Every finding on record at Twin Oaks Nursing Home

Based on interviews and record reviews, the facility failed to report an injury of unknown source with serious bodily injury to the State Survey Agency within two (2) hours for 1 (Resident #1) of 3 residents sampled for quality of care and treatment.Findings:Review of the facility's undated Abuse, Neglect, and Misappropriation of Funds Program policy and procedure, revealed, if the determination is that abuse occurred or was unable to be determined with reasonable certainty, or the source of the injury was unknown and cannot be determined, the incident will be reported by the Administrator to the Department of Health and Hospitals through the States Incident Management System.Review of the facility's State Incident Management System report #316731 revealed, in part, an incident was reported to the State Survey Agency on 12/16/2025 at 4:15PM revealing Resident #1 experienced an injury of unknown origin and had bruising to his left shoulder, which was reported by Resident #1 the week prior to 12/16/2025.Review of Resident #1's quarterly Minimum Data Set with an Assessment Reference Date of 12/09/2025, revealed, in part, Resident #1 had a Brief Interview for Mental Status of 99, which indicated Resident #1 could not be interviewed and/or confused at the time of the assessment. Further review revealed Resident #1 had impairment to his upper and lower extremities and was dependent on staff for transfers and activities of daily living.Review of nurse progress note dated 12/09/2025 at 9:42AM revealed, in part, Resident #1 complained of pain to his left shoulder.In an interview on 01/14/2026 at 3:50PM, S3Nurse Practitioner was notified on 12/11/2025 Resident #1 complained of pain to his left shoulder and ordered an x-ray of Resident #1's left shoulder.Review of Resident #1 radiology report dated 12/11/2025 revealed, in part, Resident #1 had an age-indeterminate (new or old) fracture of the proximal (closer to the center of the body) left humerus (bone in upper arm) with mild displacement of the distal (away from the center of the body) fragment.Review of Resident #1's physician progress note dated 12/16/2025 revealed, in part, an x-ray of the left shoulder and upper arm revealed an acute (sudden onset) displaced angulated fracture through the surgical neck of the humerus with medial (middle) displacement of the shaft. In an interview on 01/14/2025 at 9:51AM, S1Administrator indicated she was notified of Resident #1's reports of pain on 12/11/2025. S1Administrator further indicated she determined that the injury was not of unknown origin based on Resident #1's diagnosis of osteoporosis and did not suspect abuse; therefore, it was not reported to the State Survey Agency timely as required. In an interview on 01/15/2026 at 2:35PM, S2Director of Nursing indicated she determined that Resident #1's injury was not of unknown origin based on Resident #1's diagnosis of osteoporosis and did not suspect abuse; therefore, it was not reported to the State Survey Agency timely as required.

Based on observations and interviews, the facility failed to ensure a resident's room was maintained free of odors, soiled linens, a spill, and debris for 1 (Resident #56) of 7 (Resident #1, Resident #12, Resident #45, Resident #49, Resident #56, Resident #83, Resident #89) sampled residents investigated for environment. Findings: Observation on 08/11/2025 at 9:26AM, revealed Resident #56's room had a strong unpleasant odor. Observation further revealed linens with an odor were piled on Resident #56's roommate's bed. Further observation of Resident #56's room revealed a small puddle of an unknown liquid by the door, small pieces of paper, a straw, and other small white colored debris scattered on the floor. In an interview on 08/11/2025 at 9:31AM, S7Certified Nursing Assistant (CNA) confirmed the presence of a strong urine odor, soiled linen on Resident #56's roommate's bed, trash and debris on the floor, and a spill by the door. In an interview on 08/13/2025 at 1:42PM, S2Director of Nursing stated S7CNA confirmed the above findings in Resident #56's room. S2DON acknowledged Resident #56's room should not have been in that state.

Based on observation, interview, and record review, the facility failed to ensure respiratory nebulizer tubing was changed and dated 1 (Resident #22) of 8(Resident #1, Resident #12, Resident #13, Resident #15, Resident #22, Resident #49, Resident #56 and Resident #89) sampled residents investigated for respiratory care. Findings:Review of Resident #22's July 2025 and August 2025 physician's orders revealed, in part, the nurse was to change and date all respiratory tubing/supplies/storage bag every Sunday on the 11:00PM to 7:00AM shift. Observation on 08/11/2025 at 9:58AM revealed Resident #22's nebulizer tubing was dated 07/07/2025. Observation on 08/12/2025 at 2:45PM revealed Resident #22's nebulizer tubing was dated 07/07/2025.In an interview on 08/13/2025 at 1:09PM, S18Licensed Practical Nurse (LPN) indicated nebulizer tubing should be changed every week on Sunday. In an interview on 08/13/2025 at 1:11PM, S17LPN indicated nebulizer tubing should be changed every week on Sunday night. Observation on 08/13/2025 at 1:17PM Resident #22's nebulizer tubing was dated 07/07/2025. In an interview on 08/13/2025 at 1:19PM, S2Director of Nursing (DON) indicated nebulizer tubing was to be changed and dated, with the date tubing was changed, weekly. Observation completed with S2DON on 08/13/2025 at 2:05PM revealed Resident #22's nebulizer tubing was dated 07/07/2025. In an interview on 08/13/2025 at 2:05PM, S2DON confirmed Resident #22's nebulizer tubing had not been changed since 07/07/2025 and should be changed weekly.

Based on observations, interviews, record review, the facility failed to ensure menu substitutions were approved by the facility's dietician. Findings:Review of the facility's approved lunch menu for 08/11/2025 revealed, in part, the facility was to serve white beans, ham, steamed rice, and brussel sprouts.Observation on 08/11/2025 at 12:05PM revealed the lunch menu served was white beans, rice, and beets.In an interview on 08/12/2025 at 10:45AM, S12Dietary Manager (DM) indicated she did not document the substitution of beets for the 08/11/2025, nor had she notified S19RD for approval of the substitution. In an interview on 08/12/2025 at 2:47PM, S1Administrator indicated the before menu revision should have been documented, and S19Registered Dietician (RD) should have been notified of the above mentioned menu change.In an interview on 08/12/2025 at 3:47PM, S19RD indicated the facility had not notified him of the above mentioned substitution. There was no documented evidence, and the facility could not produce any documented evidence, S19RD was notified of the revision to the facility's lunch menu on 08/11/2025.

Based on observations and interviews the facility failed to:1. Ensure food items stored in the facility's three door refrigerator and the facility's freezer were dated once opened; 2. Ensure food items stored in the facility's three door refrigerator were covered; 3. Ensure food items from an outside source which were stored in the facility's freezer were labeled; and, 4. Ensure the sanitization test strips used to test the amount of sanitization in the dishwasher were not expired. Findings: 1. Observation on 08/12/2025 at 8:20AM revealed three undated disposable bowls with round multi colored dry cereal, and one undated disposable bowl of dry corn cereal in the facility's three door refrigerator. In an interview on 08/12/2025 at 8:30AM, S12Dietary Manager (DM) indicated the above mentioned items in the facility's three door refrigerator should have been labeled with an opened date. Observation on 08/12/2025 at 9:10AM revealed an undated partially used container of frozen chicken liver in the facility's freezer. In an interview on 08/11/2025 at 9:10AM, S12DM indicated the above mentioned item should have been labeled with an opened date once in the facility's freezer. In an interview on 8/12/2025 at 2:47PM, S1Administrator indicated above mentioned item should have been labeled with an opened date once in the facility's freezer. Observation on 08/12/2025 at 8:20AM revealed three disposable cups of a pudding like substance with no opened date in the facility's three door refrigerator. In an interview on 08/12/2025 at 8:21AM, S12DM indicated the above mentioned items in the facility's three door refrigerator should have have been labeled with an opened date. In an interview on 8/12/2025 at 2:47PM, S1Administrator indicated the above-mentioned items should have had an open date once opened. 2.Observation on 08/12/2025 at 8:20AM revealed three disposable cups of a pudding like substance not covered and in the facility's three door refrigerator. In an interview on 08/12/2025 at 8:21AM, S12DM indicated the above mentioned items in the facility's three door refrigerator should have been covered. In an interview on 8/12/2025 at 2:47PM, S1Administrator indicated the above-mentioned items should have been covered. 3. Review of the facility's Preventing Foodborne Illness policy and procedure, revised July 2014, revealed the facility only accepted prepared foods from suppliers subject to federal, state or local food service inspections and who remain in good standing with such agencies. Observation on 08/11/2025 at 9:10AM revealed a bottle of frozen hydrate alkaline water and a frozen bottle of an electrolyte drink were stored in the facility's freezer and not labeled to indicate they were from an outside food source and not from an approved supplier. In an interview on 08/11/2025 at 9:11AM, S12DM indicated the above-mentioned bottle of electrolyte drink was for a resident was from an outside source. S12DM further indicated the above-mentioned frozen bottle of hydrate alkaline water was from an outside source. In an interview on 08/12/2025 at 2:47PM, S1Administrator indicated the above mentioned items should not have been in the facility's freezer. 4. Observation on 08/13/2025 at 12:06PM revealed the sanitization test strips for the facility's low temperature dishwasher had an expiration date of 07/2025. In an interview on 08/13/2025 at 12:06PM, confirmed the sanitization test strips with an expiration date of 07/2025 were expired and should not have been used.

Based on observation, interview, and record review, the facility failed to ensure:1. Staff wore the appropriate Personal Protective Equipment (PPE) while moving a mattress in the room of a resident on contact isolation precautions (an infection control strategy that uses gloves and gowns to prevent the spread of multi-drug resistant organisms) (Resident #90); and,2. Staff wore the appropriate PPE while providing care to a resident on Enhanced Barrier Precautions (EBP) (an infection control strategy that uses gloves and gowns during high-contact resident care to reduce the spread of infection) (Resident #4).This deficient practice was identified for 2 (Resident #4, Resident #90) of 5 (Resident #4, Resident #62, Resident #76, Resident #82, Resident #90) sampled residents observed for infection control practices during direct resident care.Findings:1. Review of the facility's Isolation-Categories of Transmission-Based policy and procedure, revised on 09/2022, revealed in part, staff members should wear gloves when entering the room of a resident on contact isolation precautions. Further review revealed staff members were to wear a disposable gown upon entering the room of a resident on contact isolation precautions and avoid touching potentially contaminated surfaces with clothing after the gown was removed. Review of Resident #90's care plan with an initiated date of 08/07/2025 revealed, in part, Resident #90 had osteomyelitis (an infection of the bone). Review of Resident #90's August 2025 physician's orders revealed, in part, an order dated 08/08/2025 for contact isolation precautions related to Resident #90's Methicillin Resistant Staphylococcus Aureus (MRSA) (an infection resistant to certain antibiotics). Observation on 08/12/2025 at 1:03PM revealed Resident #90's door was opened and Resident #90's room door displayed a contact isolation precaution sign. Further observation revealed S10Maintenance moved Resident #90's uncovered mattress without wearing gloves and/or a gown. Further observation revealed as S10Maintenance moved Resident #90's uncovered mattress, the uncovered mattress touched the bottom of S10Maintenance's shirt and the top of S10Maintence's pants. In an interview on 08/12/2025 at 1:03PM, S11Assistant Director of Nursing (ADON) confirmed Resident #90 was on contact isolation precautions. S11ADON further confirmed S10Maintenance was in Resident #90 without a gown and/or gloves. S11ADON further indicated S10Maintenence should have had a gown and/or gloves on when moving Resident #90's mattress. In an interview on 08/12/2025 at 1:04PM, S10Maintenance confirmed he was in Resident #90's room without a gown and/or gloves on 08/12/2025 at 1:03PM and indicated he should have had a gown and/or gloves on when handling Resident #90's mattress. In an interview on 08/12/2025 at 1:10PM, S2Director of Nursing (DON) acknowledged S10Maintenance should have worn a gown and had gloves on while in Resident #90's room. 2. Review of the facility's undated policy and procedure titled Infection Prevention and Control Program revealed it is the policy of the facility for employees to wear Personal Protective Equipment (PPE) when there is a potential for direct exposure to body fluids. Review of the facility's policy and procedure titled Catheter Care, Urinary, dated 2001, revealed catheter care included in part, emptying the urine collection bag. In an interview on 08/11/2025 at 11:13AM, S20Licensed Practical Nurse (LPN)/Infection Preventionist (IP) indicated residents that are placed on Enhanced Barrier Precautions (EBP) are identified by a yellow sign above the resident's bed which required staff to apply Personal Protective Equipment (PPE). Observation on 08/13/2025 at 9:30AM revealed an EBP sign above Resident #4's bed that indicated a gown must be worn. Further observation revealed S16Certified Nursing Assistant (CNA) was not wearing a gown when she drained the urine from Resident #4's urine collection bag into the output container, and when she emptied the output container into the toilet. In an interview on 08/13/2025 at 9:31AM, S16CNA acknowledged she was not wearing a gown while she drained Resident #4's urine collection bag and emptied it into the toilet. S16CNA indicated she did not think it was required because the EBP sign was not on Resident #4's door. In an interview on 08/13/2025 at 1:39PM, S2DON indicated PPE should be worn for catheter care.

Based on record reviews and interview, the facility failed to ensure its facility-wide assessment addressed the behavioral health needs of its resident population as required . This deficient practice was identified for 3 (Resident #2, Resident #3, Resident #4) of 2 (Resident #2, Resident #3, Resident #4) sampled residents reviewed for behavioral health needs. Findings : Review of the facility's matrix revealed 42 residents were identified as having behavioral health needs Review of the facility's September 2024 facility-wide assessment last revised September 2024 revealed no documented evidence and the facility did not present any documented evidence its facility wide assessment addressed the behavioral health needs of its resident population, staff competencies related to the behavioral health needs of its resident population, or facility resources necessary to care for the behavioral health needs of its resident population. In an interview on 04/30/2025 at 4:15PM, S1Administrator confirmed the above mentioned findings.

Based on record reviews and interviews, the facility failed to notify the State's Long-Term Care Ombudsman of discharges in writing for 2 (Resident #3, Resident R1) of 3 (Resident #1, Resident #3, Resident R1) sampled residents reviewed for discharge requirements. Findings: Resident #3 Review of Resident #3's electronic medical record (EMR), in part, revealed he was discharged from the facility on 03/05/2025. Resident R1 Review of Resident R1's EMR, in part, revealed she was discharged from the facility on 01/11/2025. The facility did not present any documented evidence the State's Long-Term Care Ombudsman was notified of Resident #3 or Resident R1's discharge in writing as required.

Based on record reviews and interviews, the facility failed to protect a resident's right to be free from resident to resident physical abuse for 1 (Resident #4) of 4 (Resident #1, Resident #2, Resident #3, Resident #4) sampled residents reviewed for resident rights. Findings: Review of the facility's undated Abuse, Neglect and Misappropriation of Funds Program policy revealed, in part, abuse was defined as the willful infliction of injury which resulted in physical harm or pain. Further review revealed physical abuse way defined as hitting, slapping, pinching, kicking and any other means used to cause physical injury to a resident. Review of Resident #4's Electronic Medical Record (EMR) revealed, in part, a note by S4Registered Nurse (RN) dated 11/07/2024 at 10:42AM indicating Resident #4 was complaining of pain to his right upper lip after he was hit by another resident. Further review revealed when S4RN assessed Resident #4 and noted that Resident #4's right upper lip was swollen. Review of the facility's investigative documents for the above mentioned revealed a written statement signed by S5Certified Nursing Assistant which revealed S5CNA witnessed Resident #2 repeatedly hit Resident #4 in the face. In an interview on 04/30/2025 at 1:38PM, S6Quality Assurance (QA) Nurse indicated she was one of the employees investigating the incident between Resident #2 and Resident #4. S6QA Nurse further indicated she would not consider the incident which occurred between Resident #2 and Resident #4 as physical abuse because Resident #2 hit Resident #4 because he was digging in his bag. In an interview on 04/30/2025 at 2:25PM, S4RN indicated she assessed Resident #4 after he was hit in the face by Resident #2 and she noted that his lip was swollen. In an interview on 04/30/2025 at 2:50PM, S1Administrator confirmed Resident #4 hit Resident #2, but she did not not consider it to be abuse.

Based on record reviews and interview, the facility failed to ensure a resident with a new diagnosis of bipolar disorder (a mood disorder that can cause intense mood swings) was referred to the appropriate state agency for a Preadmission Screening and Resident Review (PASARR) Level II evaluation as required for 1 (Resident #3) of 2 (Resident #1, Resident #2, Resident #3) sampled residents reviewed for PASARR. Findings: Review of Resident #3's electronic medical record (EMR) revealed, in part, Resident #3 was admitted to the facility on [DATE] with a Level I PASARR which was approved for a temporary period from 01/22/2024 through 04/20/2024 for skilled therapies. Further review revealed Resident #3 received another Level I PASARR screening dated 04/21/2024 indicating Level II services were not required. Review of Resident #3's psychiatric assessment completed on 02/07/2025 revealed, in part, Resident #3 received a new diagnosis of bipolar disorder. Review of Resident #3's EMR revealed no documented evidence, and the facility did not present any documented evidence, that a Level II PASARR screening was completed for Resident #3 after his new diagnosis of bipolar disorder. In an interview on 04/29/2025 at 3:10PM, S3Social Worker indicated she had never completed a new referral to the Office of Behavioral Health for a PASARR Level II screening for Resident #3 after his new diagnosis of bipolar disorder, as required.

Based on interview record and reviews, the facility failed to report an incident of resident to resident abuse to the statewide incident management system (SIMS) as required for 2 (Resident #2, Resident #4) of 4 (Resident #1, Resident #2, Resident #3, Resident #4) sampled residents. Findings: Review of the facility's undated Abuse, Neglect and Misappropriation of Funds Program policy revealed, in part, abuse was defined as the willful infliction of injury with resulting physical harm or pain. Further review revealed physical abuse is defined as hitting, slapping, pinching, kicking and any other means used to cause physical injury to a resident. Further review revealed if the determination was that abuse occurred or was unable to determine with reasonable certainty, or the injury was unknown and cannot be determine, the incident will be reported by the administrator to the state surveying agency. Review of Resident #4's Electronic Medical Record (EMR) revealed, in part, a nurse's note by S4Registered Nurse (RN) dated 11/07/2024 at 10:42AM indicating Resident #4 was complaining of pain to his right upper lip after he was hit by another resident. Further review revealed when S4RN assessed Resident #4 she noted that his right upper lip was swollen. Review of the facility's investigative documents for the above mentioned incident revealed a written statement signed by S5Certified Nursing Assistant (CNA) which revealed S5CNA witnessed Resident #4 repeatedly hit Resident #2 in the face. In an interview on 04/30/2025 at 2:50PM, S1Administrator confirmed Resident #2 hit Resident #4 but, she did not consider it to be abuse. S1Administrator further confirmed the above mentioned findings were not reported to the SIMS.

Based on record reviews and interviews, the facility failed to ensure a thorough investigation was completed for an allegation of neglect for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents reviewed for neglect. Findings: Review of the facility's Policy for Prohibition of Abuse, Neglect and Misappropriation of Property revised on 08/05/2024 revealed, in part, the facility will have evidence of a thorough investigation of all alleged violations. Review of the facility's records revealed a report dated 08/21/2024 revealed, in part, in which the allegation of neglect was reported and investigated for Resident #1. Further review revealed Resident #1 was sent to the hospital due to a drop in blood pressure on 08/21/2024. In the emergency room Resident #1 was found to have gauze and an empty ketchup packet lodged in the back of his throat. Further review of the report revealed the lunch meal on 08/21/2024 included French fries served with ketchup. Further review revealed the camera footage was reviewed by the facility and the footage showed multiple staff members were present in the dining room, Resident #1 had fed himself, and Resident #1 had not placed a ketchup packet in his mouth. The facility's report further revealed Resident #1 did not require wound care and speculated Resident #1 obtained the gauze during the emergency transport to the hospital or when he arrived to the hospital. Review of Resident #1's August 2024 Physician Orders revealed, in part, Resident #1 had a physician's order implemented on 08/15/2024 to Apply a Bordered Gauze Pad (Gauze Pads & Dressings) to the right knee topically one time a day related to an unspecified open wound to the right knee. Review of Resident #1's August 2024 Electronic Treatment Administration Record (ETAR) revealed, in part, Resident #1 received the above mentioned application of a gauze pad and/or dressings to his right knee on 08/15/2024 through 08/21/2024. Review of the facility's camera footage on 09/04/2024 at 12:18 p.m. with S1Administrator and S3CNA Supervisor present revealed, in part, on 08/21/2024 Resident #1 was seated at a table with Random Resident #4 for the lunch meal service. Further review revealed S4Dietary Aide placed Resident #1's lunch tray in front of him on the table. Further review revealed Resident #1 was seen bringing his hands to his face and/or mouth multiple times; however, the footage was out of focus and you could not identify what items Resident #1 brought to his face and/or mouth. Further review revealed S5Housekeeper was observed walking near and/or around Resident #1 while he sat at the table in the dining room. In an interview on 09/04/2024 at 12:27 p.m., S5Housekeeper indicated the facility administrative staff had not questioned her or asked her to provide a statement of any observations S5Housekeeper made of Resident #1 in the dining room during lunch meal service on 08/21/2024. In an interview on 09/04/2024 at 12:33 p.m., S4Dietary Aide confirmed she often assisted residents in the dining room during meals services. S4Dietary Aide further indicated the facility administrative staff had not questioned her or asked her to provide a statement of any observations S4Dietary Aide made of Resident #1 in the dining room during lunch meal service on 08/21/2024. Review of Random Resident #4 revealed, in part, Random Resident #4 had a Brief Interview of Mental Status score of 15 which indicated her cognition was intact. In an interview on 09/05/2024 at 12:18 p.m., Random Resident #4 indicated the facility staff had not questioned her or asked Random Resident #4 to provide a statement of any observations Random Resident #4 made of Resident #1 while she sat at the table with Resident #1 during the lunch meal service on 08/21/2024. Review of the facility's investigative documents for Resident #1's facility report on 08/21/2024 revealed, in part, no documented evidence and the facility did not present any documented evidence S5Housekeeper, S4Dietary Aid, or Random Resident #4 was interviewed by administrative staff and/or that a statement was obtained. In an interview on 09/05/2024 at 2:38 p.m., S1Administrator confirmed Resident #1 had an active wound care order to apply a gauze dressing to Resident #1's right knee which was completed as ordered on August 8/15/2024 through 08/21/2024. S1Administrator indicated she was not aware of the above mentioned wound care orders for Resident #1. S1Administrator confirmed the facility's report for Resident #1 on 08/21/2024 indicated Resident #1 did not have orders for wound care and the information was inaccurate. S1Administrator confirmed Random Resident #4 was not interviewed by the facility's administrative staff of her observation of Resident #1 during the lunch meal service on 08/21/2024. S1Administrator confirmed the facility did not obtain interviews and/or statements from all staff who observed Resident #1 during the lunch meal service on 08/21/2014. S1Administrator further indicated the facility could have done a better job formalizing the information gathered during Resident #1's investigation.

Based on record reviews and interviews, the facility failed to ensure the nursing staff signed a verification of an accurate medication count at the beginning and end of each shift for 2 [Medication Cart (a) and Medication Cart (b)] of 2 [Medication Cart (a) and Medication Cart (b)] Medication Carts (Med Cart) observed and reviewed for accurate dispensation of controlled medications. Findings: Review of the facility's undated Controlled Substances Policy revealed, in part, the nursing staff must count controlled drugs at the end of the shift with the nurse coming on duty and the nurse going off duty. Further review revealed the nurse coming on duty and the nurse going off duty must make the count together. Further review revealed the nursing staff must document and report any discrepancies to the Director of Nursing (DON) or designee immediately. Review of Med Cart (a)'s controlled substance binder dated 05/31/2024 to 08/07/2024 revealed, in part, no documentation of signatures of the nurse coming on duty and the nurse going off duty on the following dates and shifts: 06/03/2024 the 3:00 p.m. to 11:00 p.m. shift; 06/06/2024 the 7:00 a.m. to 3:00 p.m. shift; 06/11/2024 the 11:00 p.m. to 7:00 a.m. shift; 06/14/2024 the 11:00 p.m. to 7:00 a.m. shift; 06/23/2024 the 3:00 p.m. to 11:00 p.m. and 11:00 p.m. to 7:00 a.m. shift; 06/30/2024 the 3:00 p.m. to 11:00 p.m. shift; 07/06/2024 the 11:00 p.m. to 7:00 a.m. shift; 07/11/2024 the 11:00 p.m. to 7:00 a.m. shift; 07/12/2024 the 3:00 p.m. to 11:00 p.m. and 11:00 p.m. to 7:00 a.m. shifts; 07/14/2024 the 7:00 a.m. to 3:00 p.m. and 3:00 p.m. to 11:00 p.m. shifts; 07/17/2024 the 3:00 p.m. to 11:00 p.m. shift; 07/18/2024 the 3:00 p.m. to 11:00 p.m. shift; 07/19/2024 the 7:00 a.m. to 3:00 p.m., 3:00 p.m. to 11:00 p.m., and 11:00 p.m. to 7:00 a.m. shifts; 07/22/2024 the 11:00 p.m. to 7:00 a.m. shift; 07/24/2024 the 7:00 a.m. to 3:00 p.m. and 3:00 p.m. to 11:00 p.m. shift; 07/25/2024 the 11:00 p.m. to 7:00 a.m. shift; 07/27/2024 the 3:00 p.m. to 11:00 p.m. shift; 07/29/2024 the 11:00 p.m. to 7:00 a.m. shift; 08/03/2024 the 7:00 a.m. to 3:00 p.m. shift; 08/06/2024 the 3:00 p.m. to 11:00 p.m. shift; and 08/07/2024 the 7:00 a.m. to 3:00 p.m. shift. In an interview on 08/07/2024 at 12:41 p.m., S8Licensed Practical Nurse (LPN) indicated she did not sign the narcotics book after the narcotics count on 08/07/2024 at 7:00 a.m. S8LPN further indicated she should have signed the narcotic book after she completed the narcotic count with the nurse going off duty. Review of Med Cart (b) 's controlled substance binder dated 05/22/2024 to 08/07/2024 revealed, in part, no documentation of signatures of the nurse coming on duty and the nurse going off duty on the following dates and shifts: 05/23/2024 the 7:00 a.m. to 3:00 p.m. shift; 05/27/2024 the 3:00 p.m. to 11:00 p.m. shift; 05/31/2024 3:00 p.m. to 11:00 p.m. shift; 07/05/2024 the 3:00 p.m. to 11:00 p.m. shift; 07/10/2024 11:00 p.m. to 7:00 a.m. shift; 07/14/2024 the 7:00 a.m. to 3:00 p.m. shift; 07/24/2024 the 7:00 a.m. to 3:00 p.m. shift; and 08/07/2024 the 7:00 a.m. to 3:00 p.m. shift. In an interview on 08/07/2024 at 1:08 p.m., S9LPN indicated she did not sign the narcotics book after the narcotics count on 08/07/2024 at 7:00 a.m. S9LPN further indicated she should have signed the narcotic book after she completed the narcotic count with the nurse going off duty. In an interview on 08/07/2024 at 1:15 p.m., S4Director of Nursing (DON) indicated all narcotic counts should be performed and documented in the narcotics book at the beginning and ending of each shift by the nurse coming on duty and the nurse going off duty. S4DON further indicated on the above mentioned dates narcotic counts were not documented as they should have been.

Based on observations, record reviews, and interviews, the facility failed to develop a plan of care for 1 (Resident #3) of 1 resident (Resident #3) receiving respiratory care by nasal cannula. Findings: Observation on 08/05/2024 at 9:40 a.m. revealed Resident #3 received oxygen at 2 liters per minute (LPM) by nasal cannula. Review of Resident #3's Minimum Data Set (MDS) with an assessment reference date of 04/29/2024 revealed, in part, a brief interview mental status of 13 which indicated cognitively intact. Review of Resident #3's Physician Orders dated August 2024 revealed, in part, no orders for oxygen per nasal cannula. Review of Resident #3's Care Plan revealed, in part, most current target date listed for problems identified was dated 10/01/2024. Further review of the care plan revealed no plan of care was developed for oxygen care by nasal cannula. Observation on 08/06/2024 at 11:40 a.m. revealed Resident #3's received oxygen at 4 LPM per NC. In an interview on 08/06/2024 at 11:58 a.m., S10Licensed Practical Nurse (LPN) indicated Resident #3 received oxygen at 2 LPM by NC. S10LPN further indicated no physician's order for respiratory care for Resident #3. In an interview on 08/06/2024 at 12:30 p.m., S5Assistant Director of Nursing indicated they could not find a physician's order for Resident #3' oxygen care per NC. In an interview on 08/06/2024 at 3:49 p.m., S4Director of Nursing indicated there was no plan of care developed for Resident #3's oxygen care per NC.

Based on observation, interview, and record review, the facility failed to provide nail care for 2 (Resident #28 and Resident #40) of 6 (Resident #24, Resident #28, Resident #40, Resident #47, Resident #61, and Resident #78) sampled residents investigated for activities of daily living (ADLs). Findings: Resident #28 Resident #28 was admitted to the facility on [DATE] with diagnoses of hemiplegia affecting the right side. Review of Resident #28's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 07/16/2024 revealed she had impairment on one side of her upper and lower extremities. Review of Resident #28's Care Plan revealed Resident #28 required assistance with ADLs with a goal to be kept clean, dry and well-groomed. Observation on 08/06/2024 at 2:20 p.m. revealed Resident #28's toe nails extended past the tips of her toes. Observation on 08/07/2024 at 9:40 a.m. with S13Certified Nursing Assistant (CNA) and S6MedRecords/CNA Supervisor revealed Resident #28's bilateral toe nails and bilateral fingernails extended past the tips of the nailbeds. In an interview on 08/07/2024 at 9:42 a.m., S6MedRecords/CNA Supervisor indicated Resident #28's finger nails and toe nails needed to be trimmed. In an interview on 08/07/2024 at 9:50 a.m., S12Wound Care Nurse confirmed Resident #28's finger nails and toe nails needed to be trimmed. Resident #40 Resident #40 was admitted to the facility on [DATE] with diagnoses of right side hemiplegia (paralysis on one side of the body). Review of Resident #40's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 05/02/2024 revealed Resident #40 had impairment on one side of his upper and lower extremities. Review of Resident #40's Care Plan revealed Resident #40 had a self-care deficit related right side hemiplegia with goal to be kept clean, dry and well-groomed. Review of Resident #40's ADL record from 07/23/2024 through 08/06/2024 revealed no documented evidence Resident #40's nails were trimmed. Observation on 08/06/2024 at 2:25 p.m. revealed Resident #40's nails extended past the tips of his fingers. Observation on 08/07/2024 at 12:27 p.m. revealed Resident #40's nails extended past the tips of his fingers. In an interview on 08/07/2024 at 12:30 p.m., S4Director of Nursing indicated Resident #40's nails needed to be trimmed.

Based on observation and interview, the facility failed to protect client confidentiality for 1 resident (Resident #8) of 32 sampled residents (Resident #1, Resident #3, Resident #8, Resident #11, Resident #15, Resident #25, Resident #21, Resident #24, Resident #28, Resident #29, Resident #40, Resident #43, Resident #47, Resident #53, Resident #54, Resident #56, Resident #57, Resident #60, Resident #6, Resident #67, Resident #68, Resident #70, Resident #73, Resident #78, Resident #80, Resident #88, Resident #86, Resident #87, Resident #89, Resident #340, Resident #34, and Resident #342). Findings: Observation on 08/06/2024 at 11:02 a.m. revealed Resident #8's closed exterior side of the door facing the hallway revealed written sign titled, Appointment Sheet. Further observation revealed, in part, Resident #8's written name with Tuesday, Thursday and Saturday goes to dialysis with a pick up time of 5:30 a.m. In an interview on 08/06/2024 at 12:15 p.m., S10Licensed Practical Nurse (LPN), after reading Resident #8's sign on exterior side of the door that was facing the hallway, indicated it would be a HIPPA violation, Health Insurance Portability and Accountability Act which protected the medical information in patients records and allowed for confidential communication between patients and medical professionals. S10 LPN further indicated people could figure out Resident #8 has end stage renal disease. In an interview on 08/06/2024 at 3:23 p.m., S4Director of Nursing indicated the sign on Resident #8's exterior door should not be posted.

Based on record reviews and interviews, the facility failed to ensure a Level 1 Pre-Admission Screening and Resident Review (PASARR) was completed correctly for 1 (Resident #56) of 1 (Resident #56) residents reviewed for PASARR. Findings: Resident #56 was admitted to the facility on [DATE] with diagnoses, in part, of Major Depressive Disorder, Anxiety, and Schizophrenia. Review of Resident #56's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 04/23/2024, revealed, in part, diagnosis of Major Depressive Disorder, Anxiety, and Schizophrenia. Further review revealed Resident #56 received antipsychotics on a daily basis. Review of Resident #56's record revealed a Level- 1 PASARR completed on 10/21/2021. Further review revealed Section 3: Mental Illness was marked yes. Further review revealed a referral was not made to appropriate state designated authority for Level II PASARR evaluation and determination. In an interview on 08/07/2024 at 2:05 p.m., S3Social Services indicated Resident #56's Level- 1 PASARR was completed incorrectly and a Level II PASARR should have been requested for Resident #56 due to her diagnosis of Major Depressive Disorder, Anxiety, and Schizophrenia.

Based on observation, record review, and interviews, the facility failed to ensure a resident was referred for dental services for 1 (Resident #25) of 3 (Resident #25, Resident #68, and Resident #21) sampled residents reviewed for dental services. Findings: Review of Resident #25's medical record revealed, in part, Resident #25 was admitted on [DATE]. Review of Resident #25's care plan with a goal date of 08/21/2024 revealed, in part, the potential for dental issues. Further review revealed care plan approaches to include arranging for dental appointments and periodic dental visits. Review of Resident #25's records revealed, in part, no documented evidence, and the provider could not provide any documented evidence, Resident #25 was evaluated for dental services. Review of Facility's resident dental treatment schedule dated 08/19/2024 revealed, in part, Resident #25 was not listed on the schedule for dental services. Observation on 08/05/2024 at 9:57 a.m. revealed Resident #25 did not have any upper teeth. Further observation revealed Resident #25 only had the front bottom teeth. Further observation revealed Resident #25's remaining bottom teeth were grey colored in the middle. In an interview on 08/05/2024 at 10:00 a.m., Resident #25 indicated she needed to see the dentist. Resident #25 further indicated she only had 6 teeth left and did not want to lose anymore. Resident #25 further indicated food was sometimes hard to chew. In an interview on 08/07/2024 at 12:17 p.m., S3SocialServices (SS) indicated she could not find any documentation Resident #25 was evaluated by dental services. S3SS further indicated Resident #25 was not on the dental services patient list. S3SS further indicated Resident #25 should have been evaluated for dental services. In an interview on 08/07/2024 at 12:32 p.m., S1Administrator confirmed Resident #25 should have been evaluated for dental services.

Based on observations, interviews, and record reviews the facility failed to ensure: 1. Ensure clean items in the facility's laundry room were not kept in the contaminated laundry area, and 2. Ensure staff wore proper protective equipment and performed hand hygiene during incontinence care for 1 (Resident #24) of 6 (Resident #24, Resident #28, Resident #40, Resident #47, Resident #61, and Resident #78) residents investigated for activities of daily living. Findings: 1. Observation on 08/05/2024 at 9:15 a.m. revealed the facility's clean mop heads were hung on wall hooks directly over soiled linen barrels in the facility's contaminated laundry area. Observation on 08/06/2024 at 10:52 a.m. revealed 15 of the facility's clean mop heads were hung on wall hooks in the facility's contaminated laundry area. In an interview on 08/06/2024 at 10:52 a.m., S2Laundry Supervisor confirmed the facility's clean mop heads were stored on the wall of the contaminated area of the facility's laundry room. In an interview on 08/06/2024 at 10:53 a.m., S1Administrator confirmed the facility's clean mop heads were stored on the wall of the contaminated linen area of the facility's laundry room and should not have been. 2. Review of Facility's Handwashing/Hand Hygiene Policy and Procedure last revised August 2015 revealed, in part, hand hygiene was performed before and after removing gloves. Further review revealed staff should follow the handwashing/hand hygiene procedure to prevent the spread of infection. Review of Resident #24's Care Plan with a goal date of 09/03/2024 revealed, in part, Resident #24 was on Enhanced Barrier Precaution (EBP) for a right ankle diabetic ulcer. Further review revealed staff were to wear proper EBP and perform hand hygiene before and after providing incontinence care. Observation on 08/06/2024 at 8:27 a.m. revealed an EBP sign above Resident #24's bed indicating staff must wear PPE during incontinence care. Observation on 08/06/2024 at 1:50 p.m. revealed S7Certified Nursing Assistant (CNA) entered Resident #24's room to perform incontinence care without a gown on. Further observation revealed S7CNA had on gloves and cleansed Resident #24's vaginal area, removed her gloves, and did not perform hand hygiene. S7CNA then put new gloves on. Further observation revealed S7CNA cleansed Resident #24's buttocks, removed her gloves, and did not perform hand hygiene. S7CNA then put new gloves on, positioned Resident #24, put a new adult brief on, removed gloves, and then performed hand hygiene. In an interview on 08/06/2024 at 1:49 p.m., S7CNA indicated she should have performed hand hygiene in between glove changes and should have worn a gown when performing incontinence care to Resident #24. In an interview on 08/07/2024 at 11:00 a.m., S5Assistant Director of Nursing indicated S7CNA should have performed hand hygiene in between glove changes and should have worn a gown when performing incontinence care for Resident #24. 48855

Based on record reviews and interviews, the facility failed to ensure an allegation of verbal and physical abuse was reported to the required state survey agency for 1 (Resident #1) of the 3 (Resident #1, Resident #2, and Resident #3) sampled residents investigated for abuse. Findings: Review of the facility's policy and procedure titled Policy for Prohibition of Abuse, Neglect and Misappropriation of Property with a revision date of 09/26/2017 revealed, in part, all alleged violations and all substantiated incidents should be reported to the required state agency, and any employee who becomes aware of an allegation of abuse should report the incident to a supervisor, Director of Nursing, or Administrator immediately. Further review of the policy revealed the facility will report all allegations of abuse to the state agency. Review of Resident #1's closed medical record revealed, in part, Resident #1 was admitted to the facility on [DATE] with diagnoses, in part, Alzheimer's disease, schizophrenia, depressive disorder, dementia, and anxiety. Review of Resident #1's Physician's Emergency Certificate (PEC) dated 06/03/2024 revealed, in part, Resident # assaulted the nursing home administrator. Further review of the PEC revealed Resident #1 alleged the nursing home administrator pushed her. Review of the police report document with a disposition/completion date and time of 06/03/2024 at 1:41 p.m. revealed, in part, Resident #1 stated S1Administrator pushed her on 06/03/2024. In a telephone interview on 06/25/2024 at 10:50 a.m., Resident #1's Responsible Party (RP) stated Resident #1 reported she was pushed by S1Administrator on 06/03/2024. In a telephone interview on 6/25/2024 at 11:34 a.m., the facility's Ombudsmen stated Resident #1's RP informed her Resident #1 was pushed by S1Administrator during an incident on 06/03/2024. In a telephone interview on 06/25/2024 at 11:53 a.m., Resident #1 stated S1Administrator pushed her on 06/03/2024 and Resident #1 informed the police deputy and facility staff of the incident. In an interview on 06/25/2024 at 1:42 p.m., S1Administrator stated Resident #1's RP called S2Regional Administrator 06/04/2024 and reported S1Administrator yelled at and pushed Resident #1. S1Administrator further stated Resident #1's allegation of abuse was not reported to the state agency. In an interview on 06/25/2024 at 2:28 p.m., S1Administrator denied the previously documented interview and indicated she was inconsistent in reporting her source of information. S1Administrator further indicated she must have obtained Resident #1's allegation of abuse from the police report. In an interview on 06/25/2024 at 2:30 p.m., S2Regional Administrator verified Resident#1 alleged she was abused by S1Administrator the after reviewing the police report and the PEC report. S2Regional Administrator indicated he was not made aware of Resident #1's allegation until today (06/25/2024) and further confirmed the incident was not reported to the state agency as required. In an interview on 06/26/2024 at 9:53 a.m., S3Director of Nursing (DON) stated she reviewed Resident #1's PEC and was aware Resident #1 alleged S1Administrator pushed her on 06/03/2024. S3DON further stated she was not aware if the incident was reported to the state agency and confirmed she did not report the alleged abuse of Resident #1 by S2Administrator to corporate management as required.

Based on interviews and record reviews, the facility failed to ensure residents were free of significant medication errors for 2 of 5 sampled residents (Resident #1, Resident #4) as evidenced by the facility's data entry nurse entering an order for [REDACTED]. This failed practice resulted in an actual harm for Resident #1 on December 29, 2014 when an order for [REDACTED].#1 on 03/10/2015 sustained a fall and was taken to the local hospital. Review of the hospital ' s Lab Results Form dated 03/11/2015 at 7:47pm revealed Resident #1 had a [MEDICATION NAME] time result of 17.2 (reference range = 9.0 - 12.5) and an (INR) international normalized ratio result of 1.7 (reference range = 0.8 - 1.2). Review of the local hospital's records revealed on 03/16/2015 Resident #1 had a craniotomy to drain blood from her head as a result of a subdural hematoma. This failed practice had the potential to affect all of the 114 residents residing in the facility who were receiving medications as documented on the facility's Resident Census Form. Findings: Resident #1: Resident #1 was admitted to the facility on [DATE] with diagnoses in part of Intellectual Disability, Mental [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION], Type 2 Diabetes, [MEDICAL CONDITION] Arthritis, [MEDICAL CONDITION], and Bladder Dysfunction. Review of the physician's orders [REDACTED].#1 had no new order written for [MEDICATION NAME] 7.5mg by mouth daily. Review of the physician's orders [REDACTED]. Further review revealed there was no [DIAGNOSES REDACTED]. In interview on 03/19/2015 at 9:10am, S3/Corporate Nurse stated Resident #1 received [MEDICATION NAME] 7.5 mg by mouth from December 29, 2014 until March 10, 2015. S3/Corporate Nurse stated the order was incorrectly entered into Resident #1 ' s online physician's orders [REDACTED]. Review of the facility's Monthly Pharmacy Consultation Form dated January 19, 2015 and February 16, 2015 revealed pharmacy monthly consultations were completed without drug irregularities noted. In interview on 03/19/2015 at 11:20am, S5/RPh stated he failed to notice the irregularity with the physician's orders [REDACTED].#1 while conducting the monthly pharmacy consultation reviews for January 19, 2015 and February 16, 2015. In interview on 03/19/2015 at 9:25am, S4/RN, FNP stated Resident #1 was transferred to a local imaging center for a CT (Computerized Tomography) scan of the head on 03/11/2015 for a change in sensorium resulting after Resident #1 hit her head during a fall which occurred on 03/10/2015. S4/RN, FNP stated the imaging center transferred Resident #1 to the local hospital after the result of the CT scan. S4/RN, FNP stated she became aware Resident #1 was on [MEDICATION NAME] when a physician from the local hospital telephoned her regarding the medication. S4/RN, FNP stated Resident #1 should have not been on [MEDICATION NAME]. Review of the imaging center ' s CT Report revealed Resident #1 had a bilateral pattern of a prominent subdural hematoma greatest in the frontal regions. Review of the hospital (ED) Emergency Department Arrival Form revealed Resident #1 was admitted to the ED on 03/11/2015 at 3:08pm with diagnoses in part of Altered Mental State and Acute Subdural Hematoma as a result of hitting her head on her walker. Review revealed other diagnoses included: Abnormal Coagulation Profile, Electrolyte Abnormality, and [MEDICAL CONDITION]. Review of the hospital ' s Lab Results Form dated 03/11/2015 at 7:47pm revealed Resident #1 had a [MEDICATION NAME] time result of 17.2 (reference range = 9.0 - 12.5) and an (INR) international normalized ratio result of 1.7 (reference range = 0.8 - 1.2). Review of the hospital ' s ED Provider notes dated 03/11/2015 8:00pm revealed Resident #1 received Vitamin K 5mg (a vitamin which reverses the effects of [MEDICATION NAME]) intravenously. Review of thee hospital's records revealed on 03/16/2015, Resident #1 had a craniotomy to drain blood from her head as a result of a subdural hematoma. Resident #4 Resident #4 was admitted to this facility on 12/1/14 with the following diagnoses; [MEDICAL CONDITION] Fibrillation, [MEDICAL CONDITIONS], Hypertension, [MEDICAL CONDITION], and Peripheral [MEDICAL CONDITION]. Review of Resident #4's physician's orders [REDACTED]. and [MEDICATION NAME] 600mg twice daily. Further review of the December/2014 physician's orders [REDACTED]. Review of the facility's Electronic Medication Administration Record [REDACTED]. Review of the facility's eMAR dated January/2015 revealed Resident #4 was started on [MEDICATION NAME] 7.5mg on 1/20/15 which was ordered 12/24/14 at 5:10pm. In interview on 3/19/15 at 9:10am, S3/Corporate Nurse indicated Resident #4's physician's orders [REDACTED].#1's physician's orders [REDACTED]. In Interview on 3/19/15 at 9:45am, S2/DON stated Resident #4 did not receive the correct dosage of [MEDICATION NAME] ordered on [DATE] at 5:10pm secondary to Resident #4's order was transcribed to Resident #1's physician's orders [REDACTED]. In interview on 3/19/15 at 11:20am, S5/RPh stated he failed to identify the transcription error for the medication [MEDICATION NAME] 7.5mg daily ordered for Resident #4 on 12/24/15 at 5:10pm. Review of the facility's Monthly Pharmacy Consultation Form revealed the monthly reviews were conducted by S5/RPh on 12/17/15 and 1/21/15 and no irregularities were documented.

Based on record review and interviews, the pharmacist failed to identify and report irregularities to the attending physician and the director of nursing. The facility failed to identify an order that was transcribed incorrectly for 2 (Resident #1, Resident #4) of 5 (Resident #2, Resident #3, Resident #5) sampled residents. This failed practice resulted in an actual harm for Resident #1 on December 29, 2014 when the order for Coumadin (a drug which prolongs the clotting time of blood) was transcribed to Resident #1's physician order [REDACTED]. This error was not identify during the monthly pharmcy review done following the initial dose of Coumadin. Resident #1 on 03/10/2015 sustained a fall and was taken to the local hospital. Laboratory test were ordered at the hospital for Resident #1 to evaluate the effects of the Coumadin. Review of the hospital's Lab Results Form dated 03/11/2015 at 7:47pm revealed Resident #1 had a prothrombin time result of 17.2 (reference range = 9.0 - 12.5) and an (INR) international normalized ratio result of 1.7 (reference range = 0.8 - 1.2). The local hospital records record review revealed on 03/16/2015, Resident #1 had a craniotomy to drain blood from her head as a result of a subdural hematoma. This failed practice had the potential to affect all residents at the facility who were receiving medication. The facility census was 114 as documented on the facility's Census Form. Findings: Resident #1 Review of the facility's face sheet revealed Resident #1 was admitted with diagnoses in part of Intellectual Disability, Mental Retardation, Hypertension, Type 2 Diabetes, and Rheumatoid Arthritis. Review of the physician's orders [REDACTED].#1 had no new order written for Coumadin 7.5mg by mouth daily. Review of the physician's orders [REDACTED]. Further review revealed there was no [DIAGNOSES REDACTED]. Review of the facility's eMAR (electronic Medication Administration Record) dated December 29, 2014 through March 10, 2015 revealed Resident #1 was given Coumadin 7.5mg. In interview on 03/19/2015 at 9:10am, S3/Corporate Nurse stated Resident #1 received Coumadin 7.5 mg by mouth from December 29, 2014 until March 10, 2015. S3/Corporate Nurse stated the order was incorrectly transcribed into Resident #1's online order record by the data entry nurse. In interview on 03/19/2015 at 9:25am, S4/RN, FNP stated she became aware Resident #1 was on Coumadin 7.5mg by mouth when a physician from the local hospital telephoned her regarding the medication. S4/RN, FNP stated Resident #1 was incorrectly placed on Coumadin. S4/RN, FNP stated Resident #1 was transferred to a local imaging center for a CT (Computerized Tomography) scan of the head on 03/11/2015 for a change in sensorium resulting after Resident #1 hit her head during a fall which occurred on 03/10/2015. S4/RN, FNP stated the imaging center transferred Resident #1 to the local hospital after the result of the CT scan. Review of the hospital ' s Lab Results Form dated 03/11/2015 at 7:47pm revealed Resident #1 had a prothrombin time result of 17.2 (reference range = 9.0 - 12.5) and an (INR) international normalized ratio result of 1.7 (reference range = 0.8 - 1.2). Review of the hospital ' s ED Provider notes dated 03/11/2015 8:00pm revealed Resident #1 received Vitamin K 5mg (a vitamin which reverses the effects of Coumadin) intravenously. Record review revealed on 03/16/2015, Resident #1 had a craniotomy to drain blood from her head as a result of a subdural hematoma. In interview on 03/19/2015 at 9:45am, S2/DON stated the data entry nurse incorrectly entered a Coumadin order for Resident #1. S2/DON stated the Coumadin order was for another resident in the facility with the same last name. Review of the facility's Monthly Pharmacy Consultation Form dated January 19, 2015 and February 16, 2015 revealed monthly consults were completed without drug irregularities noted. In interview on 03/19/2015 at 11:20am, S5/RPh stated he failed to notice the irregularity with the physician's orders [REDACTED].#1 and during the monthly consultations for January 19, 2015 and February 16, 2015. Resident #4 Resident #4 was admitted to this facility on 12/1/14 with the following diagnoses; Atrial Fibrillation, Chronic Obstructive Pulmonary Disease, [DIAGNOSES REDACTED], Hypertension, Deep Vein Thrombosis, and Peripheral Neuropathy. Review of Resident #4's physician's orders [REDACTED]. and Mucinex 600mg twice daily. Further review of the December/2014 physician's order [REDACTED]. Review of the facility's electronic Medication Administration Record [REDACTED]. Review of the facility's eMAR dated January/2015 revealed Resident #4 was started on Coumadin 7.5mg on 1/20/15 which was ordered 12/24/14 at 5:10pm. In interview on 3/19/15 at 9:10am, S3/Corporate Nurse indicated Resident #4's physician's orders [REDACTED].#1's physician's orders [REDACTED]. In Interview on 3/19/15 at 9:45am, S2/DON indicated Resident #4 did not receive the correct dosage of Coumadin ordered on [DATE] at 5:10pm secondary to Resident #4's order was transcribed to Resident #1's physician's orders [REDACTED]. In interview on 3/19/15 at 11:20am, S5/RPh indicated he failed to identify the transcription error for the medication Coumadin 7.5mg daily ordered for Resident #4 on 12/24/15 at 5:10pm. Review of the facility's Monthly Pharmacy Consultation Form revealed the monthly reviews were conducted by S5/RPh on 12/17/15 and 1/21/15 and no irregularities were documented.

Based on record review and interview the Administrator and Director of Nurses (DON) failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable physical, mental, and psychosocial well-being by failing to have a system in place that ensures that the Plan of Correction with a completion dated of 4/24/2011 was followed, failing to ensure that the resident's physician was notified of a change in the resident medical condition and failing to ensure resident's lab results are addressed promptly with the resident's physician. This failed practice of continued non-compliance placed Resident# F8 in an Immediate Jeopardy situation, which began on 05/21/2011 when the facility failed to recognize that the monitoring labs had not been drawn and failed to report [MEDICAL CONDITION] activity to the physician. On 5/21/2011, the resident had a [MEDICAL CONDITION] and the physician was not notified. The lab was not obtained until 05/27/2011 and the results were non-therapeutic. There was no documentation of follow up with the physician related to the level being non-therapeutic until 6/7/11. The resident's physician reviewed the results on 6/7/2011 and signed off with no new orders. The Director of Nursing was notified of the Immediate Jeopardy on 06/09/2011 at 5:02pm. An acceptable plan of removal was obtained from the facility and the Immediate Jeopardy was lifted on 06/09/2011 at 6:30pm. The deficient practice continues at a level of actual harm. The resident still remains at risk for [MEDICAL CONDITION] until his medication blood level is within a therapeutic range. Findings: Review of Physician order [REDACTED]. Further review of the resident's Care Plan under the Nursing [DIAGNOSES REDACTED]. Approaches: to monitor lab levels. Review of the nurses ' note dated 5/21/2011, written at 12:30am reads in part, that the CNA reported to the nurses a change in the resident's condition. The resident was unresponsive verbally, snoring with eye open; the resident was repositioned for comfort and will monitored every hour for [MEDICAL CONDITION] activity. There was no further documentation for this resident. There was no documentation that the resident ' s physician was notified or that the resident was monitored for [MEDICAL CONDITION] activity. Review of the resident's laboratory results dated [DATE] (over one month past the Plan of Correction completion date of 4/24/11) revealed that the resident had a [MEDICATION NAME] ([MEDICAL CONDITION] medication) blood level done with the result out of range less than 2.5L. (Therapeutic range of 10-20L) The labs result was faxed to the physician on 5/27/2011. There was no documented evidence that the facility followed -up with the physician until 6/7/11 when the physician signed off on the results. There were no new orders given by the physician for this resident pertaining to his [MEDICAL CONDITION] medication. Further review revealed that the resident had a blood draw for routine labs on 4/22/11, which did not include a [MEDICATION NAME] level. An interview on 6/9/11 at 1:47pm with S3RN Unit Manager (UM) revealed that resident's labs were drawn as scheduled in May and that she was not aware that the resident had [MEDICAL CONDITION] activity on 5/21/11. She further indicated that the nurse should have monitored the resident for [MEDICAL CONDITION] and called the physician. Review of the labs results with the S3RN/UM revealed that she was responsible to notify the resident ' s physician, which she did on 5/27/11 via a fax. The UM indicated that she did not follow-up with the physician until 6/7/11. The physician signed off on the labs and did not write any new orders. The UM indicated that the physician was not aware of the important information that the resident had a [MEDICAL CONDITION] on 5/21/11. An interview on 6/9/2011 at 3:30pm with S2DON revealed that the nurse who worked on 5/21/11 was an agency nurse and was not sure why the nurse did call the physician. The DON further indicated that the unit managers gave her monthly monitoring logs which indicated that the resident's labs were drawn. After review of the lab draw book, the DON concluded that the labs was not drawn until 5/27/11. The DON indicated that she would call the resident's physician and inform the physician that the resident had a [MEDICAL CONDITION] on 5/21/11. An interview on 6/9/2011 at 6:30pm with S2 Director of Nursing revealed that the resident's physician had been notified and new orders for [MEDICATION NAME] 200mg twice-a-day for seven days and on the 7th day [MEDICATION NAME] blood level drawn with results to be called to the physician. Review of the facility' s Plan of Removal dated 6/9/2011 reads in part that the physician was notified of the resident's [MEDICAL CONDITION] activity on 5/21/2011 and new orders were given for the resident. His [MEDICATION NAME] was increased to 200mg twice a day for seven days and repeat [MEDICATION NAME] blood lever on the 7th day and call results to physician. The Unit Managers and staff on duty were in-serviced on on-going assessments, monitoring lab results and physician notification of a change in the resident 's medical condition. The plan was accepted on 6/9/2011 at 6:30pm.

1.Based on record review and interview the facility failed to ensure that the resident's physician is notified of a change in the resident's medical condition by failing to notify the resident's physician that a resident had [MEDICAL CONDITION] activity and failing to follow up with the physician of the resident's non-therapeutic [MEDICATION NAME] blood level for 1 of 10 sample residents (F8). On 5/21/2011, the resident had a [MEDICAL CONDITION] and the physician was not notified. A [MEDICATION NAME] blood level was not obtained until 5/27/11 and the results were less than 2.5L, which is a non-therapeutic range. There was no documentation of follow up with the physician related to the level being non-therapeutic until 6/7/11. The resident's physician reviewed the results on 6/7/2011 and signed off with no new orders. This practice of noncompliance allowed for an Immediate Jeopardy situation which began on 05/21/2011 when the facility failed to recognize that the monitoring labs had not been drawn and failed to report [MEDICAL CONDITION] activity to the physician.The Director of Nursing was notified of the The Immediate Jeopardy on 06/09/2011 at 5:02pm. An acceptable plan of removal was obtained from the facility, and the Immediate Jeopardy was lifted on 06/09/2011 at 6:30pm. The deficient practice continues at a level of actual harm. The resident still remains at risk for [MEDICAL CONDITION] until his medication blood level is within a therapeutic range. 2. Based on record review and staff interview, the facility failed to ensure that all residents obtained optimal improvement and the necessary care and services to maintain the highest practicable physical and mental well-being. The facility failed to ensure 1 of 5 sampled residents (F3) received care and services as identified in the resident's plan of care. The facility failed to provide pain management for an aphasic resident, and the facility failed to consult with the resident's physician for changes in the resident's condition (vomiting and diarrhea). This deficient practice of the facility failing to provide the necessary care and services has the potential of affecting all residents residing in the facility. Findings: RESIDENT #F8 Review of Physician order [REDACTED]. Further review of the resident's Care Plan under the Nursing [DIAGNOSES REDACTED]. Approaches: to monitor lab levels. Review of the resident's laboratory results dated [DATE] revealed that the resident had a [MEDICATION NAME] ([MEDICAL CONDITION] medication) blood level done with the result out of range less than 2.5L.(therapeutic range of 10-20L) The labs results was faxed to the physician on 5/27/2011. There was no documented evidence that the facility followed -up with the physician until 6/7/11 when the physician signed off on the results. There were no new orders given by the physician for this resident pertaining to his [MEDICAL CONDITION] medication. Further review revealed that the resident had a blood draw for routine labs on 4/22/11, which did not include a [MEDICATION NAME] level. Review of the nurses' note dated 5/21/2011and written at 12:30am reads in part, that the CNA reported to the nurses a change in the resident's condition. The resident was unresponsive verbally, snoring with eye open; the resident was repositioned for comfort and will monitored every hour for [MEDICAL CONDITION] activity and given Tylenol for a low grade fever (99.2F). There was no further documentation for this resident. There was no documentation that the resident's physician was notified or that the resident was monitored for [MEDICAL CONDITION] activity. Review of the resident ' s Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]& 31 for the 10pm dose. Further review reviewed no written explanation as to why the medication was not signed off. An interview on 6/9/11 at 1:47pm with S3RN Unit Manager (UM) revealed that she was out on maternity leave until the end of April. She indicated that resident's labs were drawn as scheduled in May and that she was not aware that the resident had [MEDICAL CONDITION] activity on 5/21/11. She further indicated that the nurse should have monitored the resident for [MEDICAL CONDITION] and called the physician. Review of the labs results with the S3RN/UM revealed that she was responsible to notify the resident ' s physician, which she did on 5/27/11 via a fax. The UM indicated that she did not follow-up with the physician until 6/7/11. The physician signed off on the labs and did not write any new orders. The UM indicated that the physician was not aware of the important information that the resident had a [MEDICAL CONDITION] on 5/21/11. An interview on 6/9/11 at 2:50am with S14 LPN, after review of the MAR for the month of May 2011 indicated that she always gave all the residents their medication. She indicated that she works a split unit and sometimes the other nurse is using the MAR. She indicated that she gave the medications and must have not signed off on the MAR. An interview on 6/9/2011 at 6:30pm with S2 Director of Nursing revealed that the resident ' s physician had been notified and new orders for [MEDICATION NAME] 200mg twice-a-day for seven days and on the 7th day [MEDICATION NAME] blood level drawn with results to be called to the physician. Review of the facility ' s Plan of Removal dated 6/9/2011 reads in part that the physician was notified of the resident ' s [MEDICAL CONDITION] activity on 5/21/2011 and new orders were given for the resident. His [MEDICATION NAME] was increased to 200mg twice a day for seven days and repeat [MEDICATION NAME] blood level on the 7th day and call results to physician. The Unit Managers and staff on duty were in-serviced on on-going assessments, monitoring lab results and physician notification of a change in the resident ' s medical condition. The plan was accepted on 6/9/2011 at 6:30pm. RESIDENT # F3 Review of physician's orders [REDACTED]. Further review revealed and order for [MEDICATION NAME] 7.5mg every four hours as needed for pain. Review of the resident's Care Plan dated 1/08/2011 (post hospitalization ) Nursing Diagnosis-Impaired Verbal Communication related to physical barrier (tracheotomy) uncompensated neuromuscular impairment ABE inability to vocalize needs reads in part the facility would anticipate resident ' s needs and monitor for restlessness to indicate pain and discomfort. An interview on 6/7/11 at 3:33pm with SF8CNA revealed that she worked the 3-11 shifts on 5/26/11. SF8CNA indicated that she was the primary CNA for resident #3. She indicated that the resident makes faces and starts moving when he is in pain. She indicated that the resident had two visitors that evening, but she was not sure who they were. The CNA revealed that one of the visitors asked for the nurse, because he felt the resident was in pain. An interview on 6/7/11 at 3:40pm with SF6CNA revealed that she was not resident # F3's primary aide, but assisted the other CNA with his diaper changes. She indicated that the resident's visitors asked her to find the nurse because the resident was in pain. She indicated that SF5 LPN was the resident's nurse and she told nurse that the family wanted to speak with her. An interview on 6/7/11 at 4:15pm with SF5LPN who worked the evening shift on 5/26/11 revealed the resident had two male visitors that evening and the one of them told her that the resident appeared to be in pain. The nurse (SF5LPN) indicated that the family wanted her to give the resident something for pain. She indicated that she looked in on the resident and he appeared to have increased restlessness. She indicated that she did not give him anything for pain at that time, and waited until the scheduled medication pass. She indicated that the medication pass times in the evening are 5pm and 9pm. The nurse could not recall what time the family asked for pain medications. She indicated that she gave the resident pain medication with the 9pm med pass. Review of narcotic logs with SF5LPN for this resident revealed that the last time the resident got pain medication signed out was on 5/25/11 at midnight. Further review revealed no documentation on 5/26/11 at 9pm that the resident received any medication for pain. review of the resident's medical record revealed [REDACTED]. Further review revealed there was no documentation of an assessment or the resident's symptoms or behaviors. After review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The nurse (SF5LPN) reviewed the chart and confirmed no documentation on the 3 to 11 shift on 5/26/11, that the resident was assessed for pain or any other problems. An interview on 6/7/11 at 4:30 pm with SF3RN Unit Manager revealed that the facility did a pain assessment on the resident on 4/ 3 /11 and his score was one (1). She further indicated that she was not sure what that score meant. The Unit Manager further indicated that the staff can tell if the resident is in pain by his increased movements in bed. When he has a change in behavior such as restlessness, agitation, and shortness of breath, the pain medication calms him down. After review of the clinical record for the resident she indicated that there was no documentation on 5/26/11 on the 3-11 shifts pertaining to if the resident got any pain medications. She indicated that the nurse should have charted the resident's pain assessment. A phone interview on 6/8/11 at 10:10am with a family member of the resident revealed that he visited with the resident on 5/26/11 in the morning before 11am. He found the resident with his covers off, tears in his eyes, moving in the bed, and beating the side of the bed. He indicated that he told the nurse that the resident needed pain medication. He indicated that he had to leave for the airport and did not see them give the resident his pain medication. He indicated that another family member visited with the resident that evening and encountered the same thing, the resident was in pain. An interview on 6/8/11 at 10:48am with SF4 LPN revealed that she worked with the resident on 5/26/11 on the morning shift. She indicated that she must have been at lunch when the family member visited that morning. The nurse (SF4LPN) indicated that she could not recall if anyone told her about the family concerns related to the resident having pain. She indicated, after review of the medical record that she did not give the resident any medication for pain. An interview on 6/8/11 at 11:28am with SF3RN Unit Manager revealed that the resident's family member voiced some concerns about the resident care and services that morning (5/26/11) mainly about the resident being uncovered, but he never mentioned anything about the resident being in pain. She further indicated that she did not recall anyone mentioning that the resident needed pain medication. Review of the resident's clinical record revealed no documented evidence that the nursing staff recognized, assessed, or managed the resident's pain on 5/26/2011, when the family told the nursing staff that the resident was showing symptoms of pain. Further review revealed no mention of the description of symptoms that the resident was experiencing and if any treatment was offered.

1.Based on record review and interview the facility failed to ensure that the resident's physician is notified of a change in the resident's medical condition by failing to notify the resident's physician that a resident had [MEDICAL CONDITION] activity and failing to follow up with the physician of the resident's non-therapeutic [MEDICATION NAME] blood level for 1 of 10 sample residents (F8). On 5/21/2011, the resident had a [MEDICAL CONDITION] and the physician was not notified. A [MEDICATION NAME] blood level was not obtained until 5/27/11 and the results were less than 2.5L, which is a non-therapeutic range. There was no documentation of follow up with the physician related to the level being non-therapeutic until 6/7/11. The resident's physician reviewed the results on 6/7/2011 and signed off with no new orders. This practice of noncompliance allowed for an Immediate Jeopardy situation which began on 05/21/2011 when the facility failed to recognize that the monitoring labs had not been drawn and failed to report [MEDICAL CONDITION] activity to the physician.The Director of Nursing was notified of the The Immediate Jeopardy on 06/09/2011 at 5:02pm. An acceptable plan of removal was obtained from the facility, and the Immediate Jeopardy was lifted on 06/09/2011 at 6:30pm. The deficient practice continues at a level of actual harm. The resident still remains at risk for [MEDICAL CONDITION] until his medication blood level is within a therapeutic range. Findings: 2. Based on record review and staff interview, the facility failed to ensure that all residents obtained optimal improvement and the necessary care and services to maintain the highest practicable physical and mental well-being. The facility failed to ensure 1 of 5 sampled residents (F3) received care and services as identified in the resident's plan of care. The facility failed to provide pain management for an aphasic resident, and the facility failed to consult with the resident's physician for changes in the resident's condition (vomiting and diarrhea). This deficient practice of the facility failing to provide the necessary care and services has the potential of affecting all residents residing in the facility. Findings: RESIDENT #F8 Review of Physician order [REDACTED]. Further review of the resident's Care Plan under the Nursing [DIAGNOSES REDACTED]. Approaches: to monitor lab levels. Review of the resident's laboratory results dated [DATE] revealed that the resident had a [MEDICATION NAME] ([MEDICAL CONDITION] medication) blood level done with the result out of range less than 2.5L.(therapeutic range of 10-20L) The labs results was faxed to the physician on 5/27/2011. There was no documented evidence that the facility followed -up with the physician until 6/7/11 when the physician signed off on the results. There were no new orders given by the physician for this resident pertaining to his [MEDICAL CONDITION] medication. Further review revealed that the resident had a blood draw for routine labs on 4/22/11, which did not include a [MEDICATION NAME] level. Review of the nurses' note dated 5/21/2011and written at 12:30am reads in part, that the CNA reported to the nurses a change in the resident's condition. The resident was unresponsive verbally, snoring with eye open; the resident was repositioned for comfort and will monitored every hour for [MEDICAL CONDITION] activity and given Tylenol for a low grade fever (99.2F). There was no further documentation for this resident. There was no documentation that the resident's physician was notified or that the resident was monitored for [MEDICAL CONDITION] activity. Review of the resident ' s Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]& 31 for the 10pm dose. Further review reviewed no written explanation as to why the medication was not signed off. An interview on 6/9/11 at 1:47pm with S3RN Unit Manager (UM) revealed that she was out on maternity leave until the end of April. She indicated that resident's labs were drawn as scheduled in May and that she was not aware that the resident had [MEDICAL CONDITION] activity on 5/21/11. She further indicated that the nurse should have monitored the resident for [MEDICAL CONDITION] and called the physician. Review of the labs results with the S3RN/UM revealed that she was responsible to notify the resident ' s physician, which she did on 5/27/11 via a fax. The UM indicated that she did not follow-up with the physician until 6/7/11. The physician signed off on the labs and did not write any new orders. The UM indicated that the physician was not aware of the important information that the resident had a [MEDICAL CONDITION] on 5/21/11. An interview on 6/9/11 at 2:50am with S14 LPN, after review of the MAR for the month of May 2011 indicated that she always gave all the residents their medication. She indicated that she works a split unit and sometimes the other nurse is using the MAR. She indicated that she gave the medications and must have not signed off on the MAR. An interview on 6/9/2011 at 6:30pm with S2 Director of Nursing revealed that the resident ' s physician had been notified and new orders for [MEDICATION NAME] 200mg twice-a-day for seven days and on the 7th day [MEDICATION NAME] blood level drawn with results to be called to the physician. Review of the facility ' s Plan of Removal dated 6/9/2011 reads in part that the physician was notified of the resident ' s [MEDICAL CONDITION] activity on 5/21/2011 and new orders were given for the resident. His [MEDICATION NAME] was increased to 200mg twice a day for seven days and repeat [MEDICATION NAME] blood level on the 7th day and call results to physician. The Unit Managers and staff on duty were in-serviced on on-going assessments, monitoring lab results and physician notification of a change in the resident ' s medical condition. The plan was accepted on 6/9/2011 at 6:30pm. RESIDENT # F3 Review of physician's orders [REDACTED]. Further review revealed and order for [MEDICATION NAME] 7.5mg every four hours as needed for pain. Review of the resident's Care Plan dated 1/08/2011 (post hospitalization ) Nursing Diagnosis-Impaired Verbal Communication related to physical barrier (tracheotomy) uncompensated neuromuscular impairment ABE inability to vocalize needs reads in part the facility would anticipate resident ' s needs and monitor for restlessness to indicate pain and discomfort. An interview on 6/7/11 at 3:33pm with SF8CNA revealed that she worked the 3-11 shifts on 5/26/11. SF8CNA indicated that she was the primary CNA for resident #3. She indicated that the resident makes faces and starts moving when he is in pain. She indicated that the resident had two visitors that evening, but she was not sure who they were. The CNA revealed that one of the visitors asked for the nurse, because he felt the resident was in pain. An interview on 6/7/11 at 3:40pm with SF6CNA revealed that she was not resident # F3's primary aide, but assisted the other CNA with his diaper changes. She indicated that the resident's visitors asked her to find the nurse because the resident was in pain. She indicated that SF5 LPN was the resident's nurse and she told nurse that the family wanted to speak with her. An interview on 6/7/11 at 4:15pm with SF5LPN who worked the evening shift on 5/26/11 revealed the resident had two male visitors that evening and the one of them told her that the resident appeared to be in pain. The nurse (SF5LPN) indicated that the family wanted her to give the resident something for pain. She indicated that she looked in on the resident and he appeared to have increased restlessness. She indicated that she did not give him anything for pain at that time, and waited until the scheduled medication pass. She indicated that the medication pass times in the evening are 5pm and 9pm. The nurse could not recall what time the family asked for pain medications. She indicated that she gave the resident pain medication with the 9pm med pass. Review of narcotic logs with SF5LPN for this resident revealed that the last time the resident got pain medication signed out was on 5/25/11 at midnight. Further review revealed no documentation on 5/26/11 at 9pm that the resident received any medication for pain. review of the resident's medical record revealed [REDACTED]. Further review revealed there was no documentation of an assessment or the resident's symptoms or behaviors. After review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The nurse (SF5LPN) reviewed the chart and confirmed no documentation on the 3 to 11 shift on 5/26/11, that the resident was assessed for pain or any other problems. An interview on 6/7/11 at 4:30 pm with SF3RN Unit Manager revealed that the facility did a pain assessment on the resident on 4/ 3 /11 and his score was one (1). She further indicated that she was not sure what that score meant. The Unit Manager further indicated that the staff can tell if the resident is in pain by his increased movements in bed. When he has a change in behavior such as restlessness, agitation, and shortness of breath, the pain medication calms him down. After review of the clinical record for the resident she indicated that there was no documentation on 5/26/11 on the 3-11 shifts pertaining to if the resident got any pain medications. She indicated that the nurse should have charted the resident's pain assessment. A phone interview on 6/8/11 at 10:10am with a family member of the resident revealed that he visited with the resident on 5/26/11 in the morning before 11am. He found the resident with his covers off, tears in his eyes, moving in the bed, and beating the side of the bed. He indicated that he told the nurse that the resident needed pain medication. He indicated that he had to leave for the airport and did not see them give the resident his pain medication. He indicated that another family member visited with the resident that evening and encountered the same thing, the resident was in pain. An interview on 6/8/11 at 10:48am with SF4 LPN revealed that she worked with the resident on 5/26/11 on the morning shift. She indicated that she must have been at lunch when the family member visited that morning. The nurse (SF4LPN) indicated that she could not recall if anyone told her about the family concerns related to the resident having pain. She indicated, after review of the medical record that she did not give the resident any medication for pain. An interview on 6/8/11 at 11:28am with SF3RN Unit Manager revealed that the resident's family member voiced some concerns about the resident care and services that morning (5/26/11) mainly about the resident being uncovered, but he never mentioned anything about the resident being in pain. She further indicated that she did not recall anyone mentioning that the resident needed pain medication. Review of the resident's clinical record revealed no documented evidence that the nursing staff recognized, assessed, or managed the resident's pain on 5/26/2011, when the family told the nursing staff that the resident was showing symptoms of pain. Further review revealed no mention of the description of symptoms that the resident was experiencing and if any treatment was offered.

1.Based on record review and interview the facility failed to ensure that the resident's physician is notified of a change in the resident's medical condition by failing to notify the resident's physician that a resident had [MEDICAL CONDITION] activity and failing to follow up with the physician of the resident's non-therapeutic [MEDICATION NAME] blood level for 1 of 10 sample residents (F8). On 5/21/2011, the resident had a [MEDICAL CONDITION] and the physician was not notified. A [MEDICATION NAME] blood level was not obtained until 5/27/11 and the results were less than 2.5L, which is a non-therapeutic range. There was no documentation of follow up with the physician related to the level being non-therapeutic until 6/7/11. The resident's physician reviewed the results on 6/7/2011 and signed off with no new orders. This practice of noncompliance allowed for an Immediate Jeopardy situation which began on 05/21/2011 when the facility failed to recognize that the monitoring labs had not been drawn and failed to report [MEDICAL CONDITION] activity to the physician. The Director of Nursing was notified of the Immediate Jeopardy on 06/09/2011 at 5:02pm.An acceptable plan of removal was obtained from the facility, and the Immediate Jeopardy was lifted on 06/09/2011 at 6:30pm. The deficient practice continues at a level of actual harm. The resident still remains at risk for [MEDICAL CONDITION] until his medication blood level is within a therapeutic range. Findings: Resident # F8 Review of the nurse's note dated 5/21/2011 and written at 12:30am reads in part that the CNA reported to the nurses a change in the resident's condition. The resident was unresponsive verbally, snoring with eyes open; the resident was reposition for comfort and monitored every hour for [MEDICAL CONDITION] activity. There was no further documentation for this resident. There was no documentation that the resident's physician was notified. Review of the resident's laboratory results dated [DATE] revealed that the resident had a [MEDICATION NAME] ([MEDICAL CONDITION] medication) blood level done with the result out of range less than 2.5L.(therapeutic range of 10-20L) The labs results was faxed to the physician on 5/27/2011. There was no documented evidence that the facility followed -up with the physician until 6/7/11 when the physician signed off on the results. There were no new orders given by the physician for this resident pertaining to his [MEDICAL CONDITION] medication. An interview on 6/9/11 at 1:47pm with S3RN Unit Manager (UM) indicated that resident's labs were drawn as scheduled in May and that she was not aware that the resident had [MEDICAL CONDITION] activity on 5/21/11. She further indicated that the nurse should have monitored the resident for [MEDICAL CONDITION] and called the physician. Review of the labs results with the S3RN/UM revealed that she was responsible to notify the resident's physician, which she did on 5/27/11 via a fax. The UM indicated that she did not follow-up with the physician until 6/7/11. The physician signed off on the labs and did not write any new orders. The UM indicated that the physician was not aware of the important information that the resident had a [MEDICAL CONDITION] on 5/21/11 An interview on 6/9/2011 at 6:30pm with S2 Director of Nursing revealed that the resident ' s physician had been notified and new orders for [MEDICATION NAME] 200mg twice-a-day for seven days and on the 7th day [MEDICATION NAME] blood level drawn with results called to the physician. 2. Based on record review and interview the facility failed to ensure that the resident's physician and responsible party are notified of a change in the resident's medical condition by failing to notify the resident's physician that a resident was experiencing vomiting and diarrhea (F3) and failing to notify the resident's responsible party that the resident was hospitalized (F3) and that a resident had [MEDICAL CONDITION] activity (F8) for 2 0f 10 sampled residents (F3 & F8). The facility failed to have a monitoring system in place which would ensure the resident's physicians and responsible parties receive notification of a resident change in status. Findings: Resident # F3 Review of the resident's Care Plan dated 1/08/2011 (post hospitalization ) Nursing Diagnosis-Impaired Verbal Communication related to physical barrier (tracheotomy) uncompensated neuromuscular impairment inability to vocalize needs reads in part the facility would anticipate resident's needs and monitor for restlessness to indicate pain and discomfort. Review of the Physician order [REDACTED]. An interview on 6/7/11 at 4:15pm with SF5LPN revealed that the CNA told her that the resident had an episode of vomiting and diarrhea. The Nurse further indicated that she did not write anything in the resident's chart and did not call the physician. She indicated that she told the oncoming nurse. A phone interview on 6/7/11 at 5:25pm with SF6LPN revealed that she did not work at the facility any longer. She indicated that she worked on the night shift and relieved SF5LPN. She further indicated that the off going nurse told her that the resident had episodes of vomiting, and that usually means that the resident would have to go to the hospital. The nurse (SF6LPN) indicated that the resident was doing okay when she made rounds, but later that night the CNA called her to the room and the patient looked as if he was having a [MEDICAL CONDITION]. The resident physician was notified and orders were given to send the resident to the hospital. She indicated that she called the resident's family and did not get an answer and could did not leave a message. A phone interview on 6/8/11 at 10:10am with the resident's responsible party revealed that the he was not notified that the resident was transfer and admitted to the hospital on [DATE]. He indicated that he left his cell number months ago for the facility to contact him for any problems with resident. He indicated that the family found out that the resident was in the hospital when one of them went to the facility to visit and was told that the resident was in the hospital. Record review of the resident's clinical records revealed no documented evidence that the nurse notified the physician that the resident had episodes of vomiting and diarrhea or that that contact had been made with the family for notification that the resident had a change in condition and had been hospitalized . Resident # F3 Review of the resident's Care Plan dated 1/08/2011 (post hospitalization ) Nursing Diagnosis-Impaired Verbal Communication related to physical barrier (tracheotomy) uncompensated neuromuscular impairment inability to vocalize needs reads in part the facility would anticipate resident ' s needs and monitor for restlessness to indicate pain and discomfort. Review of the Physician order [REDACTED]. An interview on 6/7/11 at 4:15pm with SF5LPN revealed that the CNA told her that the resident had an episode of vomiting and diarrhea. The Nurse further indicated that she did not write anything in the resident ' s chart and did not call the physician. She indicated that she told the oncoming nurse. A phone interview on 6/7/11 at 5:25pm with SF6LPN revealed that she did not work at the facility any longer. She indicated that she worked on the night shift and relieved SF5LPN. She further indicated that the off going nurse told her that the resident had episodes of vomiting, and that usually means that the resident would have to go to the hospital. The nurse (SF6LPN) indicated that the resident was doing okay when she made rounds, but later that night the CNA called her to the room and the patient looked as if he was having a [MEDICAL CONDITION]. The resident physician was notified and orders were given to send the resident to the hospital. She indicated that she called the resident ' s family and did not get an answer and could did not leave a message. A phone interview on 6/8/11 at 10:10am with the resident ' s responsible party revealed that the he was not notified that the resident was transfer and admitted to the hospital on [DATE]. He indicated that he left his cell number months ago for the facility to contact him for any problems with resident. He indicated that the family found out that the resident was in the hospital when one of them went to the facility to visit and was told that the resident was in the hospital. Record review of the resident's clinical records revealed no documented evidence that the nurse notified the physician that the resident had episodes of vomiting and diarrhea or that that contact had been made with the family for notification that the resident had a change in condition and had been hospitalized . Resident # F8 Review of the nurse's note dated 5/21/2011and written at 12:30am reads in part that the CNA reported to the nurses a change in the resident's condition. The resident was unresponsive verbally, snoring with eyes open; the resident was reposition for comfort and monitored every hour for [MEDICAL CONDITION] activity. There was no further documentation for this resident. There was no documentation that the resident's family was notified. An interview on 6/9/11 at 1:47pm with SF3 RN Unit Manger indicated that she was not aware that the resident had [MEDICAL CONDITION] activity on 5/21/11. She further indicated that the nurse should have monitored the resident for [MEDICAL CONDITION] and notified the family.

Based on record review and interview the Administrator and Director of Nurses (DON) failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable physical, mental, and psychosocial well-being by failing to have a system in place that ensures that the Plan of Correction with a completion dated of 4/24/2011 was followed, failing to ensure that the resident's physician was notified of a change in the resident medical condition and failing to ensure resident's lab results are addressed promptly with the resident's physician. This practice of noncompliance allowed for an Immediate Jeopardy situation which began on 05/21/2011 when the facility failed to recognize that the monitoring labs had not been drawn and failed to report [MEDICAL CONDITION] activity to the physician. On 5/21/2011, the resident had a [MEDICAL CONDITION] and the physician was not notified. The lab was not obtained until 05/27/2011 and the results were non-therapeutic. There was no documentation of follow up with the physician related to the level being non-therapeutic until 6/7/11. The resident's physician reviewed the results on 6/7/2011 and signed off with no new orders. The Director of Nursing was notified of the Immediate Jeopardy on 06/09/2011 at 5:02pm. An acceptable plan of removal was obtained from the facility and the Immediate Jeopardy was lifted on 06/09/2011 at 6:30pm. The deficient practice continues at a level of actual harm. The resident still remains at risk for [MEDICAL CONDITION] until his medication blood level is within a therapeutic range. Findings: Review of Physician order [REDACTED]. Further review of the resident's Care Plan under the Nursing [DIAGNOSES REDACTED]. Approaches: to monitor lab levels. Review of the nurses ' note dated 5/21/2011, written at 12:30am reads in part, that the CNA reported to the nurses a change in the resident's condition. The resident was unresponsive verbally, snoring with eye open; the resident was repositioned for comfort and will monitored every hour for [MEDICAL CONDITION] activity. There was no further documentation for this resident. There was no documentation that the resident ' s physician was notified or that the resident was monitored for [MEDICAL CONDITION] activity. Review of the resident's laboratory results dated [DATE] (over one month past the Plan of Correction completion date of 4/24/11) revealed that the resident had a [MEDICATION NAME] ([MEDICAL CONDITION] medication) blood level done with the result out of range less than 2.5L. (Therapeutic range of 10-20L) The labs result was faxed to the physician on 5/27/2011. There was no documented evidence that the facility followed -up with the physician until 6/7/11 when the physician signed off on the results. There were no new orders given by the physician for this resident pertaining to his [MEDICAL CONDITION] medication. Further review revealed that the resident had a blood draw for routine labs on 4/22/11, which did not include a [MEDICATION NAME] level. An interview on 6/9/11 at 1:47pm with S3RN Unit Manager (UM) revealed that resident's labs were drawn as scheduled in May and that she was not aware that the resident had [MEDICAL CONDITION] activity on 5/21/11. She further indicated that the nurse should have monitored the resident for [MEDICAL CONDITION] and called the physician. Review of the labs results with the S3RN/UM revealed that she was responsible to notify the resident ' s physician, which she did on 5/27/11 via a fax. The UM indicated that she did not follow-up with the physician until 6/7/11. The physician signed off on the labs and did not write any new orders. The UM indicated that the physician was not aware of the important information that the resident had a [MEDICAL CONDITION] on 5/21/11. An interview on 6/9/2011 at 3:30pm with S2DON revealed that the nurse who worked on 5/21/11 was an agency nurse and was not sure why the nurse did call the physician. The DON further indicated that the unit managers gave her monthly monitoring logs which indicated that the resident's labs were drawn. After review of the lab draw book, the DON concluded that the labs was not drawn until 5/27/11. The DON indicated that she would call the resident's physician and inform the physician that the resident had a [MEDICAL CONDITION] on 5/21/11. An interview on 6/9/2011 at 6:30pm with S2 Director of Nursing revealed that the resident's physician had been notified and new orders for [MEDICATION NAME] 200mg twice-a-day for seven days and on the 7th day [MEDICATION NAME] blood level drawn with results to be called to the physician. Review of the facility' s Plan of Removal dated 6/9/2011 reads in part that the physician was notified of the resident's [MEDICAL CONDITION] activity on 5/21/2011 and new orders were given for the resident. His [MEDICATION NAME] was increased to 200mg twice a day for seven days and repeat [MEDICATION NAME] blood lever on the 7th day and call results to physician. The Unit Managers and staff on duty were in-serviced on on-going assessments, monitoring lab results and physician notification of a change in the resident 's medical condition. The plan was accepted on 6/9/2011 at 6:30pm.

1.Based on record review and interview the facility failed to ensure that the resident's physician is notified of a change in the resident's medical condition by failing to notify the resident's physician that a resident had [MEDICAL CONDITION] activity and failing to follow up with the physician of the resident's non-therapeutic [MEDICATION NAME] blood level for 1 of 10 sample residents (F8). On 5/21/2011, the resident had a [MEDICAL CONDITION] and the physician was not notified. A [MEDICATION NAME] blood level was not obtained until 5/27/11 and the results were less than 2.5L, which is a non-therapeutic range. There was no documentation of follow up with the physician related to the level being non-therapeutic until 6/7/11. The resident's physician reviewed the results on 6/7/2011 and signed off with no new orders. This practice of noncompliance allowed for an Immediate Jeopardy situation which began on 05/21/2011 when the facility failed to recognize that the monitoring labs had not been drawn and failed to report [MEDICAL CONDITION] activity to the physician. The Director of Nursing was notified of the Immediate Jeopardy on 06/09/2011 at 5:02pm.An acceptable plan of removal was obtained from the facility, and the Immediate Jeopardy was lifted on 06/09/2011 at 6:30pm. The deficient practice continues at a level of actual harm. The resident still remains at risk for [MEDICAL CONDITION] until his medication blood level is within a therapeutic range. Findings: Resident # F8 Review of the nurse's note dated 5/21/2011 and written at 12:30am reads in part that the CNA reported to the nurses a change in the resident's condition. The resident was unresponsive verbally, snoring with eyes open; the resident was reposition for comfort and monitored every hour for [MEDICAL CONDITION] activity. There was no further documentation for this resident. There was no documentation that the resident's physician was notified. Review of the resident's laboratory results dated [DATE] revealed that the resident had a [MEDICATION NAME] ([MEDICAL CONDITION] medication) blood level done with the result out of range less than 2.5L.(therapeutic range of 10-20L) The labs results was faxed to the physician on 5/27/2011. There was no documented evidence that the facility followed -up with the physician until 6/7/11 when the physician signed off on the results. There were no new orders given by the physician for this resident pertaining to his [MEDICAL CONDITION] medication. An interview on 6/9/11 at 1:47pm with S3RN Unit Manager (UM) indicated that resident's labs were drawn as scheduled in May and that she was not aware that the resident had [MEDICAL CONDITION] activity on 5/21/11. She further indicated that the nurse should have monitored the resident for [MEDICAL CONDITION] and called the physician. Review of the labs results with the S3RN/UM revealed that she was responsible to notify the resident's physician, which she did on 5/27/11 via a fax. The UM indicated that she did not follow-up with the physician until 6/7/11. The physician signed off on the labs and did not write any new orders. The UM indicated that the physician was not aware of the important information that the resident had a [MEDICAL CONDITION] on 5/21/11 An interview on 6/9/2011 at 6:30pm with S2 Director of Nursing revealed that the resident ' s physician had been notified and new orders for [MEDICATION NAME] 200mg twice-a-day for seven days and on the 7th day [MEDICATION NAME] blood level drawn with results called to the physician. 2. Based on record review and interview the facility failed to ensure that the resident's physician and responsible party are notified of a change in the resident's medical condition by failing to notify the resident's physician that a resident was experiencing vomiting and diarrhea (F3) and failing to notify the resident's responsible party that the resident was hospitalized (F3) and that a resident had [MEDICAL CONDITION] activity (F8) for 2 0f 10 sampled residents (F3 & F8). The facility failed to have a monitoring system in place which would ensure the resident's physicians and responsible parties receive notification of a resident change in status. Findings: Resident # F3 Review of the resident's Care Plan dated 1/08/2011 (post hospitalization ) Nursing Diagnosis-Impaired Verbal Communication related to physical barrier (tracheotomy) uncompensated neuromuscular impairment inability to vocalize needs reads in part the facility would anticipate resident's needs and monitor for restlessness to indicate pain and discomfort. Review of the Physician order [REDACTED]. An interview on 6/7/11 at 4:15pm with SF5LPN revealed that the CNA told her that the resident had an episode of vomiting and diarrhea. The Nurse further indicated that she did not write anything in the resident's chart and did not call the physician. She indicated that she told the oncoming nurse. A phone interview on 6/7/11 at 5:25pm with SF6LPN revealed that she did not work at the facility any longer. She indicated that she worked on the night shift and relieved SF5LPN. She further indicated that the off going nurse told her that the resident had episodes of vomiting, and that usually means that the resident would have to go to the hospital. The nurse (SF6LPN) indicated that the resident was doing okay when she made rounds, but later that night the CNA called her to the room and the patient looked as if he was having a [MEDICAL CONDITION]. The resident physician was notified and orders were given to send the resident to the hospital. She indicated that she called the resident's family and did not get an answer and could did not leave a message. A phone interview on 6/8/11 at 10:10am with the resident's responsible party revealed that the he was not notified that the resident was transfer and admitted to the hospital on [DATE]. He indicated that he left his cell number months ago for the facility to contact him for any problems with resident. He indicated that the family found out that the resident was in the hospital when one of them went to the facility to visit and was told that the resident was in the hospital. Record review of the resident's clinical records revealed no documented evidence that the nurse notified the physician that the resident had episodes of vomiting and diarrhea or that that contact had been made with the family for notification that the resident had a change in condition and had been hospitalized . Resident # F3 Review of the resident's Care Plan dated 1/08/2011 (post hospitalization ) Nursing Diagnosis-Impaired Verbal Communication related to physical barrier (tracheotomy) uncompensated neuromuscular impairment inability to vocalize needs reads in part the facility would anticipate resident ' s needs and monitor for restlessness to indicate pain and discomfort. Review of the Physician order [REDACTED]. An interview on 6/7/11 at 4:15pm with SF5LPN revealed that the CNA told her that the resident had an episode of vomiting and diarrhea. The Nurse further indicated that she did not write anything in the resident ' s chart and did not call the physician. She indicated that she told the oncoming nurse. A phone interview on 6/7/11 at 5:25pm with SF6LPN revealed that she did not work at the facility any longer. She indicated that she worked on the night shift and relieved SF5LPN. She further indicated that the off going nurse told her that the resident had episodes of vomiting, and that usually means that the resident would have to go to the hospital. The nurse (SF6LPN) indicated that the resident was doing okay when she made rounds, but later that night the CNA called her to the room and the patient looked as if he was having a [MEDICAL CONDITION]. The resident physician was notified and orders were given to send the resident to the hospital. She indicated that she called the resident ' s family and did not get an answer and could did not leave a message. A phone interview on 6/8/11 at 10:10am with the resident ' s responsible party revealed that the he was not notified that the resident was transfer and admitted to the hospital on [DATE]. He indicated that he left his cell number months ago for the facility to contact him for any problems with resident. He indicated that the family found out that the resident was in the hospital when one of them went to the facility to visit and was told that the resident was in the hospital. Record review of the resident's clinical records revealed no documented evidence that the nurse notified the physician that the resident had episodes of vomiting and diarrhea or that that contact had been made with the family for notification that the resident had a change in condition and had been hospitalized . Resident # F8 Review of the nurse's note dated 5/21/2011and written at 12:30am reads in part that the CNA reported to the nurses a change in the resident's condition. The resident was unresponsive verbally, snoring with eyes open; the resident was reposition for comfort and monitored every hour for [MEDICAL CONDITION] activity. There was no further documentation for this resident. There was no documentation that the resident's family was notified. An interview on 6/9/11 at 1:47pm with SF3 RN Unit Manger indicated that she was not aware that the resident had [MEDICAL CONDITION] activity on 5/21/11. She further indicated that the nurse should have monitored the resident for [MEDICAL CONDITION] and notified the family.