrator's office with SSD present on 1/30/2024 at 5:00 PM, the Administrator was asked about the facility's Grievance process and policy. The Administrator stated, A lot of the times they [residents/family/advocates] call and are asked if they want to file a formal complaint and decline. The Administrator was asked to provide an example of something that would be entered on the Grievance Log. The Administrator stated, Obviously if complaining if someone was mean to them or if missing items. We [facility staff] usual sweep the building and find the missing item. The Administrator was asked when an item would be replaced the Administrator responded If it is something they are adamant about we replace it. We encourage residents not to bring items of great value or sentiment because they could become misplaced. The Administrator was asked if the facility had received any grievances in person, by phone, or electronic in the past month. The Administrator stated not for a current resident. The Administrator was asked if she [Administrator] was aware of an email from Family Member #1 to the SSD. The Administrator was shown a copy of the email dated 1/11/2024, from Family Member #1 to the SSD. The Administrator stated, That resident had been discharged for more than 3 months ago. The Administrator was asked if the person is no longer a resident do you address grievances or concerns. We have never done a grievance for a former resident. The SSD has been emailing [Family Member #1] to address the issue. The Administrator was asked if the email should have been documented in the Grievance Log and an investigation documented. The Administrator stated Probably. The SSD stated that the concerns in the email were investigated. The SSD was asked for the written investigation report. The SSD stated there was no written investigation report.

Based on medical record review and interview, the facility failed to complete a Quarterly Minimum Data Set (MDS) assessment for 2 (Resident #11 and Resident #13) of 22 residents reviewed. The findings include: Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses which included Personal history of Traumatic Brain Injury, Atherosclerotic Heart Disease of Native Coronary Artery, Essential (primary) Hypertension, and Chronic Obstructive Pulmonary Disease. Medical record review revealed Resident #11 had an Annual Minimum Data Set (MDS) assessment dated [DATE]. Further medical record review revealed no Quarterly MDS assessment was completed in November 2023. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Dementia in other diseases classified elsewhere, Encephalopathy, unspecified, Nontoxic Multinodular Goiter, and Neurosyphilis, unspecified. Medial record review revealed Resident #13 had a Quarterly MDS assessment dated [DATE]. Further medical record review revealed no Quarterly MDS assessment was completed in December 2023. During an interview in the Director of Nursing (DON)'s office on 1/30/2024 at 2:30 PM, the DON was asked how often are MDS assessments to be completed for residents. The DON stated MDS assessments are done within 14 days of admission, quarterly every 92 days, when there is a significant change in the resident's condition, and annually. The DON was asked to show the surveyor the most current MDS assessment for Resident #11 in the Electronic Medical Record (EMR). The DON stated Resident #11 had an Annual MDS assessment that was completed on 8/25/2023 and a Quarterly MDS Assessment should have been completed in November 2023. The DON was asked to show the surveyor the most current MDS assessment for Resident #13 in the EMR. The DON stated Resident #13 had a Quarterly MDS assessment that was completed on 9/4/2023 and a Quarterly MDS Assessment should have been completed in December 2023. The DON confirmed the Quarterly MDS Assessments for Resident #11 and Resident #13 were overdue. During a phone interview on 1/30/2024 at 4:01 PM, the MDS Coordinator was asked when MDS assessments are completed. The MDS Coordinator stated Admission MDS assessments must be done by the 14th day after admission, Quarterly MDS assessments are completed no later than 92 days after the last MDS Assessment was completed. Annual MDS Assessments are completed annually. During an interview in the Administrator's office on 1/30/2024 at 5:15 PM, the Administrator was asked to show the surveyor the current MDS assessments for Resident #11 and Resident #13 in the EMR. The Administrator stated Resident #11 had an MDS assessment on 8/25/2023 and Resident #13 had an MDS assessment on 9/4/2023. The Administrator was asked if Quarterly MDS Assessments are due every 92 days are Resident #11 and Resident #13 current MDS assessments in compliance. The Administrator stated, I will need to talk with our MDS Coordinator. During a phone interview on 1/30/2024 at 7:20 PM, the MDS Coordinator stated the Administrator had called and stated there was a problem with MDS Assessments. The MDS Coordinator was asked to look up in the EMR the current MDS Assessments for Resident #11 and Resident #13. The MDS Coordinator stated Resident #11 had an Annual MDS assessment dated [DATE] and Resident #13 had a Quarterly MDS assessment dated [DATE]. The MDS Coordinator was asked if Quarterly MDS Assessment are to be completed by 92 days after the last MDS Assessment, was Resident #11 and Resident #13 overdue and out of compliance for Quarterly MDS Assessments. The MDS Coordinator stated Yes, you're right. They are not in compliance.

Based on facility policy review, medical record review, facility investigation, and interview, the facility failed to report an allegation of abuse, within 2 hours of occurrence, to the State Survey Agency, on 1 Facility Reported Incident (FRI) # (number) 2022111110340 reviewed. The findings include: Review of the facility's policy titled, Abuse, Neglect, Misappropriation of Resident Funds, dated 9/1/2017, revealed, .The facility has a zero tolerance policy for abuse, involuntary seclusion, neglect and misappropriation of resident property. The facility will attempt to identify and will investigate any reported violation or allegation of abuse .3. Reports must be within 24 hours (if there is not serious bodily injury) after forming your reasonable suspicion. Within 2 hours (if there is serious bodily injury) after forming your reasonable suspicion .There are two time limits for the reporting of reasonable suspicion of a crime, depending on the seriousness of the event that leads to the reasonable suspicion .1. Serious Bodily Injury-2 hour limit: If the events that cause the reasonable suspicion result in a serious bodily injury to a resident, the facility shall report the suspicion immediately, but not later than 2 hours after forming the suspicion .5. Employees of this facility who have been accused of resident abuse will be suspended from duty until the results of the investigation have been reviewed by the Administrator . Review of the FRI, ID (Identification) # (Number) 2022111110340, for Resident #3, revealed an allegation of employee-to-resident abuse, involving CNA (Certified Nursing Assistant) #2 and Resident #3, occurred on 11/10/2022 at 2:00 AM. The Administrator was immediately notified, and an abuse allegation was reported to the State Agency on 11/11/2022 at 10:34 AM, which was not within 2 hours of the abuse allegation being reported. CNA #2 was immediately suspended pending an investigation. An investigation was initiated. Staff and resident interviews were obtained, and the investigation was completed. The facility was unable to substantiate the abuse allegation. Continued review of the investigation report and employee statements revealed no concerns. During an interview on 12/7/2022 at 4:07 PM, the Administrator stated that she was the Abuse Coordinator. She stated that her expectations were for staff to report any allegations of abuse immediately. The Administrator confirmed that FRI #2022111110340, involving Resident #3, had a date and time of occurrence of 11/10/2022 at 2:00 AM and the date and time reported to the State Agency was 11/11/2022 at 10:34 AM. She stated, I thought it was 24 hours or 1 day, that I had to report it. I didn't realize it was 2 hours.

Based on facility policy review, medical record review, and interview, the facility failed to revise a care plan for 2 of 6 sampled residents (Resident #5 and Resident #6) reviewed for behaviors. The Findings include: Review of the facility's policy titled, Care Plans - Comprehensive, dated 9/1/2017 revealed, .An individualized Comprehensive Care Plan that includes measurable objectives and timetables to meet the residents's medical, nursing, mental and psychological needs is developed for each resident .Care plans are revised as changes in the resident's condition dictate. Care plans are reviewed at least quarterly . Review of the facility's policy titled, Behavioral Management Program, dated 9/1/2022, revealed, .The Program is a subcommittee of the Interdisciplinary Care Plan Team established for the facility employees to: Evaluate behaviors .Identify the root cause of the behaviors .Track, trend and analyze negative behaviors for the purpose of appropriate interventions . Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses which included Peripheral Vascular Disease, Depressive Disorders, and Chronic Kidney Disease Stage 3. Review of Resident #5's Psychiatric Evaluation dated 8/31/2022 revealed, .This is a medication check visit with [Named Resident #5]. Duloxetine [Antidepressant] was increased to 40 mg [milligram] daily related to inappropriate sexual behaviors .staff report resident has not displayed any sexual inappropriate behavior and has been around the other resident involved in the incident. Continued review of Resident #5's Psychiatric Evaluation dated 8/24/2022 revealed, .This is a staff requested psychiatric visit with [Named Resident #5] .Staff report resident was caught attempting an inappropriate sexual act with another resident .Recommendations .Increase Duloxetine to 40 mg daily r/t [related to] sexual behaviors to help decrease libdo [libido] . Review of the Quarterly MDS assessment dated [DATE], revealed Resident #5 had a BIMS score of 11 which revealed moderately impaired cognitive abilities. Review of Resident #5's current Care Plan revealed, .At risk for self/social isolation .Depression, memory deficits .mood & behavioral sx [symptoms] . The Care Plan did not address history of inappropriate sexual behaviors. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses which included Traumatic Brain Injury, Dementia, and Major Depressive Disorder. Review of Resident #6's Psychiatric Evaluation dated 8/31/2022 revealed, .Medroxyprogesterone 10 mg twice daily was started at last visit with this provider related to inappropriate sexual behaviors . Continued review of Psychiatric Evaluation dated 8/24/2022 revealed, .This is a staff requested psychiatric visit .Staff report resident was engaged in inappropriate sexual behavior with another resident .staff reports since incident resident has tried to inappropriately touch other female residents at the facility . Review of the Quarterly MDS assessment dated [DATE], revealed Resident #6 had a BIMS score of 8 which revealed moderately impaired cognitive abilities. Review of Resident #6's current Care Plan revealed, .At risk for self/social isolation .cognitive deficits, moods and behavioral sx [symptoms] . The Care Plan did not address Resident #6's history of inappropriate sexual behaviors. During an interview on 12/6/2022 at 4:00 PM, MDS Coordinator and Business Office Manager revealed Resident #5 has history of sexual acts, and her medication was increased. The MDS Coordinator stated, I know [Named Resident #5, Named Resident #6] was touching each other inappropriately in the dining room a couple of months ago. During an interview on 12/6/2022 at 4:13 PM, Social Service Director (SSD) revealed she had been employed at the facility since 7/2020. SSD stated, It was brought to my attention that [Named Resident #5, Named Resident #6] started a relationship and touching each other, he was touching her breast, and she was rubbing him in the dining room. I discussed this episode with them and explained this was something they could not do in public. Both residents were consensual with these actions. I called [Named Resident #6] conservator and the conservator was ok if the resident agreed with the sexual interaction. [Named Resident #5] was also in agreement with the sexual actions from [Named Resident #6]. [Named Resident #5] is responsible for herself and has no family. During an interview on 12/7/2022 at 3:50 PM, the Administrator was asked to review Resident #5 and Resident #6's current Care Plans, and she confirmed that sexual behaviors or a relationship between the two residents were not care planned. During an interview on 12/7/2022 at 4:00 PM, the MDS Coordinator stated, I thought the behaviors were care planned for [Named Resident #5, Named Resident #6], but we changed computer systems and this maybe why it is not there anymore.

Based on observation, test tray temperatures, and interview, the facility failed to serve palatable food at a safe and appetizing temperature during the lunch meal on 4/11/2022. The findings include: Observation in the dining room on 4/11/2022 at 12:37 PM, revealed 2 dining carts arrived in the dining room with 25 trays total (including a test tray). The last resident's meal was delivered at 12:52 PM. Observation in the hall on 4/11/2022 at 12:52 PM, revealed temperatures taken of the test tray by Cook #1 as follows: Ham-pureed 80 degrees F (Fahrenheit); Ham-chopped: 100 degrees F; Ham slice-whole: 80 degrees F; mixed vegetables: 110 degrees F; mixed vegetables-pureed: 60 degrees F; pineapple casserole: 85 degrees F; and pineapple casserole pureed: 75 degrees F. During an interview in the hall on 4/11/2022 at 12:56 PM, Cook #1 confirmed the food temperatures were not appropriate. She stated, That food should be hotter than that.

Based on facility policy review, facility documentation review, medical record review, and interview, the facility failed to ensure there was no more than 14 hours between a substantial evening meal and breakfast the following day. The findings include: Review of the facility's policy titled, Frequency of Meals, dated September 1, 2017, revealed, .It is the policy of this facility that each resident shall receive at least three (3) meals daily, as well as an evening or bedtime snack .At least three (3) meals or their equivalent are served daily, at regular times, with not more than a fourteen (14) hour span between the evening meal and breakfast . Review of the undated facility documentation titled, Meal Times, revealed 14.5 hours between the evening meal at 5:00 PM and the breakfast meal at 7:30 AM. Review of the facility documentation titled, Resident Council Meeting Minutes, dated from March 2021 thru March 2022, revealed there was no meeting to extend the mealtimes greater than the regulated 14-hour span between the evening meal and the breakfast meal. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with readmission on 4/11/2022 with diagnoses which included Major Depressive Disorder. Review of the Admission Minimum Data Set assessment dated [DATE], revealed Resident #10 had a Brief Interview for Mental Status score of 14, which indicated no cognitive impairment. Observation in the dining room on 4/11/22 at 7:41 AM, revealed 2 dining room carts arrived to the dining room for staff to serve breakfast to the residents. During an interview in the dietary department on 4/11/2022 at 2:25 PM, Cook #1 stated, We serve breakfast at 7:30 AM and supper is served at 5:00 PM. During an interview in the dietary department on 4/11/2022 at 4:00 PM, Cook #2 stated breakfast was served to the residents at 7:30 AM and supper was served at 5:00 PM. During an interview in Resident #10's room on 4/12/2022 at 10:19 AM, Resident #10 (President of the Resident Council) stated he attended resident council meetings regularly and the council had not voted to have longer than 14 hours between supper and breakfast the following day. During an interview in the conference room on 4/12/2022 at 8:25 AM, the Dietary Manager confirmed there was 14.5 hours between the supper meal at 5:00 PM and the breakfast meal the following day at 7:30 AM. During an interview in the conference room on 4/12/2022 at 8:16 AM, the Activity Director confirmed they did not have any documentation regarding a resident council meeting to approve for the mealtimes to be longer than 14-hours between supper and breakfast the following day.

Based on facility policy review, observation, and interview, the facility's dietary department failed to maintain dietary equipment in a sanitary manner and failed to ensure food was served under sanitary conditions when a male dietary employee with facial hair was observed working in the kitchen without wearing a hair net or beard net and a Certified Nurse Aide entered the kitchen without wearing a hairnet. Findings include: Review of the facility policy titled, Personnel Standards, Dietary, revised 1/1/2005, revealed, .It is the policy of this facility that dietary personnel shall follow sanitary standards .Hair nets, covering all of the hair, must be worn at all times while on duty . Review of the facility's policy titled, Food Storage, dated September 1, 2017, revealed, .it is the policy of this facility that food storage areas shall be maintained in a clean, safe, and sanitary manner .food storage areas shall be clean at all times . Observation in the dietary department on 4/11/2022 at 7:41 AM revealed the Dietary Manager was working in the kitchen without a hair net or beard net on. Observation in the dietary department on 4/11/2022 at 7:48 AM, revealed a refrigerator contained 2 cups of vegetables and a bowl of soup that were not labeled and were not dated. Continued observation revealed a can opener had a buildup of dried brown debris on the blade, the stove drip pan had an accumulation of black dried debris, the toaster had breadcrumbs on the top of the toaster and had a buildup of a sticky substance on the base, and the microwave had an accumulation of splattered debris on the inside and a buildup of debris on the door. Observation in the dietary department on 4/11/2022 at 8:00 AM, revealed Certified Nurse Aide (CNA) #1 came into the kitchen without wearing a hair net. Observation in the dietary department on 4/11/2022 at 11:24 AM, revealed the can opener continued to have a buildup of dried brown debris on the blade, the toaster continued to have breadcrumbs on the top of the toaster and had a buildup of a sticky substance on the base, and the microwave continued to have an accumulation of splattered debris on the inside and a buildup of debris on the door. During an interview in the dietary department on 4/11/2022 at 7:45 AM, the Dietary Manager confirmed he was not wearing a hair net or beard net. During an interview in the dietary department on 7:48 AM, the Dietary Manager confirmed 2 cups of vegetables and a bowl of soup in the refrigerator was not labeled or dated. Continued interview he confirmed the drip pan needed cleaned. He stated, I cleaned it 3 weeks ago. During an interview in the dietary department on 4/11/2022 at 8:00 AM, CNA #1 confirmed she entered the kitchen without wearing a hair net. During an interview in the dietary department on 4/11/2022 at 11:28 AM, Cook #1 confirmed the can opener had a buildup of dried brown debris on the blade, the toaster had breadcrumbs on the top and had a buildup of a sticky substance on the base, and the microwave had an accumulation of splattered debris on the inside and a buildup of debris on the door.

Based on facility policy review, medical record review, and interview, the facility failed to implement a person-centered care plan for 14 of 17 sampled residents (Resident #12, #13, #14, #18, #19, #21, #23, #24, #25, #29, #31, #132, #183, and #184) reviewed. The findings include: Review of the facility's policy titled, Admitting the Resident, dated [DATE], revealed, .An individualized Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident .4. The resident's Comprehensive Care Plan is developed within seven (7) days of the completion of the resident's comprehensive assessment (MDS [Minimum Data Set]) . Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with readmission on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] #12's code status was, .Do Not Attempt Resuscitate (DNR) .Comfort Measures . Review of the Care Plan dated [DATE], revealed Resident #12 had no Advance Directive care plan. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] #13's code status was, .Resuscitate (CPR [Cardiopulmonary Resuscitation]) .Full treatment . Review of the Care Plan dated [DATE], revealed Resident #13 had no Advance Directive care plan. Review of the medical record revealed Resident #14 was admitted to the facility on [DATE], with readmission on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] #14's code status was, .Resuscitate (CPR) .Full Treatment . Review of the Care Plan dated [DATE], revealed Resident #14 had no Advance Directive care plan. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] #18's code status was, .DNR .Limited Additional Interventions . Review of the Care Plan dated [DATE], revealed Resident #18 had no Advance Directive care plan. Review of the medical record revealed Resident #19 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] #19's code status was, .Resuscitate (CPR) .Full treatment . Review of the Care Plan dated [DATE], revealed Resident #19 had no Advance Directive care plan. Review of the medical record revealed Resident #21 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] #21's code status was, .Resuscitate (CPR) .Full Treatment . Review of the Care Plan dated [DATE], revealed Resident #21 had no Advance Directive care plan. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE] with readmission on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] #23's code status was, .Resuscitate (CPR) .Full Treatment . Review of the Care Plan dated [DATE], revealed Resident #23 had no Advance Directive care plan. Review of the medical record revealed Resident #24 was admitted to the facility on [DATE] with readmission on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] #24's code status was, .DNR .Limited additional interventions . Review of the Care Plan dated [DATE], revealed Resident #24 had no Advance Directive care plan. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] #25's code status was, .Resuscitate (CPR) .Full treatment . Review of the Care Plan dated [DATE], revealed Resident #25 had no Advance Directive care plan. Review of the medical record revealed Resident #29 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] #29's code status was, .DNR (Allow Natural Death) .Comfort Measures . Review of the Care Plan dated [DATE], revealed Resident #29 had no Advance Directive care plan. Review of the medical record revealed Resident #31 was admitted to the facility on [DATE] with readmission on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] #31's code status was, .DNR .Limited additional interventions . Review of the Care Plan dated [DATE], revealed Resident #31 had no Advance Directive care plan. Review of the medical record revealed Resident #132 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] .CPR Status .Yes . Review of the Care Plan dated [DATE], revealed Resident #132 had no Advance Directive care plan. Review of the medical record revealed Resident #183 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] #183's code status was, .DNR (Allow Natural Death) .Limited Interventions . Review of the Care Plan dated [DATE], revealed Resident #183 had no Advance Directive care plan. Review of the medical record revealed Resident #184 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] #184's code status was, .Resuscitate (CPR) .Full Treatment . Review of the Care Plan dated [DATE], revealed Resident #184 had no Advance Directive care plan. During an interview on [DATE] at 11:20 AM, Licensed Practical Nurse (LPN) #3 confirmed there was no care plan for Advance Directives for Residents #12, #13, #14, #18, #19, #21, #23, #24, #25, #29, #31, #132, #183, and #184.

Based on facility policy review, medical record review, observations, and interview, the facility failed to ensure dignity for 2 of 2 sampled residents (Residents #14 and #132) who required an indwelling urinary catheter. The findings include: Review of the facility's policy titled, Resident Rights Under Federal Law, revised January 2014, revealed, .The resident has a right to a dignified existence . Review of the medical record revealed Resident #14 was admitted to the facility on [DATE] with readmission on 3/17/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #14 required an indwelling catheter. Review of the current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record revealed Resident #132 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission MDS assessment dated [DATE], revealed Resident #132 required an indwelling catheter. Review of the current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Observation in Resident #14's room on 4/11/2022 at 8:25 AM, revealed the resident's urinary catheter drainage bag was hanging on the side of the bed facing the door, not covered with a privacy cover. Observation in Resident #14's room on 4/12/2022 at 8:25 AM, revealed the resident's urinary catheter drainage bag was hanging on the side of the bed facing the door, not covered with a privacy cover. Observation and interview in Resident #14's room on 4/12/2022 at 8:35 AM, Licensed Practical Nurse (LPN) #2 confirmed Resident #14's urinary catheter drainage bag was not covered with a privacy cover. Observation in the lobby on 4/11/2022 at 8:00 AM, revealed Resident #132 was sitting in a wheelchair with his catheter drainage bag in view not covered with a privacy cover. Observation and interview in the lobby on 4/11/2022 at 8:16 AM, LPN #1 confirmed Resident #132's catheter drainage bag was in view and not covered with a privacy cover.

Based on facility policy review, medical record review, observation, and interview, the facility failed to maintain patient confidentiality for 1 of 25 sampled residents (Resident #14) reviewed. The findings include: Review of the facility's policy titled, Resident Rights Under Federal Law, revised January 2014, revealed, .The resident has the right to personal privacy and confidentiality of his or her personal and clinical records . Review of the facility's policy titled, Confidentiality and Privacy, dated September 1, 2017, revealed, .It is the policy to treat all resident information as strictly confidential .Access to the resident's clinical records is limited to the staff and consultants providing services to the resident . Review of the medical record revealed Resident #14 was admitted to the facility on [DATE], with readmission on 3/17/2022, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation in the hallway on 4/11/22 at 7:53 AM, revealed Resident #14's identifiable information was on an overbed table in the hallway, viewable to anyone who passed by. Continued observation revealed there were no staff in attendance of the information. The identifiable information revealed, .CNA Care Plan .Resident: [named Resident #14] .Adm. [admit] date: 10-28-21 .Bath M [Monday] SU [Sunday] .shower .assist .day shift .Mobility .Assist x [times] 2 .Transfer .Assist x 2 .Ambulate .W/C [Wheelchair] .Eating .Set-up .Diet: regular .Grooming .Total .[NAME]/Bladder .Incontinent .Foley .Mental Status .Alert .Oriented x 3 .Confused .Vision .Adequate .Teeth .Natural .Hearing .Adequate . Observation and interview in the hallway on 4/11/2022 at 7:56 AM, Certified Nurse Aide (CNA) #2 confirmed Resident #14's CNA care plan was on an overbed table in the hall in view of anyone who walked by. She stated, I have no idea why it's there, but it shouldn't be. During an interview on 4/13/2022 at 8:08 AM, the Director Of Nursing confirmed Resident #14's CNA care plan was to be kept in the resident's closet in his room. She stated, It should not have been on a table in the hallway.

Based on facility policy review, medical record review, and interview, the facility failed to notify the State Ombudsman Office regarding transfers from the facility for 2 of 2 sampled residents (Resident #18 and #24) reviewed for hospitalization . The findings include: Review of the facility's policy titled, Admitting the Resident, dated 9/1/2017 and updated 4/13/2022, revealed, .When a resident is temporary transferred on an emergency basis to an acute care facility, copies or notices for the emergency transfers must be sent to the ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis . Review of the medical record revealed Resident #18 was admitted to the facility on [DATE] with readmission on 1/21/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record revealed Resident #18 was transferred to an Acute Hospital on 1/14/2022. Review of the medical record revealed Resident #24 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record revealed Resident #24 was transferred to an Acute Hospital on 2/6/2022. During an interview on 4/13/2022 at 10:20 AM, the Administrator confirmed she had not send a resident hospitalization list to the Ombudsman. She stated, We have never sent a list to the Ombudsman. I missed it.

Based on facility policy review, observations and interviews the facility staff failed to wear masks in the facility and in the resident care area for 1 of 3 residents (Resident #2) observed. The findings include: Review of the undated facility policy Patient Procedures revealed .If there is an eminent risk for the spread of COVID-19 to patients residing in the facility the staff will adhere to the following guidance: 1. Staff will wear a mask in all patient care areas .7. Therapy to provide treatment in patient's rooms. For patients who require balance and ambulation training, therapy staff will be permitted to do such treatment in the hallways provided that patient and therapist wear a mask at all times . Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] wit [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE] revealed Resident #2 had a BIMS score of 00 which indicated the resident was not able to be interviewed. Observation on 12/1/2020 at 8:05 AM outside of the front door of the facility revealed Licensed Practical Nurse (LPN) #1 standing at a medication cart in the short hall without a mask on. Continued observation revealed LPN #1 opened the door to let the surveyor in without a mask on. During an interview on 12/1/2020 at 8:21 AM with LPN #1 confirmed her mask was laying on top of the medication cart. I have to have a few minutes to breathe. Continued interview revealed LPN #1 only took the mask off at the medication cart. Observation on 12/1/2020 at 9:34 AM outside of Resident #2's room revealed a Speech Therapist seated in a chair and a bedside table in front of her conducting a therapy session with Resident #2 who was seated across from the Speech Therapist in a wheelchair. Continued observation revealed the Speech Therapist had the N 95 mask covering her chin not her mouth and nose. During an interview on 12/1/2020 at 9:34 AM with the Speech Therapist confirmed, staff was always to have their masks on. Continued interview revealed the Speech Therapist stated, I had dropped my mask to rub my nose. During an interview on 12/2/2020 at 12:23 PM with the DON confirmed the facility had the staff wear N 95s, goggles or face shields at all times and if there are positive cases in the building the staff were to wear full PPE (personal protective equipment). Continued interview confirmed staff were always to wear a mask unless they were in a designated area or in a break room eating lunch. During an interview on 12/2/2020 at 12:26 PM with the Administrator revealed if staff was in the residents' rooms they are required to wear masks and goggles.

Based on facility policy review, medical record review, and interview the facility failed to have a 14 day stop date for a [MEDICAL CONDITION] PRN (as needed) medication 1 resident (#83) of 5 residents reviewed. The findings include: Review of the facility policy, [MEDICAL CONDITION] Medication Use, revised 11/2018 revealed .If [MEDICAL CONDITION] medications are administered as PRN dosages repeatedly over several days, the Physician should discuss the situation with s staff and evaluate the resident as needed to determine whether the use is appropriate and the symptoms are responding to the medication. PRN doses will require a 14 day script per federal guidelines . Medical record review revealed Resident #83 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #83 had a Brief Interview of Mental Status (BIMS) score of 5 which indicated severe cognitive impairment. Medical record review of the Physician Orders dated 4/2019 and 5/2019 revealed .Trazadone (antidepressant) 25 MG (milligrams) PO (by mouth) BID (twice daily) PRN . Medical record review of the 4/2019 Medication Administration Record [REDACTED]. Interview with the Nurse Practitioner (NP) on 5/30/19 at 3:09 PM in the conference room revealed, when asked if the resident was ordered Trazadone PRN for depression the NP stated yes. Continued interview with the NP when asked if a stop date was added to an order when a PRN [MEDICAL CONDITION] medication is ordered confirmed I missed it. Interview with the Director Of Nursing (DON) on 5/30/19 at 4:27 PM in the conference room stated .we generally just call them (providers) if we see any discrepancies . Continued interview confirmed the Trazadone 25 MG PO BID PRN did not have a stop date after 14 days.

Based on facility orientation training, medical record review, observation and interview 1 Certified Nurse Aide (CNA) failed to wear gloves when handling food for 2 (#7 and #27) of 17 residents observed. The findings include: Record review of the Orientation Training Inventory and All Staff In-Service Schedule revealed documentation of teaching infection prevention and food handling to all staff that included wearing gloves when handling food for residents. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Nursing Care Plan revised 5/20/19, revealed Resident #7 needed assistance with set-up for meals but fed herself at times. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #7 required set-up assistance and supervision for meals. Medical record review revealed Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Nursing Care Plan revised 5/23/19 revealed Resident #27 required set-up and cues with meals. Medical record review of the Admission MDS dated [DATE] revealed Resident #27 required set-up and supervision for meals. Observation of Resident #7 and Resident #27 on 5/28/19 at 12:42 PM sitting next to each other in the dining room revealed CNA #1 handled the hamburger buns with her bare hands while setting up the meals for Resident #7 and Resident #27. Interview with CNA #1 on 5/28/19 at 12:45 PM in the dining room when asked how food should be handled by staff for residents she replied .1 don't know, with clean hands . Interview with the Director of Nursing (DON) on 5/30/19 at 12:50 PM in her office confirmed . staff cannot directly handle food without gloves . Interview with Assistant Director of Nursing (ADON), also know as the Infection Control Nurse, on 5/30/19 at 1:23 PM in her office confirmed . staff are taught not to touch any of the food with their bare hands . Interview with the Administrator on 5/30/19 at 1:25 PM in her office confirmed .I expect staff to wear gloves when handling residents food .

Based on facility policy review, facility procedure review, observation and interview the facility failed to maintain a clean and sanitary water dispenser and ice scoop container. The findings include: Facility policy review, Ice Machines and Ice Storage Chests, dated 9/1/17, revealed .keep ice scoop on a clean surface when not in use .clean and sanitize the tray and ice scoop daily . Record review of the facility procedure, undated, revealed . Daily: scrub all parts with warm soapy water. Use a good brush and clean thoroughly. Rinse thoroughly with fresh water and invert to air dry. Weekly: During the daily cleaning .dismantle the spout and carefully clean the entire assembly with warm soapy water. Use a good brush to clean all parts thoroughly. Rinse with fresh water and reassemble . Observation on 5/28/19 at 12:40 PM of the water dispenser in !he dining room revealed the water dispenser had a large amount of moist black material around the spigot, concentrated underneath the spigot. Continued observation revealed the drawer on the cart for the ice scoop had gray-brown dried material in the back bottom side of the drawer. Observation on 5/28/19 at 3:50 PM in the dining room revealed the water cart returned from the kitchen with the ice chest and water dispenser. Continued observation revealed moist black material remained around the spigot and gray-brown material remained in the scoop drawer. Interview with the Dietary Manager on 5/28/19 at 3:52 PM in the dining room confirmed . that looks like mold (around spigot) and that looks like scum (in drawer) .housekeeping is responsible for cleaning them .maybe a couple times a week .we don't have a policy . Continued interview with the Dietary Manager revealed the cart was used to pass ice water for residents rooms twice a day in the morning and evening, then stays in the dining room all day for refills as needed. Interview with the Administrator on 5/28/19 at 3:55 PM in the dining room confirmed .that looks like mildew (around spigot) and that looks like dirt (in drawer) .I expect the Dietary department to keep it clean .

Based on facility policy review, observation, and interview, the facility failed to perform hand hygiene for 4 residents (#21, #24, #80, #29) of 20 residents observed on 1 of 2 halls during the dining observation. The findings included: Review of the facility policy Handwashing/Hand Hygiene dated 9/1/17 revealed, .Employees must wash their hands .before and after contact with residents .the preferred method of hand hygiene is with alcohol-based hand rub .before and after direct contact with resident .after contact with objects (e.g. medical equipment) in the immediate vicinity of the resident . Observation of dining and meal tray pass on 4/23/18 from 12:45 PM - 12:55 PM, on the long hall, revealed Certified Nursing Assistant (CNA) #1 delivered Resident #21's tray to the room, set the tray up, placed the resident's shoes in the closet, and moved the resident's wheelchair. CNA #1 exited the room without washing or sanitizing the hands. Continued observation revealed CNA #1 then delivered Resident #25's tray to the room, retrieved a carton of milk from the dining room, and gave the milk to the resident. The CNA exited the room without washing or sanitizing the hands. Further observation revealed CNA #1 then delivered Resident #80's tray to the room, touched/arranged the overbed table, and exited the room without washing or sanitizing the hands. Continued observation revealed CNA #1 then delivered Resident #29's tray to the room, touched/arranged the overbed table, and exited the room without washing or sanitizing the hands. Interview with CNA #1 on 4/23/18 at 12:55pm, in the long hall, confirmed CNA #1 did not wash or sanitize the hands between residents and equipment contact. Interview with the Administrator on 4/23/18 at 1:00 PM, in the Director of Nursing's Office, confirmed staff were expected to sanitize and/or wash hands between residents and equipment contact.

Based on infection control review and interview, the facility failed to develop and implement an Antibiotic Stewardship program. The findings included: Interview and review of the facility infection control program with the Assistant Director of Nursing (ADON) on 4/25/18 at 8:00 AM, in the conference room revealed there was no documentation the facility had an Antibiotic Stewardship Program. Interview with the ADON confirmed the facility had not developed an Antibiotic Stewardship Program.

Based on medical record review, facility document review, facility policy review, review of a Standard Precaution Reference, Consultant Pharmacist Medication Regimen review, and interview, the facility failed to notify the physician of not obtaining a monthly laboratory (lab) study on November 2010, and a lab on December 20, 2010, as ordered by the physician; failed to notify the physician the lab specimen was clotted on December 17, 2010; failed to notify the responsible party of critically high laboratory results for one resident (#11) receiving anticoagulant therapy of four resident's reviewed receiving anticoagulant therapy. The facility's failure to notify the physician of the labs ordered but not obtained was likely to cause serious injury, harm, impairment, or death to resident #11 from uncontrolled bleeding related to critically high blood clotting times. The Interim Administrator, new Administrator (first day March 28, 2011), Director or Nursing (DON), Assistant Director of Nursing (ADON), Regional Compliance Nurse, and Compliance Nurse, were notified of the Immediate Jeopardy on March 31, 2011, at 9:15 a.m., in the conference room. The Immediate Jeopardy was effective November 30, 2010, and is ongoing. The findings included: Resident #11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Further medical record review revealed the resident was discharged to another long term care facility on December 22, 2010. Medical record review of the Admission Physician Orders dated October 19, 2010, through December 16, 2010, revealed "[MEDICATION NAME] (anticoagulant-blood thinner to prevent blood clots) 6 milligrams (mg) by mouth every night at bedtime...PT/INR ([MEDICATION NAME] Time/International Normalization Ratio) monthly (INR is lab test to determine blood clotting time)..." Medical record review of the lab data sheet revealed the INR (International Normalization Ratio-lab value for anticoagulation therapy to determine therapeutic range) reports were obtained from the same laboratory with the following reference therapeutic range for INR: 0.90-1.11 International Units. Medical record review of the PT/INR lab results revealed: October 26, 2010, 1.75 (physician initial on lab sheet/no date when reviewed results); no November lab; December 16, 2010, were critically high (greater than 10); December 17, 2010, lab drawn and specimen clotted, physician not notified; no December 20, 2010, lab, physician was not notified; and on December 21, 2010, a PT/INR was obtained without a physician order and was within therapeutic range. Medical record review of the INR lab dated December 16, 2010, revealed "...> 10 (greater than) critically high..." Medical record review of two physician phone orders dated December 16, 2010, revealed "...1) Vitamin K (Vitamin K for clotting, reverses the effect of [MEDICATION NAME]) 10 mg IM (Intramuscular Injection) now...2) D/C (discontinue) [MEDICATION NAME]...3) (Check) INR Friday 12-17-10 and Monday 12-20-10..." Review of the second physician order dated December 16, 2010, revealed "...(Change) Vitamin K to Vitamin K 10 mg IM Q (every) 6 (hours) x (times) 2 days for total of 8 doses..." Medical record review of the INR lab report dated December 16, 2010, revealed a hand written note, signed and dated "12-16-10", on the middle of the lab report indicating to give Vitamin K 10 mg IM and a second signed (not dated) notation indicating the [MEDICATION NAME] stopped. Further review of the INR lab report revealed "...Critical Value response: 12/16/10 7:48...(Name person) notified LPN #3 on 12/16/10 at 7:48...Readback of results: Yes..." Review of the facility "24 Hour Report/Change of Condition Report" dated December 16, 2010 revealed "...(resident #11) *Remarks (Day): INR >10/INR...12-17-20...12/20/10...Remarks (Evening) Vit (Vitamin) K IM..." Review of the December 17, 2010, 24 Hour report revealed "...(resident name)...Remarks (Day) needs PT/INR Friday 12/17/10- Remarks (Night) needs new draw clotted when lab received...with the word "Done" written in..." Further review revealed the remarks were not signed or dated. Medical record review of the nursing note dated "...12-17-10, 11:45 AM (name facility) lab reports critical INR results - >10. Called (name) nurse practitioner and received order for Vitamin K 10 mg IM now (Vitamin K for clotting reverses the effect of [MEDICATION NAME]) ; D/C (discontinue) [MEDICATION NAME]: and (check) INR Friday 12-17-10 and Monday 12-20-10..." Interview on March 31, 2011, at 7:45 a.m., by phone, with the former Medical Director/physician for resident #11, revealed the physician wanted to maintain the INR level between 1.5-2.0 and the possible side effects of elevated PT/INR would include [MEDICAL CONDITION], internal bleeding, and bleeding through the skin. Continued interview confirmed the Medical Director "probably noticed" the November 2010, PT/INR lab was missing on December 15, 2010, after reviewing the December 2010, Medication Administration Record. Further interview confirmed the Medical Director had not been notified the November 2010, PT/INR had not been obtained. Review of the facility policy for "Laboratory Protocol" dated March 2004; revised May 2005 and October 2008, revealed "...Purpose: All laboratory tests will be completed as ordered by the physician, with timely notification of results and proper documentation in the medical record....Procedure: ii. Review the lab log daily to monitor that all labs ordered for that day have been completed and initialed by the phlebotomist, that results have been received in a timely manner, physician has been notified, and the results are on the record...8. The Director of Nursing or designee will be responsible for reviewing each unit's lab log at random to verify appropriate completion and follow-through with ordered lab tests..." Review of the facility policy for "Laboratory Documentation Protocol" dated May 2007; revised October 2008, revealed "...Purpose: All laboratory tests will be completed as ordered by the physician, with timely notification of the results and proper documentation in the health information record...Procedure: 3. The charge nurse or designee will be responsible for notifying the responsible party and documenting the results in the resident's health information record..." Review of a Standard Precaution Reference, Medicinenet.com, revealed "[MEDICATION NAME]-oral, [MEDICATION NAME][MEDICATION NAME] can cause very serious (possibly fatal) bleeding...To decrease your risk for bleeding, your doctor or other health care provider will monitor you closely and check your lab results (INR test) to make sure you are not taking too much [MEDICATION NAME] is based on your medical condition, laboratory tests (such as INR)...Older adults may be at greater risk for bleeding while using this drug...This medication can cause serious bleeding if it affects your blood clotting proteins too much (shown by unusually high INR lab results)...signs of serious bleeding, including: unusual pain/swelling/discomfort, unusual/easy bruising, prolonged bleeding from cuts or gums...pink/dark urine...dizziness/[MEDICAL CONDITION]/black/tarry stools..." Review of the facility "Lab Draw Log" revealed "...*Please be certain that all* Abnormal PT/INRs are immediately phoned in to the attending!..." According to the physician orders, PT/INR were to be drawn in November 2010, and December 17 and 20, 2010. Review of the Lab Draw Log revealed no PT/INR was drawn in November or on December 20, 1010. Further review revealed a PT/INR test was drawn by a phlebotomist on December 16, 2010. Further review of the December 20, 2010, Lab Data Log revealed a line was drawn through the (resident name and room number), PT/INR (test to be obtained), and December 20, 2010 (date lab specimen to be obtained). Continued review revealed no explanation was documented regarding reason why the line was drawn through the information. Continued review revealed no indication the lab was drawn, and the physician notified the lab was not obtained as ordered. Further review of the Lab Draw Log revealed a PT/INR test was drawn by a phlebotomist on December 21, 2010, without a physician order. Review of the Consultant Pharmacist's Medication Regimen review, signed by the pharmacist on November 30, 2010: Listing of Residents Reviewed with No Recommendation for records updated between November 1, 2010 and November 30, 2010 revealed resident #11 had been reviewed and no pharmacy recommendations were documented. Interview with the consultant pharmacist on March 31, 2011, at approximately 4:00 p.m., by phone, confirmed "...make sure labs were drawn as part of the review, check levels of lab and make note of it...if lab off value that MD (physician) notified and if (MD) received notification..." Further interview confirmed the consultant pharmacist had conducted a review on November 30, 2010, and had no recommendations for resident #11. Further interview confirmed the consultant pharmacist had not identified the missing PT/INR lab in November 2010 during the monthly drug regimen review. Interview with the Assistant Director of Nursing (ADON) on March 30, 2011, at 3:45 p.m., in the conference room, confirmed the ADON was also the Lab Coordinator. Further interview confirmed the labs were routinely drawn on Tuesdays and Thursdays by lab personnel. Further interview confirmed the ADON was responsible to fill out the Lab Calendar Master Log for monthly ordered lab. Further interview confirmed there was no documentation to show a Lab Calendar Master Log had been completed for the PT/INR for resident #11. Further interview confirmed the ADON checks lab orders. Continued interview confirmed the PT/INR was not obtained for resident #11 in November 2010, December 17, 2010, or December 20, 2010, per physician orders after reviewing the Lab Draw Log and the physician had not been notified the labs were not obtained as ordered.. Interview, with the Director of Nursing (DON), on March 30, 2011, at 4:00 p.m., in the conference room, confirmed the DON was not aware of labs not obtained as ordered in November 2010. Continued interview confirmed the DON was not aware of the critically high lab results on December 16, 2010, for resident #11. Continued interview confirmed the DON expected nurses to notify the DON of critically high labs. Further interview confirmed the DON was not aware the physician had not been notified the December 17, 2010, lab specimen had clotted. Further interview confirmed the December 20, 2010, PT/INR had not been obtained as ordered and the physician had not been notified the lab had not been obtained. Interview with Licensed Practical Nurse (LPN) #3, on March 31, 2011, at 9:27 a.m., in hall outside room [ROOM NUMBER], confirmed LPN #3 documented receiving the critically high INR results on December 17, 2010, in the nursing notes. Further interview revealed LPN #3 may have dated the nursing note incorrectly and should have been dated December 16, 2010. Further interview confirmed LPN #3 did not have documentation of notifying the resident's responsible party (court appointed guardian) or the facility nursing administration of the critically high INR. Further interview confirmed the Director of Nursing came to the facility December 17, 2010, to draw the PT/INR for resident #11, which was unable to be tested by the lab due to the specimen was clotted. Interview with LPN #3 continued at 10:45 a.m., in the hall outside room [ROOM NUMBER], on March 31, 2011, confirmed LPN #3 had written the nursing note dated December 18, 2010, at 8:00 a.m., "...called (name facility) lab for INR this AM; stated that sample was rejected...signed by LPN#3..." Continued interview confirmed LPN#3 had not documented the physician had been notified the December 17, 2010, lab was rejected. Continued interview confirmed had LPN #3 notified the physician and had received orders, LPN #3 would have documented in the nursing note and completed the phone order. Further interview confirmed LPN #3 did not recall who LPN #3 talked to but "...(LPN #3) did not document it if talked to someone and should have documented it..." Interview with the responsible party (court appointed guardian) on March 31, 2011, at 10:14, by phone, confirmed the guardian had not been notified of the missed lab in November or the critically high lab on December 16, 2011. Further interview confirmed "...I would have been expected to be notified (of the missing lab and critically high level)..." Interview with Licensed Practical Nurse (LPN) #4 on March 31, 2011, at 3:45 p.m., in the hall outside room [ROOM NUMBER], confirmed LPN #4 had reviewed the Anticoagulant Monitoring Report and reported the missing lab, due in November 2010, on December 15, 2010 to the Assistant Director of Nursing. Interview with the Director of Nursing (DON) on March 31, 2011, at 10:20 a.m., in the conference room, confirmed the DON "..Usually looks at the 24 hour reports but doesn't recall looking at the December 16, 2010, report..." Continued interview confirmed the DON drew the PT/INR on December 17, 2010, for resident #11. Continued interview confirmed the DON had read the December 17, 2010, 24 hour report on resident #11 that a new draw was needed due to the sample the lab received was clotted. Continued interview confirmed the PT/INR ordered for December 20, 2010, had not been obtained as ordered by the physician and the physician was not notified.

Based on medical record review, review of the care plan, and interview, the facility failed to initiate, monitor and revise a care plan for anticoagulant therapy for one resident (#11) receiving anticoagulant therapy of four resident's reviewed receiving anticoagulant therapy. The facility's failure to initiate, monitor and revise the care plan to ensure staff were knowledgeable for monitoring and delivering care was likely to cause serious injury, harm, impairment, or death to resident #11 from uncontrolled bleeding related to critically high blood clotting times. The Interim Administrator, new Administrator (first day March 28, 2011), Director or Nursing (DON), Assistant Director of Nursing (ADON), Regional Compliance Nurse, and Compliance Nurse were notified of the Immediate Jeopardy on March 31, 2011, at 9:15 a.m., in the conference room. The Immediate Jeopardy was effective November 30, 2010 and is ongoing. The findings included: Resident #11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Further medical record review revealed the resident was discharged to another long term care facility on December 22, 2010. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had 0 out of 15 (0=severe cognitive impairment and 15= no impairment) for the Brief Interview for Mental Status; inattention and disorganized thinking was present/fluctuated; required limited assistance of one person for transfers, ambulation, toileting, and dressing; and was unsteady and only able to stabilize with human assistance for transitions and walking. Medical record review of the Admission Physician order [REDACTED].PT/INR ([MEDICATION NAME] Time/International Normalization Ratio) monthly (INR is lab test to determine blood clotting time)..." Medical record review of the Initial Nursing Plan of Care dated October 20, 2010, and updated October 26 and 27, 2010, and the Interdisciplinary Care Plan initiated November 2, 2010, revealed no care plan addressing anticoagulant therapy. Further review of the care plan initiated November 2, 2010, revealed a notation dated 12/16/10 "...Problem/Need: Resident taking [MEDICATION NAME](increased) INR (International Normalization Ratio/lab value for anticoagulation therapy to determine therapeutic range for blood clotting time) noted..." No goal was documented. "...Approaches: 12/16/10 follow standard bleeding precautions...1. Vit K (Vitamin K for clotting, reverses the effect of [MEDICATION NAME]) IM (Intramuscular) x 2 days...2. D/C (Discontinue) [MEDICATION NAME]...3. (check) INR..." Interview with the care plan coordinator, on March 31, 2011, at 1:40 p.m. in the conference room, confirmed the Initial Nursing Plan of Care and the Interdisciplinary Care Plan initiated on November 2, 2010, did not address anticoagulant therapy and did not identify any standard bleeding precautions until December 16, 2010. Interviews on March 31, 2011, with Certified Nurse Aides (CNA) #1, at 11:00 a.m., in the hall by room [ROOM NUMBER]; CNA #2 at 11:15 a.m., in the hall by room [ROOM NUMBER],; CNA #3 at 11:25 a.m., in the hall by room [ROOM NUMBER]; CNA #4 at 1:55 p.m., by phone; CNA #5, by phone at 2:15 p.m.; and CNA #6, by phone at 2:25 p.m.; confirmed they had provided direct care to resident #11 and were not aware of any specific resident currently in the facility receiving anticoagulant therapy (blood thinner). Further interviews confirmed the CNA's were not aware of receiving any training specific to the side effects of anticoagulant therapy (blood thinners). Further interviews confirmed the CNA's were not aware of the critically high lab in December and not informed to take precautions while caring for resident #11. The facility failed to care plan for anticoagulant therapy which included staff education, obtaining labs as ordered, monitoring labs, notifying the physician of the lab results, and signs of adverse effects of anticoagulant therapy to include but not limited to bleeding through the skin, bruising, pink tinged urine and black tarry stools.

Based on medical record review, review of the care plan, and interview, the facility failed to initiate, monitor and revise a care plan for anticoagulant therapy for one resident (#11) receiving anticoagulant therapy of four resident's reviewed receiving anticoagulant therapy. A revisit was conducted at Ridgetop Haven Health Center on April 18, 2011 following an acceptance of the Allegation of Compliance to remove the Immediate Jeopardy for F-279. The revist revealed the corrective actions completed on April 8, 2011, removed the Immediate Jeopardy at F-279, but noncomplainance continues at a "D" level as evidence by the findings at F-279. 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 recurr and review of the facility corrective measures by the Quality Assurance Committee. The findings included: The Facility provided an acceptable Credible Allegation of Compliance with a compliance date of April 8, 2011. An onsite visit was completed on April 108, 2011, to validate compliance. The Credible Allegation of Compliance was was validated on April 18, 2011, at 12:00 p.m. Validation of the Credible Allegation of Complaince was accomplished through medical record reivew, obsevation, and interview with Liscensed Nurse's and Certified Nursing Assistants and residents. The facility provided evidence of in-service and records for all nursing Staff, and nurse aides related to management of anticoagulation (blood thinner), clininical test values reporting, commincation and documentation. Included in the validation process was the review of facility tools used to document ongoing monitoring of obtaining lab work, physician and chart audit. Interview with the two licensed nurses confirmed the nurses had recieved trainging training on anitcoagulation therapy, physicain notification, and documentation, and updating care plans. Interview with three Certified Nursing Assistants confirmed the Certified Nursing Assistants had recieved training on the side effects of anticoagulant therapy and the residents ADL information sheet/cna care plan are updated to reflect the use of anticoagulant therapy. Resident #11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Further medical record review revealed the resident was discharged to another long term care facility on December 22, 2010. Medical record review revealed three residents (#4, #5, #10) were recieving anticoagulants and care plans for the three residents indicated the name of the anticoagulant and the necessary monitoring 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 recurr and review of the facility corrective measures by the Quality Assurance Committee.

Based on medical record review, review of National Institute of Health reference, review of a Standard Precaution Reference, facility document review, facility policy review, Consultant Pharmacist Medication Regimen review, and interview, the facility failed to follow physician's orders obtaining laboratory (lab) studies for one resident (#11) receiving anticoagulant therapy of four resident's reviewed receiving anticoagulant therapy. The facility's failure to follow physician's orders to ensure labs were obtained as ordered was likely to cause serious injury, harm, impairment, or death to resident #11 from uncontrolled bleeding related to critically high blood clotting times. The Interim Administrator, new Administrator (first day March 28, 2011), Director or Nursing (DON), Assistant Director of Nursing (ADON), Regional Compliance Nurse, and Compliance Nurse, were notified of the Immediate Jeopardy on March 31, 2011, at 9:15 a.m., in the conference room. The Immediate Jeopardy was effective November 30, 2010 and is ongoing. F-309 Substandard Quality of Care. The findings included: Resident #11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Further medical record review revealed the resident was discharged to another long term care facility on December 22, 2010. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had 0 out of 15 (0=severe cognitive impairment and 15= no impairment) for the Brief Interview for Mental Status; inattention and disorganized thinking was present/fluctuated; required limited assistance of one person for transfers, ambulation, toileting, and dressing; and was unsteady and only able to stabilize with human assistance for transitions and walking. Medical record review of the Admission Physician Orders dated October 19, 2010, through December 16, 2010, revealed "[MEDICATION NAME] (anticoagulant-blood thinner to prevent blood clots) 6 milligrams (mg) by mouth every night at bedtime...PT/INR ([MEDICATION NAME] Time/International Normalization Ratio) monthly (INR is lab test to determine blood clotting time)..." Medical record review of the lab data sheet revealed the INR (International Normalization Ratio-lab value for anticoagulation therapy to determine therapeutic range) reports were obtained from the same laboratory with the following reference therapeutic range for INR: 0.90-1.11 International Units. Medical record review revealed the following INR laboratory results: October 26, 2010, 1.75; and no November lab for INR. Medical record review of the INR lab dated December 16, 2010, revealed "...> (greater than) 10 critically high..." Medical record review of two physician phone orders dated December 16, 2010, revealed "...1) Vitamin K (Vitamin K for clotting, reverses the effect of [MEDICATION NAME]) 10 mg IM (Intramuscular Injection) now...2) D/C (discontinue) [MEDICATION NAME]...3) (Check) INR Friday 12-17-10 and Monday 12-20-10..." Review of the second physician order dated December 16, 2010, revealed "...(Change) Vitamin K to Vitamin K 10 mg IM Q (every) 6 (hours) x (times) 2 days for total of 8 doses..." Medical record review of the INR lab report dated December 16, 2010, revealed a hand written note, signed and dated "12-16-10", on the middle of the lab report indicating to give Vitamin K 10 mg IM and a second signed (not dated) notation indicating the [MEDICATION NAME] stopped. Further review of the INR lab report revealed "...Critical Value response: 12/16/10 7:48...(Name person) notified LPN #3 on 12/16/10 at 7:48...Readback of results: Yes..." Review of the facility "24 Hour Report/Change of Condition Report" dated December 16, 2010 revealed "...(resident #11) *Remarks (Day): INR >10/INR...12-17-20...12/20/10...Remarks (Evening) Vit (Vitamin) K IM..." Review of the December 17, 2010, 24 Hour report revealed "...(resident name)...Remarks (Day) needs PT/INR Friday 12/17/10- Remarks (Night) needs new draw clotted when lab received...with the word "Done" written in..." Further review revealed the remarks were not signed or dated. Medical record review of the nursing note dated "...12-17-10, 11:45 AM (name facility) lab reports critical INR results - >10. Called (name) nurse practitioner and received order for Vitamin K 10 mg IM now (Vitamin K for clotting reverses the effect of [MEDICATION NAME]) ; D/C (discontinue) [MEDICATION NAME]: and (check) INR Friday 12-17-10 and Monday 12-20-10..." Interview on March 31, 2011, at 7:45 a.m., by phone, with the former Medical Director/physician for resident #11, revealed the physician wanted to maintain the INR level between 1.5-2.0 and the possible side effects of elevated PT/INR would include [MEDICAL CONDITION], internal bleeding, and bleeding through the skin. Continued interview confirmed the Medical Director "probably noticed" the November 2010, PT/INR lab was missing after reviewing the December 2010, Medication Administration Record. Further interview confirmed the Medical Director had not been notified the November 2010, PT/INR had not been obtained. Review of NCBI Bookshelf, a service of the National Library of Medicine, National Institutes of Health, revealed reversal of the [MEDICATION NAME] toxicity or increased anticoagulation due to [MEDICATION NAME] ([MEDICATION NAME]) therapy included administration of Vitamin K. Review of a Standard Precaution Reference, Medicinenet.com, revealed "[MEDICATION NAME]-oral, [MEDICATION NAME][MEDICATION NAME] can cause very serious (possibly fatal) bleeding...To decrease your risk for bleeding, your doctor or other health care provider will monitor you closely and check your lab results (INR test) to make sure you are not taking too much [MEDICATION NAME] is based on your medical condition, laboratory tests (such as INR)...Older adults may be at greater risk for bleeding while using this drug...This medication can cause serious bleeding if it affects your blood clotting proteins too much (shown by unusually high INR lab results)...signs of serious bleeding, including: unusual pain/swelling/discomfort, unusal/easy bruising, prolonged bleeding from cuts or gums...pink/dark urine...dizziness/[MEDICAL CONDITION]/black/tarry stools..." Review of the facility policy for "Laboratory Protocol" dated March 2004; revised May 2005 and October 2008, revealed "...Purpose: All laboratory tests will be completed as ordered by the physician, with timely notification of results and proper documentation in the medical record...Procedure: 1. All physician orders received for laboratory testing will be transcribed onto the "Laboratory Log" (monthly) including the resident's name and room number, the lab test(s) ordered, and the date the labs are to be drawn....2. At the time the lab order is transcribed, a lab specific protocol will be followed...4. All recurring lab draws are to be placed on the Lab Draw Log...6. lab tests for medication monitoring will be obtained as ordered by the resident's physician...7. The Director of Nursing will assign someone from nursing management to be responsible for monitoring proper follow through with the testing...a. Comprehensive follow-through will be accomplished by the following: i. Reviewing all new admission orders [REDACTED]. Review the lab log daily to monitor that all labs ordered for that day have been completed and initialed by the phlebotomist, that results have been received in a timely manner, physician has been notified, and the results are on the record...iii. Review the physician orders monthly to identify which recurring labs are due that month and follow the lab specific protocol...iv. All hard copies of lab results received from the consulting laboratory will be sent to the attention of the Nurse manager that will be responsible for this program...v. Abnormal lab results will be reported in a timely manner...8. The Director of Nursing or designee will be responsible for reviewing each unit's lab log at random to verify appropriate completion and follow-through with ordered lab tests...9. Every month 10% of the active medical record will be audited for compliance with the laboratory protocol...10. The results of the audit will be presented to the Quality Improvement Team monthly until the lab audits are 100% for three months and quarterly thereafter..." Review of the facility policy for "Laboratory Documentation Protocol" dated May 2007; revised October 2008, revealed "...Purpose: All laboratory tests will be completed as ordered by the physician, with timely notification of the results and proper documentation in the health information record...Procedure: 1. The facility will designate a fax machine, whereby labs can be retrieved and followed up on 24 hours a day, 7 days a week...2. All critical lab values will immediately be phoned to the resident's attending MD (physician)...(The facility's charge nurse or designee will be responsible for acting on these values, as soon as they are retrieved from the facility fax. This process will take place 24 hours a day, 7 days a week.)...3. The charge nurse or designee will be responsible for notifying the responsible party and documenting the results in the resident's health information record..." Review of the facility policy for "Anticoagulant Therapy, dated 12/11/05; revised 10/08", revealed "...Purpose: Anticoagulant therapy interferes with synthesis of vitamin K dependent coagulation factors. This therapy is utilized as a [MEDICATION NAME] and treatment of [REDACTED]...1. The facility will identify residents on anticoagulant therapy...3. The facility will confirm with the physician the desired INR and/or PT testing schedule and therapeutic range at the time of the anticoagulation therapy order...5. Upon receipt of the lab results, the charge nurse or designee will review the INR and/or PT lab results and fax results to the physician...6. Throughout anticoagulant therapy, the facility will monitor the resident for signs and symptoms of bleeding and document findings on the Anticoagulant Monitoring Record...8. The facility's pharmacist consultant will review the resident's drug regimes, which includes reviewing the resident's anticoagulant therapy...9. The facility Lab Management Coordinator will monitor compliance of this protocol...10. Residents receiving Anticoagulant Therapy will be care planned. Their care plan will reflect the potential for bleeding secondary to the anticoagulant therapy..." Medical record review of the Initial Nursing Plan of Care dated October 20, 2010, and updated October 26 and 27, 2010, and the Interdisciplinary Care Plan initiated November 2, 2010, revealed no care plan addressing anticoagulant therapy. Further review of the care plan initiated November 2, 2010, revealed a notation dated "...12/16/10...Problem/Need: Resident taking [MEDICATION NAME](increased) INR noted..." No goal was documented. "...Approaches: 12/16/10 follow standard bleeding precautions...1. Vit K IM x 2 days...2. D/C [MEDICATION NAME]...3. (check) INR..." Interview with the care plan coordinator, on March 31, 2011, at 1:40 p.m. in the conference room, confirmed the Initial Nursing Plan of Care and the Interdisciplinary Care Plan initiated on November 2, 2010, did not address anticoagulant therapy and did not identify any standard bleeding precautions until December 16, 2010. Review of the facility "Lab Draw Log" revealed "...*Please be certain that all* Abnormal PT/INRs are immediately phoned in to the attending! Perform assessment on the Anticoagulant Monitoring Record..." Further review of the Lab Draw Log dated November 2010, revealed no lab specimen was drawn for resident #11. Review of the December 2010, Lab Draw Log revealed a PT/INR test was ordered, date to draw was December 16, 2010, and PT/INR was drawn by a phlebotomist on December 16, 2010; on December 17, 2010, a PT/INR was ordered to be drawn but there were no initials identifying who drew the lab specimen or the date drawn. Further review of the December 2010, Lab Draw Log revealed a PT/INR test was ordered, date to draw was December 20, 2010, and a line was drawn through the words (resident name and room number), PT/INR (test to be obtained), December 20, 2010 (date lab specimen to be obtained), without further explanation. The Lab Draw Log revealed a PT/INR test was ordered with a draw date of December 21, 2010, and a phlebotomist drew the lab specimen on December 21, 2010. Review of the Consultant Pharmacist's Medication Regimen review, signed by the pharmacist on November 30, 2010: Listing of Residents Reviewed with No Recommendation for records updated between November 1, 2010 and November 30, 2010 revealed resident #11 had been reviewed and no pharmacy recommendations were documented. Interview with the consultant pharmacist on March 31, 2011, at approximately 4:00 p.m., by phone, confirmed "...make sure labs were drawn as part of the review, check levels of lab and make note of it...if lab off value that MD (physician) notified and if (MD) received notification..." Further interview confirmed the consultant pharmacist had conducted a review on November 30, 2010, and had no recommendations for resident #11. Further interview confirmed the consultant pharmacist had not identified the missing PT/INR lab in November 2010. Interview with the Assistant Director of Nursing (ADON) on March 30, 2011, at 3:45 p.m., in the conference room, confirmed the ADON was also the Lab Coordinator. Further interview confirmed the labs were routinely drawn on Tuesdays and Thursdays by lab personnel. Further interview confirmed the ADON was responsible to fill out the Lab Calendar Master Log for monthly ordered lab. Further interview confirmed there was no documentation to show a Lab Calendar Master Log had been completed for the PT/INR for resident #11. Further interview confirmed the ADON checks lab orders. Continued interview confirmed the PT/INR was not obtained for resident #11 in November 2010, or December 20, 2010, per physician orders. Interview, with the Director of Nursing (DON), on March 30, 2011, at 4:00 p.m., in the conference room, confirmed the DON was not aware of labs not obtained as ordered in November 2010. Continued interview confirmed the DON was not aware of the critically high lab results on December 16, 2010, for resident #11. Continued interview confirmed the DON expected nurses to notify the DON of critically high labs. Further interview confirmed the DON was not aware the physician had not been notified the December 17, 2010, lab specimen had clotted. Further interview confirmed the December 20, 2010, PT/INR had not been obtained as ordered and the physician had not been notified the lab had not been obtained. Continued interview confirmed the Quality Assurance team had not identified a problem with labs not obtained per physician orders. The DON stated "...was not aware of any missed labs in November 2010." Interview with Licensed Practical Nurse (LPN) #3, on March 31, 2011, at 9:27 a.m., in hall outside room [ROOM NUMBER], confirmed LPN #3 documented receiving the critically high INR results on December 17, 2010, in the nursing notes. Further interview revealed LPN #3 may have dated the nursing note incorrectly and should have been dated December 16, 2010. Further interview confirmed LPN #3 did not have documentation of notifying the resident's responsible party (court appointed guardian) or the facility nursing administration of the critically high INR. Further interview confirmed the Director of Nursing came to the facility December 17, 2010, to draw the PT/INR for resident #11, which was unable to be tested by the lab due to the specimen was clotted. Interview with LPN #3 continued at 10:45 a.m., in the hall outside room [ROOM NUMBER], on March 31, 2011, confirmed LPN #3 had written the nursing note dated December 18, 2010, at 8:00 a.m., "...called (name facility) lab for INR this AM; stated that sample was rejected...signed by LPN#3..." Continued interview confirmed LPN#3 had not documented the physician had been notified the December 17, 2010, lab was rejected. Continued interview confirmed had LPN #3 notified the physician and had received orders, LPN #3 would have documented in the nursing note and completed the phone order. Further interview confirmed LPN #3 did not recall who LPN #3 talked to but "...(LPN #3) did not document it if talked to someone and should have documented it..." Interview with Licensed Practical Nurse (LPN) #4 on March 31, 2011, at 3:45 p.m., in the hall outside room [ROOM NUMBER], confirmed LPN #4 had reviewed the Anticoagulant Monitoring Report and reported the missing lab, due in November 2010, on December 15, 2010 to the Assistant Director of Nursing. Interviews on March 31, 2011, with Certified Nurse Aides (CNA) #1, at 11:00 a.m., in the hall by room [ROOM NUMBER]; CNA #2 at 11:15 a.m., in the hall by room [ROOM NUMBER],; CNA #3 at 11:25 a.m., in the hall by room [ROOM NUMBER]; CNA #4 at 1:55 p.m., by phone; CNA #5, by phone at 2:15 p.m.; and CNA #6, by phone at 2:25 p.m.; confirmed they had provided direct care to resident #11 and were not aware of any specific resident currently in the facility receiving anticoagulant therapy (blood thinner). Further interviews confirmed the CNA's were not aware of receiving any training specific to the side effects of anticoagulant therapy (blood thinners). Further interviews confirmed the CNA's were not aware of the critically high lab in December and not informed to take precautions. Interview with the Director of Nursing (DON) on March 31, 2011, at 10:20 a.m., in the conference room, confirmed the DON "..Usually looks at the 24 hour reports but doesn't recall looking at the December 16, 2010, report..." Continued interview confirmed the DON drew the PT/INR on December 17, 2010, for resident #11. Continued interview confirmed the DON had read the December 17, 2010, 24 hour report on resident #11 that a new draw was needed due to the sample the lab received was clotted and confirmed there were no lab results for December 17, 2010. Continued interview confirmed the physician had not been notified of the clotted sample on December 17, 2010. Continued interview confirmed the PT/INR ordered for December 20, 2010, had not been obtained as ordered by the physician.

Based on medical record review, facility document review, review of pharmacist consultant's report, and interview, the facility pharmacist consultant failed to identify PT/INR laboratory (lab) studies ordered by the physician had not been completed for one resident (#11) receiving anticoagulant therapy of four resident's reviewed receiving anticoagulant therapy. The pharmacy consultant's failure to ensure labs that were ordered and not obtained was reported to the physician was likely to cause serious injury, harm, impairment, or death to resident #11 from uncontrolled bleeding related to critically high blood clotting times. The Interim Administrator, new Administrator (first day March 28, 2011), Director or Nursing (DON), Assistant Director of Nursing (ADON), Regional Compliance Nurse, and Compliance Nurse, were notified of the Immediate Jeopardy on March 31, 2011, at 9:15 a.m., in the conference room. The Immediate Jeopardy was effective on November 30, 2010 and is ongoing. The findings included: Resident #11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Further medical record review revealed the resident was discharged to another long term care facility on December 22, 2010. Medical record review of the Admission physician orders dated October 19, 2010, through December 16, 2010, revealed "...Coumadin (anticoagulant-blood thinner to prevent blood clots) 6 milligrams (mg) by mouth every night at bedtime...PT/INR (Prothrombin Time/International Normalization Ratio) monthly (INR is lab test to determine blood clotting time)..." Medical record review of the lab data sheet revealed the INR (International Normalization Ratio-lab value for anticoagulation therapy to determine therapeutic range) reports were obtained from the same laboratory with the following reference therapeutic range for INR: 0.90-1.11 International Units. Medical record review revealed the following INR laboratory results: October 26, 2010, 1.75; and no November lab for INR. Medical record review of the INR lab dated December 16, 2010, revealed "...> (greater than) 10 critically high..." Medical record review of two physician phone orders dated December 16, 2010, revealed "...1) Vitamin K (Vitamin K for clotting, reverses the effect of Coumadin) 10 mg IM (Intramuscular Injection) now...2) D/C (discontinue) Coumadin...3) (Check) INR Friday 12-17-10 and Monday 12-20-10..." Review of the second physician order dated December 16, 2010, revealed "...(Change) Vitamin K to Vitamin K 10 mg IM Q (every) 6 (hours) x (times) 2 days for total of 8 doses..." Review of the facility policy for "Anticoagulant Therapy, dated 12/11/05; revised 10/08", revealed "...Procedure: The goal of this protocol is to effectively monitor residents receiving anticoagulant therapy, reduce the risk of bleeding, and maintaining therapeutic blood levels in accordance with the physician's order...8. The facility's pharmacist consultant will review the resident's drug regimes, which includes reviewing the resident's anticoagulant therapy..." Review of the Consultant Pharmacist's Medication Regimen review, signed by the pharmacist on November 30, 2010: Listing of Residents Reviewed with No Recommendation for records updated between November 1, 2010 and November 30, 2010 revealed resident #11 had been reviewed and no pharmacy recommendations were documented. Interview with the consultant pharmacist on March 31, 2011, at approximately 4:00 p.m., by phone, confirmed "...make sure labs were drawn as part of the review, check levels of lab and make note of it...if lab off value that MD (physician) notified and if (MD) received notification..." Further interview confirmed the consultant pharmacist had conducted a review on November 30, 2010, and had no recommendations for resident #11. Further interview confirmed the consultant pharmacist had not identified the missing PT/INR lab in November 2010. .