Every finding on record at Town East Rehabilitation and Healthcare Center

Based on observation, interview and record review, the facility failed to ensure residents were free from verbal abuse for 1, (Resident # 2) of 7 residents reviewed for abuse. The facility failed to prevent MA T from verbally abusing Resident #2 on 07/01/26. As a result of the incident, the resident stated he was upset and shaken. This failure could affect the residents and put them at risk for verbal abuse.Findings included: Record review of Resident #2's admission MDS assessment dated [DATE], revealed he was a [AGE] year-old male, who was admitted to the facility on [DATE]. The residents' diagnoses included repeated falls, need for assistance with personal care, Cerebral infarction (stroke). The MDS assessment revealed Resident #2 had a BIMS score of 13 (cognitively intact). Review of the provider investigation dated 07/08/26 and conducted by the Administrator revealed that on 7/1/26, Resident #2 alleged that a MA T in the dining room during dinner service was upset and called him a mother f***er. He also stated that Resident #3 witnessed the incident. Resident #3 was interviewed and stated that she heard the term MF used; however, she was unsure if it was directed toward anyone. MA T was also interviewed and denied making the statement. MA T was placed on suspension pending investigation. Due to the Resident #3's BIMS score, she was not considered a fully reliable source of truth. Given the circumstances, the facility chose to err on the side of caution and terminated the MA T. At this time, it is unconfirmed as to whether or not verbal abuse was experienced. The facility will continue to monitor staff for any further allegations and a daily review of residents grievances. During an observation and interview on 07/09/26 at 10:42 a.m. with Resident #2, He stated that during dinner on the day of the incident, he was in the dining room waiting to be served. He stated MA T had a bad attitude towards everyone.He stated everyone was served except him and when he asked for his food MA T called him a MF. He stated that 2 other residents were at the same table and confirmed that MA T called him a MF and he left the dining room without eating. He stated he notified the social worker about the incident.He stated a staff eventually [NAME] his dinner to the room later that evening.He stated that the next day he asked Resident #3 and #4 who were at the table with him on the day of the incident if MA T called him a MF and they did confirm that MA T did call him a MF. He stated MA T action made him feel very upset and shaken. He stated that nothing has been done by the facility. Record review of Resident #3's admission MDS assessment dated [DATE], revealed she was a [AGE] year-old female, who was admitted to the facility on [DATE]. The resident's diagnoses included Dementia (A progressive loss of memory, reasoning and communication skills), and Repeated falls. The MDS assessment revealed Resident #3 had a BIMS score of 11 (moderate memory and thinking issues). During an observation and interview on 07/09/26 at 12:50 p.m. with Resident #3, she stated that has a great personality, and she enjoys sitting with him during meals and that he was a very nice person. She stated that his conversations were great during mealtimes. She stated she remembers somebody using a curse word during dinner a few days ago directed towards , she stated that it was a female staff and she used F off. She stated that the language was uncalled for, she stated did not deserve to be spoken to that way. She stated that nothing he was doing that day called for such words. She stated that it was not an employee who said the words F off, but she does not recall exactly who it was. She stated that all the employees were nice. Record review of Resident #4's annual MDS assessment dated [DATE] revealed she was a [AGE] year-old female admitted to the facility on [DATE]. The resident diagnosis included Dementia (A progressive loss of memory, reasoning and communication skills), Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills). The MDS assessment revealed Resident #4 had a BIMS score of 07 (severe memory and thinking problems) During an interview on 07/09/26 at 1:00 p.m. with Resident #4, She stated that she was sitting at the table but was not sure what happened, but she does recall there was an argument between Resident #2 and MA T. She stated that she was not sure what led to the argument. She stated she did not hear any curse words. During an interview on 07/09/26 at 1:30 p.m. with the Social Services Director, he stated that Resident #2 was a new residentResident #2 approached him the day after the incident, teary eyed and sad. He reported to him that during dinner the night before, he had asked several times for his tray and MA T got aggravated and called him a MF and that two other residents were at the table.He reported to the administrator and called in a psych referral. The counselor was there and spoke with him today 07/09/26.He stated an incident was self-reported to HHS and a safety survey was completed with 9-10 residents that had a BIMS score of 10 or higher. MA T was suspended immediately as soon as an identification was made, Resident #2 pointed at MA T.There were no prior concerns reported about the MA T in the past. During an interview on 07/09/26 at 3:30 p.m. with the Administrator, she stated that a staff member (MA T) cursed Resident #2 in the dining during dinner on 07/01/26. She stated that the resident reported the incident to the social services director who reported it to her. She stated that they called the responsible party, physician and psych for an evaluation and started in-services for abuse/neglect and resident's rights. She stated that the psych came out on 07/09/26 to see the resident. She stated that the MA T was suspended pending investigation and was terminated after the investigation. She stated that the staff continued to monitor for any emotional distress for 72 hours after the incident and the resident has been fine since then. During an interview on 07/10/26 at 4:00 p.m. with MA T, she stated that she never called Resident #2 an MF, She stated that she was always polite to him. She stated that Resident #2 will get upset and cursed if his tray is late and will walk out of the dining room. She stated that on the said evening, she went to the 400 hall to look for his tray, but the tray had not been brought to the hall at the time. She stated that Mr. [NAME] was cursing out loud and she never said anything to him. Review of the facility's Abuse and Neglect-Clinical Protocol Policy dated 10/15/2022, revealed: Different Abuse of any Types:Staff to Resident Abuse of any Types:Deals with diverse populations including residents with dementia, mental disorders, intellectual disabilities, ethnic/cultural differences, speech/language challenges, and generational differences.The facility assumes the responsibility upon admission of ensuring safety and well-being of the resident.Education for all staff will be ensured in how to react and reason appropriately to resident behaviors.Staff are expected to be in control of their behavior and behave professionally.The facility will not accept for an employee to claim his/her action was reflexive or a knee-jerk reaction and was not intended to cause harm.Retaliation from staff is abuse, regardless of whether harm was intended.Abuse is defined at S483.5 as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology.

Based on observation, interview and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for one (Resident #1) of seven residents reviewed for medication storage. The facility failed to ensure that there were no medications inside Resident #1's room on 07/09/26. This failure could place residents at risk of misuse of medications that could lead to overdosing and other adverse reactions.Findings included: 1. Record review of Resident #1's Face Sheet, dated 07/09/26, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with Syncope and collapse (fainting or passing out due to drugs), Hypotension due to drugs (L ow blood pressure that is caused as a side effect or unintended reaction from taking medications or other substances). Record review of Resident #1's quarterly MDS Assessment, dated 07/03/26, revealed the resident had a moderate impairment in cognition with a BIMS score of 11. Record review of Resident #1's Comprehensive Care Plan, dated 09/13/25 revealed Resident #1 has impaired cognitive function/dementia or impaired thought processes related to Impaired decision making with intervention to Communicate with the resident/family/caregivers regarding resident's capabilities and needs. During an observation and interview on 07/09/26 at 10:01 a.m. with Resident #1, she stated that she was treated well and was happy with the staff. Observation at this time of her nightstand and in the drawer that was open were bottles of Supplements that included: Yucca, Wild Lettuce, Vitamin C, [NAME] Super greens and a prescription bottle of Gemtesa. She stated she takes the supplements when she needs them for her various ailments like she did at home. She stated that she brought them with her when she moved into the facility 6 months ago. She stated that the facility did not complete an inventory of her things, she was not sure if they have observed them on her nightstand or not. During an interview on 07/09/26 at 1:47 p.m. with LVN P, he stated that the Resident #1's family brings in the medications when they visit. He stated that the facility policy was that no Resident should have medication at the bedside. He stated that she may have pulled the medication out after he did Resident #1's dressing change this morning before the observation of the medications. He stated that if Resident #1 has medications in her room, she can overdose herself. He stated that Resident #1 has frequent confusion due to recurrent urinary tract infections. He stated that Resident #1's care was under the nurse and that the medications should not be kept in the room for the resident's safety. He stated that if he sees any medication in the resident's room, he removes it and calls the family and investigates how the resident got the medication and informs the DON or ADON and calls the doctor. During an interview on 07/09/26 at 2:06 p.m. with MA L, she stated that she had not noticed any medications in Resident #1's room.She stated that if she finds any medication that was visible without invading the resident privacy, she reports it to the nurse, and they go in together to retrieve the medications. She stated that the facility manages all the residents' medication and them self-medicating can lead to an overdose. She stated that the facility was liable if the resident overdoses. She stated that an overdose can lead to death of the resident or other serious side effects that can harm them. She stated that Resident #1 was frequently confused due to having frequent urinary tract infection. During an interview on 07/09/26 at 3:18 p.m. with the DON, she stated that Resident #1's family brings in the medication, and she gets them from when she goes for outside appointments. She stated that no medication or over the counter medication were allowed in the residents' room, unless they had an assessment and an order for self-administration completed. She stated that the resident may not know what they are taking and another resident may get a hold of it and use the medication. She stated that depending on the medication they were taking, it could interact with the medication given by the nurse. She stated that all staff were responsible for making sure that the residents do not have medications in their rooms. She stated that she expects any staff that finds any medication to take them to the nurse so they can address it and provide education to the residents and family. Record review of the facility policy on Storage of medication revised April 2019 revealed: 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls.'

Based on observation, interview and record review the facility failed to provide the necessary services to residents who were unable to carry out activities of daily to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 6 residents (Resident #1 and Resident #2) reviewed for ADL activities. The facility failed to change Resident #1's brief within a timely manner on either Monday or Tuesday of the week 05/03/26. The facility failed to provide Resident #2 assistance with brief change within a timely manner. These failures could place residents who required assistance with ADL's at risk for unmet care needs.Findings included: Record review of Resident #1's face sheet, dated 05/14/26, reflected a [AGE] year-old female that was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: urinary tract infection (infection in any part of the urinary system lack of coordination, muscle weakness, age-related physical debility (continuous process characterized by biological, psychological, and social changes that occur over time, impacting health and quality of life), dementia (decline in mental ability). Record review of Resident #1's annual MDS assessment, dated 05/08/26, reflected a BIMS score of 10, which indicated moderate cognitive impairment. The MDS assessment under Section GG-Functional Abilities, reflected Resident #1 was dependent on assistance with oral hygiene, toileting, showering and bathing, upper and lower body dressing, putting on/taking off footwear and personal hygiene. The MDS assessment under Section H-Bladder and Bowel, reflected Resident #1 urinary and bowel was always incontinent. Resident review of Resident #1's care plan, revised 07/18/25, reflected Resident #1 had an ADL self-care performance deficit related to Alzheimer's, confusion, dementia and limited mobility. Interventions included: assisting rails per doctor's order for safety during care provision, assisting with bed mobility, checking nail length and trimming and cleaning on bath day and as necessary, resident bedfast all or most of the time. Resident #1 was totally dependent, require mechanical lift. Monitoring/documenting PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, decline in function. Resident #1 was totally dependent with bathing/showering, dressing, feeding, personal hygiene and oral care and toileting. Resident #1 also had experiences of bladder incontinence related to confusion, dementia and impaired mobility. Interventions included: cleaning peri-area with each incontinence episode, monitoring and documenting intake and output as per facility policy. Record review of Resident #1's progress note, dated 05/05/26 at 2:26pm written by LVN I, reflected the following: Skin:Skin color is WNL. Skin warm/dry to touch. Normal skin turgor (the state of rigidity and tension in living cells or tissues).Skin note: redness to perineal (the diamond-shaped region of skin and muscle located between the bottom of the vaginal opening and the anus) area.Skin Issue: #001. Skin issue had not been evaluated. Location: Perineum. Issue type: Other skin issue. Other skin issue description: Redness/Wound was present on admission. Record review of Resident #2's face sheet, dated 05/14/26, reflected an [AGE] year-old female that was admitted to the facility on [DATE]. Resident #2 had diagnoses which included: vascular dementia (a type of dementia caused by reduced or blocked blood flow to the brain, leading to cognitive decline, memory problems, and changes in behavior and physical abilities), melena (black, tarry stools that indicate internal bleeding, usually from the upper gastrointestinal (GI) tract), urinary tract infection (infection in any part of the urinary system), cognitive communication deficit (an impairment in communication caused by underlying disruptions in cognitive processes-such as attention, memory, and executive function rather than primary speech or language deficits). Record review of Resident #2's Quarterly MDS assessment, dated 03/16/26, reflected a BIMS score of 08, which indicated moderate cognitive impairment. The MDS assessment under Section GG-Functional Abilities, reflected Resident #2 needed supervision with eating, substantial assistance with oral and personal hygiene, partial assistance with upper body dressing, and dependent with toileting, bathing, lower body dressing and putting on/taking off footwear. The MDS assessment under Section H-Bladder and Bowel, reflected Resident #2 urinary and bowel was always incontinent. Record review of Resident #2's care plan, revised 11/16/25, reflected Resident #2 had an ADL self-care performance deficiency. Interventions included: resident was independent with eating and no assistance required. Encouraging the resident to use bell to call for assistance. Bathing: Resident required assistance x 1 with bathing. Bed mobility: Resident was dependent with bed mobility. Locomotion: Resident required assistance x 1 with locomotion. Personal hygiene: Resident required assistance x 1 with personal hygiene. Toilet use: Resident requires assistance x 1 with toilet use. Dressing: Resident is totally dependent x 1 in dressing. Side rails: assisted rails up as per doctor's order for safety during care provision to assist with bed mobility. Observation for injury or entrapment related to side rail use. Transferring: Resident #2 was totally dependent and required mechanical lift. Encouraging the resident to participate to the fullest extent possible with each interaction. Resident #2 had occasional bowel and bladder incontinence related to impaired mobility and preferred to have incontinent pad inside of brief. Interventions included: cleaning peri-are with each incontinence episode, monitoring/documenting for signs/symptoms of an UTI: paining, burning, blood-tinged urine, cloudiness, nooutput, deepening of urine color, increased pulse, increased temperature, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns During an interview on 05/12/26 at 2:02 PM, Resident #1's RP stated he visited almost daily. Resident #1's RP stated there were some concerns during the week of 05/04/26. Resident #1's RP stated either 05/04/26 or 05/05/26 when was visiting it took over an hour for staff to change Resident #1's brief after he asked. Resident #1's RP stated around 12:30 PM he informed staff that Resident #1 needed her brief changed. Resident #1's RP stated a staff member told him they would get someone to assist. Resident #1's RP stated he waited 45 minutes, but no one had come to change Resident #1's brief, so he went to the nurse's station and asked for assistance again. Resident #1's RP stated he did not remember who he talked to, but he was informed by staff that they would get someone. Resident #1's RP stated he told the staff person he told someone would assist 45 minutes prior but nothing. Resident #1's RP stated he waited approximately another 35-40 minutes for staff to come to Resident #1's room. Resident #1's RP stated he returned back to the nurse's station to find out exactly who would change Resident #1's brief. Resident #1's RP stated he was told the same thing that someone would come. Resident #1's RP stated as he was walking back to the room, a nurse told a staff person that passing to change Resident #1. Resident #1's RP stated the staff member that assisted with changing Resident #1 informed him that they did not work Resident #1's room but completed the brief change. Resident #1's RP stated when Resident #1 was being cleaned, she screamed because it burned when wiping. Resident #1's RP stated he believed she had a rash although he did not look in the peri area. Resident #1's RP stated he did not know who the aide was. Resident #1 stated he believed the rash may have healed. During an interview on 05/13/26 at 10:45 AM, Resident #2 stated staff took between 30 minutes to 3 hours to answer her call light for her brief to be changed. Resident #2 stated she was changed 3x times a day. Resident #2 stated she was changed at approximately 5:00am, 11:00am and between 8:00pm-9:00pm. Resident #2 revealed on 05/12/26 her brief was only changed twice. Resident #2 revealed it was changed around lunchtime and before bed around 9:00 PM. Resident #2 stated aides have changed her brief and not returned. Resident #2 stated she had been changed and put in bed at 6:00 PM without being changed afterwards. Resident #2 stated when she needed her brief changed while in her wheelchair, staff would transfer her to the bed, change her and leave her in bed because they did not want to transfer her back to her chair. Resident #2 also stated when staff did that, she did not want to be in bed. Resident #2 stated at times she had used her call light and no response. Resident #2 stated recently she did not have any negative effects from not having her brief changed more often. During an observation of incontinent care on 05/13/26 at 10:20 AM with Resident #2, there were no skin concerns and Resident #2's skin was intact. During an interview on 05/14/26 at 2:36 PM, both the DON and Administer stated they were unaware of any issue with changing of Resident #1 and Resident #2. They stated the risks of not changing briefs were that residents would be soiled which could lead to UTIs. A policy regarding ADL care was requested from the DON on 05/12/26 at 9:28 AM and 05/21/26 at 11:24 AM but the facility did not have a policy. The policy sent was perineal care which did not address the concerns.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 7 residents reviewed for comprehensive care plans (Resident #1). The facility failed to ensure Resident #1 had a fall mat at his bedside while he was observed in bed on 02/03/2026 at 11:58 AM and 12:25 PM. This failure could place residents requiring supervision at risk for serious injury and death. Findings included: Review of Resident #1's Face Sheet on 02/03/2026 at 11:58 AM revealed he was an [AGE] year-old male admitted to the facility on [DATE] from an acute care hospital. Relevant diagnoses included dementia (decline in cognitive abilities,) respiratory failure (respiratory system cannot provide enough oxygen to the blood,) spinal stenosis (narrowing of the spine which compresses the nerves and/or spinal cord,) heart disease (disease which affects the heart,) and diabetes (chronic metabolic disease.) Review of Resident #1's Comprehensive Care Plan dated 12/26/2025 revealed resident had an actual fall with no injury with interventions that included:-floor mat-anticipate resident needs-ensure call light was in reach Review of Resident #1's MDS dated [DATE] revealed resident was severely cognitively impaired with a BIMS score of 01. He was always incontinent of bowel and bladder. He was documented with a recent fall and required a wheelchair for mobility and was completely dependent upon staff for transfers, toileting, showers, and dressing himself. Observation and attempted interview of Resident #1 on 02/03/2026 at 11:58 AM and 12:25 PM revealed he was in bed resting comfortably and his call light was in reach. No floor mat was observed beside resident's bed. Interview with Resident #1 was not successful due to his cognition. In interview with LVN A on 02/03/2026 at 12:25 PM she stated resident had a fall about a month ago. She stated Resident #1's fall precautions that should be in place and stated it included a fall mat. She stated Resident #1 should have a fall mat at the bedside and was not sure why it was not in place at this time. She stated fall mats were important for harm reduction if Resident #1 did fall. She stated it was her responsibility to ensure his fall mat was at his bedside while he was in bed. In interview with DON on 02/03/2026 at 1:55 PM she stated Resident#1 had a fall and one of the interventions was for a bedside floor mat while resting in bed. She stated it was the bedside nurse's responsibility to ensure the floor mat was present at the bedside when he was resting in bed. She stated it was important for harm reduction if Resident #1 did have a fall. In Interview with the Administrator on 02/03/2026 at 2:33 PM she stated her expectations were for Resident #1 to have a fall mat at the bedside while he was in bed. She stated it was the nurse's responsibility to ensure a fall mat was at his bedside as a measure of harm reduction if the resident does fall. She stated it was an important measure to keep her residents safe. Facility Administrator stated the facility does not have a specific fall mat policy but stated she expected the interventions listed on Resident #1's Comprehensive Care Plan to be implemented at the facility. Review of facility policy, Care Plans, Comprehensive Person-Centered, rev. 01/2025 revealed A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

Based on observation, interview and record reviews, the facility failed to ensure the residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 6 residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 was free from abuse. CNA A attempted to provide Resident #1 care on the bed by herself on 11/13/2025 which led to Resident #1 falling off the bed and sustaining a left forehead injury.An IJ was identified on 12/05/25 at 09:50 a.m. The IJ template was provided to the facility on [DATE] at 12:33 p.m. While the IJ was removed on 12/06/25 at 5:17 p.m., the facility remained out of compliance at a scope of isolated and severity level of no actual harm because all staff had not been trained on abuse/neglect, incident/accidents, and reporting. The failure could place residents at risk of abuse and serious harm. A review of the MDS quarterly assessment dated [DATE] reflected Resident#1 was a [AGE] year-old male admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses including cerebrovascular accident (a medical emergency where blood flow to the brain is suddenly interrupted, causing brain cells to die from lack of oxygen, leading to potential disability or death), non-Alzheimer's dementia (forms of cognitive decline not caused by Alzheimer's disease), Parkinson's Disease (a progressive neurological disorder where brain cells producing dopamine die, leading to movement issues like tremors, stiffness, slow movement, and balance problems, alongside non-motor symptoms such as sleep issues, depression, and cognitive changes), dysphasia (difficulty swallowing food or liquids), and muscle weakness. No BIMS score was documented, and section C100-Cognitive Skills for Daily Decision Making was coded at (2) indicating moderate cognitive impairment. Section GG, which reflects functional abilities, indicated that Resident #1 was dependent, and required two-person assistance for showers, toileting, hygiene, and bed transfers.Review of the care plan dated 10/28/25 reflected that Resident #1 required two-person assistance for bed mobility, transfers and ADLs.Review of facility accident/incident report for the month of November 2025 revealed Witnessed Fall Incident [Resident#1] 11/13/2025 at 10:00 AM.Record review of the Witnessed Fall report by LVN B dated 11/13/25 10: 00 a.m. revealed 10:00 AM Received report that resident had a fall. Nurse responded to room and observed the resident on the floor lying on his left side. Nurse observed active bleeding to the left temporal area. Resident alert upon assessment with no loss of consciousness, pressure applied to site with a clean towel. 117/62, P 88, 97.4 RR 18 CNA A was witness to the incident stated while getting the resident dressed for the day, she turned the resident on his side and that was when the resident accidentally rolled off the bed. NP, DON, and Resident#1 RP notified. 911 notified Resident#1 transferred to Hospital. Resident#1 description: Resident#1 unable to give description.Record review of Witnessed Fall IDT meeting dated 11/17/25 note by DON revealed IDT met to review resident fall. Resident#1 was in bed and CNA A was assisting with getting him dressed and rolled him over and he somehow ended up falling off the bed sustained a fall with a laceration to his head. During investigation of the fall IDT determined that Resident#1 call light was within reach, CNA A was in the room with Resident#1 and resident failed to grab the rail and rolled off the bed. IDT determined that Resident#1 needed scoop mattress in place. Resident#1 is currently on therapy services, therapy plan of care updated to focus on strength and balance to prevent falls. Education was also given to the CNA A.Review of hospital records dated 11/13/25 for Resident#1 revealed Physical exam. 2 cm V shaped Laceration to left temporal region, superficial 1 cm laceration amenable to glue on scalp. date/time: 11/13/2025 2:38 p.m.location: forehead. Laceration length: 2 cm. Anesthesia: Local infiltration: Lidocaine 1% without epinephrine.wound skin closure material used: 5-0 fast gut x 4 (5-0 fast absorbing gut is a Monofilament, collagen-based, absorbable suture designed for rapid absorption (21-42 days) and 5-7 days of tensile strength). Number of sutures: 4.Procedure described (general) as Laceration repair.location: scalp. Laceration length: 1 cm .skin closure: glue. Repair type: simple.Record review revealed Resident#1 returned to the facility on [DATE] after the visit to ER with a left forehead dressing.In an interview on 12/03/25 at 12:24 p.m. over the phone, CNA A stated that on 11/13/25 she had been providing incontinent care to Resident #1. She stated that while turning Resident #1 on to his left side, Resident#1 rolled off the bed, hitting his head on the floor with active bleeding. CNA A reported that she immediately called for help. LVN B assessed Resident #1 and found out he sustain injury with active bleeding to his left forehead. She stated Resident#1 was sent to the hospital. CNA A stated she had been assigned to Resident#1 for a long time and was not aware that Resident #1 was a two-person assist. She explained that she had always provided care for him alone. CNA A stated she was supposed to check the Kardex (a vital, often summarized, patient care tool for nurses) in the electronic medical record system to know the level of assistance each resident required. She stated, she overlooked Resident#1's level of assistance. CNA A stated the DON did a one-to-one education with her the same day after the incident. She reported she had been in-serviced on abuse/neglect/exploitation. She provided various types/examples of abuse/neglect/exploitation. She reported the Administrator was the Abuse Coordinator. She verbalized facility policies and procedures, including the steps they would take, related to the prevention and response of abuse/neglect/exploitation. She denied being aware of any abuse/neglect/exploitation at the facility.In interview on 12/04/25 at 12:25 p.m. LVN B stated she was called to Resident#1's room by CNA A. She stated CNA A told her Resident#1 rolled off the bed when CNA A turned him to his left side and he ended up in the floor. LVN B stated Resident#1 sustained an injury to his left head with active bleeding. LVN B stated she got help from LVN C who came in and applied pressure on Resident#1 left forehead injury. LVN B stated he was alert and awake. LVN B stated she called 911 and sent Resident#1 to the ER, because of the injury and active bleeding. LVN B stated she notified Resident#1's PR, the DON, and MD. LVN B stated CNA A was performing incontinent care for Resident#1 by herself. LVN B stated CNA A did not request help. LVN B stated she knew from the care plan that Resident#1 required 2 persons assist for turning in the bed. LVN B stated since Resident#1 required mechanical lift transfer from the bed to wheelchair the CNAs working with him were supposed to request help. LVN B stated CNA A worked that Hall all the time, and she knew not to Resident#1 care/bed mobility by herself. LVN B stated the risk of not following the care plan/Kardex for residents' care was falls, and injury. She reported she had been in-serviced on abuse/neglect/exploitation. She provided various types/examples of abuse/neglect/exploitation. She reported the Administrator was the Abuse Coordinator. She verbalized facility policies and procedures, including the steps she would take, related to the prevention and response of abuse/neglect/exploitation She denied being aware of any abuse/neglect/exploitation at the facility.In interview on 12/04/25 at 2:46 PM the ADON stated she had just started in the facility when the incident happened. She stated she was informed about what happened, and that Resident#1 had a fall. She stated it was the responsibility of the CNAs to check the Kardex for residents' level of assistance. She stated it was also the responsibility of the nurses in charge of each Hall to let the CNAs know if there were changes if residents had a decline. ADON stated the CNAs were supposed to get reports on the residents at the start of each shift. The ADON stated her expectation in this case was for CNA A to call another person to help her. ADON stated the risk for residents was falling, and injury. She reported that she had been in-serviced on abuse/neglect/exploitation. She provided various types/examples of abuse/neglect/exploitation. She reported the Administrator was the Abuse Coordinator. She verbalized facility policies and procedures, including the steps she would take, related to the prevention and response of abuse/neglect/exploitation. She denied being aware of any abuse/neglect/exploitation at the facility.In interview on 12/04/25 at 2:03 p.m. the DON stated, she interviewed CNA A involved in the incident and LVN B who responded to CNA A's call after the fall, who was assigned to Resident#1. She stated CNA A rolled Resident#1 over and he kept rolling and ended up in the floor. The DON stated she did not ask CNA A if she knew how many persons assist Resident#1 needed for his incontinent care/mobility in the bed. The DON stated she did not ask CNA A if she checked the Kardex, because the DON thought Resident#1 required one person assist since his admission. The DON stated Resident#1 had been living in the facility for six to seven years. She stated Resident#1 had declined but was still able to grab the side rail and help. The DON stated the Kardex stated two persons assist, and she learned that after the incident. She stated she educated the CNAs to check the Kardex daily for residents' level of assistance. She stated she was expecting CNA A to have a second person with her. She stated CNA A caused an injury to Resident#1, because she did not follow the facility policy, and that could be neglect from the CNA A side. She stated she spoke to other CNAs, about the incident, and the importance of following each resident's care needs indicated in the Kardex. She stated, after the incident she reviewed the Kardex for all the residents to make sure they are up to date. The DON stated she reported the incident to the Administrator. The DON further stated she should consider it a form of abuse/neglect and report it to HHSC.In a follow up interview with the DON on 12/05/25 at 3:30 PM she stated CNA A was as needed staff. DON stated CNA A finished her shift on the day of the incident on 11/13/25 she did not come back to work since that date (11/13/2025). In an interview with the Administrator on 12/04/25 at 2:19 p.m., the Adm. stated, she learned that Resident#1 had a fall when CNA A was providing care for him that day (11/13/25), and he ended up being sent to the hospital. She stated that the DON reported it to her. She stated she did not do any investigation, other than what the DON did. She stated she did not interview the staff to know how Resident#1 sustained the fall. She stated from her understanding it was an accident, CNA A knew Resident#1's routine, and he never had any incident. She stated Resident#1 was all the time a 1 person assist not 2 persons assist for positioning/turning in bed and there was a typo in his care plan, because sometimes it stated 1-2 person assist. She stated CNA A not checking the Kardex daily for Resident#1's care level was an oversight on CNA A's part. The Adm. stated her expectations were that the staff should look in the care plan, and Kardex to know what care level was needed for the residents. She stated without checking the care plan or the Kardex the staff would not know the appropriate care to provide for the residents, and that could be a potential neglect. She stated it was the responsibility of the charge nurses in the Hall to rely to CNAs the care level for the residents and make sure they were following residents' care plan instruction. She stated the risk to residents was falls and injury. Observations of CNA E on 12/03/25 at 10:02 a.m. of one-person in-bed peri-care per the resident care plan/Kardex revealed no concerns, and CNA E followed appropriate steps to ensure care and resident safety.Observations of CNA E and MA F on 12/03/25 at 10:25 a.m. of two-person transfers using a mechanical lift revealed no concerns-staff appeared trained in mechanical lift usage. Observations of CNA J and CNA K on 12/04/25 at 10:26 a.m. of two-person in-bed peri-care per the resident care plan/Kardex revealed no concerns, and staff followed appropriate steps to ensure care and resident safety.Observations of CNA D and CNA L on 12/04/25 at 10:50 a.m. of two-person in-bed peri-care per Resident care/Kardex revealed no concerns, and staff followed appropriate steps to ensure care and resident safety.Observations of CNA G on 12/04/25 at 11:25 a.m. of one-person in-bed peri-care per the resident care plan/Kardex revealed no concerns, and CNA G followed appropriate steps to ensure care and resident safety.Interview on 12/03/25 at 1:15 p.m. with CNA E revealed that she had been in-serviced on Abuse/Neglect and assistance with mobility this week. She was aware of where to locate a resident's care needs in his/her care plan/Kardex, and she stated she would notify the nurse if there was conflicting information. She reported she had been in-serviced on abuse/neglect/exploitation. She provided various types/examples of abuse/neglect/exploitation. She reported the Administrator was the Abuse Coordinator. She verbalized facility policies and procedures, including the steps she would take, related to the prevention and response of abuse/neglect/exploitation. She denied being aware of any abuse/neglect/exploitation at the facility.Interview on 12/03/25 at 1:29 p.m. with CNA M revealed that she had been in-serviced on Abuse/Neglect and assistance with mobility this week. She was aware of where to locate a resident's care needs in his/her care plan/Kardex, and she stated she would notify the nurse if there was conflicting information. She reported she had been in-serviced on abuse/neglect/exploitation. She provided various types/examples of abuse/neglect/exploitation. She reported the Administrator was the Abuse Coordinator. She verbalized facility policies and procedures, including the steps she would take, related to the prevention and response of abuse/neglect/exploitation. She denied being aware of any abuse/neglect/exploitation at the facility.Interview on 12/03/25 at 1:33 p.m. with MA O revealed that she had been in-serviced on Abuse/Neglect and assistance with mobility this week. She was aware of where to locate a resident's care needs in his/her care plan/Kardex, and she stated she would notify the nurse if there was conflicting information. She reported she had been in-serviced on abuse/neglect/exploitation. She provided various types/examples of abuse/neglect/exploitation. She reported the Administrator was the Abuse Coordinator. She verbalized facility policies and procedures, including the steps she would take, related to the prevention and response of abuse/neglect/exploitation. She denied being aware of any abuse/neglect/exploitation at the facility.Interview on 12/04/25 at 10:42 a.m. with CNA J revealed that she had been in-serviced on Abuse/Neglect and assistance with mobility this week. She was aware of where to locate a resident's care needs in his/her care plan/Kardex, and she stated she would notify the nurse if there was conflicting information. She reported she had been in-serviced on abuse/neglect/exploitation. She provided various types/examples of abuse/neglect/exploitation. She reported the Administrator was the Abuse Coordinator. She verbalized facility policies and procedures, including the steps she would take, related to the prevention and response of abuse/neglect/exploitation. She denied being aware of any abuse/neglect/exploitation at the facility.Interview on 12/04/25 at 12:38 p.m. with CNA L revealed that she had been in-serviced on Abuse/Neglect and assistance with mobility this week. She was aware of where to locate a resident's care needs in his/her care plan/Kardex, and she stated she would notify the nurse if there was conflicting information. She reported she had been in-serviced on abuse/neglect/exploitation. She provided various types/examples of abuse/neglect/exploitation. She reported the Administrator was the Abuse Coordinator. She verbalized facility policies and procedures, including the steps she would take, related to the prevention and response of abuse/neglect/exploitation. She denied being aware of any abuse/neglect/exploitation at the facility.Interview on 12/04/25 at 12:45 p.m. with CNA K revealed that she had been in-serviced on Abuse/Neglect and assistance with mobility this week. She was aware of where to locate a resident's care needs in his/her care plan/Kardex, and she stated she would notify the nurse if there was conflicting information. She reported she had been in-serviced on abuse/neglect/exploitation. She provided various types/examples of abuse/neglect/exploitation. She reported the Administrator was the Abuse Coordinator. She verbalized facility policies and procedures, including the steps she would take, related to the prevention and response of abuse/neglect/exploitation. She denied being aware of any abuse/neglect/exploitation at the facility.Interview on 12/04/25 at 12:50 p.m. with CNA G revealed that she had been in-serviced on Abuse/Neglect and assistance with mobility this week. She was aware of where to locate a resident's care needs in his/her care plan/Kardex, and she stated she would notify the nurse if there was conflicting information. She reported she had been in-serviced on abuse/neglect/exploitation. She provided various types/examples of abuse/neglect/exploitation. She reported the Administrator was the Abuse Coordinator. She verbalized facility policies and procedures, including the steps she would take, related to the prevention and response of abuse/neglect/exploitation. She denied being aware of any abuse/neglect/exploitation at the facility.Interview on 12/04/25 at 1:08 p.m. with CNA D revealed that she had been in-serviced on Abuse/Neglect and assistance with mobility this week. She was aware of where to locate a resident's care needs in his/her care plan/Kardex, and she stated she would notify the nurse if there was conflicting information. She reported she had been in-serviced on abuse/neglect/exploitation. She provided various types/examples of abuse/neglect/exploitation. She reported the Administrator was the Abuse Coordinator. She verbalized facility policies and procedures, including the steps she would take, related to the prevention and response of abuse/neglect/exploitation. She denied being aware of any abuse/neglect/exploitation at the facility.Interview on 12/04/25 at 1:14 p.m. with CNA H revealed that she had been in-serviced on Abuse/Neglect and assistance with mobility this week. She was aware of where to locate a resident's care needs in his/her care plan/Kardex, and she stated she would notify the nurse if there was conflicting information. She reported she had been in-serviced on abuse/neglect/exploitation. She provided various types/examples of abuse/neglect/exploitation. She reported the Administrator was the Abuse Coordinator. She verbalized facility policies and procedures, including the steps she would take, related to the prevention and response of abuse/neglect/exploitation. She denied being aware of any abuse/neglect/exploitation at the facility.Interview on 12/04/25 at 1:47 p.m. with MA Q revealed that she had been in-serviced on Abuse/Neglect and assistance with mobility this week. She was aware of where to locate a resident's care needs in his/her care plan/Kardex, and she stated she would notify the nurse if there was conflicting information. She reported she had been in-serviced on abuse/neglect/exploitation. She provided various types/examples of abuse/neglect/exploitation. She reported the Administrator was the Abuse Coordinator. She verbalized facility policies and procedures, including the steps she would take, related to the prevention and response of abuse/neglect/exploitation. She denied being aware of any abuse/neglect/exploitation at the facility.Interview on 12/04/25 at 1:56 p.m. with CNA/MA/Staffing coordinator revealed that she had been in-serviced on Abuse/Neglect and assistance with mobility this week. She was aware of where to locate a resident's care needs in his/her care plan/Kardex, and she stated she would notify the nurse if there was conflicting information. She reported she had been in-serviced on abuse/neglect/exploitation. She provided various types/examples of abuse/neglect/exploitation. She reported the Administrator was the Abuse Coordinator. She verbalized facility policies and procedures, including the steps she would take, related to the prevention and response of abuse/neglect/exploitation. She denied being aware of any abuse/neglect/exploitation at the facility.An interview 12/03/25 at 1:44 p.m. with LVN C revealed she had been in serviced on Abuse/Neglect and mobility assistance this week. She stated it was the responsibility of all the staff to follow residents' care plan for their care. She reported she had been in-serviced on abuse/neglect/exploitation. She provided various types/examples of abuse/neglect/exploitation. She reported the Administrator was the Abuse Coordinator. She verbalized facility policies and procedures, including the steps she would take, related to the prevention and response of abuse/neglect/exploitation. She denied being aware of any abuse/neglect/exploitation at the facility.An interview on 12/04/25 at 1:41 p.m. with LVN I revealed he had been in serviced on Abuse/Neglect and mobility assistance this week. He stated it was the responsibility of all the staff to follow residents' care plan for their care. He reported that he had been in-serviced on abuse/neglect/exploitation. He provided various types/examples of abuse/neglect/exploitation. He reported the Administrator was the Abuse Coordinator. He verbalized facility policies and procedures, including the steps he would take, related to the prevention and response of abuse/neglect/exploitation. He denied being aware of any abuse/neglect/exploitation at the facility.An interview on 12/03/25 at 1:44 p.m. with LVN C revealed she had been in serviced on Abuse/Neglect and mobility assistance this week. She stated it was the responsibility of all the staff to follow residents' care plan for their care. She reported she had been in-serviced on abuse/neglect/exploitation. She provided various types/examples of abuse/neglect/exploitation. She reported the Administrator was the Abuse Coordinator. She verbalized facility policies and procedures, including the steps she would take, related to the prevention and response of abuse/neglect/exploitation. She denied being aware of any abuse/neglect/exploitation at the facility.An interview on 12/04/25 at 1:51 p.m. with LVN P revealed she had been in serviced on Abuse/Neglect and mobility assistance this week. She stated it was the responsibility of all the staff to follow residents' care plan for their care. She reported she had been in-serviced on abuse/neglect/exploitation. She provided various types/examples of abuse/neglect/exploitation. She reported the Administrator was the Abuse Coordinator. She verbalized facility policies and procedures, including the steps she would take, related to the prevention and response of abuse/neglect/exploitation. She denied being aware of any abuse/neglect/exploitation at the facility.A record review of in-services titled abuse/neglect/exploitation dated 12/03/25 and conducted by the DON showed all employees had signed the documentation.Record review of facility policy titled Abuse and neglect-Clinical Protocol revised October 15, 20222 revealed The facility will ensure that each resident has the right to be free from, among things, physical or mental abuse.A record review of CNA A's Perineal Care/Incontinent Care Competency dated 06/25/25 reflected that all observation points were marked as satisfactory.Review of facility policy titled Perineal Care revised in October 2010 revealed .Preparation: 1. Review the resident's care plan to assess for any special needs of the resident.A review of the facility's Fall Prevention Program policy, revised in November 2024, revealed Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.The Immediate Jeopardy (IJ) was identified on 12/05/2024 at 09:50 a.m. The IJ Immediate Jeopardy template was provided to the ADM on 12/05/25 at 12:33 p.m.Record review of the Plan of Removal dated 12/06/2025 reflected: C.N.A. A in-serviced w/ 1: 1 on 11/13/25 by DON on resident positioning, bed mobility, using draw sheet and get assistance when needed. Review of the in-service sheet dated 11/13/25 revealed CNA A was in serviced by the DON on resident positioning, bed mobility, using the draw sheet and get assistance as needed. Phone interview with CNA A on 12/03/25 at 12:42 PM revealed she was in serviced by the DON. C.N.A. A has not worked since 11/13/25 d/t PRN status. Employee is not available and has been terminated on 12/5/25. Review of the personnel action form dated 12/05/25 revealed the CNA A was terminated. Interview with DON on 12/05/25 at 3:30 pm revealed CNA A has not worked since 11/13/25. The DON stated CNA A was as needed staff. All staff were in-serviced on Abuse/ Neglect/ Exploitation, Incidents/ Accidents and how to safely care for dependent residents on 12/3/25-12/4/25. Completed by ADON who was instructed/ trained by Compliance Nurse. Review of the in-service sheet dated 12/03/25 revealed staff were in serviced ANE, incident/accident and how to safely care, add the Hoyer lift.All residents have the potential to be affected by this alleged practice.DON/ ADMIN in-serviced on Abuse, Neglect, Incidents and Investigating to include immediate suspension of employee accused of abuse/ neglect verbally on 12/3/25 and written on 12/5/25. Completed by Compliance Nurse. Review of the in-service record dated 12/05/25 revealed the DON/Administrator were in serviced on abuse/neglect and accident incident investigation and reporting to HHSC by the Compliance Nurse. 100% Audit completed to review plan of care, Kardex and care profile on residents who are dependent assistance 12/3/25 & 12/4/25. Completed by DON/ ADON or designee with Compliance nurse oversight. Review of the Residents care plan/Kardex audit done on 12/03/25 revealed no concernsCare guides were reviewed for compliance and accuracy on 12/3/25 & 12/4/25. Completed by DON/ ADON or designee with Compliance nurse oversight. Review of care guides revealed no concerns.Nursing staff was in-serviced on guidance for accessing Kardex, care plans and how to safely care for residents with positioning and incontinent care on 12/3/25 & 12/4/25. Completed by DON/ ADON/ designee. Weekend supervisor trained to monitor incidents/ accidents on weekends and immediately report any issues identified to Administrator / DON immediately by DON on 12/5/25.Reviewed all incidents and no other instances of abuse or neglect were noted from the audit. Completed by DON/Admin on 12/3/25 & 12/4/25. Review of in-service sheet dated 12/03/25 and 12/05/25 revealed nursing staff were in serviced on guidance of abuse/neglect prevention, accident and incident investigation/reporting.Reviewed all incidents and no other instances of abuse or neglect were noted from the audit. Completed by DON/Admin on 12/3/25 & 12/4/25. Review of incident reports from September 2025-November 2025 revealed no other instances of abuse or neglect. Incident occurred 11/13/25 w/ Resident #1 was self-reported via email by DON on 12/5/25. Investigation was initiated on 12/5/2025. The facility self-reported the incident on 12/05/25. Moving forward, all Abuse/Neglect allegations will be reported and investigated per policy. DON and Administrator will ensure the investigation will be completed timely. Administrator oversight provided by Regional [NAME] President of Operations. Interview revealed no employees will be allowed to return to work until they have been in-serviced on the Abuse/ Neglect policy and how to safely care for residents. Nurses will be responsible for ensuring. DON/ ADON/Admin will monitor.Incidents/ Accidents and Complaints will be reviewed daily by DON or designee, weekend supervisor and reported to Administrator immediately for investigation. Clinical review team (Admin, DON, ADON, MDS, Director of Operation) will discuss all incidents and accidents 5 days/ week. Admin/ DON will monitor to ensure compliance.Post plan of removal monitoring on 12/06/25:Observation on 12/06/25 at 09:22 a.m. revealed Resident#1 was sitting in his wheelchair, in the TV area. Resident#1 appeared clean, and stated he was doing fine. He denied having any new falls. Resident#1 did not remember the incident.In interview on 12/06/25 at 10:58 a.m. LVN R stated Abuse was physical, mental, chemical, verbal and Neglect was failing to provide care for a patient. She stated the most recent in-service she received on abuse/neglect and fall prevention was that week. LVN R stated if a resident was dependent on care, she would look at the care profile to find what level of care he/she needed and would call for assistance while providing care. She stated if a resident had a fall, she would immediately assess the resident for pain/injuries, and immediately notify Administrator, DON, doctor and family. She stated she would send the resident out to the ER if needed. She stated resident safety was very important and she would document any incidents so other employees would know what happened and what to do. In interview on 12/06/25 at 11:10 a.m. LVN S stated the different types of abuse were physical, verbal, sexual, emotional, and Neglect was not doing something needed for a patient in a timely manner. She stated she would check on the resident care profile every day to ensure what level of care they needed. She stated she would call for assistance if a resident needed 2/3 person assist with incontinent care/transfers. She stated all the nurses had access to this information and the most recent in service she received on abuse, neglect, and how to safely care for dependent residents was that week. She stated if a resident had a fall, she would immediately notify the DON, Abuse coordinator, she would assess the resident for injuries/pain, she would notify the doctor, family, and send out to the hospital if needed. She stated she would document the incident in the progress note.In interview on 12/06/25 at 11:23 a.m. the Weekend Supervisor-RN stated abuse was physical, mental, chemical, verbal and Neglect was failing to provide care for a patient. She stated the most recent in-service she received on abuse/neglect, fall prevention was that week. She stated if a resident was dependent on care, she would look at the care profile to find what level of care he/she needed and would call for assistance while providing care. She stated if a resident had a fall, she would immediately assess the resident for pain/injuries, and immediately notify Administrator, DON, doctor and family. She stated she would send the resident out to the ER if needed. She stated resident safety was very important and she would document any incidents so other employees would know what happened and what to do. She stated she will review risk management every shift, ask the nurses of any falls, injuries, or incidents, and make sure all incidents are reported and documented. Interview on 12/06/25 at 11:44 a.m. CNA M stated forms of abuse were physical, mental, verbal, and Neglect was not providing bathing or feeding. She stated she would review resident's POC on Kardex to find what level of care that residents need during incontinent care/transfers, showers and seek assistance from other employees. She stated if a resident had a fall, she would immediately notify the charge nurse, DON, Administrator and assist them. She stated she received in services on abuse and neglect, and how to safely care for dependent residents that week. She stated she would document in POC of any incidents. Interview on 12/06/25 at 11:48 a.m. CMA F stated forms of abuse were physical, mental, verbal, and Neglect was not providing bathing or feeding. She stated she would review residents' PO

Based on observation, interview and record review, the facility failed to ensure the residents received adequate supervision and assistance to prevent accidents and hazards for 1 of 6 ( Resident #1) reviewed for accidents and hazards. CNA A failed to have another staff member help her with care, and as a result, the resident rolled out of bed and sustained a laceration on the forehead. This failure could place resident at risks for accidents and injuries. A review of the MDS quarterly assessment dated [DATE] reflected Resident#1 was a [AGE] year-old male admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses including cerebrovascular accident (a medical emergency where blood flow to the brain is suddenly interrupted, causing brain cells to die from lack of oxygen, leading to potential disability or death), non-Alzheimer's dementia (forms of cognitive decline not caused by Alzheimer's disease), Parkinson's Disease (a progressive neurological disorder where brain cells producing dopamine die, leading to movement issues like tremors, stiffness, slow movement, and balance problems, alongside non-motor symptoms such as sleep issues, depression, and cognitive changes), dysphasia (difficulty swallowing food or liquids), and muscle weakness. No BIMS score was documented, and section C100-Cognitive Skills for Daily Decision Making was coded at (2) indicating moderate cognitive impairment. Section GG, which reflects functional abilities, indicated that Resident #1 was dependent, and required two-person assistance for showers, toileting, hygiene, and bed transfers.Review of the care plan dated 10/28/25 reflected that Resident #1 required two-person assistance for bed mobility, transfers and ADLs.Review of facility accident/incident report for the month of November 2025 revealed Witnessed Fall Incident [Resident#1] 11/13/2025 at 10:00 AM.Record review of the Witnessed Fall report by LVN B dated 11/13/25 10: 00 a.m. revealed 10:00 AM Received report that resident had a fall. Nurse responded to room and observed the resident on the floor lying on his left side. Nurse observed active bleeding to the left temporal area. Resident alert upon assessment with no loss of consciousness, pressure applied to site with a clean towel. 117/62, P 88, 97.4 RR 18 CNA A was witness to the incident stated while getting the resident dressed for the day, she turned the resident on his side and that was when the resident accidentally rolled off the bed. NP, DON, and Resident#1 RP notified. 911 notified Resident#1 transferred to Hospital. Resident#1 description: Resident#1 unable to give description.Record review of Witnessed Fall IDT meeting dated 11/17/25 note by DON revealed IDT met to review resident fall. Resident#1 was in bed and CNA A was assisting with getting him dressed and rolled him over and he somehow ended up falling off the bed sustained a fall with a laceration to his head. During investigation of the fall IDT determined that Resident#1 call light was within reach, CNA A was in the room with Resident#1 and resident failed to grab the rail and rolled off the bed. IDT determined that Resident#1 needed scoop mattress in place. Resident#1 is currently on therapy services, therapy plan of care updated to focus on strength and balance to prevent falls. Education was also given to the CNA A.Review of hospital records dated 11/13/25 for Resident#1 revealed Physical exam. 2 cm V shaped Laceration to left temporal region, superficial 1 cm laceration amenable to glue on scalp. date/time: 11/13/2025 2:38 p.m.location: forehead. Laceration length: 2 cm. Anesthesia: Local infiltration: Lidocaine 1% without epinephrine.wound skin closure material used: 5-0 fast gut x 4 (5-0 fast absorbing gut is a Monofilament, collagen-based, absorbable suture designed for rapid absorption (21-42 days) and 5-7 days of tensile strength). Number of sutures: 4.Procedure described (general) as Laceration repair.location: scalp. Laceration length: 1 cm .skin closure: glue. Repair type: simple.Record review revealed Resident#1 returned to the facility on [DATE] after the visit to ER with a left forehead dressing.In an interview on 12/03/25 at 12:24 p.m. over the phone, CNA A stated that on 11/13/25 she had been providing incontinent care to Resident #1. She stated that while turning Resident #1 on to his left side, Resident#1 rolled off the bed, hitting his head on the floor with active bleeding. CNA A reported that she immediately called for help. LVN B assessed Resident #1 and found out he sustain injury with active bleeding to his left forehead. She stated Resident#1 was sent to the hospital. CNA A stated she had been assigned to Resident#1 for a long time and was not aware that Resident #1 was a two-person assist. She explained that she had always provided care for him alone. CNA A stated she was supposed to check the Kardex (a vital, often summarized, patient care tool for nurses) in the electronic medical record system to know the level of assistance each resident required. She stated, she overlooked Resident#1's level of assistance. CNA A stated the DON did a one-to-one education with her the same day after the incident. In interview on 12/04/25 at 12:25 p.m. LVN B stated she was called to Resident#1's room by CNA A. She stated CNA A told her Resident#1 rolled off the bed when CNA A turned him to his left side and he ended up in the floor. LVN B stated Resident#1 sustained an injury to his left head with active bleeding. LVN B stated she got help from LVN C who came in and applied pressure on Resident#1 left forehead injury. LVN B stated he was alert and awake. LVN B stated she called 911 and sent Resident#1 to the ER, because of the injury and active bleeding. LVN B stated she notified Resident#1's PR, the DON, and MD. LVN B stated CNA A was performing incontinent care for Resident#1 by herself. LVN B stated CNA A did not request help. LVN B stated she knew from the care plan that Resident#1 required 2 persons assist for turning in the bed. LVN B stated since Resident#1 required mechanical lift transfer from the bed to wheelchair the CNAs working with him were supposed to request help. LVN B stated CNA A worked that Hall all the time, and she knew not to Resident#1 care/bed mobility by herself. LVN B stated the risk of not following the care plan/Kardex for residents' care was falls, and injury. In interview on 12/04/25 at 2:46 PM the ADON stated she had just started in the facility when the incident happened. She stated she was informed about what happened, and that Resident#1 had a fall. She stated it was the responsibility of the CNAs to check the Kardex for residents' level of assistance. She stated it was also the responsibility of the nurses in charge of each Hall to let the CNAs know if there were changes if residents had a decline. ADON stated the CNAs were supposed to get reports on the residents at the start of each shift. The ADON stated her expectation in this case was for CNA A to call another person to help her. ADON stated the risk for residents was falling, and injury. abuse/neglect/exploitation. In interview on 12/04/25 at 2:03 p.m. the DON stated, she interviewed CNA A involved in the incident and LVN B who responded to CNA A's call after the fall, who was assigned to Resident#1. She stated CNA A rolled Resident#1 over and he kept rolling and ended up in the floor. The DON stated she did not ask CNA A if she knew how many persons assist Resident#1 needed for his incontinent care/mobility in the bed. The DON stated she did not ask CNA A if she checked the Kardex. She did not fully investigate the incident because the DON thought Resident#1 required one person assist since his admission. The DON stated Resident#1 had been living in the facility for six to seven years. She stated Resident#1 had declined but was still able to grab the side rail and help. The DON stated the Kardex stated two persons assist, and she learned that after the incident. She stated she educated the CNAs to check the Kardex daily for residents' level of assistance. She stated she was expecting CNA A to have a second person with her. She stated CNA A caused an injury to Resident#1, because she did not follow the facility policy. In a follow up interview with the DON on 12/05/25 at 3:30 PM she stated CNA A was as needed staff. DON stated CNA A finished her shift on the day of the incident on 11/13/25 she did not come back to work since that date (11/13/2025). In an interview with the Administrator on 12/04/25 at 2:19 p.m., the Adm. stated, she learned that Resident#1 had a fall when CNA A was providing care for him that day (11/13/25), and he ended up being sent to the hospital. She stated that the DON reported it to her. She stated she did not do any investigation, other than what the DON did. She stated she did not interview the staff to know how Resident#1 sustained the fall. She stated from her understanding it was an accident, CNA A knew Resident#1's routine, and he never had any incident. She stated Resident#1 was all the time a 1 person assist not 2 persons assist for positioning/turning in bed and there was a typo in his care plan, because sometimes it stated 1-2 person assist. She stated CNA A not checking the Kardex daily for Resident#1's care level was an oversight on CNA A's part. The Adm. stated her expectations were that the staff should look in the care plan, and Kardex to know what care level was needed for the residents. She stated without checking the care plan or the Kardex the staff would not know the appropriate care to provide for the residents, and that could be a potential neglect. She stated it was the responsibility of the charge nurses in the Hall to rely to CNAs the care level for the residents and make sure they were following residents' care plan instruction. She stated the risk to residents was falls and injury. A record review of in-services titled abuse/neglect/exploitation dated 12/03/25 and conducted by the DON showed all employees had signed the documentation.Record review of facility policy titled Abuse and neglect-Clinical Protocol revised October 15, 20222 revealed The facility will ensure that each resident has the right to be free from, among things, physical or mental abuse.A record review of CNA A's Perineal Care/Incontinent Care Competency dated 06/25/25 reflected that all observation points were marked as satisfactory.Review of facility policy titled Perineal Care revised in October 2010 revealed .Preparation: 1. Review the resident's care plan to assess for any special needs of the resident.A review of the facility's Fall Prevention Program policy, revised in November 2024, revealed Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.Record review of the Plan of Removal dated 12/06/2025 reflected: C.N.A. A in-serviced w/ 1: 1 on 11/13/25 by DON on resident positioning, bed mobility, using draw sheet and get assistance when needed. Review of the in-service sheet dated 11/13/25 revealed CNA A was in serviced by the DON on resident positioning, bed mobility, using the draw sheet and get assistance as needed. Phone interview with CNA A on 12/03/25 at 12:42 PM revealed she was in serviced by the DON. C.N.A. A has not worked since 11/13/25 d/t PRN status. Employee is not available and has been terminated on 12/5/25. Review of the personnel action form dated 12/05/25 revealed the CNA A was terminated. Interview with DON on 12/05/25 at 3:30 pm revealed CNA A has not worked since 11/13/25. The DON stated CNA A was as needed staff. All staff were in-serviced on Abuse/ Neglect/ Exploitation, Incidents/ Accidents and how to safely care for dependent residents on 12/3/25-12/4/25. Completed by ADON who was instructed/ trained by Compliance Nurse. Review of the in-service sheet dated 12/03/25 revealed staff were in serviced ANE, incident/accident and how to safely care, add the Hoyer lift.All residents have the potential to be affected by this alleged practice.DON/ ADMIN in-serviced on Abuse, Neglect, Incidents and Investigating to include immediate suspension of employee accused of abuse/ neglect verbally on 12/3/25 and written on 12/5/25. Completed by Compliance Nurse. Review of the in-service record dated 12/05/25 revealed the DON/Administrator were in serviced on abuse/neglect and accident incident investigation and reporting to HHSC by the Compliance Nurse. 100% Audit completed to review plan of care, Kardex and care profile on residents who are dependent assistance 12/3/25 & 12/4/25. Completed by DON/ ADON or designee with Compliance nurse oversight. Review of the Residents care plan/Kardex audit done on 12/03/25 revealed no concernsCare guides were reviewed for compliance and accuracy on 12/3/25 & 12/4/25. Completed by DON/ ADON or designee with Compliance nurse oversight. Review of care guides revealed no concerns.Nursing staff was in-serviced on guidance for accessing Kardex, care plans and how to safely care for residents with positioning and incontinent care on 12/3/25 & 12/4/25. Completed by DON/ ADON/ designee. Weekend supervisor trained to monitor incidents/ accidents on weekends and immediately report any issues identified to Administrator / DON immediately by DON on 12/5/25.Reviewed all incidents and no other instances of abuse or neglect were noted from the audit. Completed by DON/Admin on 12/3/25 & 12/4/25. Review of in-service sheet dated 12/03/25 and 12/05/25 revealed nursing staff were in serviced on guidance of abuse/neglect prevention, accident and incident investigation/reporting.Reviewed all incidents and no other instances of abuse or neglect were noted from the audit. Completed by DON/Admin on 12/3/25 & 12/4/25. Review of incident reports from September 2025-November 2025 revealed no other instances of abuse or neglect. Incident occurred 11/13/25 w/ Resident #1 was self-reported via email by DON on 12/5/25. Investigation was initiated on 12/5/2025. The facility self-reported the incident on 12/05/25. Moving forward, all Abuse/Neglect allegations will be reported and investigated per policy. DON and Administrator will ensure the investigation will be completed timely. Administrator oversight provided by Regional [NAME] President of Operations. Interview revealed no employees will be allowed to return to work until they have been in-serviced on the Abuse/ Neglect policy and how to safely care for residents. Nurses will be responsible for ensuring. DON/ ADON/Admin will monitor.Incidents/ Accidents and Complaints will be reviewed daily by DON or designee, weekend supervisor and reported to Administrator immediately for investigation. Clinical review team (Admin, DON, ADON, MDS, Director of Operation) will discuss all incidents and accidents 5 days/ week. Admin/ DON will monitor to ensure compliance.Post plan of removal monitoring on 12/06/25:Observation on 12/06/25 at 09:22 a.m. revealed Resident#1 was sitting in his wheelchair, in the TV area. Resident#1 appeared clean, and stated he was doing fine. He denied having any new falls. Resident#1 did not remember the incident.In interview on 12/06/25 at 10:58 a.m. LVN R stated Abuse was physical, mental, chemical, verbal and Neglect was failing to provide care for a patient. She stated the most recent in-service she received on abuse/neglect and fall prevention was that week. LVN R stated if a resident was dependent on care, she would look at the care profile to find what level of care he/she needed and would call for assistance while providing care. She stated if a resident had a fall, she would immediately assess the resident for pain/injuries, and immediately notify Administrator, DON, doctor and family. She stated she would send the resident out to the ER if needed. She stated resident safety was very important and she would document any incidents so other employees would know what happened and what to do. In interview on 12/06/25 at 11:10 a.m. LVN S stated the different types of abuse were physical, verbal, sexual, emotional, and Neglect was not doing something needed for a patient in a timely manner. She stated she would check on the resident care profile every day to ensure what level of care they needed. She stated she would call for assistance if a resident needed 2/3 person assist with incontinent care/transfers. She stated all the nurses had access to this information and the most recent in service she received on abuse, neglect, and how to safely care for dependent residents was that week. She stated if a resident had a fall, she would immediately notify the DON, Abuse coordinator, she would assess the resident for injuries/pain, she would notify the doctor, family, and send out to the hospital if needed. She stated she would document the incident in the progress note.In interview on 12/06/25 at 11:23 a.m. the Weekend Supervisor-RN stated abuse was physical, mental, chemical, verbal and Neglect was failing to provide care for a patient. She stated the most recent in-service she received on abuse/neglect, fall prevention was that week. She stated if a resident was dependent on care, she would look at the care profile to find what level of care he/she needed and would call for assistance while providing care. She stated if a resident had a fall, she would immediately assess the resident for pain/injuries, and immediately notify Administrator, DON, doctor and family. She stated she would send the resident out to the ER if needed. She stated resident safety was very important and she would document any incidents so other employees would know what happened and what to do. She stated she will review risk management every shift, ask the nurses of any falls, injuries, or incidents, and make sure all incidents are reported and documented. Interview on 12/06/25 at 11:44 a.m. CNA M stated forms of abuse were physical, mental, verbal, and Neglect was not providing bathing or feeding. She stated she would review resident's POC on Kardex to find what level of care that residents need during incontinent care/transfers, showers and seek assistance from other employees. She stated if a resident had a fall, she would immediately notify the charge nurse, DON, Administrator and assist them. She stated she received in services on abuse and neglect, and how to safely care for dependent residents that week. She stated she would document in POC of any incidents. Interview on 12/06/25 at 11:48 a.m. CMA F stated forms of abuse were physical, mental, verbal, and Neglect was not providing bathing or feeding. She stated she would review residents' POC on Kardex to find what level of care that residents need during incontinent care/transfers, showers and seek assistance from other employees. She stated if a resident had a fall, she would immediately notify the charge nurse, DON, Administrator and assist them. She stated she received in services on abuse and neglect, and how to safely care for dependent residents that week. She stated she would document in POC of any incidents.Interview on 12/06/25 at 3:42 p.m. DON stated types of abuse are verbal, sexual, neglect, physical, exploitation, misappropriation, and the abuse coordinator is the administrator. She stated she was in-serviced on neglect 12/3 or 4th by the Compliance Nurse, who is providing oversight. She said neglect should be reported immediately to the administrator. She stated that going forward she will check the care plan which reflected resident was a x2 person assist and she would know it was neglect since it was one staff assisting the resident instead of 2.Interview on 12/06/25 at 4:48 p.m. The Adm. stated neglect is anything unusual including injury of unknown origin or when care isn't provided. She stated clinicals are reviewed daily with IDT which reviews incident reports, falls, weight issues, infection issues, incidents and accidents. She said neglect is when the resident doesn't get the services needed, or if the plan of care is not followed such as the correct number of staff that's not used for transfer. She stated the compliance nurse is providing oversight. She stated the policy states if neglect is identified and brought to her attention, the procedure is to initiate investigation, ensure resident is assessed, notify the physician, ensure family notified, and complete self-report immediately or within a 2-hours timeframe, and in-service on abuse. She stated she was in-serviced on abuse and neglect by the Compliance nurse, verbally on 12/3 and written on 12/5. She stated an investigation re: neglect includes suspend employee (s), ensure the resident is assessed, education with staff, interview potential witnesses, notify family, physician, conduct safe surveys.

Based on observation, interviews, and record review the facility failed to ensure all drugs and biologicals were stored securely for 6 medication carts (MC#1, MC#2, MC#3, MC#4, MC#5, and MC#6) of 6 medication carts observed for medication storage. -The facility failed to lock medication carts #1, # 2, 3, #4, #5, and #6 at the nurses' station on 10/15/25 at 6:10 AM. These failures could place residents at risk of a drug diversion, or ingesting medications not prescribed for them.Findings included: During an observation on 10/15/25 at 6:10 am, medication carts #1, # 2, 3, #4, #5, and #6 were unlocked at the nursing station with drawers facing outward toward the hallways. No staff was present at the nursing station. During an interview on 10/15/25 at 6:22 am, LVN A stated the medication carts should be locked when not in use. LVN A stated she would be back after she counted the medication cart with LVN C. Surveyor asked to speak to LVN A till 10 am, and LVN A did not complete interview. During an interview on 10/15/25 at 6:55 am, LVN C stated the medication cart should be locked when not in use. LVN C stated residents can get into the medication and take the medications. LVN C stated that she did not know why all the medication carts were unlocked at the nursing station. During an interview on 10/15/25 at 8:15 am, CMA D stated all medication carts should be locked when not in use even when the medication carts are at the nursing station. CMA D stated she did not know why the medication carts was open. CMA D stated she had just gotten her keys earlier from overnight staff when surveyor entered the building. During an interview on 10/25/25 at 9:40 am, LVN I stated medication carts needed to be locked and secured when not in use. LVN I stated residents, staff and visitors could be addicted to drugs. During an interview on 10/15/25 at 10:15 am, the Regional Nurse stated no medication carts should be left unlocked when not in use even if the cart was at the nursing station. The Regional Nurse said there was a risk of residents taking medications and drug diversion. The Regional Nurse stated her expectation was for nursing staff to lock the medication carts when not in use. The surveyor did not obtain clarification on who left the medication carts unlocked and unsecured at the nursing station. Record review of facility policy, revised 04/2019 , titled Storage of Medication reflected, The facility stores all drugs and biologicals in a safe, secure, and orderly manner.1. Drugs and biologicals used in the facility are stored in locked compartments.3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.

Based on interviews and record reviews, the facility did not ensure residents who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding for 1 (Resident#1) of 5 residents reviewed. The facility failed to ensure unlicensed/untrained nursing staff did not adjust G-Tube pumps. This failure could place residents at risk of malnutrition.Record review of Resident#1's face sheet, dated 10/24/25 reflected, he was a [AGE] year-old male who was originally admitted on [DATE] and readmitted on [DATE], diagnosed with but not limited to: Hemiplegia, unspecified affecting left nondominant side (a condition where there is weakness or paralysis on the left side of the body, but the specific cause or severity of the weakness is unknown), aphasia (a language disorder that affects a person's ability to communicate), bed confinement status (a medical condition where a patient is unable to get out of bed or move without assistance, often due to injury or illness), moderate protein-calorie malnutrition (moderate protein-calorie malnutrition),unspecified nontraumatic intracerebral hemorrhage in hemisphere (a type of stroke where bleeding occurs within a cerebral hemisphere) and Gastrostomy status (refers to the presence of a surgical opening (gastrostomy) in the stomach that allows for the insertion of a tube for feeding or other purposes). Record review of Resident#1's quarterly MDS, dated [DATE] reflected his BIMS score was 99 which indicated Resident#1. Was unable to complete the interview. Record review of Resident#1's care plan, undated reflected: Resident#1 had a ADL self-care performance deficit r/t impaired balance, Musculoskeletal impairment, stroke with left sided weakness. Resident#1 ADL's needs were met by care staff. Resident#1 interventions included: Resident#1 was totally dependent on 1 care staff for feeding, he is NPO statis, currently received feeding via G-Tube. Record review of Resident #1's progress note, dated 08/17/25 at 12:50 am reflected, CNA reported resident [sic] had vomited. Asked CNA to make sure she had turn feeding tube off and just wash emesis off face and neck and [LVN A] would be there. Written by LVN A at Attempted to speak to LVN A in person on 10/15/25 between 6:22 am to 9:00am During an interview on 10/15/25 at 7:38 a.m., LVN C stated CNAs are not allowed to touch the G-Tube pumps. LVN C stated when a resident needed to be changed or taken off of the G-Tube the charge nurse for the hall was responsible for the pump. During an interview on 10/15/25 at 8:30 a.m., LVN E stated CNAs should not touch the G-Tube pumps. LVN E stated the licensed nurses had been trained on G-Tube policies and procedures. During an interview on 10/25/25 at 9:10 a.m., LVN F stated only the LVNs are supposed to provide care to the G-tube site and pump. During an interview on 10/25/25 at 9:30 a.m., CNA G stated she would press the hold button on the G-Tube pump when she checked and changed the resident every 2 hours. CNA G stated some residents pump automatically started back up after 5 minutes. CNA G stated she had observed the nurse put the G-tube machine on hold and she knew how to do it. CNA G did not know reach nurses. During an interview on 10/25/25 at 9:24 a.m., CNA H stated she would press the hold button on the G-Tube machine to change the residents. CNA H did not know of the risked to the residents. During an interview on 10/25/25 at 9:40 a.m., LVN I stated most CNAs know how to pause the G-Tube pump. LVN I stated he goes behind the CNAs to make sure the pumps are turned back on and working properly. LVN I stated he worked with his CNAs to make sure they know how to operate the G-Tube pump. During an attempted interview on 10/15/2025 at 10:30 am Resident#1 was not able to answer questions. Resident#1looked at surveyor and continued to watch television. Attempted to call LVN A on 10/15/25 at 11:15 am, unable leave voicemail. During an interview on 10/15/25 at 10:15 a.m., the Regional Nurse stated there was not a policy specifically who was responsible for providing service to the G-Tube machine. The Regional Nurse stated only the LVNs should handle the G-Tube machines. The Regional Nurse stated she only expected licensed staff to touch the G-Tube machines. The regional Nurse completed in-service with nursing staff when surveyor addressed the incident with Resident#1 and unlicensed staff adjusting G-Tube. The Regional Nurse stated their was not a specific G-Tube policy that stated who was responsible for adjusting the G-Tube. Record review of in-service training report, dated 10/15/25, titled G-Tube Operation reflected only licensed staff are allowed to adjust or put pumps on hold.

Based on observation, interview and record review the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for one of thirteen (Resident #97) residents reviewed for accidents and supervision. The facility failed to prevent Resident #97's elopement from the facility on 6/12/25 without staff being aware that she had eloped. An Immediate Jeopardy (IJ) situation was identified on 8/13/25. While the IJ was removed on 09/05/25, the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need of corrective systems. This failure could place residents at risk for serious injuries, serious harm and death. Record review of Resident #97's face sheet, dated 8/12/25, reflected an [AGE] year-old female who was admitted on [DATE]. Resident #97 had diagnoses which included dementia (brain disorders that cause a decline in cognitive functions), atrial fibrillation (an irregular heart rate), chronic kidney disease, obstructive and reflux uropathy (urine flow is blocked or flows backward), atherosclerotic heart disease (damage/disease in the heart's major blood vessels), and asthma (a chronic lung condition). Record review of Resident #97's nursing progress notes, dated 6/30/25, reflected Resident #97 was discharged from the facility on 6/30/25.Record review of Resident #97's quarterly Minimum Data Set assessment, dated 12/30/24, reflected Resident #97's BIMS score was 7, which indicated moderate cognitive impairment. Section GG0170 (Mobile Devices) reflected Resident #97 used a wheelchair for mobilizing. Section E (Behavior) reflected behavior was not exhibited for wandering. Record review of Resident #97's quarterly elopement evaluations, dated 2/11/25 and 5/13/25, reflected a score of 2, categorized as low risk for elopement. Record review of Resident #97's care plan, dated 8/12/25, reflected elopement interventions were not documented in the plan of care. Record review of the Provider Investigation Report, dated 6/19/25, reflected on 6/12/25, CNA E went to lunch and was driving down the road the facility was located on, which consisted of one lane each way, at approximately 7:15pm. CNA E noticed an elderly woman walking down the street, when the woman looked up, CNA E realized it was a resident, parked his truck and assisted her back to the facility. The physician and responsible party were notified regarding the incident. Resident was placed on 15-minute checks 6/13/25 until discharge 6/30/25. Resident #97 was discharged on 6/30/25 from the facility. Record review of a google search of the city the facility is located, Monthly Weather/AccuWeather, reflected the temperature was 80 degrees Fahrenheit on 6/12/2025, the date of Resident #97's elopement. During an interview on 8/12/25 at 9:28am, the DON stated she heard a staff member, unsure of the name, talking about the elopement incident on 6/13/25. The DON stated the charge nurse, RN AK , present during the incident, stated she was busy and forgot to report the incident. The DON stated she was unsure when the resident was last seen. The DON stated the exit doors didn't automatically open. The DON stated someone must be let out or the bar on the door was pushed and held for 15 seconds and the door lock released after the alarm sounded. The DON stated she was unsure how the resident left and stated when the alarm sounded, staff should have gone to the door and checked. The DON stated there was a receptionist from 10:00am or 10:30am, Monday-Friday, and left at 6:00pm. The DON stated once the receptionist left, the staff were responsible for watching who entered and exited the facility. An interview and observation on 08/12/2025 at 9:57am with the Maintenance Director revealed exit doors on each hall (100, 200, 200, 400), in both therapy rooms, the dining room, and the front door sounded the alarm when pushed for 15 seconds and the door lock released. Each door, except for the front door, contained signage, Push until alarm sounds, door will release in 15 seconds. Each door required a code to disarm the alarm and exit as an option . It was observed the front door followed the same process but staff at the nursing station accessed a key fob for exit/entry. During an interview on 8/12/25 at 12:20pm, CNA E revealed while sitting in his truck in the facility parking lot during his lunch break at 7:15pm, he observed Resident #97 walking out of the front entrance behind a group of family members. CNA E stated the family members walked to their cars parked in parking spaces in the front of the building while Resident #97 walked past them. CNA E stated Resident #97 was at the edge of the parking lot near the street the facility was located on. CNA E stated he got out of his truck and walked Resident #97 back into the building. During an interview on 8/12/25 at 2:30pm, RN AK revealed she checked Resident #97's vitals upon her return. RN AK stated Resident #97 appeared exhausted and short of breath, so she gave Resident #97 a breathing treatment. RN AK stated she informed the DON of the elopement the next morning because she was busy the day of the incident. RN AK stated the elopement protocol was to notify the DON within 2 hours. RN AK stated she could not remember hearing any door alarms 6/12/25. RN AK stated the last time she saw the resident was around dinner time. RN AK stated she was unaware the resident left. During an interview on 8/12/25 at 3:00pm, CNA AM stated he didn't hear the alarms on the doors the day of the incident. CNA AM stated Resident #97 normally ate in her room and he thought he gave her a dinner tray around 5:00pm. CNA AM stated he was unaware the resident was an elopement risk . During an interview on 8/12/25 at 3:40pm, the Receptionist stated her work schedule was 10:00am-6:30pm, Monday-Friday. The Receptionist stated the key fob to the front door was placed in the 100-hall binder located at the nurse's station after her shift. The receptionist stated there was another Receptionist who worked the same work hours on weekends. During an interview on 8/13/2025 at 10:16am, the Administrator stated the DON informed her the next morning after the elopement (6/12/25) the investigation began. The Administrator stated she was unsure how the resident eloped from the building. The Administrator stated the nurse, unsure of the name, heard the door alarm the day of the incident, but was busy on the hall and by the time she went to the door, there was no one there. The Administrator stated when the receptionist left, there was a key fob located at the nurse's station, which allowed visitors to enter/exit through the front door or a code was entered . The Administrator stated the risk to a resident who eloped could be weather related injuries, traffic challenges, getting hit by a car, being taken by someone or death. The Administrator stated Resident #97 did not exhibit elopement or exit seeking tendencies prior to the incident. The Administrator stated there should have been elopement interventions in the care plan according to policy since the elopement evaluation indicated elopement risk. The Administrator stated since they didn't realize the resident was missing, the emergency elopement process, according to policy, could not be implemented . Record review of the facility's provided policy on Wandering and Elopements, dated 2021, reflected If a resident is missing, initiate the elopement/missing resident emergency procedure.If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety.This was determined to be an Immediate Jeopardy (IJ) on 08/13/25 at 5:26 PM. The Administrator was notified. The Administrator was provided with the IJ template on 08/13/25 at 5:26 PM. The following Plan of Removal submitted by the facility was accepted on 08/14/25 at 10:23 AM:Plan: 1. Inservice staff responding to the access code in re-entering to ensure the door is locked and secured. The DON and ADON in-service staff and Paycom electronic educational platform in-service were pushed out to all staff August 13, 2025. 2. Compliance of Inservice completion is available by electronic review of what staff have completed listed by department and name.3. No employee will be allowed to work without completion of Inservice.4. The alarm company /regional maintenance notified the alarm to assess all doors to ensure they are audible until staff member enters the code to relock and reset alarm 8/13/2025. They will be reprogrammed by 8/14/2025 and this was completed 8/14/2025 @ 9:30am. 5. Maintenance was in-serviced/trained by regional maintenance along with ADM /DON/ADON 8/14/2025 on door alarm and functioning.6. Door alarms will be monitored weekly by maintenance and or Designee. Administrator will check for compliance with random checks monthly x6 months. 7. Any resident identified as an elopement risk will be put in a Risk Binder and placed at the Nursing station and at reception desk at this time no current resident are identified form audit completed 6/12/2025. The DON/ADON completed this August 13, 2025, Re-in serviced all staff on elopement binders and locations on 8/13/2025.8. Key fob is located now in a secure area behind the nursing station 100 drawer staff have been educated and in serviced by ADON and DON on 8/13/2025 that only nursing staff will access after 6:30pm. The Survey Team monitored the current plan of removal as follows:An observation on 8/14/25 at 3:05pm with the Maintenance Director revealed all entry and exit doors, which included the front door, remained audible for 15 seconds until staff members entered the code to relock and reset the door.An observation on 8/14/25 at 3:30pm reflected the elopement binder was located at the nurse's station. Interviews on 8/14/25 with CNA L, CNA O, CNA S, CNA T, CNA P, Housekeeper AN, Housekeeper AO, Housekeeper AP, Housekeeper AM, CMA AI, LVN AA, LVN AC, LVN AE, and LVN AA from the 6:00am-2:00pm shift, CNA M, CNA N, RN AK, CNA O, LVN AD, LVN AB, CNA R, CNA U, LVN AF, CNA V, CMA AJ, CNA H, CMA AG, CNA I, CNA J, CNA N, CNA Q and CNA K, from the 2:00PM-10:00PM shift, CNA AL, CNA F, CNA G, LVN Y, and LVN Z from the 10PM-6AM shift, and the Dietary Manager, Dietary Aide AQ, and [NAME] A revealed if a resident is missing, the charge nurse is notified immediately and instructions are followed to search for the missing resident. When the door alarm sounds, check the door and outside to see if a resident exited, enter the door code to disarm the alarm. Once the receptionist leaves, the key fob for the front door is in the 100-hall binder at the nurse's station and only nurses access it. Residents at risk for elopement are in the elopement binder at the nurse's station. Interviews with the Administration revealed the elopement process involved Code Pink for elopement/missing resident. Code Pink required all staff to come to the nurse's station to find out what resident eloped and where to start looking. The charge nurse would lead the Code Pink and notify the responsible party, the DON, ADON, and Administrator. Maintenance was responsible for checking compliance with door alarms weekly, and the elopement system for looking for missing residents in the event of a missing resident. Record review of the Assessment History dated 6/13/25 for all residents contained elopement evaluations for residents reflected there were no current and newly/admitted residents at risk for elopement. Record review reflected in-services dated 6/13/25 for all staff on elopement and notification and an elopement drill.Record review reflected a Wandering and Elopement video in Paycom was assigned to all staff 8/13/25. A required posttest for all staff, listed by staff name and department, was completed 8/13/25 and 8/14/25. Record review of the Town East Village Weekly Door Inspection dated 6/13/25 reflected door inspections of the front entrance door, the entry door on hall 100, 200, 300, 400, and the entrance doors in the therapy rooms and dining area. Record review reflected in-services on 8/14/25 on door alarm, code and door checks and functioning which included the Maintenance Director, Administrator, DON, and ADON. During the Administrative Review Process, there were identified concerns that the POR did not reflect the facility responses towards the resident who eloped from the facility and the facility response to residents at risk for elopement. The survey team reentered the facility on 8/28/25 at 8:30am. The revised Plan of Removal was submitted by the facility was accepted on 8/28/25 at 2:36pm: Plan: Staff must be immediately in serviced on responding to door alarms and ensuring the access code is re-entered to ensure the door is locked and secured. Inservice for staff on Elopement, Notification and Elopement Drill conducted on 6/13/25. Inservice on Wandering and Elopement conducted on 6/16/25. Elopement Drills in-services conducted on 6/20/25, 7/1/25 and 7/8/25. Inservice of staff responding to the access code in re-entering to ensure the door is locked and secured. DON and ADON in-service staff and Paycom electronic educational platform in-service were pushed out to all staff [DATE]. Compliance of Inservice completion is available by electronic review of what staff have completed listed by dept and name. No employee will be allowed to work without completion of Inservice.The Facility needs to ensure the door alarms remain audible until staff member enters the code to relock and reset the alarm. The alarm company /regional maintenance notified the alarm to assess all doors to ensure they are audible until staff member enters the code to relock and reset alarm 8/13/2025. They will be reprogrammed will 8/14/2025 and this was completed 8/14/2025 @ 9:30 am. Maintenance was in serviced / Trained by regional maintenance along with ADM/DON/ADON 8/14/2025 on door alarm and functioning.Door alarms to be monitored weekly by maintenance and or Designee. Administrator will check for compliance with random checks monthly X6 months. Facility failed to have a system in place to notify staff about residents at risk for elopement. Any resident identified of an Elopement will be put in Risk Binder and placed at Nursing station and at reception desk. Audit completed 8/13/2025 and no current residents identified as an elopement risk. Re-in serviced all staff on elopement binders and locations on 8/13/2025. Resident was assessed on 6/12/25 and placed on q15-minute checks on 6/13/25 when management was informed of the elopement until she discharged on 6/30/25 to a secured unit. Elopement Evaluations for current residents was initiated on 6/13/25 and upon re-admission/new admission. Inservice for nursing staff on Elopement Risk Behaviors for this resident on 6/14/25. Resident was transferred to a secured unit on 6/30/25. No other residents were at risk for elopement.Interviews revealed all staff, without recognizing if a resident is at risk for elopement, have access to a key fob located at the nursing station which grants access for entrance/exit through the front door. The key fob is available at the nursing station after the receptionist leaves at 6:30pm. Key fob is located now in a secure area behind the nursing station 100 drawer staff have been educated and in serviced by ADM and DON on 8/13/2025 that only nursing staff will access after 6:30 pm.The Survey Team monitored the current plan of removal as follows: During an interview on 8/28/25 at 9:30am, the Administrator and DON revealed there were no current residents at risk for elopement. Record review of the sign-in sheet, that contained the date, time, comments, and staff signature, reflected Resident #97 was placed on 15-minute checks on 6/13/25 until discharge on [DATE]. Record review of in-services on Elopement Risk Behaviors for Resident #97 on 6/14/25 reflected it was completed by nursing staff. Record review of in-services on 6/16/25 on Wandering and Elopement was conducted for staff. Record review of elopement drill in-services on 6/20/25, 7/1/25 and 7/8/25 reflected elopement drills and elopement procedures were implemented and followed. Record review of the Assessment History dated 8/12/25 for all residents contained elopement evaluations that reflected there were no current and newly/admitted residents at risk for elopement. Record review of in-services dated 8/13/25 for all staff on elopement/wandering reflected a new code for elopement/missing resident, Code Pink. The in-services reflected Code Pink included, if you hear this, all staff is to come to nurse's station and find out what resident and where to start looking (rooms, closets, showers, offices, rehab, outside building, off the premises until found). Charge nurse should be running it and notifying responsible party, DON/ADON, Administrator.Record review of an invoice from Firetrol Protection Systems dated 8/14/25 reflected entrance doors were reconfigured to constant audible alarm until disabled. Record review of the Assessment History on 8/28/25 for all residents contained elopement evaluations that reflected there were no current and newly/admitted residents at risk for elopement. During the Administrative Review Process, there were identified concerns that the POR did not address how the facility will monitor the doors and front desk after hours, residents' piggybacking behind exiting visitors, monitoring staff after the door alarm sounds, and how staff will account for all residents in the facility. The survey team reentered the facility on 9/4/25 at 9:08am. The revised Plan of Removal was accepted on 9/4/25 at 4:23pm and included the following: Inservice for staff on Elopement, immediate notification of an elopement, and Elopement Drill conducted by ADON on 6/13/25. This education also includes how to respond to door alarms going off: check door, check outside, and conduct a head count to ensure no missing residents. ADON was not present in facility at the time of the incident. ADON was previously educated on elopement procedures upon hire and during elopement drills throughout the year. DON reviewed educational material with ADON prior to staff in-servicing. CNA who located resident was given a one-on-one in-service by DON on immediate notification to charge nurse. Inservice conducted 6/13/25. Employee's last day worked at facility was July 31st, 2025. RN assigned to resident was given one on one in-service by DON on reporting elopement immediately to DON, ADON, or administrator. Inservice conducted 6/13/25. Inservice on Wandering and Elopement conducted on 6/16/25 by administrator. Elopement Drills in-services conducted on 6/20/25, 7/1/25 and 7/8/25 by DON. Quality improvement nurse conducted in-service with management team on elopement policies and procedures 8/1/25. Inservice of staff responding to the access code in re- entered to ensure the door is locked and secured. Initiated by Quality improvement nurse and reviewed content with Administrator and DON. DON in-serviced ADON. DON and ADON in-serviced staff and Paycom electronic educational platform in-service was pushed out to all staff on [DATE]. A Post test was required after completing education to ensure staff competency on door alarms, elopement binder, and key fob. Compliance of Inservice completion is available by electronic review of what staff have completed listed by dept and name. No employee will be allowed to work without completion of Inservice. New employees will receive education on wandering and elopement procedures upon hire.Maintenance was in serviced / Trained by regional maintenance along with ADM/DON/ADON 8/14/2025 on door alarm and functioning.Door alarms to be monitored weekly by maintenance and or Designee. Administrator will check for compliance with random checks monthly X6 months. Facility failed to have a system in place to notify staff about residents at risk for elopement. Any resident identified as an Elopement will be put in Risk Binder and placed at Nursing station and at reception desk. Audit completed 8/13/2025 and no current residents identified as an elopement risk. Re-in serviced all staff on elopement binders and locations on 8/13/2025. Residents will be reviewed in morning IDT meeting daily for new behaviors and elopement risk. If a resident is identified as an elopement risk the elopement binder will be updated. Staff will be notified of changes. The care plan will be updated, which will reflect on the Kardex for nurse and aide communication. Staff are required to view elopement binder at start of their shift to identify if there is a current resident residing in the facility that is an elopement risk. Compliance for staff competency of elopement binder (all staff) and checking binder before the start of their shift (for nursing staff) will be monitored weekly by interviewing/ observing 3 staff members each week. Staff will be selected randomly from all departments and all shifts. Resident was assessed on 6/12/25 and placed on q 15-minute checks on 6/13/25 when management was informed of the elopement until she discharged on 6/30/25 to a secure unit. Elopement Evaluations for current residents were initiated on 6/13/25 and upon re-admission/new admission. Inservice for nursing staff on Elopement Risk Behaviors for this resident on 6/14/25. The resident was transferred to a secured unit on 6/30/25. No other residents were at risk for elopement. A sign was placed on front door to remind visitors not to allow residents to follow them out. Visitors do not utilize other exit doors throughout facility; however, signs are placed on all doors that exit facility. Therapy entrance doors through halls 200 and 300 to remain locked after hours. Elopement drills were conducted weekly after the incident and continue monthly until compliance is achieved, then perform quarterly. These drills include monitoring of staff responding to the door alarms and the missing resident procedures. 8/28/25 Key fob no longer in use at facility. Receptionist and the nurses are required to go to the front door and enter the door code to allow individuals in/out of the door. An observation on 9/4/25 at 9:20am reflected nursing staff inputting a code located near the front entry door for entry for visitors. An observation on 9/4/25 at 12:00pm reflected nursing staff inputting a code located near the front entry door for entry/exit for visitors.An observation on 9/5/25 at 2:30pm revealed the Elopement Risk binder at the nursing station and receptionist desk. The key fob was not observed at the nursing station and receptionist desk. An observation on 9/5/25 at 12:30pm with the Maintenance Director revealed all entry and exit doors (the front door, the entry door on halls 100, 200, 300, 400, therapy room doors (on hall 200 and 300 and dining room doors) remained audible until staff members entered the code to relock and reset the door.An observation on 9/5/25 at 3:00pm reflected a sign on the front entry door, the entry door on halls 100, 200, 300, 400, the therapy room doors (on hall 200 and 300) and dining room doors reflected a reminder to visitors not to allow residents to follow them out. During an interview 9/4/25 at 9:30am, the Administrator and DON were advised the administrative review process revealed the plan of removal did not address how the facility will monitor the doors and front desk after hours, residents' piggybacking behind exiting visitors, monitoring staff after the door alarm sounds, and how staff will account for all residents in the facility. The Administrator stated there were weekly elopement drills for 4 weeks after the incident and once monthly thereafter. The key fob was no longer in use at the facility. The receptionist and nurses were required to go to the front door and enter the door code to allow individuals in/out of the front entry door. There is a sign on the front door for visitors to ensure residents don't follow behind them when exiting. Therapy doors are locked after the last therapists leaves for the day. Interviews on 9/4/25 with CNA T, LVN AA, LVN AC, Housekeeper AR, Housekeeper AP from the 6:00am-2:00pm shift, CNA O, CNA H, and LVN AS from the 2:00PM-10:00PM shift, CNA F, CNA AT, and LVN Z from the 10PM-6AM shift, the Dietary Manager, ADON, Business Office Manager, Receptionist, Director of Rehabilitation and Occupational Therapy Assistant revealed the binder containing residents at risk for elopement is checked at the beginning of every shift. When the door alarm sounds, respond immediately, check outside the facility for possible elopement, notify the charge nurse immediately, key in the code to stop the alarm, check the head count of each resident to ensure all residents were at the facility. The LVNs would notify the DON and Administrator immediately. During an interview 9/4/25 at 12:43pm, the Director of Rehabilitation stated the therapy doors are locked when the last therapist leaves due to patient safety. The Director of Rehabilitation stated the locked therapy doors prevented access to exit therapy doors. During an interview 9/5/25 at 2:00pm, the DON stated she randomly interviewed 2 staff members for compliance for staff competency of elopement binder and checking the binder before the start of their shift.During an interview 9/5/25 at 2:20pm, the Administrator stated part of the agenda at IDT daily morning meetings were discussing residents with behaviors and changes in behavior. The Administrator stated residents with behaviors were discussed in the IDT morning meeting by clinical staff. Record review reflected in services on 6/13/25 for staff on elopement, immediate notification of an elopement, an elopement drill and how to respond to door alarms conducted by ADON. Record review reflected the ADON was previously educated on elopement procedures upon hire and during elopement drills.Record review of the Town East Village Egress Inspections dated 6/3/25, 6/10/25, 6/13/25, 6/17/25, 6/24/25, 7/1/25, 7/8/25, 7/14/25, 7/22/25, 7/24/25, 8/5/25, 8/12/25, 8/19/25, 8/26/25, 9/2/25 reflected door inspections of the front entrance door, the entry door on halls 100, 200, 300, 400, the therapy rooms (on hall 200 and 300) and dining area right and left entrance doors. Record review on 9/5/25 reflected one-on-one in-services conducted by the DON on 6/13/25 with CNA E on immediate notification of elopement to the charge nurse. Record review on 9/5/25 reflected one-on-one in-services conducted by the DON on 6/13/25 with RN AK on reporting elopement immediately to the DON, ADON, or Administrator. Record review reflected in-services on Wandering/Elopement conducted by the Administrator on 6/16/25. Record review reflected in-services conducted by the Quality Improvement Nurse 8/1/25 on elopement policies and procedures. Record review reflected a Wandering and Elopement video in Paycom was assigned to all staff 8/13/25. A required posttest for all staff, listed by staff name and department, was completed 8/13/25 and 8/14/25. Record review of the New Team Member Orientation Agenda for new employees reflected education for new employees on elopement procedures. Record review reflected in-services on 8/13/25 for all staff on elopement/wandering. An Immediate Jeopardy (IJ) situation was identified on 8/13/25. While the IJ was removed on 09/05/25, the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need of corrective systems.

Based on observation, interview and record review the facility failed to ensure each resident bedside, toilet, and bathing facilities were adequately equipped to allow all residents to call for staff assistance through a communication system that would relays the call directly to a staff member or a centralized staff work area for 13 of 24 residents (Resident #56, Resident #6, Resident #57, Resident #5, Resident #8, Resident #79, Resident #36, Resident #78, Resident #65, Resident #50, Resident #38, Resident #53, and Resident #27) reviewed for residents' call system.1-The facility failed on 08/12/2025 to ensure the call light system was accessible to a resident lying on the floor in the shared residents' toilets located inside the residents' rooms . Resident#6. Resident#57. Resident #5. Resident #8. Resident #79. Resident #36. Resident #78. Resident #65. Resident #50. Resident #38. Resident #53. Resident #272-The facility failed to provide a working communication system that was easily at reach and would allow Resident #56 the ability to safely call for staff assistance.This failure could place residents at risk of not having a means of directly contacting caregivers in an emergency or when they needed support for daily living. 1-Observation on 08/12/25 at 10:42 AM revealed resident's shared toilet call light pull string was missing for Resident #50 and Resident #38.Observation on 08/12/25 at 11:19 AM revealed resident's shared toilet call light pull string was missing for Resident #79 and Resident #36.Observation on 08/12/25 at 11:35 AM revealed resident's shared toilet call light pull string was missing for Resident #65Observation on 08/12/25 2:24 PM revealed resident's shared toilet call light pull string was missing for Resident #6 and Resident #57. Observation on 08/12/25 at 02:53 PM revealed resident's shared toilet call light pull string was missing for Resident #78Observation on 08/12/25 3:15 PM revealed resident's shared toilet call light pull string was missing for Resident #5 and Resident #8. Observation on 08/12/25 at 03:29 PM revealed resident's shared toilet call light pull string was missing for Resident #53 and Resident #27.Interview and observation on 08/12/25 at 4:00 PM, the Maintenance Director looked at the call light outlets in the shared residents' toilets located inside the residents' rooms, and stated the call light strings were missing, and the strings needed to be within the reach of a resident who was on the floor. The Maintenance Director stated he would fix them right away. The Maintenance Director stated the risk to residents was the residents could fall and not get help. 2- Record review of Resident #56's quarterly MDS assessment, dated 08/12/25, reflected Resident #56 was an [AGE] year-old female admitted on [DATE]. Her diagnoses included dementia (a general term for a decline in mental ability severe enough to interfere with daily life, affecting memory, thinking, and behavior), weakness, and adult failure to thrive. No BIMS score or functional status was recorded for the Resident.Review of Resident #56's Comprehensive Care Plan date 07/26/25, reflected the following: Focus: [Resident #56] Risk for Falls r/t Dementia, Confusion. Goal: Resident Will Be Free of Falls thru the next review period. Intervention. Assist Resident with ambulation and transfers, utilizing therapy recommendations.An observation on 08/12/25 at 11:07 AM revealed Resident #56 was lying in bed, cleaned, groomed, and covered with a blanket her bed was in the highest position, and the call light button was on the floor behind the bed at the left side. Resident #56 was not able to answer interview questions. Observation/Interview on 08/12/25 at 2:58 PM, CNA X entered Resident# 56's room and located the call light cord and button in the floor. CNA X picked up the call light button and put it within Resident #56's reach. He stated the call light was on the floor, and not next to Resident #56. He stated the problem was she would not be able to call for help, anything could happen to her. CNA X stated if she was incontinent or having an emergency she could not call.Interview with the DON on 8/15/25 at 10:58 AM, revealed the expectation for call light placement was residents should always have the call light within reach, and the call light should be placed on the resident's dominant side. She said the risk to residents of not having their call lights within reach was delayed care. The DON stated call light string missing in the bathroom, anybody, such as the aide and nurses, were supposed to report it to the Maintenance Director to get fixed. The DON stated call light string in the bathrooms supposed to be within the reach of the resident lying in the floor. Interview on 08/15/25 at 1:02 PM, the Administrator stated her expectation was the call light button should always be within residents' reach, clipped to residents' clothes or linen, where they could reach it. She stated the risk the Resident could not calling for help if he/she sustained a fall, and not having their needs meet. She stated the missing call light string in the bathroom should be logged in in the Maintenance log binder and reported to the Maintenance Director and replaced. She stated the risk to resident may not have a way to call if they sustained a full in the bathroom. Review of the facility policy titled Resident Call light System, dated June 2020, revealed, Purpose: The purpose of this procedure is to respond to the resident's requests and needs. Policy Implementation: A call light system (audible and visual) is in place and operative in the facility. This system allows individual residents to access a system that notifies nursing that the resident has a need. Residents can communicate with the Nurse's Station from their room and/or bathing and toileting facilities. General Guidelines: .4. Ensure that the call light is easily reachable by the resident.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen reviewed for food and nutrition services. The facility failed to ensure food items were properly stored in the facility freezer on 08/12/25. These failures could affect residents who received their meals from the facility's kitchen, by placing them at risk for food-borne illness, and food contamination.Findings included: Observation on 8/12/25 at 9:45 AM in the facility freezer revealed 2 big plastic bags of frozen beef patties and 1 big plastic bag of chicken steak fries were left uncovered in opened brown boxes exposing them to frigid air. In an interview on 8/13/25 at 2:00 PM with Dietary Aide B who revealed all food items in the kitchen should be covered appropriately and it was usually the responsibility of the cooks to seal food in the freezer. She added that the risk to residents of not appropriately covering food items was residents could get sick. In an interview 8/14/25 at 3:10 PM with the Dietary Manager who stated that everyone in the kitchen was responsible for food storage, however cooks were ultimately responsible for covering food items in the freezer appropriately. She stated her expectation was all foods should be appropriately covered and sealed. She added the risk to residents of improper food storage that included dating, labeling, and covering food items was possibility of food borne illness in residents and cross contamination of food. She stated as the Dietary Manager she conducted daily rounds and routine checks to ensure proper food storage. In an interview on 08/15/2025 at 9:29 AM with [NAME] A stated everyone in the kitchen including dietary aides, cooks, and managers were responsible for appropriate food storage. She added cooks usually were responsible for food storage in the freezers. She stated all food items in the kitchen especially in the freezer should be appropriately sealed and covered to decrease the risk of food borne illness in residents and prevent cross contamination of foods. Review of the facility's policy titled Food Receiving and Storage revised July 2014, reflected, . Policy Statement: Foods shall be received and stored in a manner that complies with safe food handling practices. 7. All foods stored in the refrigerator or freezer will be covered, labeled and dated ( use by date). Review of the Food and Drug Administration Food Code, dated 2022, reflected, . Food Storage.(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety

Based on observation, interview, and record review, the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 4 (Resident #24, Resident #5 and Resident # 75 and Resident #88) of 18 residents reviewed for ADLs. The facility failed on 08/12/2025 to ensure the following:1. Resident #24 had her fingernails trimmed.2. Resident #5 had her fingernails trimmed.3. Resident #75 had her fingernails cleaned and trimmed.4. Resident #88 had his fingernails cleaned and trimmed. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a decreased quality of life.Findings included: 1-Resident #24Record review of Resident #24's MDS assessment dated [DATE] reflected Resident #24 was a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included MS (multiple sclerosis [a potentially debilitating disease in which the immune system attacks the protective covering of nerve cells (myelin) in the brain and spinal cord]), quadriplegia (paralysis of all four limbs), and heart failure. Resident #24 had a BIMS score of 14, which indicated intact cognition. The MDS functional assessment indicated Resident #24 was dependent on staff for personal hygiene. Record review of Resident #24's Care Plan dated 06/06/25, reflected the following: Focus: [Resident#24] has an ADL self-care performance deficit r/t Activity Intolerance, Confusion, Impaired balance. Goal: the Resident will maintain current level of function in through the review date. Interventions: Personal hygiene.the Resident is totally dependent on 1-2 staff for personal hygiene and oral care. In an observation and interview on 08/12/25 at 11:23 AM Resident #24 was lying in her bed. Resident #24's nails on both hands were approximately 0.6 cm in length extending from the tip of her fingers, and jagged. The nails were discolored tan with black matter underneath. Resident #24 stated she would like her fingernails trimmed and cleaned. In an interview on 08/12/25 at 3:11 PM CNA M looked at Resident #24's fingernails and stated they were dirty and needed to be trimmed. CNA M stated residents' fingernails were supposed to be cleaned on Residents 'shower days and as needed. CNA stated that both CNAs and Nurses were responsible for nailcare. She said that if Resident has diabetes, then nurses trimmed their fingernails. She stated that if nails were long and dirty, residents may be at risk of infection. 2- Resident #5 Record review of Resident #5's Quarterly assessment dated [DATE] reflected Resident #5 was a [AGE] year-old female initially admitted to the facility on [DATE]. Her relevant diagnoses included: Diabetes Mellitus (high blood glucose levels), Dementia (a general term for a decline in mental ability severe enough to interfere with daily life, affecting memory, thinking, and behavior), Muscle weakness, Cerebrovascular accident (occurs when blood flow to the brain is interrupted, causing brain damage), Alzheimer's disease ( progressive neurodegenerative disorder that is the most common form of dementia) and legal blindness. Resident #5 had a BIMS score of 9/15 which indicated Resident #5 had moderate cognitive impairment. The MDS functional assessment indicated Resident #5 needed moderate assistance from staff for personal hygiene. Review of Resident #5's comprehensive care plan revised 10/03/2024 reflected, Focus:[Resident #5] has an ADL self-care performance deficit related to Activity Intolerance, Dementia, Impaired balance. Goal: [Resident #5] will maintain current level of function in through the review date. Intervention: Encourage the [ Resident #5] to discuss feelings about self-care deficit. In an observation and interview on 08/12/2025 at 11:09 AM with Resident #5 revealed she was in her room, lying on her bed. Resident 5's nails on left hands were approximately 0.7 cm in length extending from the tip of her fingers, and jagged. The nails were discolored tan with black matter underneath. Resident #5 stated she would like her fingernails trimmed. In an interview on 08/12/2025 at 12:23 PM with Agency LVN D stated that both CNAs and nurses were responsible for ADL care including nailcare. She stated that if resident was diabetic, nurses would trim resident fingernails. She added risk of long and dirty fingernails was increased risk of infection and possible loss of skin integrity. She stated since she was an Agency nurse, she was not very familiar with all of Resident #5's care needs, adding Resident #5 had visually impairment and needed care with her personal hygiene. In an interview on 08/12/2025 at 3:26 PM with CNA C stated nail care was offered to all residents on shower days and as needed. She stated that CNAs were allowed to cut the residents' nails if they were not diabetic. She also added that not trimming or cleaning fingernails could lead to infections. 3-Resident #75Record review of Resident #75's Face Sheet dated 08/14/2025 reflected she was a [AGE] year old female with an initial admission date of 05/31/2024, diagnoses included Hemiplegia and Hemiparesis following Cerebral Infraction affecting left dominant side (paralysis or weakness on one side of the body resulting from a stroke), Vascular Dementia (reduced blood flow to the brain, leading to problems with thinking, memory, and behavior), Acute Respiratory Failure with Hypoxia (a serious medical condition where the lungs are unable to adequately oxygenate the blood (hypoxia) and maintain normal carbon dioxide levels), Acquired absence of eye (loss of an eye after birth). Record review of Resident #75's MDS assessment dated [DATE] reflected she had a BIMS score of 05 indicated her cognition was severely impaired. Resident #75 needed moderate assistance with tub/shower transfers. Resident #75 required supervision or touching assistance with personal hygiene. Record review of Resident #75's care plan with a revision date of 02/17/2025 reflected she required assistance with her ADLs (eating, toileting, showers, transfer, mobility). Goal; Resident #75 will be clean. Intervention: provide grooming and personal hygiene. Observation on 08/12/2025 at 11:08 AM revealed Resident #75 was lying in her bed; resident was nonverbal due to her declining health. Resident #75 was observed to have long and dirty fingernails up to two inches long on both hands. 4- Resident #88Record review of Resident #88's face sheet dated 08/14/2025 reflected he had an initial admission date of 05/17/2024, diagnoses included Unspecified Dementia (memory loss), Parkinson's disease with dyskinesia with fluctuations (a neurological disorder primarily affects movement, involuntary uncontrollable movements). Record review of Resident #88's MDS assessment dated [DATE] reflected he had a BIMS score of 9, which indicated moderate cognitive impairment. Resident #88 needed substantial/maximal assistance with personal hygiene. Record review of Resident #88's care plan with a revision date of 04/10/2025 reflected he had an ADLS self-care performance deficit related to Dementia, impaired balance. Interventions: Bathing/showering: Check nail length and trim and clean on bath days and as necessary. Observation and interview on 08/12/2025 at 10:34 AM revealed Resident #88 was lying in his bed and he was observed to have long and dirty finger nails up to two inches long on both hands. Resident #88 stated he would like his fingernails to be cleaned and trimmed but the staff had not offered to do it. Interview with LVN AA on 08/14/2025 at 1:45 PM revealed she was the nurse for Resident #75 and #88, she was not aware they had long and dirty fingernails. She stated it was all the nursing staff's responsibility to make sure resident fingernails were clean and trimmed. She stated long unclean fingernails increased the risk of infections and skin tear among residents and she expected all the residents to have their fingernails cleaned and trimmed. She stated she received in service on fingernail care within a month. Interview with CNA M on 08/14/2025 at 01:52 PM revealed she expected all the residents to have their fingernails cleaned and trimmed and it was the nursing staff who were responsible to clean and trim resident fingernails. She stated long dirty fingernails increased the risk of skin tear and infections among residents. She stated she received in service on fingernail care within a month. Interview with CNA N on 08/14/2025 at 02:17 PM revealed all the nurses and aides were responsible to make sure the resident's fingernails were cleaned and trimmed, not doing so would increase the risk of infections and diseases. She stated she received in service on fingernail care within the past month. Interview with RN AK on 08/14/25 at 02:30 PM revealed she expected all the residents to have their fingernails cleaned and trimmed, unless the resident refused it. She stated the nurses were responsible to make sure the resident had clean and trimmed fingernails, noted doing so increased the risk among residents to develop infections and skin tear. She stated she received in service on fingernail care within the past month. Interview with RN AK on 08/14/25 at 02:30 PM revealed she expected all the residents to have their fingernails cleaned and trimmed, unless the resident refused it. She stated the nurses were responsible to make sure the resident had clean and trimmed fingernails, nod doing so increased the risk among residents to develop infections and skin tear. She stated she received in service on fingernail care within the past month. In an interview on 08/15/25 at 10:58 AM, the DON stated nail care should be completed as needed and every time aides washed the residents' hands. The DON stated nails should be observed daily. The DON stated nurses were responsible for trimming the nails of residents who were diabetic, and CNAs could trim other residents' nails. The DON stated she expected CNAs to offer to cut and clean nails if they were long and dirty. The DON stated the ADON, and the DON would do the routine rounds to monitor. The DON stated residents having long and dirty fingernails could be an infection control issue. In an Interview on 08/15/25 at 1:02 PM, the Administrator stated nail care should be completed every day before meal, and after meal, and check the fingernail every day to make sure they are not jugged and trim as needed. She stated the activities staff participated in nails care for the residents. She stated nail care was the responsibility of the clinical care staffs, CNAs and nurses. She stated the risk to residents, they may scratch themselves or someone else or hurt themselves, and development of an infection. Record Review of the facility policy titled Care of Fingernails/Toenails revised October 2010 reflected, Purpose: The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections.

Based on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for three (Resident #34, Resident #96, Resident #97) of thirteen residents reviewed for care plans.The facility failed to develop a care plan for elopement for Resident #97 after the resident eloped on 06/12/25 and remained in the facility until discharge on [DATE].This failure could place residents at risk for not receiving care and services to meet their needs, diminished function of health, and regressions in their overall health. Record review of Resident #97's face sheet, dated 8/12/25, reflected an [AGE] year-old female who was admitted on [DATE]. Resident #97 had diagnoses which included dementia (brain disorders that cause a decline in cognitive functions), atrial fibrillation (an irregular heart rate), chronic kidney disease, obstructive and reflux uropathy (urine flow is blocked or flows backward), atherosclerotic heart disease (damage/disease in the heart's major blood vessels), and asthma (a chronic lung condition). Record review of Resident #97's quarterly Minimum Data Set assessment dated [DATE] reflected the resident's Brief Interview for Mental Status (BIMS) score was 7 which indicated moderate cognitive impairment. Section GG0170 (Mobile Devices reflected the resident used a wheelchair for mobilizing. Section E (Behavior) reflected behavior not exhibited for wandering. Record review of Resident #97's quarterly elopement evaluations dated 2/11/25 and 5/13/25 reflected a score of 2, categorized as low risk of elopement. Record review of the Provider Investigation Report, dated 6/19/25, reflected on 6/12/25, CNA E went to lunch and was driving down the road the facility was located on, which consisted of one lane each way, at approximately 7:15pm. CNA E noticed an elderly woman walking down the street, when the woman looked up, CNA E realized it was a resident, parked his truck and assisted her back to the facility. The physician and responsible party were notified regarding the incident. Resident was placed on 15-minute checks 6/13/25 until discharge 6/30/25. Resident #97 was discharged on 6/30/25 from the facility. Record review of Resident #97's nursing progress notes, dated 6/30/25, reflected Resident #97 was discharged from the facility on 6/30/25.Record review of Resident #97's care plan reviewed 8/12/25 revealed elopement interventions were not addressed in the plan of care. During an interview on 8/15/25 at 1:06pm, the MDS Coordinator stated she reviewed the elopement assessments completed upon admission and quarterly. The MDS Coordinator stated she was unsure why there were not elopement interventions in the care plans of residents at risk for elopement. The MDS Coordinator stated there should have been elopement interventions in the care plan since resident safety was the main concern. During an interview on 8/14/25 at 10:19am, the ADON stated it was her and the DON's responsibility to input elopement interventions in the care plan if the resident was identified at risk for elopement. The ADON stated she does not know why the elopement evaluations were overlooked and interventions were not placed in the care plan. During an interview on 8/15/25 at 11:05am, the DON stated she and the ADON were responsible for ensuring elopement interventions were implemented in the care plan. The DON stated there was not a process in place for reviewing elopement evaluations to determine interventions. The DON stated staff observed resident behaviors and determined elopement risk. The DON stated floor nurses completed elopement evaluations upon admissions and quarterly. The DON stated floor nurses were unaware the results of the elopement evaluation should have been relayed. The DON stated she and the ADON were responsible for relaying residents at risk of elopement to staff. The DON stated it was important to have interventions to reflect the accurate needs of the resident. During an interview on 8/12/25 at 10:16am, the Administrator stated there should have been elopement interventions for residents identified at risk according to policy. The Administrator stated the expectation was that every resident had a care plan with appropriate goals and interventions.Record review of the facility provided policy on Wandering and Elopements dated 2021 reflected If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety.

Based on observations, interviews, and record review the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 2 of 6 Residents (Resident #56, Resident #61) reviewed for respiratory care. 1-The facility failed to ensure Oxygen (O2) in use signage was on Resident #56's, and Resident#61 doorway. This failure could place residents at risk of not receiving appropriate respiratory care. 1-Record review of Resident #56's MDS assessment, dated 08/12/25, reflected Resident #56 was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included dementia (a general term for a decline in mental ability severe enough to interfere with daily life, affecting memory, thinking, and behavior), weakness, coronary artery disease (a condition where the arteries supplying blood to the heart become narrowed or blocked, usually due to plaque buildup [atherosclerosis]), and adult failure to thrive. No BIMS score was recorded for the Resident. Review of Resident #56's Comprehensive Care Plan, date 07/26/25, reflected the following: Focus: [Resident #56] has oxygen therapy r/t Ineffective gas exchange. Goal: [Resident#61] will have no signs/symptoms of poor oxygen absorption through the review date. Intervention: Monitor for signs and symptoms of respiratory distress and report to [physician] as needed. Record review of Resident #56's physician orders, dated 07/26/25, reflected, Oxygen at 3 liter per minute per nasal canula every shift and as needed to maintain oxygen saturation above 98%. Change Oxygen Tubing, and humidifier bottle every night shift every Sunday, every 7 days. Observation on 08/12/25 at 11:07 AM revealed Resident #56 was lying in her bed awake. Observation revealed the oxygen concentrator was running at 3L/min. 2-Record review of Resident #61's quarterly MDS assessment dated [DATE] reflected Resident #61 was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included acute (a sudden, life-threatening condition where the lungs cannot provide enough oxygen to the body or remove enough carbon dioxide, leading to organ dysfunction) and chronic (a gradual, long-term condition where the lungs can't effectively exchange oxygen and carbon dioxide, leading to symptoms like shortness of breath, fatigue, confusion, and a blue tint to the skin) respiratory failure, asthma (a chronic lung condition that causes inflamed and narrowed airways, leading to symptoms like coughing, wheezing, shortness of breath, and chest tightness ), and coronary artery disease (a condition where the arteries supplying blood to the heart become narrowed or blocked, usually due to plaque buildup [atherosclerosis]). Resident #61 had BIMS of 13, which indicated intact cognition. MDS also reflected Resident #61 was on Oxygen therapy. Review of Resident #61's Comprehensive Care Plan, dated 07/23/25, reflected the following: Focus: [Resident #61] has oxygen therapy r/t Ineffective gas exchange. Goal: [Resident#61] will have no signs/symptoms of poor oxygen absorption through the review date. Intervention: Monitor for signs and symptoms of respiratory distress and report to [physician] as needed. Record review of Resident #61's physician orders dated 07/27/25 reflected, Oxygen at 3 liter per minute per nasal canula every shift and as needed to maintain oxygen saturation above 98%. Change Oxygen Tubing and humidifier bottle every night shift every Sunday, every 7 days. Observation on 08/12/25 at 11:11 AM, revealed Resident #61 was sleeping in her bed. Observation revealed the oxygen concentrator was running at 3L/min. In an observation on 08/12/25 at 11:13 AM, both Resident #56 and Resident#61 in bed with oxygen at 3L min nasal canula. Observed that the residents' room doorway did not have signage for No Smoking/Oxygen in use outside the door. In an interview and observation on 08/12/25 at 3:00 PM, RN AK checked both residents (Resident#56, and Resident#61) and stated both Resident were on Oxygen therapy. She stated she did not see the Oxygen in use sign on Resident #56's and Resident #61's room door. She stated every resident on oxygen therapy should have the sign to ensure safety if flammable objects were bought to the room. RN AK stated nurses were responsible for changing nasal cannula tubing on a weekly basis and as needed. In an interview on 08/12/25 10:58 AM, the DON she stated the expectation was for the tubing to be changed on Sundays, and the nurses should check the tubing daily. She stated that the risk of not changing it in a timely manner could lead to infection control lapses and decreased quality of care. For the missing Oxygen signage in front of the room while the oxygen was in use, she stated did not see any risk, because the signage indicates No Smoking/Oxygen in Use, and the facility was designated as a none smoking place. Record review of facility policy titled Oxygen Administration revised 02/2025 reflected, Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration, and infection prevention associated with respiratory therapy tasks.4. No Smoking/Oxygen in Use signs.5. Oxygen cannula and tubing will be changed within 7-10 days or if visibly soiled. Store in a covered device (i.e. plastic bag, kangaroo pouch) between uses .

Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 8 residents (Resident#11, and Resident#70) reviewed for infection control. 1-The facility failed to ensure LVN AE did not carry and use gloves in his uniform pocket while starting the G-tube feeding (gastrostomy tube is a tube that is surgically inserted through the abdominal wall and into the stomach to provide an alternative way to deliver nutrition, fluids, and medications directly to the stomach) for Resident#11 on 08/14/25.2-The facility failed to ensure LVN AA used the required PPE for Resident#70, who was on enhanced barrier precautions due to his Feeding tube while administering him his medication per G-tube feeding on 08/14/25.These failures could place the residents at risk of cross-contamination and development of infection. 1-Record review of Resident #11's quarterly MDS assessment, dated 08/03/25, reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included dementia (a general term for a decline in mental ability severe enough to interfere with daily life, affecting memory, thinking, and behavior), Cerebrovascular accident (a medical emergency that occurs when blood flow to the brain is disrupted, causing brain cells to die), urinary tract infection and aphagia (a medical condition characterized by the inability or refusal to swallow, preventing a person from consuming food or fluids) She had a BIMS score of 10/15 which indicated moderate cognitive impairment. Further review revealed Resident #11 had a feeding tube (A feeding tube is a medical device used to provide nutrition to people who cannot obtain nutrition by mouth, are unable to swallow safely, or need nutritional supplementation).Record review of the Resident #11's care plan, dated 05/19/25, reflected, Focus: [Resident#11] requires tube feeding r/t Dysphagia (is the medical term for difficulty swallowing food or liquids). Goal. The resident will remain free of side effects or complications related to tube feeding through review date. Approach. Provide local care to G-Tube site as ordered and monitor for signs/symptom of infection.In an observation on 08/14/25 at 10:11 AM, Resident#11 lying in bed. LVN AE entered Resident #11's room to change her feeding tube dressing. LVN AE put on own, washed hands, put on clean gloves. LVN AE sanitized bed side table, removed gloves, washed hands, and put on clean gloves from his uniform pocket. LVN AE got the dressing supplies and put them on the bedside table. LVN AE removed the old dressing, cleaned the exit site with a gauze soaked with normal saline. LVN AE removed gloves, washed hands, and put clean gloves from his uniform pocket. LVN AE applied a clean split 4x4 gauze on Resident #11's feeding tube site and taped it with paper tape dated 08/14/2025. LVN AE removed the gown, gloves, washed hands, and exited the room.In interview on 08/14/2025 at 10:25 AM, LVN AE stated he had a hand full of gloves in his pocket, and he used them will taking care of the residents. When asked if he was supposed to have gloves in his pocket he replied, yes, he had them for emergency and if a resident had a cut and he needed to intervene quickly. LVN AE stated there was no difference between gloves in his pocket and the open gloves box. 2-Record review of Resident #70's quarterly MDS assessment dated , 07/07/25, reflected a [AGE] year-old male admitted on [DATE] and readmitted on [DATE]. His diagnoses included hypertension (elevated blood pressure), type 2 diabetic (elevated blood sugar), Cerebrovascular accident (a medical emergency that occurs when blood flow to the brain is disrupted, causing brain cells to die), and aphagia. He had a BIMS score of 14/15 which indicted intact cognition. Further review revealed Resident #70 had a feeding tube (A feeding tube is a medical device used to provide nutrition to people who cannot obtain nutrition by mouth, are unable to swallow safely, or need nutritional supplementation).Record review of the Resident #70's care plan, dated 07/17/25, reflected, Focus: [Resident#70] requires tube feeding r/t Dysphagia. Goal. Resident#70 will be free of aspiration through the review date. Approach. Monitor/document/report any signs/symptoms of: Aspiration fever.Infection at tube site .In an observation on 08/15/25 at 08:02 AM, there was an EBP signage on Resident #70's room door with the reading ENHANCED BARRIER PRECAUTION with the instruction of the PPE (gown, and gloves) use in high contact with the Resident and no PPE supplies outside the Room. LVN AA prepared Resident #70's morning medications using proper hand hygiene and gloves use. LVN AA took the medications to Resident #70's bed side table, washed hands and donned clean gloves, and did not put on a gown. LVN AA gave Resident #70 his medication per feeding tube, no concerns noticed. LVN AA removed gloves, washed hands, and exited the room.In an interview with LVN AA on 08/15/25 at 08:12 AM, she stated residents who had a feeding tube were under enhanced barrier precautions. LVN AA stated she received training on EBP, and she knew she had to wear gown for any high contact care with the residents in EBP. She stated the risk would be spreading germs between residents and staff. In an interview with the DON on 08/15/25 at 10:58 AM, she stated the facility did not have a policy that said not to have gloves in the pocket, but they have the policy that stated to use clean gloves from the box. She further stated the gloves in the staff uniform pocket could not be clean like the one in the box because the staff may have other things (pens, scissors, .etc.) in their pocket with the gloves, and the gloves could become contaminated. The DON stated, per the facility policy, resident's medications administration per G-tube feeding was a form of high contact with the resident in EBP. She further stated staff were trained and required to wear a gown for the resident in EBP for any contact care. She stated the risk was potential spread of infection. Record review of the facility's policy, Enhanced Barrier Precautions Cheat sheet dated May 2024, reflected, Enhanced barrier precautions EBPs - Expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Enhanced-Based Precautions are indicated during.Device care or use: central line, urinary catheter, feeding tube.

Based on observations, interviews, and record review the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 2 residents (Resident #44) reviewed for feeding tubes. The facility failed to ensure Resident #44's hydration bag for the tube feeding pump was labeled and dated. This failure could result in complications of enteral feedings such as receiving incorrect hydration or elevated risk of infection with using the same hydration bag over multiple days. Findings included: Review of Resident #44's Quarterly MDS assessment, dated 7/20/2025, revealed that Resident #44 was a [AGE] year-old male re-admitted to the facility on [DATE]. Relevant diagnoses included Unspecified Dementia (a general term for a decline in mental ability severe enough to interfere with daily life, affecting memory, thinking, and behavior), Dysphagia ( difficulty swallowing solids, liquids, or both ), Gastrostomy status (which is a surgically created opening in the stomach, typically for feeding purposes when a person cannot eat or drink normally), Diabetes mellitus (high blood glucose levels), Hypernatremia (elevated blood sodium levels). Resident #44 had a G-tube (G-tube or feeding tube - a tube inserted through the stomach that brings nutrition directly to the stomach). Resident #44 had a BIMS score of 1 suggesting severe cognitive impairment. Review of Resident #44's comprehensive care plan, dated 07/18/2025, revealed, Focus: [Resident #44] requires tube feeding: Glucerna 1.5 (G-tube formula) at 70 Milliliters per hour, with 45 Milliliters per hour water flush x 22 hours every shift per order, at risk for aspiration. Goal: [Resident#44] will maintain adequate nutritional and hydration status as evidenced by weight stable, no signs or symptoms of malnutrition or dehydration through review. Intervention: [Resident #44] Provide local care to G-tube site as ordered and monitor for signs and symptoms of infection. Review of Resident #44's Physician order dated 4/2/2025 revealed , Glucerna 1.5 at 70 Milliliters per hour with 45 Milliliters per hour water flush x 22 hours every shift. Review of Resident #44's Physician order dated 02/06/2025 revealed, Resident #44 had NPO (nothing by mouth) diet, NPO texture, NPO consistency, for Resident is NPO for everything. In an observation on 08/12/2025 at 10:40 AM, Resident #44 was lying in his bed. Resident #44 had a feeding pump at her bedside that was switched off. The feeding pump had 2 bags hanging. One bag was marked and dated as tube feeding formula and time hung. The second bag had colorless liquid, without a label noting content, date it was hung, or resident's name. In another observation and interview on 08/12/2025 at 10:43 AM, Agency LVN D walked into Resident #44's room. She donned gloves and gown. She checked Resident #44's G-tube residuals (the amount of stomach contents that remain after tube feeding.) She then started Resident #44's feeding pump. She stated she identified the bag with colorless liquid was the hydration bag and stated the bag did not have a label or date on it. She stated G-tube feeds were stopped in the morning to provide rest to the resident and she restarted it now. She stated all G-tube feeding bags should be dated and labeled each time before administering the feeds. She stated the risk of not dating the tube feed bag was an increased risk of infection related to an unknown hung date. In an interview with the ADON on 08/12/2025 at 10:57 AM, revealed her expectation was that nurses should date and label all G-tube feeding supplies including hydration bag on the pump. She stated that risk of not labeling was possibility of infection since it was unknown how long the hydration bag was hanging. In an interview on 08/14/2025 at 9:26 AM, the DON revealed that it was a standard nursing protocol to date and label tube feed formula and hydration bag with its contents, date feedings started, and resident identifier. Her expectation was that all nursing staff follow standard protocols. She stated the charge nurse who initiated the tube feeding for the resident for the day should be dating the hydration bag. She stated that risk of not dating and labeling tube feeding hydration bag was a possibility of the same bag being used for the resident for multiple days and a source of potential infection. She added as the DON, the ADON and herself rounded on all residents on daily basis to ensure quality of care was maintained. In another interview on 08/15/2025 at 2:33 PM, with the DON stated there was no specific policy for dating hydration bag for tube feeding, however, it was clinical expectation per nursing standards that all G-tube feeding supplies including hydration bag should be labeled and dated. Recommendation from American Society for Parenteral and Enteral Nutrition (ASPEN) Safe Practices for Enteral Nutrition Therapy, dated January 2017, Practice Recommendations .Standardize the labels for all Enteral formula containers, bags, or syringes to include who prepared the formula, date/time it was prepared, and date and time it was started.

Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 (Resident #1, Resident#2) of 9 residents reviewed for ADL's. The facility failed to ensure. 1-Resident#1 had his fingernails trimmed and cleaned. 2-Resident #2 had her fingernails trimmed. These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Findings include: Record review of Resident #1's Quarterly MDS assessment dated [DATE] reflected Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with of diagnoses diabetes mellites, hemiplegia or hemiparesis following cerebral infarction (result of disrupted blood flow to the brain due to problems with blood vessels that supply it), and aphasia ( a language disorder that affects the ability to speak) following cerebral infarction. He had a BIMS score of 00/15 indicating he had severe cognitive impairment. Further review revealed he was total dependent for all ADLs. Record review of Resident #1's Comprehensive Care Plan last revised 10/28/24 reflected the following Problem. Resident #1 has an ADL self-care performance deficit r/t hemiplegia impaired balance. Goal. The resident will improve current level of function in through the review date. Intervention. Encourage the resident to participate in the fullest extent Observation/interview on 01/21/25 at 2:49 PM revealed Resident#1 was lying in bed. He was observed to have both hands long fingernails of approximately 0.5 cm. that were dirty . Attempted interview with Resident#1, he could not respond, he had aphasia, and he was able to nod yes or no. He indicated he would like his fingernails trimmed and cleaned. Interview on 01/21/25 at 10:26 AM with CNA C, she looked at Resident#1 fingernail and stated they were dirty and needed to be trimmed. She further stated his fingernails needed good wash, and he could get sick, develop infection, and could also scratch himself. Record review of Resident #2's Quarterly MDS assessment dated [DATE] reflected Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including dementia (neurological conditions that cause a decline in mental abilities that affect daily life), cerebrovascular accident (result of disrupted blood flow to the brain due to problems with blood vessels that supply it) with hemiplegia or hemiparesis. She had a BIMS score of 15/15 indicating she was cognitively intact. She required moderate assistance with personal hygiene. Record review of Resident #2's Comprehensive Care Plan last revised 10/28/24 reflected the following Resident#2 has limited physical mobility r/t stroke and paralysis on the left side. Goal. The resident will remain free of complications related to immobility, including contractures, Skin breakdown .Intervention. Provide supportive care, . as needed. Observation/Interview on 01/21/25 at 9:18 AM revealed Resident #2 was lying in bed. She was observed with long fingernails of approximately 0.7 cm on both hands, with some of them chipped. Her left hand was contracted with a soft hand roll inside her hand. Interviewed with Resident #2, she stated would like her fingernails trimmed. Interview on 01/21/25 at 10:48 AM with CNA D, she looked at Resident#2 fingernail and stated they were long and some of them were chipped and needed to be trimmed. She further stated the risk to the residents they could scratch them self, and development of infection. Interview on 01/21/25 at 10:53 PM with LVN F, he stated both CNAs and LVNs were responsible for nail care. He stated if a resident had diabetes, only nurses were allowed to trim resident's nails. He stated the risk for not performing nailcare was increased risk of infection and skin break down. Interview on 01/21/25 at 1:49 PM with the DON, she stated her expectation was that nail care should be provided every shower day and as needed. She stated that both CNAs and Nurses were responsible for doing nail care on all residents; except Nurses were responsible for nailcare if resident had diagnosis of diabetes. She also stated that as the DON she conducted spot checks and daily rounds for monitoring. The DON stated residents who had dirty fingernails could be an infection control issue. Record Review of the facility policy titled Fingernails/Toenails Care of revised February 2018 reflected, The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections 1. Nail care includes daily cleaning and regular trimming

Based on observation, interview, and record review, the facility failed to ensure the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #2) of 9 residents reviewed for comprehensive care plans. The facility failed to care plan Resident #2 for ADLs. This failure could place residents at risk for possible adverse side effects, adverse consequences, and decreased quality of life. Findings include: Record review of Resident #2's Quarterly MDS assessment dated [DATE] reflected Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of dementia (neurological conditions that cause a decline in mental abilities that affect daily life), cerebrovascular accident (result of disrupted blood flow to the brain due to problems with blood vessels that supply it) with hemiplegia or hemiparesis. She had a BIMS score of 15/15 indicating she was cognitively intact. She was total dependent with personal hygiene and showering ADLs. Record review of Resident #2's Comprehensive Care Plan last revised 10/28/24 reflected the following Resident #2 has limited physical mobility r/t stroke and paralysis on the left side. Goal. The resident will remain free of complications related to immobility, including contractures, Skin breakdown .Intervention. Provide supportive care, . as needed. Further review revealed no indication of ADLs care were documented. Observation/interview on 01/21/25 at 10:39 AM, revealed Resident#2 was lying in bed and had a soft roll measuring six inches in length and two inches wide inside her contracted left hand, no skin issue noticed. Interview with Resident#2 revealed she had a history of stroke with left side paralyzed, and left-hand contraction. She stated they give her the soft hand roll since she was admitted to the facility on [DATE]. Resident#2 further stated the soft hand roll kept her finger from curling inside her hand and hurting her. Interview with the DON on 01/21/25 at 3:10 PM, the DON revealed residents' care plans were completed between herself, and MDS Coordinators. She stated the care plan should be patient centered and reflect the current care needs of the resident to ensure accurate care and resident wishes. In an interview with MDS Coordinator G on 01/21/25 at 2:07 PM, she was asked if Resident #2 had care plans interventions for her ADLs abilities, and her left-hand contraction. After looking, she stated no, none were care planned. MDS Coordinator G stated she was responsible for the care plans. She stated failing to have current and accurate care plans could potentially affect resident care. She stated staff would not know the interventions for the resident, and it could diminish the residents' care. She stated she was not sure how the above areas were missed, but stated she would correct them today. In an interview with MDS Coordinator H over the phone on 01/21/25 at 3:58 PM she stated her job was to assist in certain area of the residents' care plans, like MDS questionnaire, and PASSR. She further stated any care a resident was having should be care planned. Interview with the Administrator on 01/21/25 at 4:29 PM, the Administrator stated all the residents needed their care planned, and it was the responsibility of IDT (interdisciplinary team) , nurses, and therapy services to make sure there was a care plan for all the services rendered to the residents, other ways the residents' needs would not be meet. Review of the facility's policy titled, Care Plans-Comprehensive revised December 2016, reflected, A Comprehensive, person-centered Care Plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident .4. Each resident's Comprehensive person-centered Care Plan will be consistent with the resident's rights to . g. Receive the services and/or items included in the plan of care.

Based on observation, interview, and record review, the facility failed to ensure that residents had physician's orders for the resident's immediate care for 1 (Resident #2) of 9 residents observed for physician orders for ADLS. The facility failed to have a physician order for a soft hand roll for the contracted left hand for Resident #2. These failures could place the residents at risk of not receiving necessary care and services that could result in the worsen condition. Findings included: Record review of Resident#2's Quarterly MDS assessment dated [DATE] reflected Resident#2 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including dementia (neurological conditions that cause a decline in mental abilities that affect daily life), cerebrovascular accident (result of disrupted blood flow to the brain due to problems with blood vessels that supply it) with hemiplegia or hemiparesis. She had a BIMS score of 15/15 indicating she was cognitively intact. Record review of Resident#2's Comprehensive Care Plan last revised 10/28/24 reflected the following Resident#2 has limited physical mobility r/t stroke and paralysis on the left side. Goal. The resident will remain free of complications related to immobility, including contractures, Skin breakdown .Intervention. Provide supportive care, . as needed. Further review reflected no documentation of Resident#2 left hand contraction and care. Review of Resident #2's Physician's Order on 01/21/25 at 11:03 AM reflected no physician orders for the use of a soft hand roll in the Resident#2 left hand. Review of Resident#2 weekly skin assessment titled N Adv-Skin check dated 01/21/2025 revealed no skin issue in Resident#2 left hand. Observation/interview on 01/21/25 at 10:39 AM, revealed Resident#2 was lying in bed and had a soft roll measuring six inches in length and two inches wide inside her contracted left hand, no skin issue noticed. Interview with Resident#2 revealed she had a history of stroke with left side paralyzed, and left-hand contraction. She stated they give her the soft hand roll since she was admitted to the facility on [DATE]. Resident#2 further stated the soft hand roll kept her fingers from curling inside her hand and hurting her. Interview and observation with CNA E on 01/21/25 at 02:58 PM, she stated she knew Resident#2 had a history of stroke, and the soft roll helped with her left-hand contraction, and she stated the Resident#2 could do a lot for herself. CNA E stated nobody told her about Resident#2's soft hand roll, and that Resident #2 told her about it. Interview with RN I on 01/21/25 at 03:02 PM, she stated Resident#2 always had the soft hand roll in her left contracted hand, and she did not know that Resident#2 was supposed to have and MD order for it. RN I stated the risk to resident with no order was that the staff would not know how to use it, and that may affect the resident. Interview with the DON on 01/21/25 at 3:10 PM, the DON stated they give the soft hand roll to Resident#2 to use it for her left contracted hand on admission. The DON stated they did not know that they had to get an order for the soft hand roll. The DON did not answer the question related to the risk to resident, and stated staff know how to use it. Interview with the PT Director on 01/21/25 at 4:22 PM, she stated for the new admission they do an evaluation of the resident and will give them the soft roll if they need it. She further stated she did not know that they needed an MD order for it, and they put an order for splints. She stated when Resident#2 was admitted to the facility there use to be an organization that comes to the facility and handed the soft hand rolls to residents. She did not answer the question related to the risk to resident. Interview with the Administrator on 01/21/25 at 4:29 PM, the Administrator stated it was the responsibility of the nurse to make sure there was an order for Resident#2's hand roll. The Administrator further stated all the staff should know resident needs for contraction and that it was not progressing. The Administrator sated the staff needed the order to make sure the soft hand roll was applied properly. Review of the facility Physician order policy titled Medication and treatment order revised July 2016 revealed Orders for .and treatments will be consistent with principals of safe and effective order writing.

[Based on observations, interviews, and record review the facility failed to ensure the resident has the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 5 residents (Resident #3) reviewed for reasonable accommodation of needs. The facility failed to ensure the call light in resident room used by Resident #3 was always within reach. This failure could place resident at risk of being unable to obtain assistance for activities of daily living or in the event of an emergency. Findings included: Record review of Resident #3's face sheet dated 01/21/2025 reflected she had an original admitted [DATE], she had a diagnosesis of Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non dominant side ( a condition where a person experience paralysis or significant weakness to one side of the body), Neuromuscular dysfunction of bladder (A condition where the nerves controlling the bladder function are damaged, causing incontinence), need for assistance with personal care. Record review of Resident #3's Quarterly MDS dated [DATE] reflected she had a BIMS score of 14 indicating intact cognition, frequently incontinent to urine and bowel and needed substantial/maximal assistance with lying to sitting on the side of the bed, bed to chair. Record Review of Resident #3's Comprehensive Care Plan dated 06/23/2023 revealed she had an ADL selfcare performance deficit related to stroke, resident was totally dependent on 2 staff for repositioning and turning in bed and required mechanical lift with 2 staff assistance for transfers. Observation and interview on 01/21/2025 at 10:02 AM in Resident #3's room revealed she was lying in her scoop mattress. Resident #3 stated she had a stroke, as a result she was bed bound and she could not use her left arm. Resident stated she used call light to seek for assistance, but she could not find her call light at that time. It was observed the call light was not within reach of the resident and was hanging down towards the floor, from the left side of Resident #3's bed. Resident stated some of the employees did not make sure the call light was pinned to her clothes or was within her reach before they left the room. An interview on 01/21/2025 at 10:54 AM with CNA A revealed she was working at the facility as a PRN (as needed) for 5 months. CNA A stated she was working on the 200 hall that day, she received in services on abuse/neglect, call lights and that she always made sure the call light was within the reach of the resident at all times. She stated before she left the room after providing care to a resident, she made sure the call light was either pinned to the resident's cloth or to the bedsheet. CNA A stated not having call light within reach of the resident would lead to several issues: a resident who wanted to use the rest room might try to get up by themselves and fall, injury, dehydration if they did not get enough water to drink, delay in incontinent care which could lead to skin breakdown. She stated it was the responsibility of all the employees who provided care to the resident to ensure the call light was working and always within the reach of the resident before they left the room. She stated she received in service on call lights within the past one month. An interview and observation on 01/21/2025 at 11:14 AM with CNA B revealed she was working at the facility for 2.5 years; she was working on the 400 hall that day and she provided care to Resident #3 that day. She stated she received in service on abuse, neglect, call lights within the past one month. CNA B stated an example for neglect was when an employee not attending to the resident or not providing care in a timely manner. She stated it was important to make sure the resident's call light was working and was within the reach because someone could be in a distress or having an emergency. Someone might be trying to let the staff know that their roommate had a fall and not having the call light within reach could lead to serious consequences such as fall, injury, skin breakdown. She stated she checked on residents at least every two hours and made sure the call light was within reach of the resident before she left the room. CNA B was invited to Resident #3's room, she observed resident #3's call light was not within the resident's reach, and it was hanging towards the floor towards the left side of the bed. CNA B clipped the call light to Resident #3's cloth. CNA B stated she had changed Resident #3's brief that morning 2 hours ago and the resident had her call light within reach at that time. CNA B stated all the staff who provided care to the resident were responsible to ensure her call light was within reach. An interview on 01/21/2025 at 11:27 AM with LVN K revealed she was working at the facility for 3 months. LVN K stated her expectation from all the employees who provided care to a resident to make sure the call light was always within the reach of that resident. She stated not having a call light within reach could increase the risk of falls, injury and skin damage. She stated she and her employees received in service on call light within the past 1 month. An interview on 01/21/2025 at 01:30 PM with the facility DON revealed she was working at the facility for 9 years. She stated the CNA, nurses and all the employees were responsible to make sure the call light was always within the reach of the resident. She sated having a call light within reach was important for a resident to call for assistance whenever they were in need. She stated the risk for residents to not have a call light within reach were pain, fall, injury, hospitalization and sometimes death. An interview with the facility administrator on 01/21/2025 at 04:06 PM revealed she was working at the facility for a year. She stated all the employees were in serviced on call light every month and after each incident. She stated she expected all the employees to make sure the call light was always within the reach of the resident whether the resident was in the bed, wheelchair or in the bathroom. She stated not having a call light within reach could lead to the risk of residents not able to make the employees aware of resident's needs in a timely manner, it could lead to a fall, injury, distress, potential skin issues. Review of the facility policy titled Answering the call light revised in September 2022 revealed The purpose of this procedure is to ensure timely responses to the resident's requests and needs . 5. Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for seven (Residents #7, #22, #17, #24, #16, #5, and #25) of 11 residents reviewed for quality of care. 1. Resident #7 was admitted from the hospital due to a [MEDICAL CONDITION]. The facility was to do PT/INRs daily and resume [MEDICATION NAME] (blood thinning/anticoagulant medication) 2.5 mg, if the resident's INR was less than 2.5 (low). The lab completed a PT/INR test four days after admission and two days later the results were printed. Resident #7's INR was 0.95. Resident #7 was not given [MEDICATION NAME] 2.5 mg and another PT/INR was not conducted until surveyor intervention seven days later. 2. Resident #22 was admitted from the hospital due to [MEDICAL CONDITION] 07/27/11. The facility was to do PT/INR in the morning after his admission and then daily. Also if his INR was lower than 2.2 he was to receive [MEDICATION NAME] 2.5 mg daily. The PT/INR for the day after admission was not done. The MD wrote an order for [REDACTED].< 2.2 (sic)," and then PT/INRs each Monday. Resident #22's INR on 07/29/11 was less than 2.2, but he was not started on [MEDICATION NAME]. PT/INRs were not done on 07/30/11, and 07/31/11. 3. Resident #17 was to receive [MEDICATION NAME] 5 mg daily and PT/INR tests were to be conducted. If the resident's INR was less than 2.0 or greater than 3.2, the staff were to inform the MD. Resident #17's INR was less than 2.0 multiple times. An order was received to administer [MEDICATION NAME] 5 mg and [MEDICATION NAME] 1 mg on 07/14/11 and 07/15/11 and to check the PT/INR in one week. Resident #17 was given [MEDICATION NAME] 1 mg on 07/14/11 and 07/15/11, but not [MEDICATION NAME] 5 mg. The [MEDICATION NAME] 5 mg was put on "hold," with no MD's order to hold it. Resident #17's INR was 07/19/11 was 0.91. On 07/20/11 and 07/21/11, Resident #17 received [MEDICATION NAME] 5 mg and [MEDICATION NAME] 2 mg without a MD's order. On 07/21/11 the resident's INR was 0.88. 4. Resident #24 was receiving [MEDICATION NAME] 2.5 mg daily. There was a MD's order to check the PT/INR every Tuesday and notify the physician if the INR was less than 1.9 or greater than 3.1. A PT/INR test was performed on 07/15/11 and the resident's INR was 1.15. The lab result page was stamped indicating the MD was notified a week later on 07/22/11. Another PT/INR test was completed on 07/21/11, which was a Thursday and the resident's INR was 0.99. This lab result page was also stamped indicating the MD was notified on 07/22/11. Another PT/INR test was performed on 07/28/11 (Thursday) and the resident's INR was 0.97. This lab result page was stamped but not dated. No orders were received adjusting the [MEDICATION NAME] dosage for Resident #24. Another PT/INR was completed on 08/04/11 and the resident's INR was 0.98 and a new order was received on 08/04/11 for [MEDICATION NAME] 3.0 mg on Fridays and Saturdays and [MEDICATION NAME] 2.5 mg on Mondays, Tuesdays, Wednesdays, Thursdays and Sundays. 5. Resident #16 had a TSH level ordered on [DATE]. The test was completed on 08/01/11 with the results being 39.335. The reference range on the lab was 0.360 through 3.740. When the MD was made aware of the results four days later, after surveyor intervention, the MD gave an order to increase the resident's [MEDICATION NAME] and to recheck his TSH level in two weeks. 6. Resident #5's forearm was swollen and discolored. The resident said her nurse was busy that day, when she was asked what her nurse said about her arm. NP D assessed the resident's arm, after surveyor intervention and ordered a stat Doppler study to rule out a blood clot. LVN R said he was told about Resident #5's arm swelling by the night nurse and he said he planned to "watch it." The Doppler results indicated her [MEDICATION NAME] vein was blocked and she was sent to the hospital. 7. Resident #25 said her arm was hurting because she had bad veins. She had a history of [REDACTED]. NP D assessed the resident's arm and ordered a Doppler Study, which was completed a day later and the results were positive for a blood clot. The MD also ordered STAT [MEDICATION NAME] (blood thinning medication), but the resident did not receive her first dose for approximately 24 hours. The facility's emergency medication kit contained [MEDICATION NAME]. An Immediate Jeopardy (IJ) was identified on 08/04/11. While the IJ was lowered on 08/08/11, the facility remained out of compliance at a scope of "pattern" and a severity level of "no actual harm with potential for more than minimal harm that is not immediate jeopardy" because the facility was monitoring the implementation of the Plan of Removal (POR). These failures could affect the 17 residents, who received [MEDICATION NAME], including Residents #7, #22, #17, and #24 by placing them at risk of developing blood clots that can lead to stroke, [MEDICAL CONDITION] embolism (blood clot in the lung),and/or bruising and bleeding. The failure to notify the MD of an abnormal lab result for Resident #16, which indicated the resident's medication needed to be adjusted, could affect the 28 residents,including Resident #16, who resided on Hall 100, by placing them at a risk of delayed treatment. The failures of failing to assess and/or provide services to Residents #5 and #25 could also affect the 28 residents, including Residents #5 and #25, who resided on Hall 100, by placing them at risk of delayed treatment and complications from delayed treatment. Findings included: 1. Resident #7, a [AGE] year-old female resident, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. HOSP PPN dated 07/19/11 reflected she was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. Resident #7's HOSP MD's order dated 07/22/11 at 2:00 PM reflected: "...Dx 1) [MEDICAL CONDITION] (right) LE (lower extremity) weakness. PT INR daily for 3 days. Hold [MEDICATION NAME] restart when INR < 2.5 at 2 mg PEG (percutaneous endoscopic gastrostomy tube) daily. Goal INR 2-2.5" MD's Order dated 07/25/11 reflected: "1. PT/INR daily. Resume [MEDICATION NAME] at 2 mg per peg Q PM when INR < 2.5" Lab report dated 07/26/11 at 11:46 AM reflected INR 0.95. This lab result page reflected, "Printed 07/28/2011 12:43 PM" No other PT/INR results were found for Resident #7. PPN dictated by MD A with "Date of Visit: 07/29/11" reflected, "...Medications: Reviewed in the chart. Labs: Reviewed as available in the chart. Assessment and plan: ... 6. Stroke. Pt is at very high risk for repeated hospitalization s with increased morbidity and mortality. LVN was requested to closely monitor the patient and call if there is any significant change in the patient's condition." Resident #7's MDS assessment dated [DATE] reflected she received Anticoagulant Medication "during the last 7 days or since admission/reentry if less than 7 days." Care Plan for Resident #7 dated 07/29/11 reflected the following: "Problems: Resident is at risk for bleeding related to the use of anticoagulant therapy. Interventions: Meds as ordered. Caregiver: Nursing. Monitor labs and report to MD promptly. Caregiver: Nursing." Resident #7's MAR for July 2011 reflected the following entry dated 07/25/11: "Resume [MEDICATION NAME] to 2 mg per peg Q PM when INR < 2.5." The order was timed for 1700 (5:00 PM) No doses of [MEDICATION NAME] were documented as given during July. Resident #7's MAR for August 2011 did not reflect an entry for [MEDICATION NAME]. PPN dictated by MD M dated 08/01/11 reflected the following: "CC: Acute visit-requested by staff-dysphagia, weakness, back pain, multiple joint pain, [MEDICAL CONDITION], feeding problem, Altered mental status. Lab: Labs reviewed as available on chart. A/P (Assessment/Plan): [MEDICAL CONDITION]-continue therapy until ready for discharge with (family member). LVN told to monitor patient closely and alert providers for any significant changes in condition." Resident #7 was observed on 08/02/11 at 9:38 AM in her room during the initial tour. She was alert, oriented and pleasant. Interview with Resident #7 on 08/03/11 at 11:30 AM revealed she usually stayed in her bed and often did not want to get up. She stated she was still "pretty weak." On 08/04/11 at 11:30 AM, the DON was queried where lab results could be found if they were not on the residents' charts. ADON B checked the computer at that time and printed Resident #7's lab results from her admission orders [REDACTED]. After searching for PT/INR results, related to the order written on 07/25/11, ADON B was unable to find any PT/INR results other than one dated 07/26/11 and stated she would call the lab and inquire whether there were any other results available. On 08/04/11 at 11:56 AM, ADON B stated the INR dated 07/26/11 was the only one done. On 08/04/11 at 2:50 PM ADON C, who identified herself as the ADON assigned to Resident #7's hall, was interviewed regarding laboratory and medication ordering procedures. When queried how she could tell if a lab had been ordered, she stated they could go into the computer under "order history" and the details would be on the order page. She added there was no confirmation page with their current computer system. When queried who made sure the lab tests were ordered, ADON C stated it was the CN's responsibility. When shown the print date on Resident #7's lab result and queried who printed the result, ADON C stated the new system "...just spits labs out" and she did not know who placed the lab result in the chart. ADON C was asked when the MDs were notified of lab results and she stated the MDs, MD's Assistants or NPs were always notified. ADON C pointed out MD A's lab book. (A binder kept at the nurse's station with pockets inside for each room number. Diagnostic test results were to be placed in the folder for each resident according to their room number.) Resident #7's PT/INR results dated 07/26/11 were observed in MD A's lab book. The report reflected "Printed 07/26/2011 11:48 AM" and there were no handwritten notations made on the form to indicate it had been reviewed. ADON C explained if the report printed the day MD A came to the facility, the report was given to her, on other days the report would be given to NP D or whichever MD's Assistant or NP was there. Queried whether there was anyway to know whether any MD had seen the lab, ADON C replied "(MD A) always signs her labs and (MD M) doesn't look into the book, we have to bring it to her." When ADON C was shown the PT/INR result with two separate print dates and queried who may have placed the results in the chart and MD's lab book, she stated she did not know. During the same interview, when queried about Resident #7's MARs and why the [MEDICATION NAME] order did not appear on the August 2011 MAR, ADON C stated the [MEDICATION NAME] entry on the July 2011 MAR "...wasn't actually an order." When queried how Resident #7's situation should have worked as far as the [MEDICATION NAME] order, ADON C stated the nurse should have pulled the result and notified NP D because MD A liked her INR results within a certain range. She added the result would have then gone into the 24 hour report book to communicate to the oncoming nurse. There were no entries found related to Resident #7's lab results. When ADON C was queried about Resident #7 having one PT/INR done, the result not being reported to the MD, and the [MEDICATION NAME] not being given, she explained a STAT PT/INR test had been ordered and the [MEDICATION NAME] 2.5 mg dose was to be resumed and given as soon as available. Interview with NP D on 08/04/11 at 3:33 PM revealed he was not made aware of Resident #7's PT/INR level prior to that day. When asked if he was aware Resident #7 was supposed to be receiving [MEDICATION NAME], NP D replied, "(MD A) and I did find that she had an order to check the PT/INR daily and resume the [MEDICATION NAME] when her INR was less than 2.5." When asked when he found the order, NP D stated the same day the new order was written by MD A (Note: Physician A wrote the order on 07/25/11). When asked how the medical staff would follow-up on the lab results, NP D stated the nurses were supposed to check the labs and when "anything out of the ordinary" was found, they were to bring it to his attention, MD A, or MD M. NP D stated if he had known about her lab result, he would have ensured her [MEDICATION NAME] was started that day. NP D added that part of his job at the facility was to provide in-service training to the staff and stated one of his in-services was related to lab monitoring and when to call the MDs. When queried when the in-service was done, NP D presented his in-service book and provided an In-service Training report dated 05/18/11 with the topic titled, "Laboratory Analysis and Reporting." The in-service content included interpretation of common labs and the importance of reporting labs promptly "to prevent pts labs from declining further." PT/INR monitoring was included in the in-service. NP D stated INRs less than 1.5 or > 4 should be immediately reported to the MD, but the facility's MDs changed it. He stated the MDs decided INRs < 1.5 or > 3 should be immediately reported. Interview with ADON C on 08/04/11 at 4:04 PM revealed the STAT INR result was 0.98. ADON C was removing lab results from the printer and showed the surveyor an example of a lab result printing. She stated she looked at the results and if she noted abnormal lab values or trends she would address it then. She added if the lab result belonged to a resident cared for by another nurse, she would get the result to the proper nurse. The surveyor queried, "So it is every charge nurse's job to check the printer?" ADON C replied, "Yes." When asked if she was able to tell how Resident #7's original order was entered, she looked in the computer and then stated it had been ordered as a one-time lab test rather than daily as ordered. Lab Process document dated 07/20/10 and located in the front of the lab book at the nurse's station reflected the following: "To: Nurses and ADONs. From: (DON). 1. The nurse gets the lab order and places the order in the computer. The yellow slip from all telephone orders goes in the green pocket so the ADONs can check the orders and follow up to make sure they have been carried out. (Orders for labs have to be placed on telephone order so that this process can work and flagged in the chart). 2. Every morning the first ADON to the facility will pull the completed lab results and review for abnormalities. The physician, per protocol for abnormal and critical, will be notified and the results will be placed in the lab books for physician follow up. (The RN supervisor will complete this task on the weekend and follow up by ADONs on Monday). ... 4. The yellow slips of the telephone orders will be brought to the morning stand up meeting so any change of condition can be noted and any labs ordered acknowledged. The ADONs will follow up and make sure the orders are completed and monitor the system daily. Labs will be checked in the system by the ADONs and if they are not there they will immediately enter them and council/re-educate nurse of data entry. An undated Laboratory Communication policy provided by the DON on 08/04/11 reflected, "Procedure: When results of diagnostic tests are received by the facility, the licensed nurse should review the result, assess the resident, review the resident's medical record, and make a decision for immediate or non-immediate notification. If the decision is for non-immediate notification, the licensed nurse should fax the results to __. ... All panic lab values, unless the value is normal for that person, should immediately be relayed (by phone call) to the physician." An IJ was identified on 08/04/11 at 4:55 PM in the area of Quality of Care, and the Administrator and the DON were notified at that time. A POR was requested at that time. An interview on 08/04/11 at 5:48 PM with LVN N, CN who had been assigned to Resident #7, revealed she had seen the order for [MEDICATION NAME] on the MAR for July 2011. When asked why it was not given, LVN N replied, "I never got an INR. Queried whether she ever looked for a lab result, she replied, " I didn't know where to look for an INR, I'm new." When asked how long she had worked at the facility, LVN N replied, "three weeks." When asked if she ever knew to check labs, LVN N stated, "I usually when I came in the nurse would say, 'Here's her labs', I never knew to look." Interview with LVN G, CN for Resident #7, on 08/05/11 at 1:15 PM revealed she had written the [MEDICATION NAME] order on the MAR. When queried about the order, LVN G pointed to the MAR and stated, "I was the one who wrote the FYI (for your information), that wasn't an official order. It was an FYI to alert the second shift. When queried why she thought it was not on the MAR for August 2011, LVN G stated she thought it was because it was not an official order and just an FYI. When queried who was supposed to check the lab reports, LVN G stated the ADONs pulled the labs reports in the morning and gave them to the charge nurses and "...if you had to know something, you pull the lab and check." When queried whether she knew it was supposed to be a daily lab and she had input the order incorrectly as a one time order, LVN G stated "I did not know that." When asked why she thought this was not an "official order," LVN G explained it was because the medication was not supposed to be given until the INR was in range and that was why she put it on the first MAR, to remind the second shift to look for a result. On 08/05/11 at 3:36 PM, LVN J, CN who had been assigned to Resident #7, was interviewed regarding Resident #7's lab and [MEDICATION NAME] orders. When shown the MAR for July 2011 and queried regarding no doses given, LVN J stated, "I was waiting on the INR." When queried whether she ever looked for the lab results, LVN J stated she was unable to get into the computer system as she was new. When queried whether she ever asked anyone else to look, LVN J stated "just the day nurse and I would go back and forth; she never told me the INR was back." When queried whether she had access to the computer at that time, LVN J replied, "No." During an interview on 08/05/11 at 10:55 a.m. MD A was queried if she saw Resident #7's INR lab result dated 07/26/11. She replied, "I don't remember. If I see it it'll have my signature on it." When asked if she would expect to be called for a lab result reflecting an INR value of 0.95, MD A replied, "if they're (resident) is on [MEDICATION NAME] then yes. I have a folder for every hall where labs are kept." MD A reviewed Resident #7's medical record and commented "I don't see [MEDICATION NAME] on her (Resident #7) admission order. It was put on my order on the 25th (July)." The surveyor informed MD A that her progress notes on 07/29/11 and 08/01/11 reflected, "labs reviewed in chart." MD A revealed "when I see a resident I look for labs in the folder." When MD A was asked if she requested labs that were not in the folder she replied "many times I do and they (nursing staff) will print them out." When asked if she reviewed any of Resident #7's labs MD A replied, "I would say that I didn't see it because I always sign them." When asked if she received phone calls from facility staff when a resident's lab report was abnormal, MD A replied, "Most of the time we expect to get a call from staff." When asked if she always received a call from staff when lab reports were abnormal, MD A replied, "yes." When asked if she recalled looking or requesting Resident #7's lab report on 07/29/11, MD A replied, "no." When asked if she typically reviewed her resident's MARs and medications, MD A replied, "Yes, I check if there is a discrepancy." When asked if she recalled increasing a resident's [MEDICATION NAME] dosage and not seeing a predictable change in the resident's PT/INR values, MD A replied, "Yes, but I don't think in this building. In those cases we've had two people (nurses) sign (the MAR) that the med (medication) was given." When asked if there have been cases where abnormal labs have not been reported to her MD A replied, "I'm sure things have come up and that's why we started the folders and then things improved. Before that it was hard to see where labs were going. Now I can track it better." The surveyor informed MD A that Resident #7's lab reports were not reviewed or signed for six days between 07/25/11 and 08/01/11, when the resident was seen by MD M and it was not discovered by facility staff. MD A replied, "I ask them to print them out, sometimes they're busy or sometimes I forget." The facility's POR was accepted on 08/08/11 and reflected the following: all charts audited for residents receiving [MEDICATION NAME] to identify routine lab orders; MD called for routine lab orders for any residents receiving [MEDICATION NAME] without lab orders; all charts audited for PT/INR results as ordered; Lab book initiated for all PT/INR lab orders to be drawn; Lab Tracking would be completed to monitor labs; all nursing staff will be in-serviced on anticoagulants, including s/s of toxicity and labs, in-services would be conducted by NP D; new admissions (readmission) orders would be reviewed by the AN within 72 hours; new admission orders [REDACTED] to the clinical meeting with lab log book; labs would be printed out each day prior to the morning meeting, between 12:00 PM and 2:00 PM and again by 6:00 PM by the ADON and WS; after review of the lab results, the ADON or WS would stamp the lab and notify the MD, resident and/or family; if needed, a new TPO would be obtained; the ADON or WS would communicate verbally to the CN any changes in the MD's orders and complete the PT/INR flow sheets and MARs as indicated. Interview with the DON on 08/06/11 at 1:15 PM revealed new procedures had been put into place and staff were receiving inservice training prior to beginning their shifts. Lab results were set up to print twice per day, at 9:00 AM and 2:00 PM. Chart audits had been completed and ordered lab tests were being documented in a lab binder. All labs were to be signed and dated and all abnormal results were to be called to the MDs. Printed lab results were to be placed directly into the resident's chart after being reviewed and called. PT/INR results were to be documented on the MAR and "Anticoagulation Therapy Monitoring" forms were initiated on all residents receiving anticoagulants. Interviews conducted on 08/06/11 from 1:25 PM through 2:46 PM with LVN G, LVN S, LVN T, LVN J, LVN U, LVN V, and LVN O revealed they had attended the in-service training and they answered the questions regarding the POR appropriately. Interviews conducted on 08/07/11 from 1:47 PM through 2:31 PM with LVN H, RN I, LVN K and LVN L revealed they attended the in-service training and they answered the questions regarding the POR appropriately. 2. A review of the NN dated 07/18/11 at 3:30 p.m. revealed Resident #22 was an [AGE] year-old male, who was initially admitted to the facility from the hospital, following an [MEDICAL CONDITION] suffered on 06/30/11. ANA dated 07/27/11 reflected Resident #22 was alert and oriented to self only and had [MEDICAL CONDITION]. ANA dated 07/27/11 reflected Resident #22 was readmitted to the facility on [DATE] at 1:45 PM after having his feeding tube surgically replaced. TPO dated 07/27/11 reflected, "2. CBC, CMP, TSH, [MEDICATION NAME], Lipid Panel, Mg (Magnesium), PT/INR in AM then daily. Resume [MEDICATION NAME] 2.5 mg via peg tube daily when INR is less than 2.2 ..." The computer generated order sheet dated 07/28/11 for Resident #22 was printed by the DON on 08/08/11. The printout reflected LVN Q entered all the tests into the computer except the order "PT/INR in AM then daily." MD A's Acute visit and initial H&P dated 07/29/11 reflected, "1. Debility noted. Pt. has a guarded prognosis secondary to multiple medical problems... 3. [MEDICAL CONDITION]/[MEDICATION NAME] therapy. Will monitor PT/INR periodically and modify [MEDICATION NAME] dosage if needed. Staff is to call if INR is less than 1.9 or greater than 3.2 or if there are any signs of bleeding. Staff is to check a stat PT and INR. We will restart the [MEDICATION NAME] at 2.5 mg. a day if the INR is less than 2.2. ... 5. Stroke/[MEDICAL CONDITION]/[MEDICAL CONDITION]. Pt is at very high risk for repeated [MEDICAL CONDITION] events. Will continue therapy to achieve maximum possible potential. Pt has an extremely guarded prognosis and is at very high risk for repeated hospitalization s with increased morbidity and mortality. LVN was requested to closely monitor the patient and call if there is any significant change in the patient's condition." A TPO for Resident #22 dated 07/29/11 reflected a STAT PT/INR, resume [MEDICATION NAME] at 2.5 mg at night and daily PT/INRs until INR "< 2.2, then PT/INR q Monday." The order was signed by the MD and a nurse signed the order on 08/01/11. Lab result dated 07/29/11 reflected Resident #22's INR was 1.73. A TPO dated 07/31/11 reflected to resume [MEDICATION NAME] 5 mg daily and check the PT/INR in AM. TPO for Resident #22 dated 08/01/11 reflected, "Check PT/INR q Monday & Thursday & call if INR <1.9 or >3.0. [MEDICATION NAME] 2.5 mg not 5 mg at q HS." Lab results dated 08/01/11 for Resident #22 reflected an INR of 1.03. Lab results dated 08/02/11 for Resident #22 reflected an INR of 1.06. Observation on 08/02/11 at 9:00 AM revealed Resident #22 was awake and sitting up in a specialized wheelchair in his room and a family member was visiting. Lab results dated 08/03/11 for Resident #22 reflected an INR of 1.01. There was no documentation the MD was notified of the low INR results, so the MD could adjust [MEDICATION NAME] dosage if desired. [DIAGNOSES REDACTED]. A TPO for Resident #22 dated 08/04/11 reflected [MEDICATION NAME] 3 mg daily. During an interview on 08/05/11 at 10:55 AM, MD A revealed, "We have issues with labs and we're trying to figure it out so these things don't happen." When asked if she had issues with [MEDICATION NAME] labs previously, MD A replied, "The exact situation happened here last week with (Resident #22). I caught it. I told them (facility staff) to put discharge orders in the front of the chart not the back. If I don't see [MEDICATION NAME] on the admission order, I don't look at the discharge order necessarily." Resident #22 was observed on 08/05/11 at 3:55 PM. He was lying in bed with his feeding tube infusing at 50 cc per hour. ADON C was interviewed on 08/05/11 at 4:10 PM regarding Resident #22's [MEDICATION NAME] therapy. She stated, "Dr. (MD A) came Friday (07/29/11) and realized that Mr.(Resident #22) hadn't been getting [MEDICATION NAME]. She looked at the hospital transfer orders and saw that the [MEDICATION NAME] was discontinued. She also looked and there were no PT/INR lab results in the chart although it had been ordered daily on 07/27/11 when he was readmitted . The doctor then ordered a stat PT/INR on 07/29/11. That was the first one he had since he had come back from the hospital. He should have been started back on [MEDICATION NAME] 2.5 mg. on 07/29/11, but that didn't happen ..." Resident #22 was observed on 08/08/11 at 1:00 PM. He was lying in bed asleep and a family member was visiting. An interview with LVN Q on 08/08/11 at 1:40 PM revealed she was the AN and she put the admission labs in the computer. LVN Q stated she did not usually put in PT/INRs. She stated when she received an admission she went back to ensure the orders were done. LVN Q stated she did not know why the PT/INR order was not in the computer. She stated she probably did not look a the resident's chart. She stated she was not sure. 3. Resident #17's admission orders [REDACTED]. [DIAGNOSES REDACTED]. Resident #17's TPO dated 07/04/11 reflected, "(Check) PT/INR q Tuesday and call if INR < 2.0 or > 3.2." Lab result for Resident #17 dated 07/05/11 reflected INR 0.92. There were no indications the physician had been notified of the results. PPN dated 07/08/11 revealed Resident #17 had a history of [REDACTED]. Resident #17's lab result dated 07/08/11 at 4:05 PM reflected INR 0.86. The lab result reflected "Printed 07/11/2011 8:11 AM." A handwritten note on the lab result reflected, "Pt off [MEDICATION NAME] 2 (secondary to) epistaxis (nosebleed). LE Ultrasound nl will continue 0 (no) [MEDICATION NAME]. (MD W)." Resident #17's July 2011 MAR reflected she was receiving [MEDICATION NAME] 5 mg daily. Resident #17's lab result dated 07/13/11 at 6:25 AM reflected INR 0.89. There was no indication the MD was notified. Resident #17's TPO dated 07/14/11 reflected, "Give [MEDICATION NAME] 1 MG tab tonight and tomorrow and continue with 5 MG 1 tab PO daily. Recheck PT INR in one week." Resident #17's lab result dated 07/19/11 at 9:05 AM reflected INR 0.91. There was no indication the MD was notified. Resident #17's lab result dated 07/21/11 at 9:05 AM reflected INR 0.88. Resident #17's Lab result dated 07/26/11 at 6:20 AM reflected INR 1.47. Resident #17's July 2011 MAR reflected the daily 5 mg dose of [MEDICATION NAME] was held on 07/14/11 and 07/15/11, and Resident #17 received the 1 mg dose of [MEDICATION NAME] on those dates. There was no MD order to hold the routine 5 mg dose of [MEDICATION NAME]. On 07/14/11 and 07/15/11 the resident received only 1 mg of [MEDICATION NAME] instead of the intended 6 mg dose. Resident #17's July 2011 MAR reflected [MEDICATION NAME] 2 mg was administered in addition to the routine 5 mg daily dose of [MEDICATION NAME] on 07/20/11 and 07/21/11. There were no MD orders to administer the extra 2 mg dose of [MEDICATION NAME] on 07/20/11 and 07/21/11. On 08/04/11 at 4:05 PM the surveyor asked the DON for assistance in locating the order, and/or documentation for Resident #17 to receive [MEDICATION NAME] 2 mg on 07/20/11 and 07/21/11. The DON and RNC F stated they did not find an order for [REDACTED].#17's medical record. NP D was interviewed on 08/04/11 at 5:30 PM regarding [MEDICATION NAME] dosages and INR results. He revealed when residents were taking [MEDICATION NAME] and had low INR results, which were not affected by changing the dosage of [MEDICATION NAME], he started to suspect residents might not be receiving [MEDICATION NAME]. He explained residents on a substantial dose of [MEDICATION NAME] would not have the medication dosage adjusted until it was certain the [MEDICATION NAME] was given. NP D stated the facility addressed the problem by having licensed nurses administer [MEDICATION NAME] instead of the MAs. He stated, when that approach failed, the facility initiated the [MEDICATION NAME] count sheets beginning 07/16/11 for Resident #17. NP D stated review of INR results indicated this approach was also ineffective. During this time NP D was not able to find an order for [REDACTED]. An interview on 08/04/11 at 5:50 PM with LVN O revealed the facility created a count sheet system to track when [MEDICATION NAME] was given to residents. LVN O revealed the system was initiated due to resident's PT/INR lab results being "off." She provided the Resident #17's count sheet, which was started on 07/16/11 and it included date, time, the dosage administered and the number of pills remaining. Resident #17's count sheet for [MEDICATION NAME] 5 mg tablets reflected one tablet was signed out daily from 07/16/11 through 08/03/11. 4. Resident #24, an [AGE] year-old male, re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. F309 is continued in F9999 on page 95. .

Based on observation, interview and record review, the facility failed to provide MD ordered drugs to four (Resident #7, #17, #22 and #25) of seven residents reviewed for anticoagulant (blood thinning) therapy. 1. Resident #7 was admitted from the hosp due to a CVA. The facility was to do PT/INRs daily and resume Coumadin (blood thinning/anticoagulant medication) 2.5 mg, if the resident's INR was less than 2.5. The lab completed a PT/INR test four days after admission and two days later the results were printed. Resident #7's INR was 0.95. Resident #7 was not given Coumadin 2.5 mg and another PT/INR was not conducted until surveyor intervention seven days later. 2. Resident #22 was admitted from the hosp due to a CVA on 07/27/11. The facility was to do PT/INR in the morning after his admission and then daily. Also if his INR was lower than 2.2 he was to receive Coumadin 2.5 mg daily. The PT/INR for the day after admission was not done. The MD wrote an order for [REDACTED].< 2.2(sic)," and then PT/INRs each Monday. Resident #22's INR on 07/29/11 was less than 2.2, but he was not started on Coumadin. PT/INRs were not done on 07/30/11, and 07/31/11. 3. Resident #17 was to receive Coumadin 5 mg daily and PT/INR tests were to be conducted. If the resident's INR was less than 2.0 or greater than 3.2, the staff were to inform the MD. Resident #17's INR was less than 2.0 multiple times. An order was received to administer Coumadin 5 mg and Coumadin 1 mg on 07/14/11 and 07/15/11 and to check the PT/INR in one week. Resident #17 was given Coumadin 1 mg on 07/14/11 and 07/15/11, but not Coumadin 5 mg. The Coumadin 5 mg was put on "hold," with no MD's order to hold it. Resident #17's INR was 07/19/11 was 0.91. On 07/20/11 and 07/21/11, Resident #17 received Coumadin 5 mg and Coumadin 2 mg without a MD's order. On 07/21/11 the resident's INR was 0.88. 4. Resident #25 said her arm was hurting because she had bad veins. She had a history of [REDACTED]. NP D assessed the resident's arm and ordered a Doppler Study, which was completed a day later and the results were positive for a blood clot. The MD also ordered STAT Lovenox (blood thinning medication), but the resident did not receive her first dose for approximately 24 hours. The facility's emergency medication kit contained Lovenox. An Immediate Jeopardy (IJ) was identified on 08/04/11. While the IJ was removed on 08/08/11, the facility remained out of compliance at a scope of "pattern" and a severity level of "no actual harm with potential for more than minimal harm that is not immediate jeopardy" because the facility was monitoring the implementation of the Plan of Removal (POR). These failures could affect the 17 residents, who received Coumadin, including Residents #7, #22, #17, and #25 by placing them at risk of developing blood clots that can lead to stroke, pulmonary embolism (blood clot in the lung),and/or bruising and bleeding. Findings included: 1. Resident #7, a [AGE] year-old female resident, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Hosp PPN dated 07/19/11 reflected she was admitted to the hosp on 07/18/11 with a [DIAGNOSES REDACTED]. Resident #7's hosp MD's order dated 07/22/11 at 2:00 PM reflected: "...Dx 1) Acute CVA Rt (right) LE (lower extremity) weakness. PT INR daily for 3 days. Hold Coumadin restart when INR < 2.5 at 2 mg PEG (percutaneous endoscopic gastrostomy tube) daily. Goal INR 2-2.5" MD's Order dated 07/25/11 reflected: "1. PT/INR daily. Resume Coumadin at 2 mg per peg Q PM when INR < 2.5" Lab report dated 07/26/11 at 11:46 AM reflected INR 0.95. This lab result page reflected, "Printed 07/28/2011 12:43 PM" No other PT/INR results were found for Resident #7. PPN dictated by MD A with "Date of Visit: 07/29/11" reflected, "...Medications: Reviewed in the chart. Labs: Reviewed as available in the chart. Assessment and plan: ...6. Stroke. Pt is at very high risk for repeated hospitalization s with increased morbidity and mortality. LVN was requested to closely monitor the patient and call if there is any significant change in the patient's condition." Review of Resident #7's MDS assessment dated [DATE] revealed she received Anticoagulant Medication "during the last 7 days or since admission/reentry if less than 7 days." Care Plan for Resident #7 dated 07/29/11 reflected the following: "Problems: Resident is at risk for bleeding related to the use of anticoagulant therapy. Interventions: Meds as ordered. Caregiver: Nursing. Monitor labs and report to MD promptly. Caregiver: Nursing." Review of Resident #7's MAR for July 2011 revealed the following entry dated 07/25/11: "Resume Coumadin to 2 mg per peg Q PM when INR < 2.5." The order was timed for 1700 (5:00 PM) No doses of Coumadin were documented as given during July. Review of Resident #7's MAR for August 2011 revealed no entry for Coumadin. Interview on 08/04/11 at 11:30 AM with the DON and ADON B revealed, the PT/INR order written on 07/25/11 could not be located. ADON B was unable to find any PT/INR results other than one dated 07/26/11. On 08/04/11 at 11:56 AM, ADON B stated the INR dated 07/26/11 was the only one done. During the same interview, when queried about Resident #7's MARs and why the Coumadin order did not appear on the August 2011 MAR, ADON C stated the Coumadin entry on the July 2011 MAR "...wasn't actually an order." When queried how Resident #7's situation should have worked as far as the Coumadin order, ADON C stated the nurse should have pulled the result and notified Nurse Practitioner D because MD A liked her INR results within a certain range. She added the result would have then gone into the 24 hour report book to communicate to the oncoming nurse. There were no entries found related to Resident #7's lab results. When ADON C was queried about Resident #7 having one PT/INR done, the result not being reported to the MD, and the Coumadin not being given, she explained a STAT PT/INR test had been ordered and the Coumadin 2.5 mg dose was to be resumed and given as soon as available. Interview with NP D on 08/04/11 at 3:33 PM revealed he was not made aware of Resident #7's PT/INR level prior to that day. When asked if he was aware Resident #7 was supposed to be receiving Coumadin, NP D replied, "(MD A) and I did find that she had an order to check the PT/INR daily and resume the Coumadin when her INR was less than 2.5." When asked when he found the order, NP D stated the same day the new order was written by MD A (Note: MD A wrote the order on 07/25/11). When asked how the medical staff would follow-up on the lab results, NP D stated the nurses were supposed to check the labs and when "anything out of the ordinary" was found, they were to bring it to his attention, MD A, or MD M. NP D stated if he had known about her lab result, he would have ensured her Coumadin was started that day. NP D added that part of his job at the facility was to provide in-service training to the staff and stated one of his in-services was related to lab monitoring and when to call the MDs. When queried when the in-service was done, NP D presented his in-service book and provided an In-service Training report dated 05/18/11 with the topic titled, "Laboratory Analysis and Reporting." The in-service content included interpretation of common labs and the importance of reporting labs promptly "to prevent pts (patient's) labs from declining further." PT/INR monitoring was included in the in-service. NP D stated INRs less than 1.5 or > 4 should be immediately reported to the MDs, but the facility's MDs changed it. He stated the MDs decided INRs < 1.5 or > 3 should be immediately reported. Interview with ADON C on 08/04/11 at 4:04 PM revealed the STAT INR result was 0.98. ADON C was removing lab results from the printer and showed the surveyor an example of a lab result printing. She stated she looked at the results and if she noted abnormal lab values or trends she would address it then. She added if the lab result belonged to a resident cared for by another nurse, she would get the result to the proper nurse. The surveyor queried, "So it is every charge nurse's job to check the printer?" ADON C replied, "Yes." When asked if she was able to tell how Resident #7's original order was entered, she looked in the computer and then stated it had been ordered as a one-time lab test rather than daily as ordered. An IJ was identified on 08/04/11 at 4:55 PM in the area of Quality of Care and the Administrator and the DON were notified at that time. A POR was requested at that time. An interview on 08/04/11 at 5:48 PM with LVN N, CN who had been assigned to Resident #7, revealed she had seen the order for Coumadin on the MAR for July 2011. When asked why it was not given, LVN N replied, "I never got an INR. Queried whether she ever looked for a lab result, she replied, " I didn't know where to look for an INR, I'm new." When asked how long she had worked at the facility, LVN N replied, "three weeks." When asked if she ever knew to check labs, LVN N stated, "I usually when I came in the nurse would say, 'Here's her labs', I never knew to look." Interview with LVN G, CN for Resident #7, on 08/05/11 at 1:15 PM revealed she had written the Coumadin order on the MAR. When queried about the order, LVN G pointed to the MAR and stated, "I was the one who wrote the FYI (for your information), that wasn't an official order. It was an FYI to alert the second shift. When queried why she thought it was not on the MAR for August 2011, LVN G stated she thought it was because it was not an official order and just an FYI. When queried who was supposed to check the lab reports, LVN G stated the ADONs pulled the labs reports in the morning and gave them to the charge nurses and "...if you had to know something, you pull the lab and check." When queried whether she knew it was supposed to be a daily lab and she had input the order incorrectly as a one time order, LVN G stated "I did not know that." When asked why she thought this was not an "official order," LVN G explained it was because the medication was not supposed to be given until the INR was in range and that was why she put it on the first MAR, to remind the second shift to look for a result. On 08/05/11 at 3:36 PM, LVN J, CN who had been assigned to Resident #7, was interviewed regarding Resident #7's lab and Coumadin orders. When shown the MAR for July 2011 and queried regarding no doses given, LVN J stated, "I was waiting on the INR." When queried whether she ever looked for the lab results, LVN J stated she was unable to get into the computer system as she was new. When queried whether she ever asked anyone else to look, LVN J stated "just the day nurse and I would go back and forth; she never told me the INR was back." When queried whether she had access to the computer at that time, LVN J replied, "No." During an interview on 08/05/11 at 10:55 a.m. MD A was queried if she saw Resident #7's INR lab result dated 07/26/11. She replied, "I don't remember. If I see it it'll have my signature on it." When asked if she would expect to be called for a lab result reflecting an INR value of 0.95, MD A replied, "if they're (resident) is on Coumadin then yes. I have a folder for every hall where labs are kept." MD A reviewed Resident #7's medical record and commented "I don't see Coumadin on her (Resident #7) admission order. It was put on my order on the 25th (July)." The surveyor informed MD A that her PPNs on 07/29/11 and 08/01/11 reflected, "labs reviewed in chart." MD A revealed "when I see a resident I look for labs in the folder." When MD A was asked if she requested labs that were not in the folder she replied "many times I do and they (nursing staff) will print them out." When asked if she reviewed any of Resident #7's labs MD A replied, "I would say that I didn't see it because I always sign them." When asked if she received phone calls from facility staff when a resident's lab report was abnormal, MD A replied, "Most of the time we expect to get a call from staff." When asked if she always received a call from staff when lab reports were abnormal, MD A replied, "yes." When asked if she recalled looking or requesting Resident #7's lab report on 07/29/11, MD A replied, "no." When asked if she typically reviewed her resident's MARs and medications, MD A replied, "Yes, I check if there is a discrepancy." When asked if she recalled increasing a resident's Coumadin dosage and not seeing a predictable change in the resident's PT/INR values, MD A replied, "Yes, but I don't think in this building. In those cases we've had two people (nurses) sign (the MAR) that the med (medication) was given." When asked if there have been cases where abnormal labs have not been reported to her MD A replied, "I'm sure things have come up and that's why we started the folders and then things improved. Before that it was hard to see where labs were going. Now I can track it better." The surveyor informed MD A that Resident #7's lab reports were not reviewed or signed for six days between 07/25/11 and 08/01/11, when the resident was seen by MD M and it was not discovered by facility staff. MD A replied, "I ask them to print them out, sometimes they're busy or sometimes I forget." The facility's POR was accepted on 08/08/11 and reflected the following: all charts audited for residents receiving Coumadin to identify routine lab orders; MD called for routine lab orders for any residents receiving Coumadin without lab orders; all charts audited for PT/INR results as ordered; Lab book initiated for all PT/INR lab orders to be drawn; Lab service will audit 100% of all labs by 08/08/11 and results of the lab audit would be reviewed and appropriate actions taken on 08/08/11; Lab tracking would be completed to monitor labs; all nursing staff will be in-serviced on anticoagulants, including s/s of toxicity, labs, prior to any current nurse beginning duties on the floor beginning on the second shift on 08/05/11 through 08/07/11, they would be required to attend the education and complete the post test, education would be conducted upon orientation for new hires, immediately for current licensed nurses, monthly for the next 90 days then quarterly for 12 months and quarterly thereafter, training would be monitored by the DON and competency based post testing would be conducted with each in-service and orientation, in-services would be conducted by NP D and further in-services will be conducted throughout the weekend by RN I, who was trained by NP D; and Pharmacy consultant would audit patients with anticoagulants on 08/10/11 and the Pharmacy consultant reports for past 60 days would be reviewed to identify any concerns noted related to anticoagulant therapies. The POR also reflected the following: new admissions (readmission) orders would be reviewed by the AN within 72 hours; new admission orders [REDACTED] reviewed daily by Nsg Adm or designee for completion; all lab orders would be added to the lab log and reviewed daily by Nsg Adm or designee. The POR reflected the following: the CN would obtain MD order for labs needed; the CN would place the order in the lab book; a copy of the lab orders would be brought to the clinical meeting with lab log book; labs would be printed out each day prior to the morning meeting, between 12:00 PM and 2:00 PM and again by 6:00 PM by the ADON and Weekend supervisor; after review of the lab results, the ADON or weekend supervisor would stamp the lab and notify the MD, resident and/or family; if needed, a new MD's order would be obtained; the ADON or Weekend Supervisor would communicate verbally to the CN any changes in the MD's orders and complete the PT/INR flow sheets and MARs as indicated; the pharmacy would be notified of any new orders by the CN; and the ADON or Weekend Supervisor would monitor to ensure the MD order was followed, medications were delivered and the initial dose was given. The POR reflected the facility would monitor the system daily during the morning meeting, weekly during the Standards of Care meeting and during the Quality Assurance Meeting. Interviews conducted on 08/06/11 from 1:25 PM through 2:46 PM with LVN G, LVN S, LVN T, LVN J, LVN U, LVN V, and LVN O revealed they had attended the in-service training and they answered the questions regarding the POR appropriately. Interviews conducted on 08/07/11 from 1:47 PM through 2:31 PM with LVN H, RN I, LVN J, LVN K and LVN L revealed they attended the in-service training and they answered the questions regarding the POR appropriately. 2. A review of the admission nurse's note dated 07/18/11 at 3:30 p.m. revealed Resident #22 was an [AGE] year-old male, who was initially admitted to the facility from the hosp, following an Embolic CVA he suffered on 06/30/11. TPO dated 07/27/11 reflected, "2...PT/INR in AM then daily. Resume Coumadin 2.5 mg via peg tube daily when INR is less than 2.2 ..." The computer generated order sheet dated 07/28/11 for Resident #22 was printed by the DON on 08/08/11. The printout reflected LVN Q entered all the tests into the computer except the order "PT/INR in AM then daily." Acute visit and initial H&P dated 07/29/11, signed by MD A, were reviewed. Documentation under Assessment and Plan reflected, "1. Debility noted. Pt. has a guarded prognosis secondary to multiple medical problems... 3. Atrial fibrillation/Coumadin therapy. Will monitor PT/INR periodically and modify Coumadin dosage if needed. Staff is to call if INR is less than 1.9 or greater than 3.2 or if there are any signs of bleeding. Staff is to check a stat PT and INR. We will restart the Coumadin at 2.5 mg. a day if the INR is less than 2.2. ... 5. Stroke/Aphasia/[DIAGNOSES REDACTED]. Pt is at very high risk for repeated Cerebrovascular events. Will continue therapy to achieve maximum possible potential. Pt has an extremely guarded prognosis and is at very high risk for repeated hospitalization s with increased morbidity and mortality. LVN was requested to closely monitor the patient and call if there is any significant change in the patient's condition." TPO order for Resident #22 dated 07/29/11 reflected a STAT PT/INR, resume Coumadin at 2.5 mg at night and daily PT/INRs until INR "< 2.2, then PT/INR q Monday." The order was signed by the MD and a nurse signed the order on 08/01/11. Lab result dated 07/29/11 reflected Resident #22's INR was 1.73. A TPO order for Resident #22 dated 07/29/11 reflected a STAT PT/INR, resume Coumadin at 2.5 mg at night and daily PT/INRs until INR "< (sic)2.2, then PT/INR q Monday." The order was signed by the MD and a nurse signed the order on 08/01/11. A TPO order dated 07/31/11 reflected to resume Coumadin 5 mg daily and check the PT/INR in AM. TPO for Resident #22 dated 08/01/11 reflected, "Check PT/INR q Monday & Thursday & call if INR <1.9 or >3.0. Coumadin 2.5 mg not 5 mg at q HS." Lab results dated 08/01/11 for Resident #22 reflected an INR of 1.03. Lab results dated 08/02/11 for Resident #22 reflected an INR of 1.06. Lab results dated 08/03/11 for Resident #22 reflected an INR of 1.01. There was no documentation the MD was notified of the low INR results, so the MD could adjust Coumadin dosage if desired. [DIAGNOSES REDACTED]. A TPO for Resident #22 dated 08/04/11 reflected Coumadin 3 mg daily. During an interview on 08/05/11 at 10:55 AM, MD A revealed, "We have issues with labs and we're trying to figure it out so these things don't happen." When asked if she had issues with Coumadin labs previously, MD A replied, "The exact situation happened here last week with (Resident #22). I caught it. I told them (facility staff) to put discharge orders in the front of the chart not the back. If I don't see Coumadin on the admission order, I don't look at the discharge order necessarily." ADON C was interviewed on 08/05/11 at 4:10 PM regarding Resident #22's Coumadin therapy. She stated, "Dr. (MD A) came Friday (07/29/11) and realized that Mr.(Resident #22) hadn't been getting Coumadin. She looked at the hosp transfer orders and saw that the Coumadin was discontinued. She also looked and there were no PT/INR lab results in the chart although it had been ordered daily on 07/27/11 when he was readmitted . The doctor then ordered a stat PT/INR on 07/29/11. That was the first one he had since he had come back from the hosp. He should have been started back on Coumadin 2.5 mg. on 07/29/11, but that didn't happen ..." An interview with LVN Q on 08/08/11 at 1:40 PM revealed she was the AN. She stated she put the admission labs in the computer. LVN Q stated she did not usually put in PT/INRs. She stated when she received an admission she went back to ensure the orders were done. LVN Q stated she did not know why the PT/INR order was not in the computer. She stated she probably did not look at the resident ' s chart. She stated she was not sure. 3. Review of Resident #17's admission orders [REDACTED]. Review of Resident #17's TPO dated 07/04/11 reflected, "(Check) PT/INR q Tuesday and call if INR < 2.0 or > 3.2." Lab result for Resident #17 dated 07/05/11 reflected INR 0.92. There were no indications the MD had been notified of the results. Review of a PPN dated 07/08/11 revealed Resident #17 was seen by her primary MD due to swelling in both legs. Resident #17 had a history of [REDACTED]. "Assessment and Plan" reflected Left Leg deep vein thrombosis/coumadin therapy. Staff is to check a stat PT INR today and call with the results. Will monitor PT/INR periodically and modify coumadin dosage if needed. Staff is to call if INR is less than 1.9 or greater that 3.2 or if there are any signs of bleeding." Resident #17's lab result dated 07/08/11 at 4:05 PM reflected INR 0.86. The lab result reflected "Printed 07/11/2011 8:11 AM." A handwritten note on the lab result reflected, "Pt off coumadin 2 (secondary to) epistaxis (nosebleed). LE (lower extremity) Ultrasound nl (normal) will continue 0 (no) coumadin. (MD W)." Review of Resident #17's July 2011 MAR revealed Resident #17 was receiving Coumadin 5 mg daily. Resident #17's lab result dated 07/13/11 at 6:25 AM reflected INR 0.89. There was no indication the MD was notified. Resident #17's TPO dated 07/14/11 reflected, "Give Coumadin 1 MG tab tonight and tomorrow and continue with 5 MG 1 tab PO daily. Recheck PT INR in one week." Resident #17's lab result dated 07/19/11 at 9:05 AM reflected INR 0.91. There was no indication the MD was notified. Review of the MDS assessment dated [DATE] revealed Resident #17 was an [AGE] year-old female, who was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #17's lab result dated 07/21/11 at 9:05 AM reflected INR 0.88. Resident #17's Lab result dated 07/26/11 at 6:20 AM reflected INR 1.47. Resident #17's July 2011 MAR reflected the daily 5 mg dose of Coumadin was held on 07/14/11 and 07/15/11, and Resident #17 received the 1 mg dose of Coumadin on those dates. There was no MD's order to hold the routine 5 mg dose of Coumadin. On 07/14/11 and 07/15/11 the resident received only 1 mg of Coumadin instead of the intended 6 mg dose. NN for Resident #17 dated 07/04/11 through 07/25/11 were reviewed. The only nurse's note regarding Coumadin was dated 07/14/11 and reflected, "ID (initial dose) of Coumadin 1 MG given as ordered." Resident #17's July 2011 MAR reflected Coumadin 2 MG was administered in addition to the routine 5 MG daily dose of Coumadin on 07/20/11 and 07/21/11. There were no MD's orders to administer the extra 2 MG dose of Coumadin on 07/20/11 and 07/21/11. On 08/04/11 at 4:05 PM the surveyor asked the DON for assistance in locating the order, and/or documentation for Resident #17 to receive Coumadin 2 mg on 07/20/11 and 07/21/11. The DON and Regional Nurse Consultant F revealed they did not locate an order for [REDACTED].#17's medical record. Review of Resident #17's count sheet for Coumadin 5 mg tablets revealed one tablet was signed out daily from 07/16/11 through 08/03/11. 4. Resident #25 readmitted on [DATE], per the face sheet dated 07/30/11. Resident #25 had the following diagnoses, per the MDS assessment dated [DATE]: Anemia, HTN, DM, [DIAGNOSES REDACTED], Malignant Neoplasm of Rectum and Abnormality of Gait. Admission MD's orders for Resident #25 dated 07/26/11 reflected no anticoagulant medications were prescribed. NN dated 07/26/11 reflected, "Bruising noted to RUE (right upper extremity) elbow & hand." MD A's PPN dated 07/27/11 reflected Hx of DVT, Peripheral Neuropathy. NN for Resident #25 dated 08/02/11 reflected "? s/s or c/o pain noted. (Name of lab) to be here in AM (morning) for venous Doppler." NP D's PPN dated 08/02/11 reflected, "My arm is swollen & the Doctor said I could put ice on it. [AGE] year female w/ recent admission to (facility name). See initial progress notes. It states that her arm has been swollen for a few days. + tenderness, + [DIAGNOSES REDACTED]. Denies chest pain, palpitations, SOB, ? (increased) breathlessness, fever, chills. Also c/o tingling to BLE (bilateral lower extremities) extremities which she designates as a chronic problem. d/t "peripheral neuropathy" ROS (review of systems): as above. Other - (negative). PE: R (right) arm, [DIAGNOSES REDACTED]tous w/warmth over redden areas, edematous, tender w/palpitations. Assessment: 1. suspect DVT vs. Cellulitis 2. Peripheral Neuropathy. Plan: 1. Stat venous Doppler, Keflex 500 mg, PO TID x 7 days (for seven days). 2. Lyrica 50 mg PO BID. Family states pt was taking B/F (before) hospital. (NP D's signature)." Upper extremity venous ultrasound report dated 08/03/11 reflected "Impression: There is recent virtually occlusive clot at the axillary and brachial veins and also at the basilic vein at the right arm superficially." MD Orders dated 08/03/11 reflected Lovenox 80 mg subcutaneous q 12 hours due DVT. The order also reflected to send the Lovenox STAT and to do INRs daily, and then start Coumadin 3 mg PO q PM the day after beginning Lovenox..." Review of Resident #25's MAR dated August 2011 revealed she did not receive her first dose of Lovenox until 08/04/11 at 8:00 PM. NP D's progress note dated 08/04/11 reflected "Reviewed Doppler results - + DVT w/axillary & brachial veins & also at basilica vein superficially, DVT protocol implemented. Plan: monitor H&H. Last HgB 8.3. Pt w/hx of recent blood loss. Anemia due to surgery. (NP D's signature)." On 08/05/11 at 9:28 AM Resident #25 revealed to surveyor "My arm had been hurting me because I have bad veins." She stated the IV that was required during her recent surgery on 07/20/11 had irritated the veins in her right arm. Resident #25 stated then she had two PICC (peripherally inserted central catheter) lines put in, which offered some relief but caused further irritation after the PICC line was removed. An observation of Resident #25's right upper arm at that time revealed it was red and swollen. Resident #25 further stated she "told doctors for a couple days that my arm was sore before the NP (NP D) looked at it and told me he would have a doppler done. I told Dr (MD M) prior to the NP (NP D). I was told I wouldn't know the results until the next day after the doppler was done. I didn't tell them right away. The doppler was done and they found a clot. They're putting me on Coumadin, it's been ordered. They have to give me two shots of something (medication) first. I haven't been given any shots yet but will get Coumadin today. Three years ago I had surgery and had a clot form afterwards. I was discharged from the hosp and started rehab (at the same facility) and starting seeing spots in the distance. I have no recollection after that. That happened here after back surgery. On 08/08/11 at 10:19 AM NP D revealed an unidentified staff member informed him on 08/02/11 that Resident #25's arm was painful and swollen. NP D revealed he assessed Resident #25 and found her arm to be warm to touch, red and swollen. He also revealed he suspected Resident #25 either had a DVT or cellulitis. NP D was aware of Resident #25's history of a DVT. NP D also stated he meant to order a doppler test for Resident #25 stat, but forgot to write the order stat, so the doppler was completed 24 hours later. Observation on 08/08/11 at 4:05 PM in the facility medication room revealed Lovenox 30 mg pre-filled syringes, Lovenox 40 mg pre-filled syringes, and Coumadin one mg, two mg and five mg tablets were in the facility's emergency medication box. 5. While the IJ was removed on 08/08/11 at 2:20 PM, the facility remained out of compliance at a scope of "pattern" and a severity level of "no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility continued to monitor the implementation of the POR. The ADM and DON were informed at that time. 6. The facility's POR dated 08/04/11 reflected 17 residents received Coumadin. The facility's undated 802 Roster/Sample Matrix form reflected 28 residents resided on Hall 100.

Based on observation, interview and record review, the ADM and the DON failed to effectively and efficiently manage the facility's resources to attain or maintain the highest practicable physical well-being for five (Residents #7,#17,#22,#24,#25) of seven residents reviewed for [MEDICATION NAME] (anti-coagulant/blood thinner) and three (Residents #16, #5 and #25) of 11 residents reviewed for assessments. 1. The ADM failed to supervise and monitor the DON to ensure the DON implemented P/P for lab services, changes in condition, and assessment and the DON supervised the ADONs and CNs. The 2. The DON failed to implement P/P for lab services to ensure labs were completed timely, were ordered according to physician's orders [REDACTED]. 3. NP D said he saw problems with labs and he conducted an inservice titled "Laboratory Analysis and Reporting." 4. Resident #7 was admitted from the hospital due to a [MEDICAL CONDITION]. The facility was to do PT/INRs daily and resume [MEDICATION NAME] 2.5 mg, if the resident's INR was less than 2.5. The lab completed a PT/INR test four days after admission and two days later the results were printed. Resident #7's INR was 0.95. Resident #7 was not given [MEDICATION NAME] 2.5 mg and another PT/INR was not conducted until surveyor intervention seven days later. 5. Resident #22 was admitted from the hospital due to [MEDICAL CONDITION] 07/27/11. The facility was to do PT/INR in the morning after his admission and then daily. Also if his INR was lower than 2.2 he was to receive [MEDICATION NAME] 2.5 mg daily. The PT/INR for the day after admission was not done. The MD wrote an order for [REDACTED].< 2.2(sic)," and then PT/INRs each Monday. Resident #22's INR on 07/29/11 was less than 2.2, but he was not started on [MEDICATION NAME]. PT/INRs were not done on 07/30/11, and 07/31/11. 6. Resident #17 Resident #17 had a history of [REDACTED]. If the resident's INR was less than 2.0 or greater than 3.2, the staff were to inform the MD. Resident #17's INR was less than 2.0 multiple times. An order was received to administer [MEDICATION NAME] 5 mg and [MEDICATION NAME] 1 mg on 07/14/11 and 07/15/11 and to check the PT/INR in one week. Resident #17 was given [MEDICATION NAME] 1 mg on 07/14/11 and 07/15/11, but not [MEDICATION NAME] 5 mg. The [MEDICATION NAME] 5 mg was put on "hold," with no MD's order to hold it. Resident #17's INR was 07/19/11 was 0.91. On 07/20/11 and 07/21/11, Resident #17 received [MEDICATION NAME] 5 mg and [MEDICATION NAME] 2 mg without a MD's order. On 07/21/11 the resident's INR was 0.88. 7. Resident #24 was receiving [MEDICATION NAME] 2.5 mg daily. There was a MD's order to check the PT/INR every Tuesday and notify the MD if the INR was less than 1.9 or greater than 3.1. A PT/INR test was performed on 07/15/11 and the resident's INR was 1.15. The lab result page was stamped indicating the physician was notified a week later on 07/22/11. Another PT/INR test was completed on 07/21/11, which was a Thursday and the resident's INR was 0.99. This lab result page was also stamped indicating the MD was notified on 07/22/11. Another PT/INR test was performed on 07/28/11 (Thursday) and the resident's INR was 0.97. This lab result page was stamped but not dated. No orders were received adjusting the [MEDICATION NAME] dosage for Resident #24. Another PT/INR was completed on 08/04/11 and the resident's INR was 0.98 and a new order was received on 08/04/11 for [MEDICATION NAME] 3.0 mg on Fridays and Saturdays and [MEDICATION NAME] 2.5 mg on Mondays, Tuesdays, Wednesdays, Thursdays and Sundays. 8. Resident #16 had a TSH level ordered on [DATE]. The test was completed on 08/01/11 with the results being 39.335. The reference range on the lab was 0.360 through 3.740. When the MD was made aware of the results four days later, after surveyor intervention, the MD gave an order to increase the resident's [MEDICATION NAME] and to recheck his TSH level in two weeks. 9. Resident #5's forearm was swollen and discolored. The resident said her nurse was busy that day, when she was asked what her nurse said about her arm. NP D assessed the resident's arm, after surveyor intervention and ordered a stat Doppler study to rule out a blood clot. LVN R said he was told about Resident #5's arm swelling by the night nurse and he said he planned to "watch it." The Doppler results indicated her [MEDICATION NAME] vein was blocked and she was sent to the hospital. 10. Resident #25 said her arm was hurting because she had bad veins. She had a history of [REDACTED]. NP D assessed the resident's arm and ordered a Doppler Study, which was completed a day later and the results were positive for a blood clot. The MD also ordered STAT [MEDICATION NAME] (blood thinning medication), but the resident did not receive her first dose for approximately 24 hours. The facility's emergency medication kit contained [MEDICATION NAME]. An Immediate Jeopardy (IJ) was identified on 08/04/11. While the IJ was removed on 08/08/11, the facility remained out of compliance at a scope of "pattern" and a severity level of "no actual harm with potential for more than minimal harm that is not immediate jeopardy" because the facility was monitoring the implementation of the Plan of Removal (POR). These failures could affect all 104 residents residing in the facility. Findings included: 1. HOSP PPN dated 07/19/11 reflected she was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. MD's Order dated 07/25/11 reflected: "1. PT/INR daily. Resume [MEDICATION NAME] at 2 mg per peg Q PM when INR < 2.5" Lab report dated 07/26/11 at 11:46 AM reflected INR 0.95. This lab result page reflected, "Printed 07/28/2011 12:43 PM." No other PT/INR results were found for Resident #7. Resident #7's MAR for July 2011 reflected an entry dated 07/25/11: "Resume [MEDICATION NAME] to 2 mg per peg Q PM when INR < 2.5." The order was timed for 1700 (5:00 PM) No doses of [MEDICATION NAME] were documented as given during July. Resident #7's MAR for August 2011 did not reflect an entry for [MEDICATION NAME]. On 08/04/11 at 11:30 AM, the DON was queried where lab results could be found if they were not on the residents' charts. ADON B checked the computer at that time and printed Resident #7's lab results from her admission orders [REDACTED]. After searching for PT/INR results, related to the order written on 07/25/11, ADON B was unable to find any PT/INR results other than one dated 07/26/11 and stated she would call the lab and inquire whether there were any other results available. On 08/04/11 at 11:56 AM, ADON B stated the INR dated 07/26/11 was the only one done. An interview on 08/04/11 at 2:50 PM ADON C, who identified herself as the ADON assigned to Resident #7's hall, revealed she look in the computer under "order history" and the details of the lab order would be on the order page. When queried who made sure the lab tests were ordered, ADON C stated it was the CN's responsibility. When shown the print date on Resident #7's lab result and queried who printed the result, ADON C stated the new system "...just spits labs out" and she did not know who placed the lab result in the chart. ADON C was asked when the physicians were notified of lab results and she stated the MDs, MD's Assistants or NPs were always notified. ADON C pointed out MD A's lab book. Resident #7's PT/INR results dated 07/26/11 were observed in MD A's lab book. The report reflected "Printed 07/26/2011 11:48 AM" and there were no handwritten notations made on the form to indicate it had been reviewed. ADON C explained if the report printed the day MD A came to the facility, the report was given to her, on other days the report would be given to NP D or whichever MD's Assistant or NP was there. Queried whether there was anyway to know whether any physician had seen the lab, ADON C replied "(MD A) always signs her labs and (MD M) doesn't look into the book, we have to bring it to her." When ADON C was shown the PT/INR result with two separate print dates and queried who may have placed the results in the chart and physician's lab book, she stated she did not know. During the same interview, when queried about Resident #7's MARs and why the [MEDICATION NAME] order did not appear on the August 2011 MAR, ADON C stated the [MEDICATION NAME] entry on the July 2011 MAR "...wasn't actually an order." When queried how Resident #7's situation should have worked as far as the [MEDICATION NAME] order, ADON C stated the nurse should have pulled the result and notified NP D because MD A liked her INR results within a certain range. She added the result would have then gone into the 24 hour report book to communicate to the oncoming nurse. There were no entries found related to Resident #7's lab results. When ADON C was queried about Resident #7 having one PT/INR done, the result not being reported to the MD, and the [MEDICATION NAME] not being given, she explained a STAT PT/INR test had been ordered and the [MEDICATION NAME] 2.5 mg dose was to be resumed and given as soon as available. Interview with NP D on 08/04/11 at 3:33 PM revealed he was not made aware of Resident #7's PT/INR level prior to that day. When asked if he was aware Resident #7 was supposed to be receiving [MEDICATION NAME], NP D replied, "(MD A) and I did find that she had an order to check the PT/INR daily and resume the [MEDICATION NAME] when her INR was less than 2.5." When asked when he found the order, NP D stated the same day the new order was written by MD A (Note: MD A wrote the order on 07/25/11). NP D stated the nurses were supposed to check the labs and when "anything out of the ordinary" was found, they were to bring it to his attention, MD A, or MD M. NP D stated if he had known about her lab result, he would have ensured her [MEDICATION NAME] was started that day. NP D added part of his job was to provide in-service training to the staff and stated one of his in-services was related to lab monitoring and when to call the physicians. When queried when the in-service was done, NP D presented his in-service book and provided an In-service Training report dated 05/18/11 with the topic titled, "Laboratory Analysis and Reporting." The in-service content included interpretation of common labs and the importance of reporting labs promptly "to prevent pts labs from declining further." PT/INR monitoring was included in the in-service. NP D stated INRs less than 1.5 or > 4 should be immediately reported to the physician, but the facility's physicians changed it. He stated the physicians decided INRs < 1.5 or > 3 should be immediately reported. When NP D was asked what prompted him to do the in-service on 05/18/11 he replied, "I look at what I see going on with my nurses. If I see deficits, I generate an in-service." NP D was then asked, "So you saw a deficit?" NP D replied, "I saw a deficit, I mean. I saw a need." When asked if he was getting his lab results, NP D stated, "Not sure I always do." Interview with ADON C on 08/04/11 at 4:04 PM revealed the STAT INR result was 0.98. ADON C was removing lab results from the printer and showed the surveyor an example of a lab result printing. She stated she looked at the results and if she noted abnormal lab values or trends she would address it then. She added if the lab result belonged to a resident cared for by another nurse, she would get the result to the proper nurse. The surveyor queried, "So it is every charge nurse's job to check the printer?" ADON C replied, "Yes." When asked if she was able to tell how Resident #7's original order was entered, she looked in the computer and then stated it had been ordered as a one-time lab test rather than daily as ordered. An interview on 08/04/11 at 5:48 PM with LVN N, CN who had been assigned to Resident #7, revealed she had seen the order for [MEDICATION NAME] on the MAR for July 2011. When asked why it was not given, LVN N replied, "I never got an INR. Queried whether she ever looked for a lab result, she replied, " I didn't know where to look for an INR, I'm new." When asked how long she had worked at the facility, LVN N replied, "three weeks." When asked if she ever knew to check labs, LVN N stated, "I usually when I came in the nurse would say, 'Here's her labs', I never knew to look." Interview with LVN G, CN for Resident #7, on 08/05/11 at 1:15 PM revealed she had written the [MEDICATION NAME] order on the MAR. When queried about the order, LVN G pointed to the MAR and stated, "I was the one who wrote the FYI, that wasn't an official order. It was an FYI to alert the second shift. When queried why she thought it was not on the MAR for August 2011, LVN G stated she thought it was because it was not an official order and just an FYI. LVN G stated the ADONs pulled the labs reports in the morning and gave them to the CNs and "...if you had to know something, you pull the lab and check." When queried whether she knew it was supposed to be a daily lab and she had input the order incorrectly as a one time order, LVN G stated "I did not know that." When asked why she thought this was not an "official order," LVN G explained it was because the medication was not supposed to be given until the INR was in range and that was why she put it on the first MAR, to remind the second shift to look for a result. On 08/05/11 at 3:36 PM, LVN J, CN who had been assigned to Resident #7, was interviewed regarding Resident #7's lab and [MEDICATION NAME] orders. When shown the MAR for July 2011 and queried regarding no doses given, LVN J stated, "I was waiting on the INR." When queried whether she ever looked for the lab results, LVN J stated she was unable to get into the computer system as she was new. When queried whether she ever asked anyone else to look, LVN J stated "just the day nurse and I would go back and forth; she never told me the INR was back." When queried whether she had access to the computer at that time, LVN J replied, "No." During an interview on 08/05/11 at 10:55 a.m. MD A was queried if she saw Resident #7's INR lab result dated 07/26/11. She replied, "I don't remember. If I see it it'll have my signature on it." When asked if she would expect to be called for a lab result reflecting an INR value of 0.95, MD A replied, "if they're (resident) is on [MEDICATION NAME] then yes. I have a folder for every hall where labs are kept." MD A reviewed Resident #7's medical record and commented "I don't see [MEDICATION NAME] on her (Resident #7) admission order. It was put on my order on the 25th (July)." The surveyor informed MD A that her progress notes on 07/29/11 and 08/01/11 reflected, "labs reviewed in chart." MD A revealed "when I see a resident I look for labs in the folder." When MD A was asked if she requested labs that were not in the folder she replied "many times I do and they (nursing staff) will print them out." When asked if she reviewed any of Resident #7's labs MD A replied, "I would say that I didn't see it because I always sign them." When asked if she received phone calls from facility staff when a resident's lab report was abnormal, MD A replied, "Most of the time we expect to get a call from staff." When asked if she always received a call from staff when lab reports were abnormal, MD A replied, "yes." When asked if she recalled looking or requesting Resident #7's lab report on 07/29/11, MD A replied, "no." When asked if she typically reviewed her resident's MARs and medications, MD A replied, "Yes, I check if there is a discrepancy." When asked if she recalled increasing a resident's [MEDICATION NAME] dosage and not seeing a predictable change in the resident's PT/INR values, MD A replied, "Yes, but I don't think in this building. In those cases we've had two people (nurses) sign (the MAR) that the med (medication) was given." When asked if there have been cases where abnormal labs have not been reported to her MD A replied, "I'm sure things have come up and that's why we started the folders and then things improved. Before that it was hard to see where labs were going. Now I can track it better." The surveyor informed MD A that Resident #7's lab reports were not reviewed or signed for six days between 07/25/11 and 08/01/11, when the resident was seen by MD M and it was not discovered by facility staff. MD A replied, "I ask them to print them out, sometimes they're busy or sometimes I forget." Lab Process document dated 07/20/10 and located in the front of the lab book at the nurse's station reflected the following: "To: Nurses and ADONs. From: (DON). 1. The nurse gets the lab order and places the order in the computer. The yellow slip from all telephone orders goes in the green pocket so the ADONs can check the orders and follow up to make sure they have been carried out. (Orders for labs have to be placed on telephone order so that this process can work and flagged in the chart). 2. Every morning the first ADON to the facility will pull the completed lab results and review for abnormalities. The physician, per protocol for abnormal and critical, will be notified and the results will be placed in the lab books for physician follow up. (The RN supervisor will complete this task on the weekend and follow up by ADONs on Monday).... 4. The yellow slips of the telephone orders will be brought to the morning stand up meeting so any change of condition can be noted and any labs ordered acknowledged. The ADONs will follow up and make sure the orders are completed and monitor the system daily. Labs will be checked in the system by the ADONs and if they are not there they will immediately enter them and council/re-educate nurse of data entry. An undated Laboratory Communication policy provided by the DON on 08/04/11 reflected, "Procedure: When results of diagnostic tests are received by the facility, the licensed nurse should review the result, assess the resident, review the resident's medical record, and make a decision for immediate or non-immediate notification. If the decision is for non-immediate notification, the licensed nurse should fax the results to __. If the results are normal or the test was done on a routine basis, and the nurse expects the physician or advanced practice nurse in the facility that week, the results do not have to be faxed, but may be left in the Communication Manual for review. All panic lab values, unless the value is normal for that person, should immediately be relayed (by phone call) to the physician." 2. A review of the admission NN dated 07/18/11 at 3:30 p.m. revealed Resident #22 was an [AGE] year-old male, who was initially admitted to the facility from the hospital, following an [MEDICAL CONDITION] suffered on 06/30/11. TPO dated 07/27/11 reflected, "2. CBC, CMP, TSH, [MEDICATION NAME], Lipid Panel, Mg (Magnesium), PT/INR in AM then daily. Resume [MEDICATION NAME] 2.5 mg via peg tube daily when INR is less than 2.2 ... " The computer generated order sheet dated 07/28/11 for Resident #22 printed by the DON on 08/08/11 reflected "PT/INR in AM then daily" was not entered. TPO Resident #22 dated 07/29/11 reflected a STAT PT/INR, resume [MEDICATION NAME] at 2.5 mg at night and daily PT/INRs until INR "< 2.2, then PT/INR q Monday." The order was signed by the MD and a nurse signed the order on 08/01/11. Lab result dated 07/29/11 reflected Resident #22's INR was 1.73. TPO dated 07/31/11 reflected to resume [MEDICATION NAME] 5 mg daily and check the PT/INR in AM. TPO for Resident #22 dated 08/01/11 reflected, "Check PT/INR q Monday & Thursday & call if INR <1.9 or >3.0. [MEDICATION NAME] 2.5 mg not 5 mg at q HS." Lab results dated 08/01/11 for Resident #22 reflected an INR of 1.03. Lab results dated 08/02/11 for Resident #22 reflected an INR of 1.06. Lab results dated 08/03/11 for Resident #22 reflected an INR of 1.01. There was no documentation the MD was notified of the low INR results, so the MD could adjust [MEDICATION NAME] dosage if desired. TPO for Resident #22 dated 08/04/11 reflected [MEDICATION NAME] 3 mg daily. During an interview on 08/05/11 at 10:55 AM, MD A revealed, "We have issues with labs and we're trying to figure it out so these things don't happen." When asked if she had issues with [MEDICATION NAME] labs previously, MD A replied, "The exact situation happened here last week with (Resident #22). I caught it. I told them (facility staff) to put discharge orders in the front of the chart not the back. If I don't see [MEDICATION NAME] on the admission order, I don't look at the discharge order necessarily." ADON C was interviewed on 08/05/11 at 4:10 PM regarding Resident #22's [MEDICATION NAME] therapy. She stated, "Dr. (MD A) came Friday (07/29/11) and realized that Mr.(Resident #22) hadn't been getting [MEDICATION NAME]. She looked at the hospital transfer orders and saw that the [MEDICATION NAME] was discontinued. She also looked and there were no PT/INR lab results in the chart although it had been ordered daily on 07/27/11 when he was readmitted . The doctor then ordered a stat PT/INR on 07/29/11. That was the first one he had since he had come back from the hospital. He should have been started back on [MEDICATION NAME] 2.5 mg. on 07/29/11, but that didn't happen ..." An interview with LVN Q on 08/08/11 at 1:40 PM revealed she was the AN and she put the admission labs in the computer. LVN Q stated she did not usually put in PT/INRs. She stated when she received an admission she went back to ensure the orders were done. LVN Q stated she did not know why the PT/INR order was not in the computer. She stated she probably did not look at the resident's chart. She stated she was not sure. 3. Resident #17's admission orders [REDACTED]. [DIAGNOSES REDACTED]. Resident #17's TPO dated 07/04/11 reflected, "(Check) PT/INR q Tuesday and call if INR < 2.0 or > 3.2." Lab result for Resident #17 dated 07/05/11 reflected INR 0.92. There were no indications the physician had been notified of the results. PPN dated 07/08/11 revealed Resident #17 had a history of [REDACTED]. Resident #17's lab result dated 07/08/11 at 4:05 PM reflected INR 0.86. The lab result reflected "Printed 07/11/2011 8:11 AM." A handwritten note on the lab result reflected, "Pt off [MEDICATION NAME] 2 (secondary to) epistaxis (nosebleed). LE Ultrasound nl will continue 0 (no) [MEDICATION NAME]. (MD W)." Resident #17's July 2011 MAR reflected she was receiving [MEDICATION NAME] 5 mg daily. Resident #17's lab result dated 07/13/11 at 6:25 AM reflected INR 0.89. There was no indication the MD was notified. Resident #17's TPO dated 07/14/11 reflected, "Give [MEDICATION NAME] 1 MG tab tonight and tomorrow and continue with 5 MG 1 tab PO daily. Recheck PT INR in one week." Resident #17's lab result dated 07/19/11 at 9:05 AM reflected INR 0.91. There was no indication the MD was notified. Resident #17's lab result dated 07/21/11 at 9:05 AM reflected INR 0.88. Resident #17's Lab result dated 07/26/11 at 6:20 AM reflected INR 1.47. Resident #17's July 2011 MAR reflected the daily 5 mg dose of [MEDICATION NAME] was held on 07/14/11 and 07/15/11, and Resident #17 received the 1 mg dose of [MEDICATION NAME] on those dates. There was no MD order to hold the routine 5 mg dose of [MEDICATION NAME]. On 07/14/11 and 07/15/11 the resident received only 1 mg of [MEDICATION NAME] instead of the intended 6 mg dose. Resident #17's July 2011 MAR reflected [MEDICATION NAME] 2 mg was administered in addition to the routine 5 mg daily dose of [MEDICATION NAME] on 07/20/11 and 07/21/11. There were no MD orders to administer the extra 2 mg dose of [MEDICATION NAME] on 07/20/11 and 07/21/11. On 08/04/11 at 4:05 PM the surveyor asked the DON for assistance in locating the order, and/or documentation for Resident #17 to receive [MEDICATION NAME] 2 mg on 07/20/11 and 07/21/11. The DON and RNC F stated they did not find an order for [REDACTED].#17's medical record. NP D was interviewed on 08/04/11 at 5:30 PM regarding [MEDICATION NAME] dosages and INR results. He revealed when residents were taking [MEDICATION NAME] and had low INR results, which were not affected by changing the dosage of [MEDICATION NAME], he started to suspect residents might not be receiving [MEDICATION NAME]. He explained residents on a substantial dose of [MEDICATION NAME] would not have the medication dosage adjusted until it was certain the [MEDICATION NAME] was given. NP D stated the facility addressed the problem by having licensed nurses administer [MEDICATION NAME] instead of the MAs. He stated, when that approach failed, the facility initiated the [MEDICATION NAME] count sheets beginning 07/16/11 for Resident #17. NP D stated review of INR results indicated this approach was also ineffective. During this time NP D was not able to find an order for [REDACTED]. An interview on 08/04/11 at 5:50 PM with LVN O revealed the facility created a count sheet system to track when [MEDICATION NAME] was given to residents. LVN O revealed the system was initiated due to resident's PT/INR lab results being "off." She provided the Resident #17's count sheet, which was started on 07/16/11 and it included date, time, the dosage administered and the number of pills remaining. 4. Resident #24, an [AGE] year-old male, re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #24's HOSP Discharge Summary dated 07/14/11 reflected the discharge [DIAGNOSES REDACTED]. Resident #24's admission orders [REDACTED]. Laboratory orders included PT/INR q Tuesday. MD's orders dated 07/15/11 reflected: "PT/INR today. Call if INR < 1.9 or > 3.1. PT/INR q Tuesdays." Lab results dated 07/15/11 reflected INR 1.15. This result was stamped indicating MD A was notified of the results on 07/22/11. Lab results dated 07/21/11, which was a Thursday (Note: The PT/INR was to be checked every Tuesday) reflected INR 0.99. This result was stamped indicating MD A was notified of the results on 07/22/11. Lab results dated 07/28/11 (Thursday) reflected INR 0.97. This result was stamped and initialed with no date. Consolidated MD Orders for the month of August 2011 reflected, "Check PT/INR Q Tuesday. Call M.D. if < 1.9 or >3.1" Lab results dated 08/04/11 (Thursday) reflected INR 0.98. This result was not stamped or initialed. MD's Order for Resident #24 dated 08/04/11 reflected "Change [MEDICATION NAME] to 3.0 mg p.o. Q Fri & Sat @ 1700 (5:00 PM). [MEDICATION NAME] 2.5 mg P.O. Q mon, tues, wed, thur & sun @ 1700." Resident #24's MARs for July 2011 and August 2011 reflected he received [MEDICATION NAME] 2.5 mg at 5:00 PM daily from 07/14/11 through 08/04/11. 5. Resident #16, a [AGE] year-old male, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. MD's orders dated 07/28/11 for Resident #16 reflected TSH level. Resident #16's H&P dated 08/01/11 and signed by the Medical Director reflected, "Past History: ....[MEDICAL CONDITION] ..." On 08/05/11 at 5:00 PM, the surveyor was unable to locate laboratory results. ADON C was queried and was not able to locate results, so a report was accessed and printed from the computer. ADON C was shown the order for a lab written on 07/28/11 and was asked why no staff or MD had reviewed the lab results. ADON C stated she was surprised to see admission lab orders as Resident #16 was one of the Medical Director's residents and he typically did not order admission labs. When shown the order indicating MD P had ordered the lab tests and not the Medical Director, ADON C stated she would look into it. Lab result dated 08/01/11 reflected: "TSH 39.335. Reference Range 0.360 - 3.740." MD's orders dated 08/05/11 for Resident #16 reflected "D/C [MEDICATION NAME] 25 mcg PO QD. Start [MEDICATION NAME] 75 mcg tab (one) tab PO QD. Recheck TSH in two weeks." (Note: This order was entered after surveyor inquiry.) 6. Resident #5, a [AGE] year-old female resident, re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical Record/Progress Notes dated 08/02/11 for Resident #5 reflected, "... This most recent transfer to acute care was for suspicious infected AV (Arteriovenous) shunt by the [MEDICAL TREATMENT] center ..... also noted w/acute blood loss from bleeding AV shunt which was corrected. Transferred back to (facility name) for continued rehab. Also pt noted with a (left) AVC (sic) hematoma." Observation on 08/03/11 at 11:30 AM revealed Resident #5 was walking near the nurses' station and was cradling her left forearm with her right hand. Her left hand and forearm was very swollen and discolored. When asked what happened, Resident #5 stated she did not know, but her hand was swollen. When asked what her nurse had said about it, she replied, "He's busy today." NP D was observed nearby and asked to look at Resident #5's hand. After assessing her hand, NP D stated he would order a Doppler study to rule out a blood clot. PPN signed by NP D and dated 08/03/11 at 11:30 AM reflected "Summoned to pts side by state worker in hallway. 'My arm is swollen' + pain, intermittent + tenderness, ? (absent of) fever/chills, denies chest pains, palpitations, SOB. PE: ...LUE [MEDICAL CONDITION], darkened colored, Bluish hue, + mild numbness, warm to touch over humerus, cool to touch fingers, capillary refill < 4 sec, radial pulse palpable faintly, shunt with palpable thrill. Assessment: ? (increased) pain & [MEDICAL CONDITION] r/o [MEDICAL CONDITION] vs. [MEDICAL CONDITION] vs. malfunctioning shunt. Plan: STAT venous Doppler." Interview with LVN R, the CN assigned to Resident #5, on 08/03/11 at 11:50 AM revealed he had been told about the swelling in Resident #5's hand by the night nurse. When queried what he had intended to do about it, LVN R replied, "Watch it." Review of the 24 Hour Report/Change of Condition Report dated 08/03/11 revealed an entry under the columns "Remarks (Night)" and "Remarks (Day) for Resident #5 which reflected, "Lt hand [MEDICAL CONDITION]." PPN signed by NP D and dated 08/03/11 at 2:25 PM reflected: "Preliminary lab reviewed (Doppler) ? Findings suggestive of occlusive [MEDICATION NAME] vein. Transfer pt to Acute Care." Interview with NP D on 08/03/11 at 3:30 PM revealed Resident #5 had been sent to the hospital. When queried about the findings of the Doppler study, NP D stated, "Based on the preliminary report her [MEDICATION NAME] vein was completely occluded. So based on her symptoms, I sent her to the hospital." 7. Resident #25 readmitted on [DATE], per the face sheet dated 07/30/11. Resident #25 had the following diagnoses, per the MDS assessment dated [DATE]: [MEDICAL CONDITION], HTN, DM, [MEDICAL CONDITION], Malignant Neoplasm of Rectum and Abnormality of Gait. NN dated 07/26/11 reflected, "Bruising noted to RUE elbow & hand." MD A's PPN dated 07/27/11 reflected, "[MEDICAL CONDITION], Hx of [MEDICAL CONDITION], Peripheral [MEDICAL CONDITION]" NP D's PPN dated 08/02/11 reflected, "My arm is swollen & the Doctor said I could put ice on it. [AGE] year female w/ recent admission to (facility name). See initial progress notes. It states that her arm has been swollen for a few days. + tenderness, + [DIAGNOSES REDACTED]. Denies chest pain, palpitations, SOB, ? (increased) breathlessness, fever, chills. Also c/o tingling to BLE extremities which she designates as a chronic problem. d/t "[MEDICAL CONDITION]" ROS: as above. Other - (negative). PE: R (right) arm, [DIAGNOSES REDACTED]tous w/warmth over redden areas, [MEDICAL CONDITION], tender w/palpitations. Assessment: 1. suspect [MEDICAL CONDITION] vs. [MEDICAL CONDITION] 2. Peripheral [MEDICAL CONDITION]. Plan: 1. Stat venous Doppler, Keflex 500 mg, PO TID x 7 days (for seven days). 2. [MEDICATION NAME] 50 mg PO BID. Family states pt was taking B/F hospital. (NP D's signature)." UE venous ultrasound report dated 08/03/11 reflected "Impression: There is recent virtually occlusive clot at the axillary and brachial veins and also at the basilic vein at the right arm superficially." F490 is continued in F9999 on page 106. MD's Orders dated 08/03/11 reflected [MEDICATION NAME] 80 mg subcutaneous q 12 hours due D

Based on interview and record review, the facility failed to provide and/or obtain laboratory services to meet the needs of its residents for four (Residents #7, #16, #22, and #24) of eight residents reviewed for laboratory services. 1. Resident #7 was admitted from the hospital due to a [MEDICAL CONDITION]. The facility was to do PT/INRs daily and if the resident's INR was less than 2.5 they were to administer medication. The lab completed a PT/INR test four days after admission and two days later the results were printed. Resident #7's INR was 0.95. Another PT/INR was not conducted until surveyor intervention seven days later. 2. Resident #22 was admitted from the hospital due to [MEDICAL CONDITION] 07/27/11. The facility was to do PT/INR in the morning after his admission and then daily. Also if his INR was lower than 2.2 he was to receive medication. The PT/INR for the day after admission was not done. The MD wrote an order for [REDACTED].< 2.2 (sic)," and then PT/INRs each Monday. PT/INRs were not done on 07/30/11, and 07/31/11. 3. Resident #24 was receiving [MEDICATION NAME] 2.5 mg daily. There was a MD's order to check the PT/INR every Tuesday and notify the MDs if the INR was less than 1.9 or greater than 3.1. Another PT/INR test was completed on 07/21/11, which was a Thursday and the resident's INR was 0.99. Another PT/INR test was performed on 07/28/11 (Thursday) and the resident's INR was 0.97. Another PT/INR was completed on 08/04/11 (Thursday) and the resident's INR was 0.98. 4. Resident #16 had a TSH level ordered on [DATE]. The test was completed on 08/01/11 with the results being 39.335. The reference range on the lab was 0.360 through 3.740. An Immediate Jeopardy (IJ) was identified on 08/04/11. While the IJ was removed on 08/08/11, the facility remained out of compliance at a scope of "pattern" and a severity level of "no actual harm with potential for more than minimal harm that is not immediate jeopardy" because the facility was monitoring the implementation of the Plan of Removal (POR). These failures could affect the 17 residents, who received [MEDICATION NAME], including Residents #7, #22, #17, and #24 by placing them at risk of developing blood clots that can lead to stroke, [MEDICAL CONDITION] embolism (blood clot in the lung),and/or bruising and bleeding. These failures could also affect the 28 residents,including Resident #16, who resided on Hall 100, by placing them at a risk of delayed treatment. Findings included: 1. Resident #7, a [AGE] year-old female resident, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Hospital PPN dated 07/19/11 reflected she was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. Resident #7's hospital MD's order dated 07/22/11 at 2:00 PM reflected: "...Dx 1) [MEDICAL CONDITION] (right) LE (lower extremity) weakness. PT INR daily for 3 days. Hold [MEDICATION NAME] restart when INR < 2.5 at 2 mg PEG (percutaneous endoscopic gastrostomy tube) daily. Goal INR 2-2.5" MD's Order dated 07/25/11 reflected: "1. PT/INR daily. Resume [MEDICATION NAME] at 2 mg per peg Q PM when INR < 2.5" Lab report dated 07/26/11 at 11:46 AM reflected INR 0.95. This lab result page reflected, "Printed 07/28/2011 12:43 PM." No other PT/INR results were found for Resident #7. Progress note dictated by MD A with "Date of Visit: 07/29/11" reflected, "...Labs: Reviewed as available in the chart...." Care Plan for Resident #7 dated 07/29/11 reflected the following: "Problems: Resident is at risk for bleeding related to the use of anticoagulant therapy. Interventions: Meds as ordered. Caregiver: Nursing. Monitor labs and report to MD promptly. Caregiver: Nursing." Progress note dictated by MD M dated 08/01/11 reflected the following: "...Lab: Labs reviewed as available on chart...." Interview with Resident #7 on 08/03/11 at 11:30 AM revealed she usually stayed in her bed and often did not want to get up. She stated she was still "pretty weak." On 08/04/11 at 11:30 AM, the DON was queried where lab results could be found if they were not on the residents' charts. ADON B checked the computer at that time and printed Resident #7's lab results from her admission orders [REDACTED]. After searching for PT/INR results, related to the order written on 07/25/11, ADON B was unable to find any PT/INR results other than one dated 07/26/11 and stated she would call the lab and inquire whether there were any other results available. On 08/04/11 at 11:56 AM, ADON B stated the INR dated 07/26/11 was the only one done. On 08/04/11 at 2:50 PM ADON C, who identified herself as the ADON assigned to Resident #7's hall, was interviewed regarding laboratory and medication ordering procedures. When queried how she could tell if a lab had been ordered, she stated they could go into the computer under "order history" and the details would be on the order page. She added there was no confirmation page with their current computer system. When queried who made sure the lab tests were ordered, ADON C stated it was the CN's responsibility. When ADON C was queried about Resident #7 having one PT/INR done, the result not being reported to the MD, and the [MEDICATION NAME] not being given, she explained a STAT PT/INR test had been ordered and the [MEDICATION NAME] 2.5 mg dose was to be resumed and given as soon as available. Interview with NP D on 08/04/11 at 3:33 PM revealed he was not made aware of Resident #7's PT/INR level prior to that day. When asked if he was aware Resident #7 was supposed to be receiving [MEDICATION NAME], NP D replied, "(MD A) and I did find that she had an order to check the PT/INR daily and resume the [MEDICATION NAME] when her INR was less than 2.5." When asked when he found the order, NP D stated the same day the new order was written by MD A (Note: MD A wrote the order on 07/25/11). When asked how the medical staff would follow-up on the lab results, NP D stated the nurses were supposed to check the labs and when "anything out of the ordinary" was found, they were to bring it to his attention, MD A, or MD M. NP D stated if he had known about her lab result, he would have ensured her [MEDICATION NAME] was started that day. NP D added that part of his job at the facility was to provide in-service training to the staff and stated one of his in-services was related to lab monitoring and when to call the MDs. When queried when the in-service was done, NP D presented his in-service book and provided an In-service Training report dated 05/18/11 with the topic titled, "Laboratory Analysis and Reporting." The in-service content included interpretation of common labs and the importance of reporting labs promptly "to prevent pts (patient's) labs from declining further." PT/INR monitoring was included in the in-service. NP D stated INRs less than 1.5 or > 4 should be immediately reported to the MD, but the facility's MDs changed it. He stated the MDs decided INRs < 1.5 or > 3 should be immediately reported. Interview with ADON C on 08/04/11 at 4:04 PM revealed the STAT INR result was 0.98. ADON C was removing lab results from the printer and showed the surveyor an example of a lab result printing. When asked if she was able to tell how Resident #7's original order was entered, she looked in the computer and then stated it had been ordered as a one-time lab test rather than daily as ordered. Lab Process document dated 07/20/10 and located in the front of the lab book at the nurse's station reflected the following: "To: Nurses and ADONs. From: (DON). 1. The nurse gets the lab order and places the order in the computer. The yellow slip from all telephone orders goes in the green pocket so the ADONs can check the orders and follow up to make sure they have been carried out. (Orders for labs have to be placed on telephone order so that this process can work and flagged in the chart).... 4. The yellow slips of the telephone orders will be brought to the morning stand up meeting so any change of condition can be noted and any labs ordered acknowledged. The ADONs will follow up and make sure the orders are completed and monitor the system daily. Labs will be checked in the system by the ADONs and if they are not there they will immediately enter them and council/re-educate nurse of data entry. An IJ was identified on 08/04/11 at 4:55 PM in the area of Lab Services and the Administrator and the DON were notified at that time. A POR was requested at that time. An interview on 08/04/11 at 5:48 PM with LVN N, CN who had been assigned to Resident #7, revealed she had seen the order for [MEDICATION NAME] on the MAR for July 2011. When asked why it was not given, LVN N replied, "I never got an INR. Queried whether she ever looked for a lab result, she replied, " I didn't know where to look for an INR, I'm new." When asked how long she had worked at the facility, LVN N replied, "three weeks." When asked if she ever knew to check labs, LVN N stated, "I usually when I came in the nurse would say, 'Here's her labs', I never knew to look." During an interview with LVN G, CN for Resident #7, on 08/05/11 at 1:15 PM, she was asked if she knew it was supposed to be a daily lab and she had input the order incorrectly as a one time order, LVN G stated "I did not know that." On 08/05/11 at 3:36 PM, LVN J, CN who had been assigned to Resident #7, was interviewed regarding Resident #7's lab and [MEDICATION NAME] orders. When shown the MAR for July 2011 and queried regarding no doses given, LVN J stated, "I was waiting on the INR." When queried whether she ever looked for the lab results, LVN J stated she was unable to get into the computer system as she was new. When queried whether she ever asked anyone else to look, LVN J stated "just the day nurse and I would go back and forth; she never told me the INR was back." When queried whether she had access to the computer at that time, LVN J replied, "No." The facility's POR was accepted on 08/08/11. The plan reflected the following: all charts audited for residents receiving [MEDICATION NAME] to identify routine lab orders; MD called for routine lab orders for any residents receiving [MEDICATION NAME] without lab orders; all charts audited for PT/INR results as ordered; Lab book initiated for all PT/INR lab orders to be drawn; Lab service will audit 100% of all labs by 08/08/11 and results of the lab audit will be reviewed and appropriate actions taken on 08/08/11; Lab tracking will be completed to monitor labs; new admissions (readmission) orders will be reviewed by the AN within 72 hours; new admission orders [REDACTED] The POR reflected the following: the CN would will obtain MD order for labs needed; the CN will place the order in the lab book; a copy of the lab orders will brought to the clinical meeting with lab log book. The POR reflected the facility would monitor the system daily during the morning meeting, weekly during the Standards of Care meeting and during the Quality Assurance Meeting. Interview with the DON on 08/06/11 at 1:15 PM revealed new procedures had been put into place and staff were receiving inservice training prior to beginning their shifts. Lab results were set up to print twice per day, at 9:00 AM and 2:00 PM. Chart audits had been completed and ordered lab tests were being documented in a lab binder. All labs were to be signed and dated and all abnormal results were to be called to the MDs. Printed lab results were to be placed directly into the resident's chart after being reviewed and called. PT/INR results were to be documented on the MAR and "Anticoagulation Therapy Monitoring" forms were initiated on all residents receiving anticoagulants. Interviews conducted on 08/06/11 from 1:25 PM through 2:46 PM with LVN G, LVN S, LVN T, LVN J, LVN U, LVN V, and LVN O revealed they had attended the in-service training and they answered the questions regarding the POR appropriately. Interviews conducted on 08/07/11 from 1:47 PM through 2:31 PM with LVN H, RN I, LVN K and LVN L revealed they attended the in-service training and they answered the questions regarding the POR appropriately. 2. A review of the admission nurse's note dated 07/18/11 at 3:30 p.m. revealed Resident #22 was an [AGE] year-old male, who was initially admitted to the facility from the hospital, following an [MEDICAL CONDITION] suffered on 06/30/11. TPO dated 07/27/11 reflected, "2. CBC, CMP, TSH, [MEDICATION NAME], Lipid Panel, Mg (Magnesium), PT/INR in AM then daily. Resume [MEDICATION NAME] 2.5 mg via peg tube daily when INR is less than 2.2 ... " The computer generated order sheet dated 07/28/11 for Resident #22 was printed by the DON on 08/08/11. The printout reflected LVN Q entered all the tests into the computer except the order "PT/INR in AM then daily." Acute visit and initial H&P dated 07/29/11, signed by MD A reflected, "...Staff is to check a stat PT and INR. We will restart the [MEDICATION NAME] at 2.5 mg. a day if the INR is less than 2.2. ..." A TPO for Resident #22 dated 07/29/11 reflected a STAT PT/INR, resume [MEDICATION NAME] at 2.5 mg at night and daily PT/INRs until INR "< 2.2, then PT/INR q Monday." The order was signed by the MD and a nurse signed the order on 08/01/11. Lab result dated 07/29/11 reflected Resident #22's INR was 1.73. A TPO dated 07/31/11 reflected to resume [MEDICATION NAME] 5 mg daily and check the PT/INR in AM. TPO for Resident #22 dated 08/01/11 reflected, "Check PT/INR q Monday & Thursday & call if INR <1.9 or >3.0. [MEDICATION NAME] 2.5 mg not 5 mg at q HS." Lab results dated 08/01/11 for Resident #22 reflected an INR of 1.03. Lab results dated 08/02/11 for Resident #22 reflected an INR of 1.06. Lab results dated 08/03/11 for Resident #22 reflected an INR of 1.01. There was no documentation the MD was notified of the low INR results, so the MD could adjust [MEDICATION NAME] dosage if desired. [DIAGNOSES REDACTED]. A TPO for Resident #22 dated 08/04/11 reflected [MEDICATION NAME] 3 mg daily. During an interview on 08/05/11 at 10:55 AM, MD A revealed, "We have issues with labs and we're trying to figure it out so these things don't happen." When asked if she had issues with [MEDICATION NAME] labs previously, MD A replied, "The exact situation happened here last week with (Resident #22). I caught it. I told them (facility staff) to put discharge orders in the front of the chart not the back. If I don't see [MEDICATION NAME] on the admission order, I don't look at the discharge order necessarily." ADON C was interviewed on 08/05/11 at 4:10 PM regarding Resident #22's [MEDICATION NAME] therapy. She stated, "Dr. (MD A) came Friday (07/29/11) and realized that Mr.(Resident #22) hadn't been getting [MEDICATION NAME]. She looked at the hospital transfer orders and saw that the [MEDICATION NAME] was discontinued. She also looked and there were no PT/INR lab results in the chart although it had been ordered daily on 07/27/11 when he was readmitted . The doctor then ordered a stat PT/INR on 07/29/11. That was the first one he had since he had come back from the hospital. He should have been started back on [MEDICATION NAME] 2.5 mg. on 07/29/11, but that didn't happen ..." An interview with LVN Q on 08/08/11 at 1:40 PM revealed she was the AN. She stated she put the admission labs in the computer. LVN Q stated she did not usually put in PT/INRs. She stated when she received an admission she went back to ensure the orders were done. LVN Q stated she did not know why the PT/INR order was not in the computer. She stated she probably did not look at the resident's chart. She stated she was not sure. 3. Resident #24, an [AGE] year-old male, re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #24's admission orders [REDACTED]. Laboratory orders included PT/INR q Tuesday. MD's orders dated 07/15/11 reflected: "PT/INR today. Call if INR < 1.9 or > 3.1. PT/INR q Tuesdays." Lab results dated 07/21/11, which was a Thursday (Note: The PT/INR was to be checked every Tuesday) reflected INR 0.99. Resident #24's Care Plan dated 07/22/11 reflected: "Problems: Resident is at risk for bleeding R/T (related to) the use of medication for increasing blood flow. Goals: Resident will have lab with in the theraputic (sic) range for the next 90 days. Interventions: Monitor labs for theraputic (sic) range and report abnormals to MD promptly. Caregiver: Nursing..." Lab results dated 07/28/11 (Thursday) reflected INR 0.97. Consolidated MD Orders for the month of August 2011 reflected, "Check PT/INR Q Tuesday. Call M.D. if < 1.9 or >3.1" Lab results dated 08/04/11 (Thursday) reflected INR 0.98. Resident #24's Interdisciplinary Discharge Summary dated 08/05/11 reflected he was discharged home on[DATE]. 5. Resident #16, a [AGE] year-old male, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. MD's orders dated 07/28/11 for Resident #16 reflected "Admit labs: CBC, CMP, TSH, Lipid Panel, RPR, CRP, Vit B12 (Vitamin B12), Folate, Pre-[MEDICATION NAME]." Resident #16's H&P dated 08/01/11 and signed by the Medical Director reflected, "Past History: ....[MEDICAL CONDITIONS] ..." On 08/05/11 at 5:00 PM, the surveyor was unable to locate laboratory results. ADON C was queried and was not able to locate results, so a report was accessed and printed from the computer. ADON C was shown the order for a lab written on 07/28/11 and was asked why no staff or MD had reviewed the lab results. ADON C stated she was surprised to see admission lab orders as Resident #16 was one of the Medical Director's residents and he typically did not order admission labs. When shown the order indicating MD P had ordered the lab tests and not the Medical Director, ADON C stated she would look into it. Lab result dated 08/01/11 reflected: "TSH 39.335. Reference Range 0.360 - 3.740." MD's orders dated 08/05/11 for Resident #16 reflected "D/C [MEDICATION NAME] 25 mcg PO QD. Start [MEDICATION NAME] 75 mcg tab (one) tab PO QD. Recheck TSH in two weeks." (Note: This order was entered after surveyor inquiry.) 6. While the IJ was removed on 08/08/11 at 2:20 PM, the facility remained out of compliance at a scope of "pattern" and a severity level of "no actual harm with potential for more than minimal harm that is not immediate jeopardy" because the facility continued to monitor the implementation of the POR. The ADM and DON were informed at that time. 7. The facility's POR dated 08/04/11 reflected 17 residents received [MEDICATION NAME]. The facility's undated 802 Roster/Sample Matrix form reflected 28 residents resided on Hall 100.

Based on interview and record review, the facility failed promptly notify the MD of lab results for five (Residents #7, #16, #17, #22, and #24) of eight residents reviewed for laboratory services. 1. Resident #7 was admitted from the hospital due to a [MEDICAL CONDITION]. The facility was to do PT/INRs daily and if the resident's INR was less than 2.5 they were to administer medication. The lab completed a PT/INR test four days after admission and two days later the results were printed. Resident #7's INR was 0.95. The MD had not been notified of the results. Another PT/INR was not conducted until surveyor intervention seven days later. 2. Resident #22 was admitted from the hospital due to [MEDICAL CONDITION] 07/27/11. The facility was to do PT/INR in the morning after his admission and then daily. Also if his INR was lower than 2.2 he was to receive medication. The PT/INR for the day after admission was not done. The MD wrote an order for [REDACTED].< 2.2 (sic)," and then PT/INRs each Monday. PT/INRs were not done on 07/30/11, and 07/31/11. The MD was not notified of the results. 3. Resident #17 was to receive [MEDICATION NAME] 5 mg daily and PT/INR tests were to be conducted. If the resident's INR was less than 2.0 or greater than 3.2, the staff were to inform the MD. Resident #17's INR was less than 2.0 multiple times. On 07/21/11 the resident's INR was 0.88. The MD was not notified of the results. 4. Resident #24 was receiving [MEDICATION NAME] 2.5 mg daily. There was a MD's order to check the PT/INR every Tuesday and notify the MD if the INR was less than 1.9 or greater than 3.1. A PT/INR test was completed on 07/21/11, which was a Thursday and the resident's INR was 0.99. Another PT/INR test was performed on 07/28/11 (Thursday) and the resident's INR was 0.97. Another PT/INR was completed on 08/04/11 (Thursday) and the resident's INR was 0.98. The MD was not notified promptly of several results. 5. Resident #16 had a TSH level ordered on [DATE]. The test was completed on 08/01/11 with the results being 39.335. The reference range on the lab was 0.360 through 3.740. The MD was not notified of the results until after surveyor intervention. An Immediate Jeopardy (IJ) was identified on 08/04/11. While the IJ was removed on 08/08/11, the facility remained out of compliance at a scope of "pattern" and a severity level of "no actual harm with potential for more than minimal harm that is not immediate jeopardy" because the facility was monitoring the implementation of the POR. These failures could affect the 17 residents, who received [MEDICATION NAME], including Residents #7, #22, #17, and #24 by placing them at risk of developing blood clots that can lead to stroke, [MEDICAL CONDITION] embolism (blood clot in the lung),and/or bruising and bleeding. These failures could also affect the 28 residents, including Resident #16, who resided on Hall 100, by placing them at a risk of delayed treatment. Findings included: 1. Resident #7, a [AGE] year-old female resident, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Hospital PPNdated 07/19/11 reflected she was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. MD's Order dated 07/25/11 reflected: "1. PT/INR daily. Resume [MEDICATION NAME] at 2 mg per peg Q PM when INR < 2.5" Lab report dated 07/26/11 at 11:46 AM reflected INR 0.95. This lab result page reflected, "Printed 07/28/2011 12:43 PM." No other PT/INR results were found for Resident #7. PPN dictated by MD A with "Date of Visit: 07/29/11" reflected, "...Medications: Reviewed in the chart. Labs: Reviewed as available in the chart...." Care Plan for Resident #7 dated 07/29/11 reflected the following: "Problems: Resident is at risk for bleeding related to the use of anticoagulant therapy. Interventions: Meds as ordered. Caregiver: Nursing. Monitor labs and report to MD promptly. Caregiver: Nursing." PPN dictated by MD M dated 08/01/11 reflected the following: "...Lab: Labs reviewed as available on chart....." Interview with Resident #7 on 08/03/11 at 11:30 AM revealed she usually stayed in her bed and often did not want to get up. She stated she was still "pretty weak." On 08/04/11 at 2:50 PM ADON C, who identified herself as the ADON assigned to Resident #7's hall, was interviewed. When shown the print date on Resident #7's lab result and queried who printed the result, ADON C stated the new system "...just spits labs out" and she did not know who placed the lab result in the chart. ADON C was asked when the MDs were notified of lab results and she stated the MDs, MD Assistants or NPs were always notified. ADON C pointed out MD A's lab book. (A binder kept at the nurse's station with pockets inside for each room number. Diagnostic test results were to be placed in the folder for each resident according to their room number.) Resident #7's PT/INR results dated 07/26/11 were observed in MD A's lab book. The report reflected "Printed 07/26/2011 11:48 AM" and there were no handwritten notations made on the form to indicate it had been reviewed. ADON C explained if the report printed the day MD A came to the facility, the report was given to her, on other days the report would be given to NP D or whichever MD Assistant or NP was there. Queried whether there was anyway to know whether any MD had seen the lab, ADON C replied "(MD A) always signs her labs and (MD M) doesn't look into the book, we have to bring it to her." When ADON C was shown the PT/INR result with two separate print dates and queried who may have placed the results in the chart and MD's lab book, she stated she did not know. Interview with NP D on 08/04/11 at 3:33 PM revealed he was not made aware of Resident #7's PT/INR level prior to that day. When asked how the medical staff would follow-up on the lab results, NP D stated the nurses were supposed to check the labs and when "anything out of the ordinary" was found, they were to bring it to his attention, MD A, or MD M. NP D stated if he had known about her lab result, he would have ensured her [MEDICATION NAME] was started that day. NP D added that part of his job at the facility was to provide in-service training to the staff and stated one of his in-services was related to lab monitoring and when to call the MDs. When queried when the in-service was done, NP D presented his in-service book and provided an In-service Training report dated 05/18/11 with the topic titled, "Laboratory Analysis and Reporting." The in-service content included interpretation of common labs and the importance of reporting labs promptly "to prevent pts (patient's) labs from declining further." PT/INR monitoring was included in the in-service. NP D stated INRs less than 1.5 or > 4 should be immediately reported to the MD, but the facility's MDs changed it. He stated the MDs decided INRs < 1.5 or > 3 should be immediately reported. Interview with ADON C on 08/04/11 at 4:04 PM revealed the STAT INR result was 0.98. ADON C was removing lab results from the printer and showed the surveyor an example of a lab result printing. She stated she looked at the results and if she noted abnormal lab values or trends she would address it then. She added if the lab result belonged to a resident cared for by another nurse, she would get the result to the proper nurse. The surveyor queried, "So it is every charge nurse's job to check the printer?" ADON C replied, "Yes." Lab Process document dated 07/20/10 and located in the front of the lab book at the nurse's station reflected the following: "To: Nurses and ADONs. From: (DON)... 2. Every morning the first ADON to the facility will pull the completed lab results and review for abnormalities. The MD, per protocol for abnormal and critical, will be notified and the results will be placed in the lab books for MD follow up...." An undated Laboratory Communication policy provided by the DON on 08/04/11 reflected, "Procedure: When results of diagnostic tests are received by the facility, the licensed nurse should review the result, assess the resident, review the resident's medical record, and make a decision for immediate or non-immediate notification. If the decision is for non-immediate notification, the licensed nurse should fax the results to __. If the results are normal or the test was done on a routine basis, and the nurse expects the MD or advanced practice nurse in the facility that week, the results do not have to be faxed, but may be left in the Communication Manual for review. All panic lab values, unless the value is normal for that person, should immediately be relayed (by phone call) to the MD." An IJ was identified on 08/04/11 at 4:55 PM in the area of Lab Services and the Administrator and the DON were notified at that time. A POR was requested at that time. An interview on 08/04/11 at 5:48 PM with LVN N, CN who had been assigned to Resident #7, revealed, " I didn't know where to look for an INR, I'm new." When asked how long she had worked at the facility, LVN N replied, "three weeks." When asked if she ever knew to check labs, LVN N stated, "I usually when I came in the nurse would say, 'Here's her labs', I never knew to look." Interview with LVN G, CN for Resident #7, on 08/05/11 at 1:15 PM revealed the ADONs pulled the labs reports in the morning and gave them to the CNs and "...if you had to know something, you pull the lab and check." During an interview on 08/05/11 at 10:55 a.m. MD A was queried if she saw Resident #7's INR lab result dated 07/26/11. She replied, "I don't remember. If I see it it'll have my signature on it." When asked if she would expect to be called for a lab result reflecting an INR value of 0.95, MD A replied, "if they're (resident) is on [MEDICATION NAME] then yes. I have a folder for every hall where labs are kept." MD A reviewed Resident #7's medical record and commented "I don't see [MEDICATION NAME] on her (Resident #7) admission order. It was put on my order on the 25th (July)." The surveyor informed MD A that her PPN on 07/29/11 and 08/01/11 reflected, "labs reviewed in chart." MD A revealed "when I see a resident I look for labs in the folder." When MD A was asked if she requested labs that were not in the folder she replied "many times I do and they (nursing staff) will print them out." When asked if she reviewed any of Resident #7's labs MD A replied, "I would say that I didn't see it because I always sign them." When asked if she received phone calls from facility staff when a resident's lab report was abnormal, MD A replied, "Most of the time we expect to get a call from staff." When asked if she always received a call from staff when lab reports were abnormal, MD A replied, "yes." When asked if she recalled looking or requesting Resident #7's lab report on 07/29/11, MD A replied, "no." When asked if there have been cases where abnormal labs have not been reported to her MD A replied, "I'm sure things have come up and that's why we started the folders and then things improved. Before that it was hard to see where labs were going. Now I can track it better." The surveyor informed MD A that Resident #7's lab reports were not reviewed or signed for six days between 07/25/11 and 08/01/11, when the resident was seen by MD M and it was not discovered by facility staff. MD A replied, "I ask them to print them out, sometimes they're busy or sometimes I forget." The facility's POR was accepted on 08/08/11. The plan reflected the following: all charts audited for residents receiving [MEDICATION NAME] to identify routine lab orders; MD called for routine lab orders for any residents receiving [MEDICATION NAME] without lab orders; all charts audited for PT/INR results as ordered; Lab book initiated for all PT/INR lab orders to be drawn; Lab service will audit 100% of all labs by 08/08/11 and results of the lab audit would be reviewed and appropriate actions taken on 08/08/11; Lab tracking will be completed to monitor labs. The POR reflected the following: the CN would obtain MD order for labs needed; the CN would place the order in the lab book; a copy of the lab orders would be brought to the clinical meeting with lab log book; labs would be printed out each day prior to the morning meeting, between 12:00 PM and 2:00 PM and again by 6:00 PM by the ADON and Weekend supervisor; after review of the lab results, the ADON or weekend supervisor would stamp the lab and notify the MD, resident and/or family; if needed, a new MD's order would be obtained; the ADON or Weekend Supervisor would communicate verbally to the CN any changes in the MD's orders. Interview with the DON on 08/06/11 at 1:15 PM revealed new procedures had been put into place and staff were receiving inservice training prior to beginning their shifts. Lab results were set up to print twice per day, at 9:00 AM and 2:00 PM. Chart audits had been completed and ordered lab tests were being documented in a lab binder. All labs were to be signed and dated and all abnormal results were to be called to the MDs. Printed lab results were to be placed directly into the resident's chart after being reviewed and called. Interviews conducted on 08/06/11 from 1:25 PM through 2:46 PM with LVN G, LVN S, LVN T, LVN J, LVN U, LVN V, and LVN O revealed they had attended the in-service training and they answered the questions regarding the POR appropriately. Interviews conducted on 08/07/11 from 1:47 PM through 2:31 PM with LVN H, RN I, LVN K and LVN L revealed they attended the in-service training and they answered the questions regarding the POR appropriately. 2. A review of the admission nurse's note dated 07/18/11 at 3:30 p.m. revealed Resident #22 was an [AGE] year-old male, who was initially admitted to the facility from the hospital, following an [MEDICAL CONDITION] suffered on 06/30/11. TPO dated 07/27/11 reflected, "2. CBC, CMP, TSH, [MEDICATION NAME], Lipid Panel, Mg (Magnesium), PT/INR in AM then daily. Resume [MEDICATION NAME] 2.5 mg via peg tube daily when INR is less than 2.2 ... " The computer generated order sheet dated 07/28/11 for Resident #22 was printed by the DON on 08/08/11 reflected "PT/INR in AM then daily" was not entered in the computer. A TPO for Resident #22 dated 07/29/11 reflected a STAT PT/INR, resume [MEDICATION NAME] at 2.5 mg at night and daily PT/INRs until INR "< 2.2, then PT/INR q Monday." The order was signed by the MD and a nurse signed the order on 08/01/11. Lab result dated 07/29/11 reflected Resident #22's INR was 1.73. A TPO dated 07/31/11 reflected to resume [MEDICATION NAME] 5 mg daily and check the PT/INR in AM. TPO for Resident #22 dated 08/01/11 reflected, "Check PT/INR q Monday & Thursday & call if INR <1.9 or >3.0. [MEDICATION NAME] 2.5 mg not 5 mg at q HS." Lab results dated 08/01/11 for Resident #22 reflected an INR of 1.03. Lab results dated 08/02/11 for Resident #22 reflected an INR of 1.06. Lab results dated 08/03/11 for Resident #22 reflected an INR of 1.01. There was no documentation the MD was notified of the low INR results, so the MD could adjust [MEDICATION NAME] dosage if desired. During an interview on 08/05/11 at 10:55 AM, MD A revealed, "We have issues with labs and we're trying to figure it out so these things don't happen." When asked if she had issues with [MEDICATION NAME] labs previously, MD A replied, "The exact situation happened here last week with (Resident #22). I caught it. I told them (facility staff) to put discharge orders in the front of the chart not the back. If I don't see [MEDICATION NAME] on the admission order, I don't look at the discharge order necessarily." ADON C was interviewed on 08/05/11 at 4:10 PM regarding Resident #22's [MEDICATION NAME] therapy. She stated, "Dr. (MD A) came Friday (07/29/11) and realized that Mr.(Resident #22) hadn't been getting [MEDICATION NAME]. She looked at the hospital transfer orders and saw that the [MEDICATION NAME] was discontinued. She also looked and there were no PT/INR lab results in the chart although it had been ordered daily on 07/27/11 when he was readmitted . The doctor then ordered a stat PT/INR on 07/29/11. That was the first one he had since he had come back from the hospital. He should have been started back on [MEDICATION NAME] 2.5 mg. on 07/29/11, but that didn't happen ..." 3. Review of Resident #17's TPO dated 07/04/11 revealed, "(Check) PT/INR q Tuesday and call if INR < 2.0 or > 3.2." Lab result for Resident #17 dated 07/05/11 reflected INR 0.92. There were no indications the MD had been notified of the results. Resident #17's lab result dated 07/08/11 at 4:05 PM reflected INR 0.86. The lab result reflected "Printed 07/11/2011 8:11 AM." A handwritten note on the lab result reflected, "Pt off [MEDICATION NAME] 2 (secondary to) epistaxis (nosebleed). LE (lower extremity) Ultrasound nl (normal) will continue 0 (no) [MEDICATION NAME]. (MD W)." Review of Resident #17's July 2011 MAR indicated [REDACTED]. Resident #17's lab result dated 07/13/11 at 6:25 AM reflected INR 0.89. There was no indication the MD was notified. Resident #17's TPO dated 07/14/11 reflected, "Give [MEDICATION NAME] 1 MG tab tonight and tomorrow and continue with 5 MG 1 tab PO daily. Recheck PT INR in one week." Resident #17's lab result dated 07/19/11 at 9:05 AM reflected INR 0.91. There was no indication the MD was notified. Review of the MDS assessment dated [DATE] revealed Resident #17 was an [AGE] year-old female, who was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #17's lab result dated 07/21/11 at 9:05 AM reflected INR 0.88. Resident #17's Lab result dated 07/26/11 at 6:20 AM reflected INR 1.47. NP D was interviewed on 08/04/11 at 5:30 PM regarding [MEDICATION NAME] dosages and INR results. He revealed when residents were taking [MEDICATION NAME] and had low INR results, which were not affected by changing the dosage of [MEDICATION NAME], the facility started to suspect residents might not be receiving [MEDICATION NAME]. He continued to explain residents on a substantial dose of [MEDICATION NAME] would not have the medication dosage adjusted until it was certain the [MEDICATION NAME] was given. NP D stated the facility addressed the problem by having licensed nurses administer [MEDICATION NAME] instead of the MAs. He stated, when that approach failed, the facility initiated the [MEDICATION NAME] count sheets beginning 07/16/11 for Resident #17. NP D stated review of INR results indicated this approach was also ineffective. During this time NP D was not able to locate an order for [REDACTED]. 4. Resident #24, an [AGE] year-old male, re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #24's admission orders [REDACTED]. Laboratory orders included PT/INR q Tuesday. MD's orders dated 07/15/11 reflected: "PT/INR today. Call if INR < 1.9 or > 3.1. PT/INR q Tuesdays." Lab results dated 07/15/11 reflected INR 1.15. This result was stamped indicating MD A was notified of the results on 07/22/11. Lab results dated 07/21/11, which was a Thursday (Note: The PT/INR was to be checked every Tuesday) reflected INR 0.99. This result was stamped indicating MD A was notified of the results on 07/22/11. Resident #24's Care Plan dated 07/22/11 reflected: "Problems: Resident is at risk for bleeding R/T (related to) the use of medication for increasing blood flow. Goals: Resident will have lab with in the theraputic (sic) range for the next 90 days. Interventions: Monitor labs for theraputic (sic) range and report abnormals to MD promptly. Caregiver: Nursing..." Lab results dated 07/28/11 (Thursday) reflected INR 0.97. This result was stamped and initialed with no date. Consolidated MD Orders for the month of August 2011 reflected, "Check PT/INR Q Tuesday. Call M.D. if < 1.9 or >3.1" Lab results dated 08/04/11 (Thursday) reflected INR 0.98. This result was not stamped or initialed. MD's Order for Resident #24 dated 08/04/11 reflected "Change [MEDICATION NAME] to 3.0 mg p.o. Q Fri & Sat @ 1700 (5:00 PM). [MEDICATION NAME] 2.5 mg P.O. Q mon, tues, wed, thur & sun @ 1700." Review of Resident #24's MARs for July 2011 and August 2011 revealed he received [MEDICATION NAME] 2.5 mg at 5:00 PM daily from 07/14/11 through 08/04/11. Resident #24's Interdisciplinary Discharge Summary dated 08/05/11 reflected he was discharged home on[DATE]. 5. Resident #16, a [AGE] year-old male, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. MD's orders dated 07/28/11 for Resident #16 reflected "Admit labs: CBC, CMP, TSH, Lipid Panel, RPR, CRP, Vit B12 (Vitamin B12), Folate, Pre-[MEDICATION NAME]." Resident #16's History and Physical dated 08/01/11 and signed by the Medical Director reflected, "Past History: ....[MEDICAL CONDITIONS] ..." On 08/05/11 at 5:00 PM, the surveyor was unable to locate laboratory results. ADON C was queried and was not able to locate results, so a report was accessed and printed from the computer. ADON C was shown the order for a lab written on 07/28/11 and was asked why no staff or MD had reviewed the lab results. ADON C stated she was surprised to see admission lab orders as Resident #16 was one of the Medical Director's residents and he typically did not order admission labs. When shown the order indicating MD P had ordered the lab tests and not the Medical Director, ADON C stated she would look into it. Lab result dated 08/01/11 reflected: "TSH 39.335. Reference Range 0.360 - 3.740." MD's orders dated 08/05/11 for Resident #16 reflected "D/C [MEDICATION NAME] 25 mcg PO QD. Start [MEDICATION NAME] 75 mcg tab (one) tab PO QD. Recheck TSH in two weeks." (Note: This order was entered after surveyor inquiry.) 6. While the IJ was removed on 08/08/11 at 2:20 PM, the facility remained out of compliance at a scope of "pattern" and a severity level of "no actual harm with potential for more than minimal harm that is not immediate jeopardy" because the facility continued to monitor the implementation of the POR. The ADM and DON were informed at that time. 7. The facility's POR dated 08/04/11 reflected 17 residents received [MEDICATION NAME]. The facility's undated 802 Roster/Sample Matrix form reflected 28 residents resided on Hall 100.