Every finding on record at West Melbourne Health & Rehabilitation Center

Based on interview, and record review, the facility failed to respond in writing to repeated grievances identified by resident council over a six-month period, (June to November 2025).Findings: During Resident Council meeting on 12/02/25 at 10:34 AM, members of Resident Council verified they met monthly. The members stated several grievances had been voiced regarding nurse and aide staffing, staff customer service and dietary issues. The residents in attendance agreed the same concerns were voiced month after month without a resolution from the facility. The group expressed no one ever responded to the grievances and informed them of what was done. Review of the grievance log from June through November of 2025 revealed one grievance from the Resident Council dated 11/12/25, in regard to their concerns with staff being loud, rude, and on their cell phones in the dining room. Further review of Resident Council minutes from June through November 2025 revealed the staff customer service concerns about staff on their cell phones was repeated several times. There were also repeat grievances for the cleanliness of the shower rooms. On 12/03/25 at 3:40 PM, the Activity Director stated she attended every Resident Council meeting and helped facilitate conversations between the council and the facility. She stated typically she did not fill out a grievance form unless it was a majority concern for the group, but Resident Council minutes were discussed during the facility's daily morning management meeting. The Activity Director explained they decided as a group how to handle the concerns, then they were handed off to the related department head. She confirmed this process was completed verbally and there was no written documentation of the process. The Activity Director acknowledged Resident Council members reported they did not feel like anyone was listening to them. n 12/04/25 at 9:41 AM, the Nursing Home Administrator explained his expectation related to Resident Council concerns was for the Activities Director to bring their concerns to their daily morning meeting to discuss, then hand the concerns off to the appropriate Department Head. He acknowledged the Resident Council concerns were not written up into a grievance form which would show how or if the concerns were addressed. Review of the facility's policy and procedure for Resident and Family Grievances effective 3/30/12 revealed that grievances which were verbal should be recorded on the grievance form which would serve as communication to other staff members. One of the various forms of grievances included verbal complaints during Resident Council meetings. The policy described that the staff member who received the grievance should complete the grievance form.

Based on observation, interview, and record review, the facility failed to maintain the overall cleanliness of the kitchen and ensure that food was stored and distributed in a sanitary manner.Findings:On 12/01/25 at 10:10 AM, the initial kitchen tour inspection was conducted with the Kitchen Manager. She stated she had been in the position for two years but had been a Certified Nursing Assistant prior to her current position. Initial observation found the floor unclean, as evidenced by stuck on food under the tables and equipment. The Kitchen Manager said the floors were cleaned every night prior to closing the kitchen but once per month the Maintenance Department power washed the floors. She was unsure when maintenance had last done the floors. The shelves directly below the steam table had a sticky residue and stuck on food. Next to the dishwashing sink there was a table used for meal prep that had a top shelf where spices were stored. The spice bottle lids were visibly dirty, sticky, and unable to close due to crusted spice flakes and residue on them. There was a half empty clear container used to store food thickener that was covered in an unknown substance, including the lid and a similar uncleaned container of breadcrumbs. Upon lifting both containers off the shelf, ants crawled all over the shelf which had not been cleaned. The Kitchen Manager stated shelves were wiped daily at the end of the day.A short time later the kitchen equipment was inspected, and it was noted that the oven was dirty with burnt food on both the doors and inside. The Kitchen Manager said the ovens were cleaned daily. Upon opening the walk-in refrigerator, there was a large tray on the bottom left side that had meat juices dripping on the floor and a box on top of that containing defrosted chicken. On the top right shelf there was a clear container with fruit punch that had been dated to be used prior to 11/30/25 and had not been discarded. There was a stainless-steel container with an unknown orange sauce that was labeled to be used prior to 11/28/25 and not discarded. In the walk-in freezer there was a box of sausage patties and a box of frozen empanadas, that had been left open to air, and the items had freezer burn. The Kitchen Manager stated that all staff were responsible for ensuring defrosted meat juices were contained within the drip tray to prevent the spread of bacteria. The manager said staff were supposed to ensure all food items past their use by date were discarded daily and packaged food items had to be securely closed to prevent spoilage and ensure freshness.In the dry storage closet, there were open items such as a bag of sugar, box of potato pearls, and package of gravy mix that had not been appropriately closed and were not dated. The floor in this room had dried, crusted food around the legs of the shelves, that was acknowledged by the Kitchen Manager.On 12/01/25 at 10:30 AM, the Kitchen Manager provided the cleaning schedule for November and December 2025 and it revealed staff were signing off they were conducting the daily cleaning of all areas of the kitchen to include counters, floors, walk-in fridge, and kitchen equipment. The Kitchen Manager stated these areas were not assigned to a specific person on a rotating basis because it was the responsibility of all staff to ensure the kitchen was clean and food items were discarded after their use by date.On 12/04/25 at 1:45 PM, the Maintenance Director confirmed the kitchen floors had been power washed on 11/19/25. He said power washing was conducted monthly and as needed. He said he was not aware of the condition of the floors and agreed that they needed to be cleaned.

Based on interview, and record review, the facility failed to ensure the Quality Assessment & Assurance (QAA) / Quality Assurance and Performance Improvement (QAPI) committee conducted performance improvement activities to ensure prior improvement measures were sustained. Findings: Review of the facility's QAPI Plan revealed the facility would gather information from various sources including past surveys to identify and clarify issues or problems, design and implement interventions, assess results and sustain improvements using a root cause process. During the previous recertification survey conducted 12/11/23 to 12/14/23, the facility had deficiencies cited at F677 for Activities of Daily Living (ADL) care not provided to a dependent resident related to nail care, F695 for tracheostomy care and oxygen therapy not provided as ordered, and at F812 for storage/preparation/service of food in a sanitary manner. During this survey, the facility was found to again be in noncompliance with F677 for ADL care not provided to a dependent resident related to oral care and showers, F695 for respiratory care related to use of a continuous positive airway pressure (CPAP) machine and F812 for store/prepare/serve food in sanitary conditions related to dirty surfaces, presence of insects, opened and undated food and improper defrosting of meat products. As a result of the repeat deficiency, it was identified there was insufficient auditing and oversight to prevent the citation. On 12/04/2025 3:59 PM, the Administrator stated there had been some changes in staff including management staff. He verified that with the changes with staff, some things just got dropped. The Administrator acknowledged that QAPI plans were supposed to continue to exist beyond changes in staff.

Based on observation, interview, and record review, the facility failed to promote dignity during dining for 1 of 2 residents reviewed for dignity, of a total sample of 49 residents, (#20).Findings: Review of resident #20's medical record revealed he was originally admitted to the facility on [DATE] and readmitted from an acute care hospital on [DATE] with diagnoses including quadriplegia (spinal cord injury affecting all four limbs), dysphagia (difficulty swallowing), and type 2 diabetes. Review of resident #20's Minimum Data Set (MDS) annual assessment with an Assessment Reference Date of 9/02/25 revealed a Brief Interview for Mental Status score of 15 out of 15, indicating intact cognition. The MDS assessment identified impairment of both upper and lower extremities. The assessment revealed resident #20 was totally dependent on staff for all activities of daily living (ADLs) except toileting hygiene, for which he required substantial assistance, and was dependent on staff for mobility. Review of resident #20's comprehensive care plan, revised on 9/04/25, revealed the resident was unable to perform self-care and required total assistance related to quadriplegia. The stated goal indicated his ADL needs would be met within 90 days. Review of resident #20's comprehensive care plan, revised on 9/04/25, identified a problem related to weight loss. An additional care plan addressing potential weight loss indicated the resident was dependent on staff for assistance with all meals and directed nursing staff to allow adequate time for meals to be consumed. On 12/01/25 at 1:48 PM, a female staff member was observed standing while feeding lunch to resident #20. There was no chair in the resident's room for staff to sit during the meal. On 12/01/25 at 4:07 PM, resident #20 stated there used to be an extra chair in his room, however, it was removed a few weeks earlier because his roommate's wheelchair did not fit in the room, and the chair was not replaced. He shared, Certified Nursing Assistants (CNAs) normally stood while feeding him. Resident #20 expressed he preferred staff to sit while assisting him with his meals which allowed them to take their time due to his swallowing difficulties. On 12/03/25 at 11:53 AM, CNA B stated she had assisted resident #20 with lunch the previous day while standing. She indicated she sat sometimes but acknowledged she did not always do so. CNA B explained this depended on the available space in the room. She confirmed she was standing while assisting resident #20 during lunch the previous day and breakfast that morning. She did not recall whether a chair was available in the resident's room. The CNA stated some rooms did not have chairs but acknowledged it was better for the residents to be seated and at eye level of the dependent residents while they ate. On 12/03/25 at 12:50 PM, CNA C stated she typically sat down to assist residents who required help with meals in order to remain at eye level and would obtain a chair if one was not present in the room. She confirmed she stood while assisting resident #20 due to his condition and the presence of special devices attached to his bed. She explained she elevated the head of the bed during meals but remained standing. CNA C indicated she had not discussed or requested guidance regarding resident #20's meal set-up with anyone. On 12/03/25 at 3:53 PM, Licensed Practical Nurse (LPN) C stated resident #20 was dependent on staff for all ADLs. She indicated she did not recall observing CNAs sitting while assisting resident #20 with meals. She stated she had observed most CNAs sitting while feeding other residents but had also observed some standing, noting it depended on chair availability. She stated CNAs preferred to be at eye level with residents and, at times, she had encouraged CNAs to sit. On 12/04/25 at 10:11 AM, during an interview with the C Wing's Unit Manager (UM) and the Director of Nursing (DON), the UM stated CNAs normally sat when feeding residents, however CNAs stood while feeding resident #20 because he liked to watch television while eating. The UM explained CNAs could obtain information on how to care for assigned residents by reviewing the care plan, or consulting nurses or other CNAs familiar with the resident. The DON stated any deviation from standard care should be included in the resident's individualized care plan and confirmed the standing position described as resident #20's preference was not documented in the comprehensive care plan. Later, at approximately 3:00 PM, the UM stated there were 25 residents in the facility who were dependent on staff for eating. Review of the admission packet provided to all residents included a list of Resident Rights and read, The Facility strives to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect, in full recognition of his individuality.

Based on interview, and record review, the facility failed to follow generally accepted accounting principles in the management of resident personal funds for 1 of 2 residents reviewed for personal funds, of a total sample of 49 residents, (#13).Findings: Review of resident #13's medical record revealed she was readmitted to the facility on [DATE]. Her diagnoses included Parkinsonism, chronic obstructive pulmonary disease, and neuropathy. Review of the Minimum Data Set quarterly assessment with an Assessment Reference Date of 9/29/25 revealed resident #13 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 indicating mild cognitive impairment. A BIMS score of 12/15 indicates the individual has a relatively good level of cognitive function, (retrieved on 12/17/25 from www.clevelandclinic.org). On 12/02/25 at 9:17 AM, resident #13 stated she had not received bank statements or the facility's financial statements. She shared the facility managed her finances and she would like to receive monthly statements to know her balance. She stated she was schedule to have her hair done that day and did not even know whether she had sufficient funds in her account to pay for the service. On 12/03/25 at 10:21 AM, Financial Specialist Assistant A stated she managed resident trust accounts. She indicated quarterly statements were mailed to residents or resident representatives. She confirmed resident #13 had a resident trust account. She explained earlier in the year the facility learned resident #13 maintained an external bank account and received a pension from the Veterans Administration. She stated the facility assisted resident #13 with transferring those funds into her resident trust account and with reapplying for Medicaid. She further mentioned resident #13 had a Power of Attorney (POA) added to manage her affairs effective 5/27/25. Financial Specialist Assistant A explained when a resident served as their own responsible party, quarterly statements were mailed to the facility and delivered to the resident's room. She stated she failed to mail statements to the POA because the address on file listed the resident and the facility's address. She explained the appropriate process when a POA was added was to update the POA address in the system so quarterly statements would be automatically mailed to the POA. She confirmed resident #13 would have been mailed the first quarter 2025 statement in April and stated statements could be provided upon request, despite the presence of a POA. Financial Specialist Assistant A was unable to provide evidence resident #13 or her POA received any quarterly statements during 2025. On 12/03/25 at 10:37 AM, Financial Specialist Assistant F stated resident #13 requested a copy of her trust account statement earlier that morning but she had not yet provided one. She said she notified resident #13's POA of the resident's request. Review of the current admission packet provided to all residents revealed a list of Resident Rights which included the management of personal funds which read, Your individual financial records will be available to you through quarterly statement and upon the written request of you or your Responsible Party.

Based on interview, and record review, the facility failed to refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident's date of discharge from the facility, for 1 of 1 resident reviewed for discharge, of a total sample of 49 residents, (#151). Findings: Resident #151 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, intervertebral disc degeneration of lumbar region, major depressive disorder, and essential primary hypertension. Review of the Minimum Data Set quarterly assessment with assessment reference date of 5/08/25 revealed resident #151 had Brief Interview for Mental Status score of 5 out of 15 which indicated severe cognitive impairment. Review of resident #151's medical record revealed her daughter, Jeannelle [NAME], was resident #151's guardian, emergency contact, responsible party for decision making, durable power of attorney (POA) - financial and received the financial statements. Review of resident #151's medical record revealed she was discharged home on 5/19/25. In a phone interview on 12/04/25 at 2:27 PM, resident #151s guardian explained her mother had been out of the facility more than 30 days and the facility had not refunded the money in her accounts. She explained she reached out to the facility multiple times in the summer of 2025 and met with the Nursing Home Administrator (NHA) in September 2025 to discuss the positive balance but had not received the refunded money. Review of emails dated 6/20/25 to 7/07/25 from resident #151's guardian to the facility revealed she requested the refund and verified her home address. On 12/03/25 at 10:51 AM, Business Office Staff A reviewed resident #151's financial records and stated she had Medicaid as the primary payor when she discharged home on 5/19/25. She reported there was a positive balance in the primary account and stated they didn't normally issue the refund until all payor sources were paid. Business Office Staff A explained resident #151's Medicaid Aetna had not been paid. She stated, when there was a positive balance, they gave it to the Business Office Manager (BOM), who issued the refund if necessary. Business Office Staff A provided a current financial statement dated May 2025 for resident #151 which indicated a positive balance of $517.06. On 12/03/25 at 11:34 AM, the Regional NHA reviewed resident #151's financial records, stated she still has some open claims, and acknowledged the positive balance on her account. On 12/03/25 at 12:28 PM, the facility NHA acknowledged resident #151's positive balance had not been refunded. Review of the facility policy, [NAME] and Refunds with revision date 6/04/12, revealed: Refunds will be issued in accordance with both State and Federal guidelines.

Based on observation, interview, and record review, the facility failed to provide maintenance and housekeeping services necessary to maintain a sanitary, orderly, and comfortable interior in 2 of 2 shower rooms, on 1 of 3 units, (B-Wing).Findings: On 12/02/25 at 10:03 AM, resident #33 shared there was a black substance above the door in one of the B wing shower rooms. On 12/04/25 at 1:28 PM, the Housekeeping Director stated he was responsible for managing housekeeping and laundry services. He shared he performed monthly audits of residents' rooms to ensure conditions were in good order. An observation of the east individual shower room in the B-wing was conducted with the Housekeeping Director at 1:48 PM. A black substance was observed on the ceiling near the air conditioner vent and on the vent itself (photographic evidence obtained). The Housekeeping Director stated the black substance resulted from condensation from the air conditioner vent. He indicated housekeeping staff were responsible for cleaning the exterior of the vent, while maintenance staff were responsible for the ceiling. An observation of the B-wing north-side individual shower room was also conducted, during which a similar substance was observed near the shower area. The Housekeeping Director stated housekeepers checked the showers every morning and performed a deep clean weekly. He explained special chemicals were used to remove mildew and acknowledged the condition of the showers was not acceptable. He said his expectation was for shower rooms to be clean. On 12/04/25 at 1:59 PM, the Maintenance Director stated he expected staff to inform him of maintenance needs, as staff were in resident rooms and common areas more frequently than he was. The Maintenance Director stated he was unaware of the black substance found in the east individual shower room on the B-Wing. He explained the substance was caused by the dust mixed with condensation from the vent. He reiterated no one had reported the condition of the shower room ceiling. The Maintenance Director said his expectation was for shower rooms to be clean and homelike for residents. On 12/04/25 at 2:16 PM, the Administrator reviewed the photograph obtained from the shower room and confirmed he expected the shower rooms to be kept clean. Review of the facility's policy titled Resident Environment Quality dated 3/01/10 revealed its purpose was to protect the health and safety of residents, personnel, and the public. The policy process included the directive, Preventive maintenance schedules, for the maintenance of the building and equipment, should be followed to maintain a safe environment.

Based on observation, interview, and record review, the facility failed to follow the grievance process by not making a prompt effort to resolve a grievance and not keeping the resident apprised of the progress toward resolution for 1 of 3 residents reviewed for personal property, of a total sample of 49 residents, (#20).Findings: Review of resident #20's medical record revealed he was originally admitted to the facility on [DATE] and readmitted from an acute care hospital on [DATE] with diagnoses including quadriplegia (paralysis of all four limbs), dysphagia (difficulty swallowing), and type 2 diabetes. Review of resident #20's Minimum Data Set (MDS) annual assessment with an Assessment Reference Date of 9/02/25 revealed a Brief Interview for Mental Status score of 15 out of 15, indicating intact cognition. The MDS assessment noted it was very important to resident #20 to take care of his personal belongings. On 12/01/25 at 4:33 PM, resident #20 stated approximately three months earlier, while being moved from the A wing to the C wing, facility staff were moving his dresser and pushed it forcefully, causing his television (TV) to fall and break. He indicated the TV was a 55-inch (name brand) smart TV that cost approximately $1,600.00 and stated he would accept a replacement costing $900.00 if it had the same features. Resident #20 mentioned he was asked to provide a copy of the purchase receipt for replacement purposes which he did. He further stated the Social Services Director (SSD) later informed him the Administrator (NHA) said the amount was too much to reimburse for a TV. Review of resident #20's medical record revealed an interdisciplinary progress note dated 12/17/24 documenting a care plan meeting held at the resident's bedside with his fiance participating via telephone. The note read, Resident received a big screen TV this quarter from his brother. He and roommate watch it together. Review of a Grievance/Complaint Form dated 6/12/25 described the concern as, During care, resident's personal TV was knocked over and broke. Staff confirmed that they were giving care and broke the TV. The action to resolve the concern read, Resident was notified that TV will be reimbursed. The form documented the resolution as, Resident stated that reimbursement will be sufficient and was signed by the SSD on 6/13/25. Attached to the Grievance/Complaint Form was a receipt showing the TV cost of $1,299.95 and the sales tax of $88.44. Also attached was a Request for Payment form dated 8/15/25, which indicated the SSD requested a check payable to resident #20 in the amount of $1,388.37. The explanation of the expenditure read, TV was broken by staff while giving care, and the form was signed by the NHA. On 12/03/25 at 5:29 PM, the SSD stated resident #20 was provided another TV in the interim and the NHA was working on obtaining a replacement. The SSD acknowledged there should have been timely follow-up with resident #20 and documentation regarding the status of his grievance. On 12/04/25 at 2:20 PM, the NHA stated it should not have taken this long to resolve resident #20's grievance. The NHA acknowledged the grievance process was not followed but stated the issue was now being addressed. Review of the facility's policy titled Resident and Family Grievances, dated 3/30/12, revealed the Social Service designee was responsible for taking steps to resolve grievances and documenting actions taken in the social service progress notes. The policy further indicated the NHA was responsible for following up with the resident, with the assistance from the Social Service designee, to discuss actions taken to resolve the grievance. Review of the admission packet provided to all residents included a list of Resident Rights outlining the Grievance Procedure. The procedure stated the facility would investigate and attempt to resolve all grievances promptly and provide investigative findings and a plan of action.

Based on interview, and record review, the facility failed to develop a comprehensive person-centered care plan for a resident with antipsychotic medications for 1 of 5 residents reviewed for high-risk medications, of a total of 49 residents, (#116); the facility failed to develop an individualized care plan to include paranoid schizophrenia for 1 of 5 residents reviewed for Pre-admission Screening and Resident Review (PASARR), (#103),of a total sample of 49 residents.Findings: 1.Review of resident #116's medical record revealed she was readmitted to the facility on [DATE] with diagnoses of hypertensive heart disease without heart failure, Alzheimer's disease, dementia with psychotic disturbances, major depressive disease and anxiety. Review of resident #116's admission Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD)of 11/16/25 revealed a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated severe cognitive impairment. The assessment showed resident #116 received high-risk medications including anti-psychotics, anti-anxiety and anti-depressants. Review of resident #116's electronic medication record revealed medication orders for Quetiapine 25 milligrams (mg) twice daily for dementia with psychotic disturbances. Review of resident #116's medical record revealed a comprehensive care plan for anti-psychotic medications was not developed for the resident after the completion of the admission MDS assessment. Review of a pharmacy recommendation dated 11/04/25 revealed the recommendation for guidance for the interdisciplinary care plan related to the anti-psychotic, Quetiapine. The recommendations included: identifying common behavioral expressions, implementing and reassessing appropriate person-centered interventions, and discussing the appropriateness of the current dose with the provider. On 12/04/25 at 11:21 AM, the MDS Coordinator explained her responsibilities included to oversee the MDS assessments and development of care plans. She stated that she reviewed hospital records, progress notes and facility assessments to develop a resident's care plan. She stated that resident #116 was a new admission and her comprehensive care plan was not finished yet. She acknowledged that a comprehensive care plan needed to be completed within seven days of the admission assessment which for resident #116 was 11/26/25. The MDS Coordinator stated she did not review pharmacy recommendations and confirmed the recommendation from 11/04/25 was not passed along to her. She validated a care plan for anti-psychotic medication was not created for the resident. Review of the facility's policy and procedure titled Person Centered Care Plans reads the facility develops a comprehensive centered plan of care for each resident that includes measurable objectives and timelines to meet a residents medical, nursing and mental needs. The policy stated that a comprehensive care plan should be completed within seven days of admission Resident Assessment Instrument assessment. 2. Review of the medical record revealed resident #103, a [AGE] year-old male was admitted to the facility from an acute care hospital on 5/13/23 with diagnoses that included diffuse traumatic brain injury, major depressive disorder, persistent mood disorders, brief psychotic disorder, mood affective disorder, generalized anxiety disorder, pseudobulbar affect, and paranoid schizophrenia. The most recent MDS Quarterly Assessment with an ARD of 11/03/25 noted the resident had a BIMS score of 3 out of 15 which indicated severe cognitive impairment. Active diagnoses included seizure disorder, anxiety disorder, depression, and schizophrenia. The resident received high-risk medications that included anti-anxiety, anti-depressant, and anticonvulsant medications during the look back period. The medical record showed resident #103 had active diagnoses that included paranoid schizophrenia. Review of the Comprehensive Care Plan Report revealed no plan of care for the issue of schizophrenia with anxiety with potential for complications until 12/04/25, the last day of the survey. On 12/04/25 at 10:50 AM, the MDS Coordinator explained she was responsible for developing and updating comprehensive care plans. She said resident #103 had an active diagnosis of paranoid schizophrenia which she confirmed was a serious mental illness. Later, at 11:14 AM, the MDS Coordinator said she checked the care plan, and she had just created a missing problem for potential for complications of schizophrenia with anxiety care plan. She explained the problem was missing and should have been included in the care plan for resident #103. Review of the facility's standards and guidelines titled Person Centered Care Plans dated 8/15/18 outlined the facility developed a comprehensive person-centered plan of care for each resident to meet medical and mental/psychosocial needs identified in the comprehensive assessment. The guidelines noted ongoing reviews were conducted and individualized interventions were entered to meet residents' care needs.

Based on observation, interview, and record review, the facility failed to ensure residents received proper and timely assistance with Activities of Daily Living (ADLs) to maintain cleanliness and dignity for 2 of 3 residents reviewed for ADLs, of a total sample of 49 residents, (#20 and #143).Findings: 1.Review of resident #20's medical record revealed he was originally admitted to the facility on [DATE] and readmitted from an acute care hospital on [DATE] with diagnoses including quadriplegia (paralysis of all four limbs), dysphagia (difficulty swallowing), and type 2 diabetes. Review of resident #20's Minimum Data Set (MDS) annual assessment with an Assessment Reference Date (ARD) of 9/02/25 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. The MDS assessment indicated no rejection of evaluation or care necessary to achieve goals for health and well-being. The MDS assessment showed resident #20 had impairment of both upper and lower extremities and was totally dependent on staff for all ADLs except toileting hygiene, for which he required substantial assistance. The MDS assessment further indicated he was dependent on staff for mobility. Review of resident #20's comprehensive care plan, revised on 9/04/25, revealed he was unable to perform self-care and required total assistance related to quadriplegia. The stated goal indicated ADL needs would be met within 90 days. Interventions added on 12/24/24 included assisting resident #20 with brushing his teeth and providing oral care. On 12/01/25 at 4:07 PM, resident #20 stated he primarily received bed baths and occasionally received showers. He indicated his scheduled shower days were Mondays and Thursdays and expressed a preference for bed baths. He mentioned Certified Nursing Assistants (CNAs) did not routinely brush his teeth as part of daily care and would only do so occasionally if he requested it. On 12/03/25 at 11:53 AM, CNA B stated she had been assigned to care for resident #20 for approximately two weeks. She shared she provided him with a full bed bath this morning, including washing his hair. She stated she did not brush his teeth during the bed bath and did not recall brushing his teeth the previous day, saying, I probably did not. She acknowledged oral care was not provided and stated she should have brushed his teeth or at least offered it. On 12/04/25 at 10:11 AM, during an interview with the C-Wing Unit Manager (UM) and the Director of Nursing (DON), the UM stated CNAs were expected to provide oral care, encourage showers or provide bed baths, change linens and clothing, and encourage residents to get out of bed. She explained CNAs could obtain information regarding resident care needs by reviewing the plan of care or consulting nurses or CNAs familiar with the resident. The DON stated any deviation from expected care should be documented in the individualized resident-specific care plan. Review of the facility's policy titled Brushing the Resident's Teeth, effective 10/01/10, revealed its purpose was to provide oral hygiene to clean and freshen the resident's mouth and teeth, reduce the potential for oral infections, stimulate the gums, and remove food particles. The policy indicated oral hygiene was to be provided twice daily unless contraindicated by a physician or the resident desired more frequent hygiene. 2. Review of resident #143's medical record revealed he was originally admitted on [DATE] and readmitted to the facility from an acute care hospital on [DATE]. His diagnoses included hemiplegia (one-sided paralysis) and hemiparesis (one-sided weakness) following a stroke, rheumatoid bursitis (swelling of this small sac) of the left elbow, hearing loss, and type 2 diabetes. Review of resident #143's MDS quarterly assessment with an ARD of 8/30/25 revealed a BIMS score of 12 out of 15, indicating mild to moderate cognitive impairment. The MDS assessment indicated no rejection of evaluation or care necessary to achieve goals for health and well-being. The MDS assessment showed resident #143 required partial to moderate assistance with showers and transfers. Review of resident #143's comprehensive care plan, revised on 10/03/25, revealed he required assistance to safely complete daily activities of care. Interventions included bathing per schedule and encouraging the resident to wash, rinse and dry body parts within his ability. Another intervention read, Make bathing process pleasant by ensuring non-hurried atmosphere, give assistance as needed. On 12/01/25 at 2:11 PM, resident #143 stated he went approximately three weeks without receiving a shower or bed bath prior to the previous week. He indicated showers resumed only after he had to throw a fit because he felt stinky. He stated he learned the prior week his scheduled showers days were Tuesday and Friday. On 12/03/25 at 1:12 PM, CNA E stated resident #143 scheduled shower days were Tuesday and Friday morning during the 7:00 AM and 3:00 PM shift. She mentioned resident #143 refused a shower the prior week because he had received one on the previous day with the help of a therapist. She produced shower sheets showing resident #143 received a shower on 12/02/25 and 11/25/25. Review of additional shower sheets revealed no evidence resident #143 received showers on 10/31, 11/4, 11/11, 11/14, 11/18 and 11/28. Shower sheets for 11/7 and 11/21 could not be located by the CNA. She stated showers were documented both electronically and on shower sheets but was unable to explain why showers were not documented as completed. Review of resident #143's physician orders included an order dated 9/11/25 for showers on Tuesday and Friday evening. Review of the schedule for showers on the C-Wing located in the shower binder at the nurses' station showed resident #143's showers were scheduled for Tuesday & Friday during the day shift. Review of the Point of Care (POC) History document dated 10/31/25 through 12/04/25 revealed CNAs documented functional ability for tub or shower transfer but did not document whether a shower was provided. The document showed first-shift CNAs selected not applicable or did not answer for the bathing transfer task 22 of 32 days. Review of the C-Wing Shower List form used by CNAs instructed staff to sign off as showers are given and nurse to initial, and also read, Hair washed, nail cleaned and clipped if needed, teeth/dentures brushed with mouth care 2 times a day. Review of the shower sheets revealed no staff signature acknowledging resident #143 received showers on the following dated: 10/31, 11/4, 11/11, 11/14, 11/18, and 11/28 of 2025. Shower sheets for 11/7 and 11/21 were not found by facility staff. On 12/03/25 at 4:04 PM, Licensed Practical Nurse (LPN) D stated CNAs were required to sign shower sheets and notify the nurse if a resident refused care. She indicated nurses were responsible for following up on refusals and documenting them in a nursing note. Review of resident #143's Progress Notes from October 2025 through 12/04/25 did not reveal documentation of refusals of showers. On 12/04/25 at 10:44 AM, during an interview with the C-Wing Unit Manager (UM) and the Director of Nursing (DON), the UM stated resident #143's shower days were Tuesday and Friday during the 3:00 PM to 11:00 PM shift, then stated the shower binder reflected the same days but during a different shift. The UM explained if a resident requested specific showers days or times, a physician order would be entered to update the POC. She added CNAs would honor resident requests for showers outside scheduled days. The UM and DON confirmed no shower sheets were found for 11/07 or 11/21 and there was no evidence resident #143 received a shower on his scheduled days on 10/31, 11/04, 11/11, 11/14, 11/18, and 11/28. The DON stated she was unaware the POC did not include documentation of whether a shower or bed bath was provided to resident #143. The DON concluded she expected CNAs to provide showers on assigned days, and document care provided or refusals. On 12/04/25 at 11:50 AM, the Staff Development Coordinator stated all CNAs were trained on the POC system the previous year when it was changed. She explained the shower order was not entered correctly, resulting in the task not appearing on the POC for CNAs to document. Review of the policy titled Bath - Shower or Tub, effective 10/01/10, included showers and tub baths promote resident cleanliness and comfort and residents were to receive showers or tub baths as needed.

Based on observation, interview, and record review, the facility failed to implement the recommended Restorative Nurse Program (RNP) to provide mobility and Range of Motion (ROM) services to improve or maintain functional ability for 1 of 2 residents reviewed for rehabilitation and restorative services, out of a total sample of 49 residents, (#13).Findings: Review of resident #13's medical record revealed she was readmitted to the facility on [DATE]. Her diagnoses included Parkinsonism, insomnia, chronic obstructive pulmonary disease, neuropathy, and schizoaffective disorder. Review of the Minimum Data Set quarterly assessment with Assessment Reference Date of 9/29/25 revealed resident #13 had a Brief Interview for Mental Status score of 12 out of 15, indicating moderate cognitive impairment. The MDS assessment noted no rejection of evaluation or care necessary to achieve goals for health and well-being. The MDS assessment showed resident #13 required partial assistance with oral hygiene, substantial assistance with toileting, shower, and dressing, and was totally dependent on staff for putting on and removing footwear and personal hygiene. The resident utilized a wheelchair for mobility and required supervision and partial assistance for bed mobility and sitting in bed. The MDS assessment further indicated resident #13 did not receive therapy services or RNP during the look-back period. On 12/01/25 at 11:30 AM, resident #13 stated was waiting to speak with her nurse practitioner to request therapy. She shared when she enrolled in hospice, she was told she could not receive therapy; however, she later clarified with hospice staff that she could have some therapy services. She stated she previously worked with therapy on two occasions and felt better afterward, despite being unable to walk. She said she did not recall receiving RNP services after therapy concluded. Review of the Physical Therapy (PT) Discharge Summary with dates of service from 1/23/25 through 3/19/25 revealed a long-term goal to Establish and train nursing with FMP (Functional Maintenance Plan) and RNP. The summary documented Certified Nursing Assistant (CNA) training in slide-board transfers initiated on 3/04/25 and completed on 3/19/25. Skilled interventions included bed mobility and transfer training and the summary showed resident #13 made good progress. Discharge recommendations indicated resident #13 was discharged to nursing care with an FMP and an RNP. The prognosis to maintain current level of function was excellent with participation in RNP, excellent with participation in FMP, and good with consistent staff follow-through. Review of the Physical Therapy FMP form signed on 3/13/25 revealed RNP interventions included active ROM (AROM) and bed mobility. The goal was for resident #13 to perform two sets of ten bilateral lower extremity exercises in the supine (lying back) position within tolerance to improve strength and functional mobility. An additional Physical Therapy FMP dated 3/19/25 included a goal to assist the resident with functional transfers out of bed throughout the week within tolerance, utilizing a sliding board. Review of resident #13's Point of Care (POC) History report for 2025 revealed documentation of AROM on 1/30/25 and 2/17/25, with bed mobility documented on 1/30/25. There was no evidence in the medical record resident #13 received the therapy-recommended exercises initiated on or after 3/13/25. Review of resident #13's Observation Detail List Report dated 7/04/25, completed by the RNP nurse, did not include restorative nursing goals or a restorative plan. The documented care plan action was to Continue Current Care Plan. The RNP was not incorporated in the comprehensive care plan. On 12/04/25 3:14 PM, the RNP nurse stated she had served in the RNP role for the past two years and was responsible for implementing the FMPs recommended by therapy. She indicated two Restorative Certified Nursing Assistants (RCNAs) were responsible for performing ROM exercises, applying splints, assisting residents with dining, and following dietary recommendations. She shared therapy staff completed FMPs upon discharge and provided training to RCNAs. She stated she entered FMP as orders in the medical record, specifying frequency, and expected the RCNAs to document services provided. She indicated the FMP duration was 90 days, after which the resident was discharged from the program. She stated residents who declined or failed to improve were referred back to therapy. She stated resident #13 began RNP services sometime in February and was assigned ROM exercises. She acknowledged RCNAs did not document sessions provided. She stated if a resident refused RNP services, RCNAs were expected to notify her and she would speak with the resident, though she acknowledged such conversations were not always documented. She indicated resident #13 refused exercises at times but validated these refusals were not documented. She stated she asked an RCNA whether services were provided to resident #13 and the RCNA stated they were but could not recall if documentation was completed. She indicated she did not recall documenting resident #13's progress or discharge from the RNP and could not state with certainty whether resident #13 received the RNP services as recommended by therapy. On 12/04/25 at 3:33 PM, the Director of Therapy stated if there was a change in a resident's condition requiring therapy, the RNP team was expected to notify her. She indicated there were no regular scheduled meetings with the RNP team. She stated the FMP was reviewed every 90 days by RNP staff and could be continued or discontinued without therapy input. She mentioned FMP recommendations were resident-specific and included ROM, splint use, and ambulation, with the purpose of maintaining gains achieved through therapy. Review of the facility's policy titled Restorative Services, dated 10/01/10, revealed the purpose was to ensure residents received necessary rehabilitative services, prevent avoidable physical and mental deterioration, and assist residents in achieving or maintaining their highest practicable level of functioning and psychological well-being. The policy required review of FMPs to ensure continued appropriateness, daily documentation or restorative services, and to review and update the care plan as needed.

Based on observation, interview, and record review, the facility failed to obtain physician orders for respiratory treatments for 1 of 2 residents reviewed for respiratory care, of a total sample of 49 residents, (#33).Findings: Review of the medical record revealed resident #33 was admitted to the facility on [DATE] with diagnoses including acute and chronic respiratory failure with hypoxia (low levels of oxygen), chronic obstructive pulmonary disease (COPD), type 2 diabetes, and Cor pulmonale (enlargement of the right ventricle of the heart due to lung diseases). Review of the Minimum Data Set (MDS) admission assessment with an Assessment Reference Date of 11/13/25 revealed resident #33 had a Brief Interview for Mental Status score of 14 out of 15, indicating intact cognition. The MDS assessment indicated the resident did not exhibit behavioral symptoms or reject evaluation or care that was necessary to achieve her goals for health and well-being. The MDS assessment revealed resident #33 experienced shortness of breath (SOB) with exertion, used a manual wheelchair for mobility, and received continuous oxygen (O2) therapy. Review of a physician's Progress Note dated 11/03/25, prior to her admission to the facility, revealed resident #33 used a continuous positive airway pressure (CPAP) machine at night. The note included diagnosis of obstructive sleep apnea and obesity hypoventilation syndrome. A CPAP machine is a common treatment for sleep apnea and functions to keep the airway open during sleep to ensure adequate oxygenation. CPAP use can significantly improve sleep quality and reduce the risk of health complications, including heart disease and stroke (retrieved from www.clevelandclinic on 12/12/25). Review of resident #33's comprehensive care plan, revised on 11/24/25, revealed a potential for complications related to COPD, SOB, acute respiratory failure with hypoxia, and chronic Cor pulmonale. The stated goal was for the resident to exhibit no signs of respiratory distress. A care plan addressing the use of O2 therapy was initiated on 11/18/25. On 12/02/25 at 10:03 AM, resident #33 stated she used a CPAP machine at night but had not used it since being admitted to the facility because it had not been connected. She stated she expected nursing staff to address the issue but no follow up occurred. She pointed to the CPAP machine resting on a nightstand next to her bed. Review of resident #33's Observation Detail List Report dated 11/07/25 revealed documentation of a respiratory system review. The form indicated BiPAP/BPAP was checked as respiratory device used by the resident. Review of a nursing progress note dated 11/08/25 read, . Nasal O2 on at 2l (liters), O2 Sat (saturation) 97%. States at night she sleeps with CPAP on. Review of resident #33's Progress Notes revealed an Activities Note dated 11/10/25, which read, Resident is alert/oriented makes own choices regarding activity involvement, on oxygen, CPAP, utilizes w/c (wheelchair) for mobility admitted to the care for short term rehabilitative care . Review of resident #33's physician orders revealed there were no orders for CPAP use. Review of an admission care conference note dated 11/26/2025 revealed resident #33 was receiving O2 therapy and exhibited SOB. On 12/03/25 at 1:48 PM, Certified Nursing Assistant (CNA) E stated resident #33 used O2, and she reported to the nurse if it was not set up correctly. CNA E indicated resident #33 had mentioned she needed to use her CPAP machine. CNA E reported when she began her shift at 7:00 AM, the resident #33 was sitting in bed or at the edge of the bed using O2 but not the CPAP. On 12/03/25 at 3:43 PM, Licensed Practical Nurse (LPN) D stated resident #33 had recently transferred from another unit and she was not familiar with her care. LPN D indicated she had not previously seen the CPAP in the resident's room. On 12/04/25 at 11:19 AM, the C-Wing Unit Manager (UM) stated new residents were discussed during clinical meetings held the day after admission. She explained admission observations, physician orders, progress notes, and initial labs were reviewed at the meeting. She stated resident #33 was admitted to the B-Wing on 11/07/25 and the B-Wing UM or the weekend supervisor would have reviewed the admission documentation. She mentioned resident #33 transferred to the C-Wing on 11/26/25. She stated she obtained a physician order for CPAP use on 12/02/25 after noticing the machine while assisting the resident in searching for a ring. She indicated if a nurse observed a CPAP machine in a resident's room, the expectation would be to question its use, review the medical record, and obtain a physician order.

Based on observation, interview, and record review, the facility failed to ensure that residents who experienced trauma received trauma-informed care for 1 of 2 residents reviewed for mood/behavior, of a total sample of 49 residents, (#9). Findings:Resident #9 was admitted to the facility on [DATE] with diagnoses of type 2 diabetes and obstructive sleep apnea. The facility added the diagnoses generalized anxiety disorder on 2/27/25, post-traumatic stress disorder (PTSD) on 3/13/25, and major depressive disorder on 3/26/25.Review of the Minimum Data Set (MDS) Annual Assessment with Assessment Reference Date of 11/05/25 revealed resident #9 had a Brief Interview for Mental Status score of 15/15 which indicated she was cognitively intact. The MDS listed PTSD as one of her diagnoses, on 3/13/25.The electronic medical record (EMR) contained a Trauma-Informed Care Observation dated 2/09/25 which revealed resident #9 had personally experienced a natural disaster, witnessed an assault with a weapon, and was a victim of a sexual assault.On 12/02/25 at 12:35 PM, resident #9 reported she and her sister were sexually assaulted by her stepfather and her uncle when they were minors. She stated she still experienced flashbacks and nightmares related to those events. Resident #9 explained there was a male resident in the facility who resembled one of her attackers. She expressed he had never done anything to her but seeing him would sometimes bring back bad memories.Review of resident #9's comprehensive care plan revealed a trauma informed care plan had not been developed to address emotional support, identify triggers, or instruct staff how to assist her to effectively cope with her emotions.On 12/04/25 at 2:16 PM, the Social Services Director (SSD) provided the Psychiatric Mental Health Nurse Practitioner (PMHNP) notes for resident #9. Review of the documentation revealed a note dated on 5/06/25 which indicated resident #9 was seen due to depression, anxiety, mood disorder, psychosis and PTSD. Per the note, resident #9 reported she was not sleeping for more than two hours and felt down.The note also identified possible triggers which included certain scents of cologne, lighting, and loud noises. The PMHNP recommended to add PTSD to the care plan with interventions to provide quiet and consistent environment, and supportive therapy.There was no care plan to address the trauma, or interventions to support the resident, or promote her psychosocial well-being added.On 12/03/25 at 3:16 PM, the SSD reviewed resident #9's medical record. She verified a screening was conducted which indicated resident #9 had experienced trauma. The SSD acknowledged there was no comprehensive care plan for PTSD to address resident #9's trauma, potential triggers, and interventions, and commented the resident absolutely should have had one.In a follow up interview on 12/04/25 at 3:02 PM, the SSD stated it was the responsibility of Social Services and/or nursing to review the psychiatric notes and follow up on any recommendations.The facility's policy on trauma informed care dated 10/25/22 indicated, the plan of care should be developed by the interdisciplinary team. The document advised the Care Plan team should decide which residents needed a behavior management program versus residents that were care planned with appropriate interventions.

Based on observation, interview, and record review, the facility failed to ensure complete medical records were readily accessible, and not restricted to access for 16 of 16 total sampled residents, (#1, #2, #3, #4, #5, #6, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25); and failed to ensure hard copy medical records were safeguarded for all residents. Findings: On 2/05/24 at 9:40 AM, an entrance conference was held with the Nursing Home Administrator (NHA) and Director of Nursing (DON). The survey team requested items that included access to all residents' complete medical records. On 2/05/24 at 1:20 PM, surveyors were unable to view any sampled residents' Comprehensive Care Plans in the Electronic Health Record (EHR). On 2/05/24 at 3:58 PM, the Minimum Data Set (MDS) Coordinator said she had to obtain records from multiple sources to complete assessments and she didn't have direct access to all the EHRs. She explained the Social Services Director kept residents' behavioral health progress notes in her office. On 2/05/24 at 3:51 PM, the NHA was informed the medical records provided to surveyors were not complete and excluded pertinent physician progress notes, diagnostics, and laboratory results. She could not explain the issues, and said she had to notify the DON to assist. She acknowledged medical record access delayed and impeded the survey process. On 2/05/24 at 4:00 PM, the DON provided resident #1's hard chart that contained hospital clinical records. The record did not include physicians' progress notes or X-ray reports completed during the resident's stay at the facility. On 2/05/24 at 4:20 PM, the DON reviewed a copy of resident #1's physician's progress note dated 1/24/24, and signed on 2/05/24, and a chest X-ray report dated 1/24/24 with a handwritten undated and unsigned note that read, MD (Medical Doctor) aware resident to the ER (emergency room ). The DON stated, I have no idea who wrote the note; it should have been signed and dated. On 2/06/24 at 11:10 AM, the C Unit Manager explained, Certified Nursing Assistant's (CNAs) used the EHR system for residents plan of care and status and it was where they also documented their daily tasks. She checked the EHR system and demonstrated where the resident records were located. She said the DON or Medical Records Licensed Practical Nurse (LPN) had to assist with any restrictions and stated, you must not have full access. On 2/06/24 at 11:33 AM, the Medical Records LPN conveyed that surveyors were restricted from accessing and viewing the CNA documentation for all residents. She explained she would jointly view the sampled residents' records through her access, and the Regional Nurse Consultant had to arrange surveyor access through their IT (Information Technology) department. On 2/06/24 at 10:03 AM, the Medical Records LPN said she was responsible for the facility's medical records process, and she was the only person with a key to access closed records. She explained physician progress notes were filed into the records every few months. She stated physicians A sent his progress notes in bulk every few months, and they were filed as they were received. She said when she worked as a nurse on nursing units, she had to call the lab or X-ray provider to obtain faxed reports because her access was restricted. On 2/06/24 at 12:16 PM, the DON said the Regional Nurse Consultant was working on obtaining access to EHR for surveyors as it was restricted. She explained facility staff could jointly view the sampled resident records with surveyors. She conveyed she understood the survey process had been impeded by medical record accessibility delays and stated, I don't know why you guys can't see everything. On 2/06/24 at 12:18 PM, surveyors were unable to review resident #16's physician progress notes and requested copies from the DON. At 2:44 PM, the DON said she wasn't sure where the records were and she had to find them. On 2/06/24 at 2:54 PM, the DON explained, nurses accessed resident medical records from the facility's EHR program that included care plans, physician's orders, and nurse progress notes. She said lab results and X-ray reports had to be accessed from their own independent programs, and physician's progress notes were received by email approximately 30 days from an encounter. She pointed to her laptop and explained that when nurses needed to retrieve up to date clinical status information for the doctor, they used the facility's EHR program and stated, they can check the orders. On 2/06/24 at 10:15 AM, the Medical Records LPN said 2024 medical records were kept in her office. During a joint observation, she demonstrated where 2023 records were stored in a closet inside an unlocked and publicly accessible copy/mail room located in the main lobby. She slid open an unlocked wooden door where approximately 30 cardboard boxes were observed on shelves. She explained, the boxes contained all residents' 2023 medical records. She acknowledged the records were not securely locked or properly safeguarded and stated, I must've left it unlocked from yesterday. On 2/06/24 at 11:33 AM, the Medical Records LPN explained the Maintenance Director had to fix the lock on the storage closet in the copy/mail room. At 2:55 PM, the Maintenance Director recalled earlier that day he received a request to repair the lock on the sliding doors of the storage closet in the copy/mail room. He stated he wasn't sure what was wrong with it, and he thought they couldn't find the key. On 2/06/24 at 3:44 PM, during a joint observation, the Medical Records office wooden door was observed open and unlocked. The MDS Coordinator and two other staff were seated directly outside the office at a conference room table. The Medical Records LPN demonstrated where 2024 medical records were stored in her office. She opened an unlocked, non-fireproof file cabinet where documents were contained. She stated she had locked her office door when she left, and remembered another staff had a key who must hav opened it. She said she wasn't sure if the room or file cabinets were properly safeguarded for fire loss. On 2/06/24 at 2:54 PM, the DON stated it was important to ensure safeguarding of medical records for confidentiality and HIPAA (Health Insurance Portability and Accountability Act) compliance. Review of the facility's standards and guidelines dated October 1, 2010 titled Maintenance of Medical Records page 1 read, PURPOSE: The facility safeguards medical records by establishing guidelines for the maintenance of resident records. Review of the Medical Records LPN job description provided by the facility titled Unit Coordinator read, . 6. a. Maintain confidentiality of all data, including resident, employee, and operations data and comply with HIPAA Privacy and Security. ESSENTIAL JOB FUNCTIONS . 10. Maintain and file discharge and reduced medical records in an orderly and appropriate manner. Safety and Equipment Functions . fire protection and prevention . Review of the Facility assessment dated [DATE] read, 3.7 (facility name) uses an electronic health record using (software program name) and a hard chart where MDS, consultant visits, labs, hospital records are stored etc. Laptops are used for documentation. Inter-disciplinary assessments and documentation from (software program name) are all housed inside the EMR (Electronic Medical Record). The Center communicates via email to department heads and corporate partners, uses fax for pharmacy and receives electronic referrals through hospital-based portals. The Center has routine back up procedures and provides alternate means of documentation in the event of a power outage or internet outages. The Center use of electronic records is a work in progress and evolves with the changing needs of the Center.

Based on interview, and record review, the facility failed to complete dietary assessment within recommended timeframes for 2 of 2 residents and failed to obtain preferences and allergies pertaining to lactose intolerance for 1 resident of a total sample of 16 residents, (#20, #24). Findings: 1. Resident #20, a [AGE] year-old female was admitted to the facility on [DATE]. Her diagnoses included pulmonary embolism, hypertension, and gastroesophageal reflux disease. Review of the resident's physician orders revealed an entry dated 12/14/23 which indicated the resident was on a regular diet, and Lactose intolerant. No milk. No cheese. On 2/06/24 at 11:55 AM, the Dietary Manager explained that within seventy-two (72) hours of admission, the resident was seen by the Dietary Manager, and an Admission Dietary Assessment was completed. The resident's food allergies, and preferences were obtained, and populated to the resident's meal ticket. The Dietary Manager stated she did not complete an Admission Assessment/Dietary Review for resident #20. She noted the resident did not get the weekly menu provided when the Dietary Review was completed. She stated she was not aware of the resident's allergies. She stated that on admission, Dietary would receive a diet order, but preferences, and allergies would not be listed. She said food allergies would be obtained by the Dietary Manager. Review of the Week-At-A-Glance Spring/Summer Menus 2023 served during the time the resident was in the facility, revealed milk and cheese were included in the items served. The resident's physician order dated 12/14/23 was reviewed with the Dietary Manager. She explained the order did not get placed on the resident's meal ticket. Review of the resident's meal tracker Activity Log Report dated 12/13/23, read Allergies Added: No allergies entered. 2. Resident #24, a [AGE] year-old female was admitted to the facility on [DATE]. Her diagnoses included diabetes type II, metabolic encephalopathy, and chronic pancreatitis Review of the resident's clinical records revealed an Admission Assessment/Dietary Review was not obtained until 2/04/24, 96 hours after admission. On 2/06/24 at 12:10 PM, the Dietary Manger confirmed the resident was admitted on [DATE] and was not assessed until 2/04/24. She stated the assessment was late. The facility's policy Nutritional Assessment with effective date of May 25,2012, read, The Dietary Manager should complete the Dietary Review Form within 72 hour of admission or readmission to the facility.

Based on interview and record review, the facility failed to provide written Notification of Transfer or Discharge forms to the residents or their representative for 1 of 1 resident reviewed for hospitalization , out of a total sample of 52 residents, (#5). Findings: Resident #5 was admitted to the facility on [DATE] with diagnoses of acute respiratory failure, acute pulmonary edema, hypertensive heart disease, acute congestive heart failure and cardiomyopathy. Review of resident #5's medical record revealed she was transferred to the hospital on 12/07/23. A progress note dated 12/07/23 read, Resident with seizure activity. Physician notified and order obtained to send to emergency department. The medical record did not contain a Notification of Transfer or Discharge form for the hospitalization . On 12/13/23 at 5:04 PM, the Social Services Director (SSD) stated she did not know who completed the Notification of Transfer or Discharge forms. She explained she sent a monthly log to the Ombudsman for residents who were transferred to the hospital but was not aware a Notification of Transfer or Discharge form needed to be completed. The SSD suggested maybe medical records would have them. On 12/13/23 at 5:08 PM, the Medical Records clerk stated the social services department was responsible for completing the Notification of Transfer or Discharge forms. She reported she did not have copies in her office or in closed medical records. The Medical Records clerk explained she would need to speak with the Director of Nursing (DON) for further clarification. On 12/13/23 at 5:12 PM, the DON said she was not aware of who completed the Notification of Transfer or Discharge forms. She verbalized she thought social services was responsible. The DON explained the resident's representative was made aware by phone when a resident transferred to the hospital but did not know if written notification was provided to the resident or representative. On 12/13/23 at 5:16 PM, the Administrator verified the SSD was responsible for completing the Notification of Transfer or Discharge forms and providing to family or resident. The Administrator stated she was not aware the forms were not being completed. On 12/13/23 at 5:26 PM, the SSD provided a notebook which contained completed Notification of Transfer or Discharge forms. There were not any forms completed since May 2023. The Administrator acknowledged the forms had not been completed or provided to any residents or resident representative since that time for any resident who transferred to the hospital. She explained there had been a change in Social Service Directors during that time and the forms had not been completed since May. The facility's policy and procedure for Transfer, Discharge and Therapeutic Leaves dated 6/26/19 read, A copy of resident/guest bed hold and admission policies/transfer to hospital notice should be provided upon transfer by assigned nurse to resident and or representative of resident.

Based on observation, interview, and record review, the facility failed to ensure dishes were washed at the appropriate temperature, with regard to the dish machine's data plate and manufacturer's instructions. Findings: On 12/11/23 at 11:06 AM, during kitchen observation, the Dietary Manager started the dish machine and put a couple of empty dish racks through the machine. The temperature dial on the dish machine showed temperature to be 156 degrees Fahrenheit (F). The Data Plate, on the machine, noted the wash temperature should be 160 degrees F. The dish machine temperature log dated 12/11/23 noted the morning wash temperature was 155 degrees F. The Dietary Manager identified the initials next to the recorded temperature as Dietary Aide L. On 12/11/23 at approximately 11:15 AM, Dietary Aide L verified he recorded the temperatures that morning. He stated he had continued to wash dishes. Dietary Aide L explained that was the first temperature and the water got hotter as he ran the machine but acknowledged he did not record any of those temperatures. Dietary Aide L stated he did not report the low temperature to the Dietary Manager. On 12/14/23 at 11:13 AM, the Dietary Manager provided a work order which showed the dish machine had been serviced on 12/12/23 at 11:43 AM. She reported the facility had continued to serve on regular dishes and flatware as the rinse cycle reached the appropriate temperature to sanitize the dishes. She acknowledged the dishes were not washed at the temperature listed on the machine's data plate and the manufacturer's guidelines. On 12/14/23 at 2:13 PM, Dietary Aide L was observed running dish racks through the dish machine. The temperature dial on the dish machine did not reach 160 degrees F on the wash cycle as four racks of dishes passed through the machine. Dietary Aide L stated he checked the wash temperature earlier but did not check temperatures on every rack that went through. Dietary Aide L stated the wash temperature did reach the correct temperature in the morning. The Dietary Manger came into the dish room and verified the wash temperature was lower than 160 degrees F. The dish machine temperature log dated 12/14/23 did not have any recorded temperatures for the current cycle. The Food and Drug Administration 2017 Food Code notes in section 4-501.15A, that a warewashing machine and its auxiliary components shall be operated in accordance with the machines data plate and other manufacturer's instructions.

Based on observation, interview, and record review, the facility failed to maintain proper infection control practices to prevent contamination during tracheostomy care for 1 of 4 residents reviewed for respiratory care, (#40) and failed to ensure the appropriate personal protective equipment (PPE) was donned prior to entry to transmission-based precaution rooms to prevent the potential for cross contamination for 2 of 2 residents reviewed for transmission-based precautions, (#109, #199) of a total sample of 52 residents. Findings: 1. Resident #40 was admitted to the facility on [DATE] and readmitted from acute care hospital on 12/27/21 with diagnoses including chronic respiratory failure, dependence on supplemental oxygen, attention to tracheostomy, anoxic brain damage, cerebral infarction, and seizures. A tracheostomy (also called a tracheotomy) is an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs. After creating the tracheostomy opening in the neck, surgeons insert a tube through it to provide an airway and to remove secretions from the lungs (retrieved on 12/21/23 from www.hopkinsmedicine.org). Review of the physician orders for December 2023 included enhanced barrier precautions related to trach (tracheostomy), oxygen at 2 liters continuous via trach for SOB (shortness of breath), and tracheostomy care. Resident #40's care plan started on 1/31/23 for chronic respiratory failure with SOB (shortness of breath), included approaches to suction trach as ordered. On 12/11/23 at 10:45 AM resident #40 was observed lying in bed on her right side with oxygen via trach collar and she was audibly congested. She had white to clear mucous draining from her mouth down her right cheek. On 12/12/23 at 5:10 PM, an interview and observation was conducted with Licensed Practical Nurse (LPN) A who was assigned to resident #40 on the 3 PM to 11 PM shift. The resident was in bed with her neck dressing around trach tube was saturated with white mucous. The suction canister at the bedside was noted to be 3/4 full of pale white colored fluid. On 12/12/23 at 11:32 AM, the assigned LPN B who worked the 7 AM to 3 PM shift said she already suctioned resident #40 4 times today because the resident had a lot of secretions. On 12/12/23 at 11:45 AM, an observation of trach care and suctioning was observed with LPN B. The Unit Manager (UM) B Wing and Staff Development nurse were present in the room and assisted with care. There was a sign on resident #40's door that read enhanced precautions with instructions to use hand sanitizer, wear gloves and gown for high contact resident activities which included tracheostomy. Prior to entry into the room LPN D stated the only PPE (personal protective equipment) that should be worn was a gown and gloves for trach care and suctioning procedure. The LPN wore a gown, gloves, and face mask. The UM and Staff Development nurse also wore gown and gloves but did not wear face mask. All 3 staff did not wear face shield. The facility's policy for Guidance for Implementing Enhanced Barrier Precautions in the Nursing Home, updated 7/12/22, read, Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high contact resident care activities that provide opportunities for transfer of MDROs [Multi Drug Resistant Organisms] to staff hands and clothing The use of gown and gloves for high contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home resident with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection .Table: Summary of Personal Protective Equipment [PPE] Use and Room Restriction When Caring for Resident in Nursing Homes: Standard Precautions: Applies to All resident with an of the following .Tracheostomy/ventilator regardless of MDRO colonization status. PPE use for these situations: Device care or use .Tracheostomy/ventilator .Face protection may also be needed if performing activity with risk of splash or spray . Observation of PPE supplies outside resident #40's room only included gowns and gloves. There was a box of facemasks noted at the nurses' station, but no face shields were available on the unit. Resident #40 was lying in bed with her head and upper body elevated approximately 45 degrees. The suction canister remained 3/4 full of white thick fluid. The UM put resident #40's oxygen trach collar to the side of her neck and the LPN proceeded to attempt to suction the resident. The LPN put her finger over the catheter suction port and suctioned while she introduced the catheter into the trach. The UM then donned sterile gloves and took over suctioning procedure and suctioned large amount of thick white mucous. The UM repeatedly suctioned approximately 4-5 times and the resident had strong cough reflex and expectorated large amount of mucous from the trach tube herself. While changing the trach ties resident #40 coughed/sprayed mucous directly into the UM's face who was not wearing face mask or eye shield. By the end of the procedure the suction canister was 90% full. On 12/14/23 at 12 PM, an interview was conducted with the Director of Nursing (DON) and the Assistant DON (ADON) who was in training to be the Infection Preventionist (IP). Currently the DON was the IP nurse. The DON and ADON verified the nurses should have emptied the suction canister when 3/4 full prior to doing trach care and suctioning procedures. They both acknowledged the staff should have anticipated a high likelihood of splash/spray due to resident #40's history of having strong cough reflex during care and should have donned face masks and eye protection. On 12/14/23 at 2:11 PM a telephone interview was conducted with the Respiratory Therapist (RT). The RT said she always wore face mask and eye shield when providing care because the resident's secretions splatter everywhere, and she would expect the nursing staff to wear appropriate PPE as well. 32131 2. Resident #109 was admitted to the facility on [DATE] with diagnosis that included Corona Virus Disease 2019 (COVID-19). Review of the resident's clinical record revealed a physician order dated 12/08/23 with a stop date of 12/18/23 for droplet precautions. On 12/11/23 at 11:50 AM, a sign posted on the resident's door in English and Spanish read, special droplet/contact precautions. The sign directed that everyone must: clean hands when entering and leaving room, wear an approved N95 or equivalent or higher-level respirator at all times, wear eye protection, and gown and glove at door. A three-drawer container at the entrance of the resident's room in the hallway contained the appropriate PPE. On 12/11/23 at 11:52 AM, Certified Nursing Assistant (CNA) I entered the resident's room, without the appropriate PPE. The CNA did not perform hand hygiene prior to entry, nor wear a gown, or eye protection. CNA I wore a KN95 mask. When she exited from the room, the CNA stated she did not get report, and was not sure what type of isolation the resident was on. She stated she did not read the sign that was posted on the resident's door. On 12/11/23 at 11:57 AM, the 300 Hall Registered Nurse/Unit Manager (RN/UM) stated resident #109 was on droplet precautions, and signage on the resident's room door instructed staff must clean their hands when entering/ leaving room, wear an N95 equivalent/higher mask, wear eye protection, don gown and gloves at the door/on entry to the room. The UM stated CNA I, did not have a regular floor assignment as she was the concierge, and did not get a shift-to-shift report. The UM said the CNA should have read the sign posted on the resident's door. On 12/11/23 at approximately 12 PM, CNA I stated she did not wear the appropriate PPE to enter the resident's room, and only had on a KN95 mask. She verbalized she should have read the sign. On 12/12/23 at 10:45 AM, the Infection Preventionist stated resident #109 was on droplet precautions and staff were required to wear an N95 mask, gown, gloves, and eye protection when entering the room. Observation of CNA I on 12/11/23 at 11:52 AM, was shared with the Infection preventionist. She stated she was made aware, and staff should have worn the appropriate PPE prior to entering the room. The facility's policy titled, Droplet Precautions with effective date of September 1, 2017 read, Signage should be placed on door .to notify staff, residents and visitors to follow indicated precautions. 3. Resident #199 was admitted to the facility on [DATE]. Her diagnoses included encephalopathy, stage IV pressure ulcer, Klebsiella pneumonia, and resistance to multiple antibiotics. Review of the resident's clinical record revealed a physician order dated 12/13/23 for Contact Isolation. On 12/13/23 at 9:16 AM, a Physical Therapist D was in the resident's room working with the resident. Signage posted on the resident's room door indicated the resident was on contact isolation precautions, and directed that in addition to cleaning hands before entering and leaving the room, providers and staff must also put on gloves and gown before room entry, and discard gloves and gown before room exit. An overdoor container with an adequate amount of the required PPE was in place. The Therapist had on gloves, but did not have on a gown, and was at the resident's bedside physically touching the resident, working on her lower extremities. On 12/13/23 at 9:31 AM, Physical Therapist D stated she was working with resident #199 for strengthening of her bilateral lower extremities. She acknowledged the resident was on contact isolation precautions, and stated she had gloves on and a mask, but did not have on a gown even though she was in contact with the resident. The Therapist stated she read the posted sign prior to entry to the resident's room, went in to say hello, but then continued with her therapy session. She said she realized she should have worn a gown along with her gloves since she was in contact with the resident. She stated there was the potential for cross contamination. The Center for Disease Control advised that Healthcare personnel caring for patients on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. (Retrieved from www.cdc.gov/infection control on 12/15/23).

Based on interview, and record review, the facility failed to develop a baseline care plan within 48 hours of admission for 1 of 1 resident reviewed for pain management of a total sample of 52 residents, (#199). Findings: Resident #199 was admitted to the facility on [DATE]. Her diagnoses included encephalopathy, stage IV pressure ulcer, Klebsiella pneumonia, and resistance to multiple antibiotics. Review of the resident's physician orders revealed entries dated 12/08/23, 12/09/23, and on 12/12/23 for pain management/ medications. Review of the resident's clinical record revealed care plan potential for pain with start date of 12/11/23. A baseline care plan developed within 48 hours of the resident's admission could not be identified. On 12/14/23 at 4:10 PM, the Regional Case Manager stated baseline care plans were developed within 48 hours of admission and were revised when the comprehensive care plan was developed. On 12/14/23 at 4:30 PM, the Registered Nurse/ Minimum Data Set Coordinator (RN/MDS) stated the facility's process was that a baseline care plan should be developed on admission. A baseline care plan summary would then be printed, and a meeting would be held with the resident and family for review of the baseline care plan within 48 hours of the resident's admission. A signature indicating understanding and receipt of the baseline care plan would be obtained at that time. The RN/MDS Coordinator confirmed the resident was admitted on [DATE] but stated a baseline care plan was not developed for the resident within the relevant timeframe. The facility's policy, Person Centered Care Plan with effective date of August 15, 2018, read, According to federal regulations, the facility develops and implements a baseline plan of care within 48 hours of admission that includes the minimum healthcare information necessary to properly care for the immediate needs of the resident .Baseline Plan of Care- should be initiated by MDSC (Minimum Data Set Coordinator)/designee based on referral information, dietary observation, resident/guest and/or representative and staff input within 48 hours of admission. Baseline care plan summary provided to resident/resident representative, by MDSC, after baseline care plan established and prior to completion of comprehensive care plan.

Based on interview, and record review, the facility failed to ensure residents were involved in developing the comprehensive person-centered plan of care for 1 of 3 residents reviewed for participation in care plan, of a total sample of 52 residents, (#52). Findings Resident #52, a [AGE] year-old female was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included chronic systolic (congestive) heart failure, diabetes type II, mild intermittent asthma, other chronic pain, and shortness of breath. Review of the resident's annual Minimum Data Set (MDS) assessment, with Assessment Reference Date of 9/20/23 revealed the resident's cognition was intact, with a Brief Interview for Mental Status score of 15 out of 15. On 12/11/23 at 4:04 PM, resident #52 stated she did not get invited to her care plan meetings. On 12/13/23 at 10:42 AM, the Registered Nurse/ Unit Manager (RN/UM) for the 200 Hall stated resident/family were invited to their care plan meeting by the Social Service Director (SSD), or the UM The UM explained the SSD sent a letter to the family with the scheduled date of the care plan meeting, and if the resident/family could not attend the meeting in person, they could participate via telephone, or the meeting could be held in the resident's room. She verbalized she had recently assumed the position as UM and had not participated in a care plan meeting with the resident yet. On 12/14/23 at 9:43 AM, an interview was conducted with the Regional Case Manager, and the Registered Nurse (RN)/ MDS Coordinator. The RN/MDS Coordinator explained the process for scheduling a care plan meeting included running a roster for the next month's care plans /assessments due, mapping the meetings on the calendar, providing a list of the residents that had care plan meeting coming up to the receptionist, who would send the letter to the resident/family. She noted if any responses were obtained either verbal or via telephone, the response would be documented. If there was no response, the facility would attempt to call the resident or family. The RN/MDS Coordinator stated care plan meetings were held with the Interdisciplinary team (IDT), and a care plan summary was completed in the resident's electronic medical record, and documentation would be done regarding all persons/representative who attended the meeting. She stated that if the resident did not want to come to the MDS office, the IDT would go to the resident's room, and have the care plan meeting at the resident's bedside. The RN/MDS Coordinator stated documentation of the last care plan meeting held on 8/03/21 for resident #52, indicated the resident's daughter participated via telephone. When asked if resident #52 was invited/participated in the care plan meeting, the RN/MDS Coordinator said the resident should have received a letter. The Regional Case Manager stated review of the resident's clinical records, revealed the resident was not listed as her own responsible party. When asked if that would prevent her from being invited to the care plan meeting, the RN/MDS Coordinator said, we normally invite the resident. On 12/14/23 at 11:46 AM, the Social Services Assistant Staff E, stated that between September 2022 to May 2023 she sent invitation letters for care plan meetings to residents and family members. She explained she placed the invitation letters in envelopes, and gave them to the Receptionist, who would deliver letters to the resident/family. When the resident or family responded, a copy of the letter with the response was placed in the residents' physical chart. The resident's physical chart was reviewed with Staff E. A letter dated August 3, with no year documented was addressed to the resident's daughter, and to the resident. Two options were listed, I will attend, I will not attend neither of the options were selected. No other invitation letter was found in the resident's chart. On 12/14/23 at 11:56 AM, resident # 52 was resting in bed. She stated she did not receive any invitation to her care plan meetings. A copy of the letter found in the resident's chart was reviewed with the resident. She explained she had not received any letter and recalled her daughter told her the facility had called her, but she never received an invitation. Resident #52 said she wanted to participate in her care plan meeting. On 12/14/23 at 1:58 PM, the RN/MDS Coordinator provided a copy of the Care Conference Summary dated 8/03/23. Review of the document with the RN/ MDS Coordinator revealed the resident's daughter's name was documented in the area for Family/Resident Attendance- name of person invited. The resident's name was not included. The document indicated the resident's next care conference was on 10/03/2023, however, a Care Conference Summary could not be identified for this meeting. On 12/14/23 at 2:17 PM, the RN/MDS Coordinator stated a care conference was scheduled for the resident on 10/05/23 at 1:30 PM but was not held. The facility's policy Person Centered Care Plan with effective date of August 15, 2018, read, Conducting the Interdisciplinary Person-Centered Care Plan Meeting a) the team, including the resident/guest and their desired representatives when possible should present findings from assessment .discuss suggested new goals or approaches . Any input gained from the resident/guest should be recorded in the plan of care and the resident/guest participation should be recorded in the EMR (Electronic Medical Record).

Based on interview, and record review, the facility failed to ensure effective communication and collaboration between members of the interdisciplinary team to provide necessary care and services to attain the highest practicable well-being and prevent complications related to a urinary tract infection (UTI) for 1 of 4 residents reviewed for UTIs, of a total sample of 11 residents, (#1). The facility's failure to follow the physician's orders and treat a change in condition resulted in actual harm. Findings: Review of resident #1's medical record revealed he was originally admitted to the facility on [DATE]. He was discharged to the hospital on 8/09/22 and readmitted on [DATE]. His diagnoses included retention of urine, chronic prostatitis, benign prostatic hyperplasia, and stroke. Review of the Minimum Data Set (MDS) quarterly assessment with Assessment Reference Date 11/21/22 revealed resident#1's Brief Interview for Mental Status score was 12 which indicated moderate cognitive impairment. The MDS assessment noted no rejection of evaluation or care necessary to obtain goals for health and well-being. The assessment showed he needed extensive assistance from staff for bed mobility and toilet use and was always continent of bowel and bladder. Review of the medical record revealed resident #1 had a care plan for potential for incontinent episodes of bladder and bowels, initiated on 4/14/22. The interventions directed staff to observe for signs and symptoms of infection. A care plan for actual infection, initiated on 10/04/22, also directed staff to observe for signs and symptoms of infection, labs/cultures as ordered and observe for signs and symptoms of sepsis which included a positive blood culture and altered level of consciousness. The goal noted resident #1 would not have complications related to infection. Review of resident #1's physician's orders revealed a laboratory order dated 1/13/23 which read, CBC (complete blood count), CMP (comprehensive metabolic panel), UA & C&S (urinalysis with culture and sensitivity), may straight cath (catheter) dx (diagnosis) increase confusion. A straight catheter, also called an intermittent catheter, is a soft, thin tube used to obtain or pass urine from the body. (Retrieved from www.healthline.com). Review of the Departmental Notes revealed a note dated 1/13/23 which read, CBC, CMP, U/A CS increased confusion POA (power of attorney) notified. Review of the laboratory log dated 1/14/23 revealed two names were written on the form, including resident #1. Under Labs Ordered it listed CMP, CBC with diff, UA & C&S. The form showed under Specimen Obtained two lines with arrows pointing downward, initials AP and the date 1/14. The words End of Labs was entered in the 4th line right after resident #1's name. Review of subsequent notes dated 1/19/23, 1/20/23 and 1/27/23 revealed resident #1 was responsive with some confusion, refused to get up stated he is tired from last night . refused meals and resident attempted to eat lunch in the dining room but was unsuccessful due to fatigue. Review of resident #1's orders revealed weekly summary to be documented including vital signs, mental status, appetite and any new changes in medication or conditions. Vital signs documented on 1/2/23, 1/6/23, 1/16/23, and 1/23/23 were within normal parameters. There was no evidence in the medical record that vital signs were obtained from 1/24/23 until 1/29/23, when resident #1 was transferred to the hospital. Review of a progress note dated 1/29/23 read, Resident in bed lethargic but responsive, refused evening meds (medications) and poor appetite per off going shift nurse. Vital signs temp (temperature) 98.3, P (pulse) 94, R (respirations) 18, BP (blood pressure) 148/88, O2 sat (oxygen saturation) 93%. Call placed to MD (physician) answering service. On call ARNP [sic] (Advance Practice Registered Nurse). returned call and informed her of resident status and refusal of meds, new order for CBC, CMP, UA/CS in AM may straight cath. Resident straight cath as ordered, urine specimen collected and placed in cwing (C Wing) refrigerator to be picked up by lab tech. Call placed to laboratory for blood work to be done and specimen picked up. Writer went back to room and check [sic] resident. O2 sat 86%, HR (heart rate) 112, O2 started at 2 L (liters) via nasal canula, O2 sat went up to 89, increase to 3 L then 4 L O2 remains between 89-90%. Call placed to ARNP [sic] and informed her of low O2 sat, new order to transfer resident to ER (emergency room ) for eval via 911. On 4/11/23 at 8:37 AM, during a telephone interview, resident #1's spouse explained she received a call from the facility and was told her husband had low oxygen and was lethargic and was going to be transferred to the hospital for evaluation. She reported he was admitted to the Intensive Care Unit due to sepsis. She stated resident #1 was previously treated 3 or 4 times for UTIs in the facility. She indicated a week or so before he was transferred to the hospital, she received a call from the facility and was told labs were ordered because of resident #1's increased confusion. She explained after that call, she visited him and noticed a urine cup and catheter by his bedside, and she figured it had not yet been collected. She stated she did not hear back from the facility, so she thought he was tested , and results were fine. She explained in the past he had needed intravenous (IV) antibiotics to treat the UTIs. She said the facility was well aware he got UTIs. She indicated on 1/30/23, she visited the facility and told the nurse the condition she found her husband in the hospital and informed her he not only had low oxygen and was lethargic, but he was also septic. She stated she was upset because the nurse acted like it was not a big deal. She recalled a friend had visited resident #1 a few days before he was transferred to the hospital and noticed he was not right. She indicated the friend told his assigned nurse, but the nurse ignored what the friend said. She indicated she did not know if he was tested by the facility and not treated or not tested at all. She mentioned her husband always requested to be up in his wheelchair daily but the days prior to the hospitalization he refused because was getting sicker with the UTI. She stated after all he went through, she would not allow him to return to the facility. Sepsis is the body's overwhelming and life-threatening response to an infection which can lead to tissue damage, organ failure, and death. (Retrieved from Appendix PP, Centers for Medicare & Medicaid Services). On 4/10/23 at 4:30 PM, the Unit Manager (UM) explained the night shift nurses collected the urine specimen and placed it in refrigerator for pick up the next day. She noted the lab technician would sign off when they collected the blood specimens in the morning. She reviewed the log which showed the lab technician's initials dated 1/14/23 that indicated the lab technician collected the specimen on 1/14/23. She stated she looked for the facility's yellow copy of the requisition form but could not find one for resident #1. The UM explained when she returned to the facility on [DATE] no one mentioned labs for resident #1 were not collected. She stated she checked with the lab company and confirmed the labs were not obtained on 1/14/23 as ordered for resident #1. She did not explain why the labs were not done. She mentioned resident #1 had increased confusion and they wanted to find out why and treat it. She acknowledged resident #1 did not get treated and ended up in the hospital. On 4/11/23 at 10:55 AM, Licensed Practical Nurse (LPN) B recalled resident #1 received intravenous antibiotic in the past to treat urinary tract infections. She reported they had a practitioner available in the facility from 7 AM to 7 PM and laboratory services available for immediate orders if needed. She noted if a UTI was not treated, confusion increased, and infection would get worse. On 4/11/23 at 12:24 PM, APRN C explained he worked under the direction of the facility's Medical Director and was available in the facility from Monday through Friday. He confirmed he ordered a CBC, CMP and UA C/S for resident #1 on 1/13/23 based on reports of increased confusion. He said he ordered the labs to find out what was going on with the resident, if he had some kind of infection. He indicated he did not visit resident #1 on the day he wrote the lab orders or the day after. He explained if this was a resident he followed, he would have flagged his chart and had a conversation with the nurse about the labs he ordered. He stated he did not see any notes in his records and resident #1 was not seen again. He verbalized resident #1's treatment was delayed and the resident probably did go septic. APRN C added, bottom line is harm came to the resident and it is an adverse event. On 4/11/23 at 5:56 PM, the Director of Nursing (DON) stated the process should have been when labs were ordered, they would be collected, and they had copy of the requisition and results. She did not explain how the labs and urine specimen was missed for resident #1 and why there was no follow up. The DON acknowledged resident #1 went to a higher level of care and she did not know what happened to him. She confirmed he had not returned to the facility, and they had not spoken to his family. On 4/12/23 at 8:30 AM, during a telephone interview, the Medical Director stated he was also resident #1's attending physician. He stated APRN C was in the facility from Monday through Friday and took calls and managed residents during the day. He indicated if there was something APRN C needed assistance with or was presented with a more complicated situation, he would contact the physician. He explained resident #1 suffered a stroke and had a history of pneumonia and UTIs. He noted if a resident with a UTI was not treated, oxygen saturation and blood pressure will drop, and he would end up in the hospital with sepsis. He stated that best practice would have been for APRN C to write a note or communicate with his practice to follow up after he ordered blood work and urine cultures. He noted this was not done. He added, something fell through the cracks somehow. He said this was unfortunate because he liked to address issues early to avoid sending residents to the hospital if possible. He indicated he even listened to housekeeping staff if they mentioned a resident was sleepier than usual, not eating right or any staff reported changes in a resident's condition because that lead to early intervention. He stated, early intervention is always the best option. He indicated UTIs needed to be handled properly especially in the elderly because they could get sick very fast. He reflected based on the clinical presentation from the nurse's note on 1/29/23, resident #1 probably had sepsis. He stated comorbidities play a part and contributed to the worsening of infection. On 4/10/23 at 4:22 PM, the DON explained she called the laboratory and was told they had no recent record of labs for resident #1. On 4/12/23 at 1:56 PM, the DON stated she did not see harm for resident #1. She indicated she reviewed all the documentation from the nurses after the labs were missed and there was no indication of worsening of symptoms. She stated she was not questioning the missed labs and verified they did not notify the physician or follow up on why the labs were not done. She acknowledged the resident's change in condition and subsequent transfer to the hospital. On 4/12/23 at 3:27 PM, during a telephone interview, the Director of the laboratory explained they did not receive specimens for resident #1 in January. He stated the last specimen received for testing was in October 2022. He indicated when a specimen was collected, it was brought and entered in their system the same day. He explained if staff had followed up and noted they did not receive lab results, they should have called the lab and would have been informed that specimens were not received. Review of the medical record did not contain evidence of an evaluation by a practitioner of resident #1 on or after 1/13/23. There was no indication the laboratory had been contacted to inquire about lab results, or communication with the physician to inform him the labs were not obtained. Review of the facility's policy and procedure for Laboratory and Radiology Services - Diagnostic Testing Services dated 10/1/2010 read, Each resident has the right to receive diagnostic services, in a timely manner, to meet his/her needs for diagnosis, treatment and prevention.

Based on interview and record review, the facility failed to honor advance directives for a Do Not Resuscitate Order (DNRO) for 1 of 8 residents reviewed for advance directives, of a total sample of 58 residents, (#293). This failure contributed to resident #293 receiving cardiopulmonary resuscitation (CPR) despite her explicit wish for a natural, dignified death and placed her at risk for serious injury / impairment / prolonged death. While resident #293 suffered resuscitation attempts including chest compressions, there was a high likelihood she could have experienced severe pain, broken bones, organ damage and a prolonged dying process on a mechanical life support system. On [DATE] at 4:34 AM, resident #293 was found unresponsive. Her assigned nurse, Licensed Practical Nurse (LPN) H, checked the paper chart and did not see a yellow State of Florida DNRO form. The nurse did not follow the facility's policy to check the physician's orders [REDACTED].#293 had an active DNRO. Nurses initiated and performed CPR for over 20 minutes, contrary to resident #293's wishes. When emergency medical personnel arrived, they continued aggressive resuscitation attempts for at least another 9 minutes before resident #293 was pronounced dead. Later that day, staff discovered resident #293's DNRO. There was no yellow State of Florida DNR form in the chart as her original form was sent to medical records when she was transferred to the hospital on [DATE]. The yellow State DNR form was not returned to the new chart when resident #293 was readmitted from the hospital on [DATE]. The facility's failure to honor advance directives put all residents with advance directives for DNR at risk, and resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was removed on [DATE]. Findings: Resident #293 was [AGE] years old. She was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. Resident #293 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set discharge assessment with assessment reference date of [DATE] revealed resident #293 died in the facility, 23 days after re-admission. Resident #293 had a care plan in the category Quality of Life that read, I have a DNR (Do Not Resuscitate) Status. The care plan was initiated on [DATE], reviewed on [DATE], and discussed with resident #293's daughter, her Power of Attorney (POA) on [DATE], the morning after re-admission. The care plan goal was resident #293's end-of-life wishes would be honored. The interventions indicated her decision concerning DNR status would be respected, the physician would review and uphold her wishes and she would receive comfort measures and pain management when needed. Review of resident #293's medical record revealed a physician's orders [REDACTED]. The order was discontinued on [DATE] when she was discharged to the hospital and resumed when she was readmitted . The updated order dated [DATE] read, DNR Yellow Copy in Chart. Resident #293's closed paper chart included a yellow form titled, State of Florida DO NOT RESUSCITATE ORDER that read, Based upon informed consent, I the undersigned, hereby direct that CPR be withheld or withdrawn. The physician's statement read, I hereby direct the withholding or withdrawing of cardiopulmonary resuscitation . from the patient in the event of the patient's cardiac or respiratory arrest. The document was dated [DATE] and was signed by resident #293's daughter/POA (Power of Attorney) and the facility's Medical Director. Review of Departmental Notes revealed a nursing progress note dated [DATE] at 11:46 PM regarding resident #293's re-admission to the facility and verification of her medication orders with the physician. There was no documentation of confirmation of her advance directives. A nursing note dated [DATE] at 5:52 PM, revealed resident #293 was transferred from the COVID unit to C Wing. The note indicated her family was notified of the move, but it did not include verification of her code status or current health condition. On [DATE] at 6:38 AM, LPN N recorded a timeline of resident #293's last hour of life. The document revealed at 4:34 AM, a Code Blue was announced. A Code Blue is a life threatening medical emergency such as cardiac or respiratory arrest (Retrieved from www.merriam-webster.com on [DATE]). The note indicated staff took the emergency cart to resident #293's room . and CPR in progress. At 4:35 AM, the 911 system was activated and 20 minutes later, at 4:55 AM, paramedics arrived on the C Wing. Emergency personnel took over CPR at 4:56 AM and continued to provide aggressive resuscitation efforts for resident #293. On [DATE] at 5:05 AM, the paramedics finally pronounced resident #293 dead after a total of 31 minutes of CPR. On [DATE] at 2:23 PM, the Director of Nursing (DON) recalled she received a telephone call from the facility in the early morning hours on [DATE]. She stated LPN H informed her of the Code Blue called for resident #293. The DON said, My first question was if she was a full code. The assigned nurse told me she was a full code. I asked if she followed the appropriate steps. The DON explained she expected nurses to check physician's orders [REDACTED]. She stated if there was no computer access available, nurses should check the printed physician's orders [REDACTED]. The DON stated later that day she reviewed resident #293's EMR and discovered an active DNRO. She stated LPN H informed her she did not check the EMR to verify if there was a DNRO or other advance directives. The DON explained LPN H checked the paper chart instead, did not see the yellow State DNRO form, and assumed resident #293 was full code status. The DON stated during an investigation of the incident she discovered the yellow State DNRO form was returned to the Medical Records office when resident #293 was discharged to the hospital on [DATE]. She explained the form should have been returned to the new chart when resident #293 was re-admitted to the facility on [DATE]. She said the nursing staff should have verified it was present when the DNRO order was reactivated in EMR. On [DATE] at 2:52 PM, the Medical Records nurse explained resident #293 was sent to the hospital with a copy of her yellow State DNRO form, but the hospital did not send it back with her on re-admission. He stated the admission nurse reactivated the DNRO in the EMR after all admission orders [REDACTED]. The Medical Records nurse stated the facility intended to have a DNR committee comprised of unit managers, the Social Services Director and himself meet weekly to review all admissions for advance directives and appropriate paperwork in the chart. He confirmed the DNR committee had not conducted any meetings, and other actions discussed such as back-up binders with copies of all residents' yellow State DNRO forms were not yet in place. On [DATE] at 3:02 PM, the DON stated the facility's root cause analysis determined the incident occurred because the yellow State DNR form was not pulled forward from the old chart which was sent to medical records. She stated the medical records nurse was educated on ensuring previous DNROs were available on re-admission, and nurses received education on verification of code status in the physician's orders [REDACTED]. However, she acknowledged the education did not include instructions on ensuring a yellow State DNRO form was obtained and placed in the paper chart on admission or re-admission. She confirmed the same situation could occur again for residents who were admitted after-hours if the Medical Records nurse was not available. On [DATE] at 1:47 PM, the DON explained an interdisciplinary team (IDT) was responsible for reviewing charts of newly admitted and readmitted residents in scheduled weekday meetings. She provided a checklist that read, DNR order/DNR in chart/signed by R.P.(responsible party)/M.D. **Pull forward for readmits/LTC. The DON stated resident #293's chart was reviewed by the IDT, and the need to obtain her yellow State DNRO form from Medical Records was noted. She acknowledged there was inadequate follow up, and this action was never completed. Review of the job description for Medical Records staff, reviewed on [DATE], revealed he/she was responsible for preparing the medical record upon admission, maintaining the record and closing it on discharge. Essential job functions included entering resident information into the computer system for new admissions and prepares records . ensuring all necessary forms are present. On [DATE] at 3:32 PM, during a telephone interview, LPN H recalled on [DATE] at approximately 4:30 AM, Certified Nursing Assistant (CNA) I called her to resident #293's room. LPN H stated when she arrived at the bedside, resident #293 was unresponsive. She said, I called her name and I shook her . I checked for breathing, no respirations. I went back to the desk and called the other nurse (LPN N). I checked the chart and there was no yellow DNR. I called a Code Blue so everybody from the other unit came to help me. LPN H stated 3 nurses, herself and LPNs N and O, took turns performing chest compressions and ventilation on resident #293 while another nurse activated 911. LPN H said, We continued doing compressions until EMS got there and took over. There were 3 or 4 paramedics and I stepped out because I was exhausted. We were doing it for a long time. She explained she did not check the resident #293's EMR for her code status or DNRO, instead she went directly to the paper chart. LPN H said, When I did not see the paper, I realized I had to do something. Even if I went to the computer and saw the order I still would have done compressions I still know I need a DNR form. It is the law of Florida. The company policy in Alabama is not more important than Florida. LPN H explained the incident could have been avoided if the person responsible for placing the yellow DNRO form in the chart did his job. LPN H said, It should be the first thing you see. They told us if we don't see the yellow paper but if there is an order we should call the doctor, but there is no time for that. We only have 6 minutes to save a life. She explained on the night shift the process of calling a physician's answering service, leaving a message and receiving a call back could take up to 45 minutes. LPN H reiterated that although she received education after the incident, she would still make the same decision today. She stated she would initiate CPR if there was no yellow State of Florida DNRO form in a resident's chart, even if there was a DNRO in the EMR. On [DATE] at 1:13 PM, during a telephone interview, CNA I stated on [DATE] she entered resident #293's room after 4:00 AM. She said, I touched her and called her name, but I could not wake her. She did not respond. I don't like the way she looked. CNA I stated she called LPN H into the room. She recalled LPN H left the room to check resident #293's chart and then shouted, Full Code. CNA I said, The nurses all came, and they started working on her. On [DATE], all 6 nurses assigned to residents on the 7:00 AM to 3:00 PM shift were provided with the same scenario of a resident found unresponsive who had an active DNRO in the EMR, but no yellow State DNRO form in the paper chart. At 9:10 AM, LPN J said, If I see an order in the computer and the resident does not have a yellow sheet, I would have to do CPR. At 9:20 AM, Registered Nurse (RN) K said, If they have an order in the computer but does not have a yellow sheet, I would do CPR. If you do not have a yellow sheet, they are a full code until it is clarified. I need a valid sheet to be DNR. At 10:10 AM, LPN L said, If they have a DNR order and no yellow sheet in the chart they will be coded. The yellow sheet is the key. Review of the job descriptions for LPNs and RNs, reviewed on [DATE] revealed essential job functions including Contact physician regarding resident's change in condition and implements orders Assure care is provided per resident's advance directives and facility policy . Ensure that nursing staff personnel honor the resident's refusal of treatment request . On [DATE] at 11:06 AM, the administrator, DON and regional administrator were informed that although all nurses confirmed receiving education on CPR and advance directives since the incident with resident #293 on [DATE], 3 of the 6 nurses verbalized they would initiate CPR even if a resident had an active physician's DNRO if the yellow State DNRO form was not available. The DON and administrator stated additional education and validation of comprehension were necessary to ensure nurses followed physicians' orders and honored residents' advance directives. Review of the DON's job description, reviewed on [DATE] revealed a purpose to ensure the highest practicable level of quality care is maintained at all times. The DON's essential job functions included ensuring all nurses knew and complied with Residents' Rights rules and advance directives. Review of the Administrator's job description reviewed on [DATE] revealed a responsibility to assist with planning and developing in-services and educational activities. On [DATE] at 2:16 PM, during a telephone interview with the facility's Medical Director, he stated he was informed resident #293 received CPR although she had an active DNRO. The Medical Director was aware of the root cause and stated he offered suggestions during Quality Assurance and Performance Improvement (QAPI) meetings. The Medical Director recalled he suggested that the facility retain a copy of the yellow State of Florida DNRO form at the nurses' station when someone went to the hospital. The Medical Director stated he also offered to provide a presentation on CPR/advance directives for facility staff, but he had not yet been contacted regarding assisting with in-services. The Medical Director said, I told them it was a violation of the residents' rights and I asked them to put something in place to prevent it from happening again. Review of the facility's QAPI Committee 4 Step Plan dated [DATE] and QAPI meeting minutes dated [DATE] revealed discussion of concerns related to honoring advance directives and action plans. Individual education was provided to the Medical Records nurse on pulling forward the yellow State DNRO form to residents' new charts on re-admission, but there was no back-up system implemented to ensure all staff had access to this information. Education was provided for nurses on following physician's orders [REDACTED]. However, in-services did not provide clear instructions to nurses on ensuring advance directives were obtained, accurate and available for every resident on admission and re-admission. The Facility Assessment reviewed on [DATE] revealed residents' code status was monitored by social services on admission and regularly thereafter. The document indicated if a resident desired no resuscitative measures, the physician is contacted for appropriate orders to allow natural death. The Facility Assessment indicated a resident's code status would be communicated to nursing staff by placing the document on the front cover of the resident's chart. Review of the facility's policy and procedure Cardio [MEDICAL CONDITION] Resuscitation (CPR) effective [DATE] revealed a purpose to circulate [MEDICATION NAME] blood to vital organs for residents who experience [MEDICAL CONDITION], until emergency medical services personnel arrived. CPR would be performed .in accordance with the resident/guest(s) advance directives or in the absence of advance directives or a Do Not Resuscitate (DNR) order. The policy indicated the original DNRO should be handwritten by the physician, entered into the order system and the original kept in a plastic sleeve in the chart. The policy and procedure for Advance Directives and Refusal of Treatment - Florida effective [DATE] read, The resident has the right to refuse treatment, to refuse to participate in experimental research and to formulate an advance directive for the management of his/her care. The document indicated DNROs could be completed at any point in resident's care including on admission, re-admission and with a change in status. The policy read, These forms and related attachments should be placed in the front of the medical record housed in a plastic sheath. Orders, of course, should be written in the physician orders [REDACTED]. Review of the corrective measures for IJ removal implemented by the facility as of [DATE] revealed the following: o 1:1 education was provided for the Medical Records nurse regarding pulling the yellow State DNRO form forward to new charts on re-admission. o An audit of all residents' paper charts was conducted to ensure yellow State DNROs were in place under the advance directives tab for all residents with DNROs in the EMR. o All nurses were educated on checking the EMR for code status and following the physician's orders [REDACTED]. o Code Blue drills were conducted on each shift for 3 days, daily for 3 days and then at least weekly. Review of in-service attendance sheets revealed drills were conducted according to the action plan, across all shifts on 11 days between [DATE] to [DATE]. Drills were on-going. o The facility will continue to require nurses to complete quarterly Emergent Care Protocols training that includes instruction on CPR and advance directives. o 5 DNR binders were created as a back-up for the yellow State DNRO form in the paper charts; 1 for Social Services, 1 for Medical records and 1 on each unit (A, B and C Wings). The binders were noted on 3 of 3 nursing units on [DATE]. o Education for nurses was revised on [DATE] to include verification by 2 nurses of the yellow State DNRO form in the charts of admissions and re-admissions. A post-test will be required to ensure nurses understood in-services provided. Review of the DNR Post Test results revealed 19 of a total of 45 nurses were tested and all scored 100%. o Admission staff will verify residents' DNR status and place the yellow State DNRO form in the admission packet. o Unit Managers will ensure the DNR binders are accessible at the nurses' stations and complete daily verification of accuracy.

Based on observation, interview and record review, the facility failed to provide a secure environment and adequate supervision for 1 of 1 resident, reviewed for elopement, (#1). These failures contributed to the elopement of resident #1 and placed him at risk for serious injury/impairment/death. While resident #1 was out of the facility unsupervised, there was high likelihood he could have been hit by a car, fallen or become lost. On 11/02/19 at approximately 1:53 PM, a staff member unlocked the door near the therapy gym and resident #1, a vulnerable adult, exited the facility unsupervised. Resident #1 walked along a heavily-trafficked 6 lane highway. A Good Samaritan saw resident #1 and drove him to his family's home. The facility did not know resident #1's whereabouts until his daughter and the Good Samaritan returned him to the facility approximately 90 minutes later. The facility's failure to provide a secure environment and adequate supervision resulted in substandard quality of care at the Immediate Jeopardy level starting on 11/02/19. The Immediate Jeopardy was removed on 11/04/19. Findings: Cross reference to F835 Resident #1 was admitted to the facility from home on 11/01/19. His [DIAGNOSES REDACTED]. Review of resident #1's medical record revealed resident #1 arrived at the facility on 11/01/19 at 11:00 AM. A Nursing Admission Review indicated resident #1 had short-term and long-term memory problems, impaired vision, was only sometimes understood, and his ability was limited with making concrete requests. An Elopement Risk Review form completed on 11/01/19 at 3:50 PM, revealed the responses to risk factor screening questions were indicative of resident #1's high risk for elopement. The evaluation showed resident #1 had memory problems, psychiatric disorders, dementia, depression and was a new admission. Other risk factors identified during the admission evaluation noted resident #1 stated he wanted to go home, was confused, ambulated without assistance, paced without purpose and attempted to leave the facility. The document indicated resident #1 was observed wandering, intruded on the privacy of others and was at risk of getting to dangerous places. The Elopement Risk Review read, Resident is at risk related to poor cognitive function, active exit seeking behaviors. A nurse's progress note on 11/01/19 at 4:28 PM, read, Resident exit seeking, (wander alert bracelet) placed on ankle for resident's personal safety. During a telephone interview with resident #1's daughter on 11/14/19 at 3:32 PM, she explained the family was no longer able to care for the resident at home due to his worsening dementia. The daughter stated she was at the facility on 11/01/19, the day of her father's admission and confirmed he was confused and kept repeating that he was at a doctor's appointment. Resident #1's daughter stated later that evening, facility staff notified her by telephone that they placed a wander bracelet on her father because he attempted to exit the facility. The daughter stated she was at home the following afternoon, on 11/02/19, when she answered the doorbell and saw her father on the door step with his suitcase, accompanied by 2 strangers. She stated the couple told her they found her father walking on a busy highway in the area of the facility. The daughter said, I broke down when I saw him. It was overwhelming and I started crying. My mom was very upset when she saw him at home. It added to her depression. The daughter stated the couple drove her and her father back to the facility a few minutes later, at about 3:20 PM. She stated her father's nurse recalled she saw him with a suitcase earlier that day, but neither she nor anyone else was aware he left the facility. The daughter said, The nurses need to check new people and get acquainted with them to know their routine. The facility did not know he was missing. I wanted him to be safe. On 11/14/19 at 5:19 PM, a telephone interview was conducted with the Good Samaritan, who found resident #1 and transported him to the daughter's home. He stated he was driving along the busy 6-lane highway and observed an older gentleman, resident #1, standing at the corner of a major intersection. The Good Samaritan said, He was talking to himself and pointing in different directions. The Good Samaritan explained resident #1's behavior was so unusual that he continued to observe him and was alarmed when he stepped off the curb and crossed the intersection through the flow of on-coming traffic. He stated resident #1 waved his hat at the cars to stop them as he crossed the 6-lane road. The Good Samaritan explained he drove past resident #1 and pulled into the driveway of a business as resident #1 continued to walk along the sidewalk with his suitcase. He stated he got out of his car, approached resident #1 and asked if he was alright. Resident #1 informed him that he was just released from the hospital and did not have a ride home. The Good Samaritan said resident #1 did not have any identification but was able to provide his home address. The Good Samaritan drove resident #1 to his daughter's home approximately 20 minutes away and informed her he found her father wandering across a busy intersection. The Good Samaritan stated resident #1 resisted the daughter's attempts to return him to the facility so he offered to drive them both in his car. The surveyor reviewed the facility's video camera recording that showed the therapy gym door and resident #1 as he stood at the door with a rolling suitcase on 11/02/19 at 1:53 PM. During a brief interaction between resident #1 and a staff member near the door, Certified Nursing Assistant (CNA) B, a woman carrying a large box approached the door from the hallway behind them. Another staff member, CNA A, who was visible outside the door, punched a code in the keypad to unlock the door and held it open for both resident #1 and the woman with the box to exit the building. The video showed resident #1 turned left and walked away from the facility with his rolling suitcase, out of camera range. On 11/15/19 at 2:47 PM, the surveyors retraced resident #1's likely elopement route. The facility's parking lot ended at a private road across from an adjacent assisted living community. Resident #1 would have crossed through a 4-way stop sign to arrive at a busy 2-lane side street that bordered a busy shopping center with a large supermarket, restaurants and stores. The side street ended at a busy 6-lane highway and resident #1 would have turned left to cross the side street with no crosswalk, and continued walking adjacent to the busy 6-lane highway. Along the elopement route, resident #1 crossed 9 side streets and 17 driveways for businesses such as large retail stores, medical buildings and strip malls. The sidewalk had areas of uneven, cracked and broken pavement, and there were drainage ditches adjacent to the sidewalk. The ditches varied in length and depth, and some held more than 6 inches of water. Some intersections had raised and sloping sidewalks due to drainage structures underneath, creating a steep drop off to the adjacent highway. The heavily trafficked intersections and busy driveways were challenging to navigate as motor vehicles turned on red lights, and on 2 occasions did not stop before driving across the sidewalk and turned onto the main highway. During the 30-minute journey, the surveyors heard occasional horns and sirens of emergency vehicles in addition to the continuous noise of heavy traffic along the 1.2 mile elopement route. The weather on 11/02/19 at 1:53 PM was 78 degrees Fahrenheit and overcast. (www.timeanddate.com) 11/20/19 at 12:17 PM. On 11/15/19 at 11:19 AM, Licensed Practical Nurse (LPN) [NAME] stated she completed resident #1's admission assessment on 11/01/19. She described resident #1 as confused and not understanding. She explained resident #1 thought he was in the facility for an appointment only and was not aware he was there for long-term placement. LPN [NAME] stated nursing staff were expected to check on all assigned residents at least every 2 hours and at the change of shift. She validated the facility did not have a protocol for more frequent monitoring of newly admitted residents or residents at risk for elopement. During interviews on 11/15/19 at 10:02 AM and 11/16/19 at 11:39 AM, the receptionist recalled on 11/01/19 at about 4:30 PM she noticed a man standing by the front door. She stated she was not sure if he was a resident, so she asked the Long Term (LT) Minimum Data Set (MDS) nurse who was passing by in the hallway. The receptionist stated when the LT MDS nurse confirmed he was a new resident, she told the LT MDS nurse, You might want to put a wander (bracelet) on him. The receptionist explained there was a binder with information on residents at risk for elopement at the front desk, however resident #1's information was not included as he did not have a wander bracelet at that time. When asked how she identified newly admitted residents, she stated she was always notified by admissions or nursing departments. However, she was not aware resident #1 was admitted at 11:00 AM, more than 5 hours before she observed him attempting to exit through the front door. The receptionist explained both the front and therapy doors were always locked and required either an entry code or buzzer to unlock them. She stated she was responsible for monitoring the front door from 8:30 AM to 5:00 PM Mondays through Fridays, but the therapy door was not manned by staff. The receptionist stated visitors and some providers had the code to unlock the doors, but were required to sign in only at the front door. On 11/15/19 at 9:40 AM, the Social Services Director (SSD) stated she assisted the LT MDS nurse to assess resident #1's cognitive status. She explained the Brief Interview for Mental Status (BIMS) assessment resulted in a score of 6 which indicated severe cognitive impairment. The SSD said, The decision for the (wander bracelet) was based on BIMS score and his confusion, asking if he was sleeping here tonight. The SSD confirmed the front and therapy doors were always locked, but she provided the code to all family members, visitors and some residents. On 11/14/19 at 11:45 AM, the LT MDS nurse recalled on the day resident #1's daughter brought him to the facility for long term placement, she told him he was going to a doctor's appointment. The LT MDS nurse stated she saw him wandering in the halls and placed a wander alert bracelet on him after notifying the daughter. The LT MDS nurse explained she created a care plan for elopement that afternoon. Review of the medical record revealed a care plan for potential for elopement, initiated on 11/01/19 with the goal, I will not elope x 90 days. The interventions included listen and observe for potential signs of elopement, redirect with conversation/activities, contact family to sit with him and appropriate exercise when observed exit seeking/exit attempt. During a telephone interview on 11/14/19 at 10:52 AM, CNA A stated on 11/02/19 she was outside the therapy door, returning from her lunch break. She observed 2 people inside the building standing at the door, a man with a suitcase and woman with a box. CNA A explained she entered the code on the keypad to unlock the door and held the door open for them to exit the building. CNA A was not aware the man was a new resident in the facility. She stated at the end of her shift she was not aware there was a missing resident. In interviews on 11/14/19 at 3:00 PM and 11/16/19 at 10:35 AM, LPN D stated she was assigned to resident #1 on the day shift, from 7:00 AM to 3:00 PM on 11/02/19. LPN D recalled she spoke with resident #1 several times during that morning. She described him as frantic, very upset and very concerned about his missing wallet. LPN D said, I noticed he was walking around with a suitcase at about 11:00 AM. I spoke with him and he continued to talk about the wallet. He was new to me, so I did not know his normal pattern. I do the best I can to decide how often to monitor. LPN D stated she did not remember seeing him after 11:00 AM. The first time LPN D realized resident #1 was missing was when the daughter returned him to the facility during change of shift report after 3:00 PM. LPN D stated the weekend nursing supervisor informed her resident #1 had eloped. On 11/15/19 at 12:17 PM, the DON stated that on 11/02/19 staff informed her by telephone that resident #1 eloped, was found on (the highway), and was brought back to the facility by his daughter. The DON explained on Monday, 11/04/19, she reviewed the video recording from 11/01/19. She stated at 1:52 PM, resident #1 was observed leaving the building through the therapy door. She stated CNA A unlocked the door using the code and allowed resident #1 to leave. The DON said, The CNAs did not follow the protocol. The DON stated her expectation was staff would validate the identity of persons prior to allowing them to exit the facility. She explained assigned nursing staff were to check on all residents at a minimum of every 2 hours and at change of shift. The DON acknowledged high acuity or newly admitted residents should be monitored more frequently and stated every 30-45 minutes was reasonable for new residents. On 11/16/19 at 1:15 PM, CNA C stated he was assigned to resident #1 during the day shift on 11/02/19. He received report from the off-going night shift CNA that resident #1 was independent with activities of daily living except for supervision with toileting. He did not receive report from the nurse. CNA C stated he was not informed resident #1 was an elopement risk or that he had attempted to leave the building the previous day. He observed resident #1 throughout the day shift, and last saw him ambulating in the hallway at about 1:20 PM. CNA C acknowledged the expectation was nursing staff would do walking rounds at the change of every shift to share information and visualize all residents. However, he said, We did incomplete walking rounds and did not attempt to check on resident #1 with the on-coming CN[NAME] He validated residents should be checked every 2 to 2 ½ hours, but more frequently if the resident was new or confused. CNA C was asked how he obtained pertinent information on newly admitted residents. He explained he relied on verbal report only. He did not know how to access residents' care plans. On 11/16/19 at 1:37 PM, the weekend nursing supervisor confirmed CNAs gave a verbal report at change of shift, but she was not sure how the they obtained information on the residents' safety risks including elopement. A Nursing Notes form dated 11/02/19 at 4:00 PM read, Resident's daughter arrived at the facility at 3:21 PM with resident stating resident left facility and given a ride to her home by an unknown party. Review of the policy #NM. I-18 Elopements and Wandering Residents, effective 5/30/14 read, Purpose: To identify those residents who wander so that appropriate interventions can be put in place in an effort to provide adequate supervision and safety. The process included evaluation, use of wander bracelets, monitoring of door alarms and missing resident procedures. On 11/14/19 at 1:47 PM, the DON and the administrator stated they determined the root cause of resident #1's elopement was multiple employees made poor decisions. They explained CNA A opened the therapy door when she re-entered the building without validating who was leaving through the door. CNA B who was inside the therapy door also did not validate the identity of people exiting the facility. The facility also identified that CNA C and LPN D who were assigned to resident #1 on the day shift and CNA G and LPN H who were assigned to him on the evening shift did not follow procedures to always identify and verify all assigned residents during shift change report. When questioned how the staff identified residents, the administrator said, The residents do not have any form of identification on their persons. He stated the electronic medical record included residents' photographs. On 11/16/19 at 12 PM, the Administrator, DON and Regional Nurse Consultant were informed that concerns were identified at the Immediate Jeopardy level starting on 11/02/19. Review of corrective measures implemented by the facility revealed the following: On return to the facility, resident #1 received a head-to-toe assessment, was placed on 1:1 supervision and had a new wander bracelet placed. Review of the facility's Quality Assurance and Performance Improvement Plan (QAPI) revealed 2 CNAs and 2 nurses received written warnings for failure to comply with facility protocol related to identifying all assigned residents at shift change. The 2 CNAs who assisted resident #1 to exit the facility were terminated. The facility conducted an ad hoc meeting on 11/4/19 at 8:30 AM that was attended by the required QAA committee members. In-services began on 11/04/19 and no staff members were permitted to work prior to completing mandatory education. The topics included Do not open the door for anyone unless you have verified, they are not a resident and if they require supervision for their safety. Ask questions and Walking Rounds. During report staff must lay eyes on residents - specifically those that are high risk for elopement. The facility conducted 3 elopement drills during the week of 11/04/19 that impacted all 3 shifts and random drills continued. During the scheduled QAA meeting held on 11/13/19, the facility reviewed resident #1's safety plan. He continued on 1:1 supervision and placement arrangements were in process for a secured unit. As of that date, 195 of 200 employees were in-services on elopement prevention. The facility reinforced the protocol for visualization of all residents at shift change. In addition, the facility ordered new wander bracelets with a stronger band. Interviews conducted with staff from 11/14/19 to 11/16/19 revealed they were knowledgeable of the elopement prevention policies and procedures.

Based on observation, interview and record review, the facility administration failed to use its resources effectively to provide adequate supervision and a secure environment to ensure the safety of 1 of 1 resident reviewed for elopement, (#1). These failures contributed to the elopement of resident #1 and placed him at risk for serious injury/impairment/death. While resident #1 was out of the facility unsupervised, there was high likelihood he could have been hit by a car, fallen or become lost. On 11/02/19 at approximately 1:53 PM, a staff member unlocked the door near the therapy gym and resident #1, a vulnerable adult, exited the facility unsupervised. Resident #1 walked along a heavily-trafficked 6 lane highway. A Good Samaritan saw resident #1 and drove him to his family's home. The facility did not know resident #1's whereabouts until his daughter and the Good Samaritan returned him to the facility approximately 90 minutes later. The facility's failure to identify the need for adequate supervision and ensure a secure environment resulted in substandard quality of care at the Immediate Jeopardy level, starting on 11/02/19. The Immediate Jeopardy was removed on 11/04/19. Findings: Cross reference to F689 Resident #1 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Review of resident #1's medical record revealed he arrived at the facility on 11/01/19 at 11:00 AM. A Nursing Admission Review indicated resident #1 had short-term and long-term memory problems, impaired vision and was only sometimes understood, with ability limited to making concrete requests. An Elopement Risk Review form completed on 11/01/19 at 3:50 PM during the admission data collection process revealed the responses to risk factor screening questions were indicative of resident #1's high risk for elopement. The evaluation showed resident #1 had memory problems, psychiatric disorders, dementia, depression and was a new admission. Other risk factors identified during the admission evaluation noted resident #1 stated he wanted to go home, was confused and could ambulate without assistance, paced without purpose and attempted to leave the facility. The document indicated resident #1 was observed wandering and intruding on the privacy of others and was at risk of getting to dangerous places. The Elopement Risk Review read, Resident is at risk related to poor cognitive function, active exit seeking behaviors. A nurse's progress note on 11/01/19 at 4:28 PM, read, Resident exit seeking, (wander bracelet) placed on ankle for resident's personal safety. On 11/15/19 at 12:17 PM, the surveyor reviewed the video recording with the Administrator and the Director of Nursing (DON). It showed resident #1 standing at the therapy door with a rolling suitcase on 11/02/19 at 1:53 PM. The DON verified the Certified Nursing Assistant (CNA) B in the video as the staff member who briefly interacted with resident #1. The DON also identified another staff member, as CNA A who was visible outside the door, and who punched a code in the keypad to unlock the door. In the video recording CNA A held the door open for resident #1 and a woman carrying a large box exit the building. The DON explained both CNAs did not follow the facility's protocol, and the wander alert system did not alarm because resident #1 was not wearing the wander alert bracelet. The DON acknowledged facility staff were not aware resident #1 was not in the building until the daughter returned him that afternoon. On 11/15/19 at 10:02 AM, the receptionist explained she worked Monday through Friday from 8:30 AM to 5:00 PM. She stated the front door was always locked and she was responsible for using a buzzer to unlock it for visitors and ensuring residents did not leave through the front door unsupervised. She confirmed visitors were expected to sign in, collect a visitor badge at the desk and wear it while in the facility. The receptionist was asked how visitors entered the facility outside of the lobby hours. She said, If you are a family member you would more than likely have the code . I can't say for sure if any residents have the code. We do not like to give the code out to residents. The receptionist explained some outside providers who visited the facility regularly, such as hospice staff and transportation company employees also knew and used the code to unlock the doors. She stated there were doorbells at the front and at the therapy doors for people who did not have the door codes. During the interview, the receptionist unlocked the front door for visitor Z, who entered the lobby and started walking past the desk towards the hallway that led to residents' rooms. The receptionist called out and reminded visitor Z she needed to sign in and take a visitor badge. Visitor Z said, I've never had to do that before. Later that morning at 10:53 AM, visitor Z explained she visited relatives regularly and usually used the therapy door to enter and exit the facility. She said, On the weekends I've always used the code to get in the doors . I go in and out, don't have to sign in or get a badge. Today was the first day. She confirmed there was no receptionist at the therapy door. Visitor Z acknowledged it was not always possible to differentiate between visitors and residents and someone could make a mistake. She stated nobody ever spoke to her regarding not allowing other people in and out of the facility. On 11/15/19 at 11:06 AM, visitor Y stated her relative had been a resident of the facility in (YEAR) and she was provided with the door code then. Visitor Y explained although her relative was discharged , they still returned occasionally to visit with staff and other residents. Visitor Y said, Over the past year the code hasn't changed. I still use it. We can get in whenever we want. She confirmed the therapy door was used by many people and was never monitored by staff. On 11/15/19 at 12:34 PM, the administrator explained visitors were expected to sign in and out in the visitors' logbook at the front desk. He acknowledged visitors were provided with the access code to the front and therapy doors to the facility. The administrator validated visitors who entered and exited through the unattended therapy door were not required to sign in and out and could allow residents to exit the building in error. He said, The opportunity is there . It does not have the same level of security as the front door. On 11/15/19 at 4:49 PM, the administrator stated the facility had a Safety Committee which was a sub-committee of the Quality Assessment and Assurance (QAA) committee. He explained prior to resident #1's elopement, there was discussion by the Safety Committee regarding closing off the facility's therapy door. The administrator said, We discussed the logistics including codes being changed, notification of the fire department and informing families. He confirmed despite the Safety Committee's recommendation, no action was taken to close off or improve security of the therapy door. The administrator confirmed after resident #1's elopements, the door codes were not changed, and the facility did not send letters to family members regarding security concerns at doors. He said, We did not inform families because the elopement incident was related to staff. The administrator stated the wander management system added an extra level of supervision that failed because resident #1 removed his wander bracelet and 2 staff members did not verify he was a resident and not a visitor before they assisted him to leave. When asked if the QAA committee addressed the possibility of resident elopement due to a visitor unlocking the door, he reiterated the committee focused on the actual cause of resident #1's elopement. He said, That is a 'What if?' I believe we are in a safe situation. Review of the manufacturer's guide for the transmitter (revised 11/16/17) revealed the wander management system used by the facility was . not a substitute for identification and monitoring by professional staff. The guide indicated the system was designed to enhance existing procedures to protect residents. On 1/16/19 at 10:55 AM, the Maintenance Director stated he was head of the facility's Safety Committee. He explained the Safety Committee usually met monthly and provided meeting minutes to the administrator for discussion in the Monthly QAA Committee meeting. The Maintenance Director stated the functions of the Safety Committee included looking at overall safety in the facility and identifying potential problems. He confirmed one of the issues he identified was the need to improve the procedure for monitoring after-hours visitors by possibly locking the therapy door after 5:30 PM. He was asked to explain how the Safety Committee deemed the facility to be secure if visitors had the door access code and signing in and use of a visitor badge was only required if entering through the front door, but not the therapy door. The Maintenance Director said, I have been here for [AGE] years and I never liked that door. I like the idea of a 1 in, 1 out building . we were talking about making sure the building was secure, general safety with the world we live in. The Maintenance Director could not recall the last time the door code was changed, but stated it was more than 2 years ago. When asked how long administration had been aware of the need for improved security throughout the facility and specifically at the therapy door, the Maintenance Director acknowledged the discussion about shutting down the side door was in process as far back as (MONTH) 2019 when the Fire Marshall visited. On 11/15/19 at 11:19 AM, licensed practical nurse (LPN) E, stated she did resident #1's admission evaluation and determined he was at risk for elopement. She confirmed the facility's policy was to do rounds at least every 2 hours. LPN [NAME] stated there was no specific schedule or requirement for monitoring newly admitted residents and information was passed on between shifts in verbal report. On 11/15/19 at 11:57 AM, CNA F stated she usually received report on new residents from the nurse. She confirmed she had not received any education on frequent monitoring of new residents. On 11/16/19 at 10:35 AM, LPN D stated she was assigned to resident #1 on the day he eloped from the facility. She explained she received report at the start of her shift regarding resident #1's confusion and presence of a wander bracelet for elopement risk. LPN D confirmed resident #1 was confused, agitated and wandering around the unit with a suitcase. She said, He was new to me, so I did not know his normal pattern. I do the best I can to decide how often to monitor. LPN D stated she last saw resident #1 at about 11:00 AM and did not see him again until the daughter returned him to the facility more than 4 hours later. On 1/16/19 at 1:15 PM, CNA C stated he was assigned to resident #1 on the shift he eloped. He explained he received verbal report from the off-going night shift CNA, who did not mention resident #1 was at risk for elopement. CNA C confirmed he did not receive report from the assigned nurse and therefore was not made aware resident #1 was at risk for elopement. When asked how he obtained pertinent information on new residents on his assignment, CNA C said, We use scrap sheets of paper and take notes. For new residents they have bands if they come from the hospital. If not, depending on the nurse, they will let us know if they had time to review the notes. CNA C was not able to demonstrate use of the electronic medical record related to residents' care plans. He confirmed at the end of his shift he gave verbal report to the on-coming shift regarding resident #1 requiring little to no assistance with activities of daily living. CNA C acknowledged he still was not aware of resident #1's risk for elopement at the end of the shift and did not verify resident #1's whereabouts prior to leaving. He explained he usually checked on all his assigned residents every 2 to 2½ hours. On 11/16/19 at 1:37 PM, the weekend nursing supervisor confirmed the facility no longer used written care plans for CNAs. She stated she was unsure how CNAs would get information on their assigned residents other than in verbal report. During interviews on 11/15/19 at 12:17 PM and 11/16/19 at 12:28, the DON explained she expected nursing staff to check on their assigned residents at a minimum of every 2 hours and during change of shift report. She stated although there was no standard protocol for monitoring newly admitted residents, she felt staff should be aware of the need for more frequent monitoring. The DON said, Every 30 to 45 minutes is reasonable for new residents. However, she acknowledged the specific frequency of monitoring newly admitted residents was not a topic addressed in staff education and training. The DON confirmed it was natural for newly admitted residents to want to return to their previous home setting. She validated these residents were therefore, at risk for elopement during their adjustment period to life in the facility. The DON explained all staff received quarterly training on elopement, including management of doors and procedures related to visitors. She confirmed the facility conducted regular elopement drills to assess staff response to a resident's elopement. However, the DON acknowledged the facility currently had no auditing method to determine if staff could demonstrate the required response to a person without visitor badge leaving the building. Review of the 2019 Mandatory Monthly Facility Inservices revealed Elopement Training was scheduled 4 times for the year for all staff. Information used for the training was policy NM.I-18 Elopements and Wandering Residents. The policy revealed a purpose of providing adequate supervision and safety for residents who wandered. The policy indicated the facility would use locked doors and alarms to prevent elopements, but did not address procedures for management of visitors, securing unattended doors or staff role in prevention. The Facility Assessment Annual Review 2019 - 2020 reviewed on 10/09/19, revealed . the facility has the necessary care and services, equipment and staff competencies to address the current and future needs . of residents with dementia. The document indicated staff competencies would be validated regularly through daily supervision, rounds and direct care observation. Review of the job description for the Director of Maintenance dated 6/30/03, revealed a requirement to Support, cooperate with, and implement specific procedures and programs for safety . including security . The DON's job description dated 9/01/09, revealed administrative functions included maintaining and periodically updating written nursing policies and procedures. The DON was expected to ensure staff and visitors followed all safety regulations. The Administrator's job description dated 6/30/03, revealed a general purpose, To direct day-to-day functions of the facility . to ensure that the highest practicable level of care is provided to the residents. Standard requirements of the position included ensuring a safe and secure environment. The administrator was required to Plan, develop, organize, implement, evaluate, maintain, monitor and supervise and direct all facility departments and overall operations . and implement changes as necessary. The job description revealed the administrator had the responsibility of ensuring all staff, residents and visitors adhered to established policies and procedures. Review of corrective measures implemented by the facility revealed the following: On return to the facility, resident #1 received a head-to-toe assessment, was placed on 1:1 supervision and had a new wander bracelet placed. Review of the facility's Quality Assurance and Performance Improvement Plan (QAPI) revealed 2 CNAs and 2 nurses received written warnings for failure to comply with facility protocol related to identifying all assigned residents at shift change. The 2 CNAs who assisted resident #1 to exit the facility were terminated. The facility conducted an ad hoc meeting on 11/4/19 at 8:30 AM that was attended by the required QAA committee members. In-services began on 11/04/19 and no staff members were permitted to work prior to completing mandatory education. The topics included Do not open the door for anyone unless you have verified they are not a resident and if they require supervision for their safety. Ask questions and Walking Rounds. During report staff must lay eyes on residents - specifically those that are high risk for elopement. The facility conducted 3 elopement drills during the week of 11/04/19 that impacted all 3 shifts and random drills continue. During the scheduled QAA meeting held on 11/13/19, the facility reviewed resident #1's safety plan. He continued on 1:1 supervision and placement arrangements were in process for a secured unit. As of that date, 195 of 200 employees were in-services on elopement prevention. The facility reinforced the protocol for visualization of all residents at shift change. In addition, the facility ordered new wander bracelets with a stronger band. Interviews conducted with staff from 11/14/19 to 11/16/19 revealed they were knowledgeable of the elopement prevention policies and procedure.

Based on interview and record review, the facility failed to ensure the attending physician was informed when discolorations to abdomen and inner thighs were identified for 1 of 13 sampled residents on anticoagulant medication (#1). Failure to notify the physician resulted in the resident requiring emergency transport to the hospital when laboratory blood work for [MEDICATION NAME] time (PT) and international normalized ratio (INR) were above the normal levels. PT/INR tests are measures of the extrinsic pathway of coagulation. These tests, called PT/INR, are used to determine the clotting tendency of blood, in the measure of [MEDICATION NAME] ([MEDICATION NAME]) dosage. Immediate Jeopardy was identified for resident #1 starting on 12/01/2013 and it was removed at the survey completion on 12/27/13. The facility's practice caused, or is likely to cause serious injury, harm, impairment, or death to an isolated number of residents receiving anticoagulant medications. Anticoagulant medications, commonly called "blood thinners" prevent the blood from clotting and can cause a person to bleed more easily, which can be severe and/or life threatening. Some signs of bleeding may include: unusual bleeding or bruising, pin point red spots on the skin, bleeding from the gums, and bleeding or oozing from wounds or needle injections (www.drugs.com). The number of residents in the facility was 133 and 10 of them were currently receiving the anticoagulant [MEDICATION NAME]. The administrator and the director of nursing were notified of Immediate Jeopardy on 12/27/2013. Non-compliance continues to exist at a lower severity and scope of D, isolated no actual harm with potential for no more than minimal harm to other residents who receive services from staff who were not educated and the need to implement a QA plan to monitor and prevent reoccurrence. Cross Reference to F329 Findings: Record review revealed resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was sent out to the hospital on [DATE] for altered mental status, sluggish, lethargic, and possible [MEDICAL CONDITIONS]. The resident returned to the facility with a [DIAGNOSES REDACTED]. On 12/01/13 at 4:04 p.m., nurse #C's documented, "The resident's assigned CNA (certified nursing assistant #B) reported to the nurse of multiple discolored areas to the resident's inner thighs and abdominal area. Resident currently on multiple anticoagulants including [MEDICATION NAME], and [MEDICATION NAME] subcutaneous injection (SQ). Resident states she is unsure of when the discolored area appeared. Call placed to family to inform of resident's current condition as well as side effects of medications. Will continue to monitor for changes throughout shifts." A call to the physician was not documented in the resident's medical record. Review of the physician's orders [REDACTED]. [MEDICATION NAME] was ordered on [DATE] and the [MEDICATION NAME] and [MEDICATION NAME] were ordered on [DATE]. An interview was conducted with the CNA #B on 12/27/13 at 8:55 a.m. She stated she works part time on Friday and Sunday on the 7-3 shift and is floated to different wings every time she works. On Sunday, 12/01/13, she said she was assigned to resident #1 but could not recall the details. She stated she was providing care, saw the bruises on the resident's abdomen and inner thighs, and immediately reported it to nurse #C. She could not tell if it was new discoloration because it was the first time she saw the resident. Nurse #C was interviewed on 12/27/13 at 9:05 a.m. and she stated she floats to all 3 wings of the facility and all 3 shifts. It was the first time she saw the discolorations/ bruises on the resident's abdomen and inner thighs. She said she had not assessed her skin condition before. She said she then reported this to the weekend supervisor. She denied conducting a skin assessment but left it to the supervisor to assess the resident. She also admitted that she did not call the family member or inform the physician about the newly identified discolorations and bruising. An interview was conducted with the 7-3 shift weekend supervisor, nurse #D, on 12/27/13 at 11:20 a.m. She indicated that nurse #C called her to report the bruises/discolorations on the inner thighs and the abdomen. She said she looked at the areas, and indicated the color of the bruises in the abdomen were dark purple and the inner thighs were purplish in color. She stated she did not conduct a complete assessment and did not obtain any measurements to obtain baseline for monitoring of the bruises and determine if it was increasing. She said she did not document any of the findings in the nurses' progress notes. She said she reviewed the resident's medications and assumed that the bruises in the abdomen were caused by the [MEDICATION NAME] injections and asked other staff (unable to recall names) what could have been the possible cause of the bruising in the inner thighs. She said she assumed the cause of the bruising occurred because of the Hoyer lift which was used in order to weigh the resident. She said she called the responsible party family member about the discolorations in the abdomen and the inner thighs and then called the nurse on call, a registered nurse (RN) and C wing unit manager (UM), and informed her of the incident. She admitted that she did not call the attending physician about the newly identified bruises/discolorations in the abdomen and the inner thighs. An interview was conducted with the UM nurse #A on 12/27/13 at 9:15 a.m. She stated she received a call from the nursing supervisor about the discolorations on 12/01/13 but did not come to the facility to investigate and assess the resident. The next day, Monday 12/02/13, the issue of the discolorations were discussed during the interdisciplinary team (IDT) meeting. She admitted that she did not go to the resident to assess the skin condition but did complete an incident report. Review of the incident report dated 12/02/13 at 3 p.m. described the injury as discoloration to inner thighs. It indicated that the physician was notified of the skin discolorations/bruises on 12/02/13 at 1:20 p.m. The description of the incident read, "Resident was weighted with a Hoyer lift on 11/30/13. Resident was noted with a small amount of discoloration to bilateral inner thighs from Hoyer pad against thighs." The UM completed and signed the incident report without conducting an investigation and without conducting a thorough skin assessment of the resident. She made her report based on what the weekend nursing supervisor informed her. Both the UM and the nursing supervisor did not document anything about the bruises in the resident's medical record. A telephone interview was conducted with the attending physician on 12/27/13 at 9:40 a.m. He stated he did not recall receiving a call on 12/02/13 at approximately 1:20 p.m. about the identified discolorations in the inner thighs and abdomen of the resident. He stated he definitely would give an order to obtain a PT/INR for this resident if he was informed about the bruises or discolorations. Corrective Action to remove Immediate Jeopardy was conducted by the facility after the incident. Based on the facility's corrective action, Immediate Jeopardy was removed on 12/27/2013. Corrective Action was conducted by the facility after the incident. In-service education was conducted by the director of nursing to the licensed staff on 12/25/2013, 12/26/2013, and 12/27/2013. The education consisted of the following: Step 1 Educate with 1:1 (on to one) in-service for nurses on C wing day shift working on 11/21/13 that they need to do the following: 1. When using the coagulant machine, must record results in the medical records. 2. Must notify the physician if the PT/INR level is out of range. 3. Must document the notification to the physician. Step 2 1. Audited customers (residents) on anti-coagulant therapy to ensure PT/INR were complete, were in range, and documented in the medical records. 2. If not, results are documented in the medical record and physician was notified if level is out of range. Step 3 In-service nurses with the following: 1. When using the coagulant machine, must record the results in the medical records 2. Must notify the physician if PT/INR is out of range. 3. Must document the notification to the physician. 4. Follow the system for pulling and recording lab requisitions, make sure labs are received, and necessary follow-up is complete. 5. When assessing a customer related to a bruise, follow-up as necessary. Assessment, and notification to family, physician, and abuse coordinator if there is a bruise of unknown origin, and document in the medical record. 6. Follow-up care plan as laid out for anti-coagulant medications. Step 4 1. Unit manager/designee will conduct QI monitoring, and continue until substantial compliance is met. Step 5 1. The medical director confirmed the attending physician has the responsibility of writing the orders and following up on the results of the laboratory orders. 2. The medical director will discuss the issues with the attending physician who failed to follow-up on his orders. 3. The medical director will follow-up closely and educate the physician. 4. The medical director will discuss these issues in the facility's Quality Assurance (QA) meeting and the QA committee will be advised of outcome with the primary physician. In an interview with the DON and administrator on 12/27/13 at 12:30 p.m., they presented steps for their plan to address the noncompliance. Although the DON indicated no licensed staff will be allowed to begin their shift until they have been educated, as of 12/27/13, 6 licensed staff members had yet to be educated on completion of PT/INR per physicians orders either by the laboratory or the use of the CoagChek XS System, notification of the physician, and documentation in the medical record. The facility had not completed a QA meeting in which the medical director will discuss the findings of the deficiencies with the QA committee and implement a plan for monitoring to prevent reoccurrence. The immediate jeopardy was removed as on 12/27/13 and the severity and scope was reduced to D, isolated no actual harm with potential for more than minimal harm.

Based on interview and record review, the facility failed to conduct a complete skin assessment when discolorations/bruises were identified on 1 of 13 sampled residents on anti-coagulant therapy (#1). Failure to conduct a complete skin assessment resulted in the resident requiring emergency transport to the hospital when laboratory blood work for [MEDICATION NAME] time (PT) and international normalized ratio (INR) were above the normal levels. PT/INR are measures of the extrinsic pathway of coagulation. These tests, called PT/INR, are used to determine the clotting tendency of blood, in the measure of [MEDICATION NAME] ([MEDICATION NAME]) dosage. Immediate Jeopardy was identified for resident #1 starting on 12/01/2013 and it was removed at the survey completion on 12/27/13. The facility's practice caused, or is likely to cause serious injury, harm, impairment, or death to an isolated number of residents receiving anticoagulant medications. Anticoagulant medications, commonly called "blood thinners" prevent the blood from clotting and can cause a person to bleed more easily, which can be severe and/or life threatening. Some signs of bleeding may include: unusual bleeding or bruising, pin point red spots on the skin, bleeding from the gums, and bleeding or oozing from wounds or needle injections (www.drugs.com). The number of residents in the facility was 133 and 10 of them were currently receiving the anticoagulant [MEDICATION NAME]. The administrator and the director of nursing were notified of Immediate Jeopardy on 12/27/2013. Non-compliance continues to exist at a lower severity and scope of D, isolated no actual harm with potential for no more than minimal harm to other residents who receive services from staff who were not educated and the need to implement a QA plan to monitor and prevent reoccurrence. Cross Reference to F329 Findings: Record review revealed resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was sent to the hospital on [DATE] for altered mental status, sluggish, lethargic, and possible [MEDICAL CONDITIONS]. The resident returned to the facility with a [DIAGNOSES REDACTED]. The last minimum data set ((MDS) dated [DATE] assessed the resident's cognition as alert and oriented and able to verbalize her needs. The resident was also assessed as requiring assistance with all activities of daily living (ADLs). On 12/01/13 at 4:04 p.m., the nurse #C's documented, "The resident's assigned CNA (certified nursing assistant #B) reported to the nurse of multiple discolored areas to the resident's inner thighs and abdominal area. Resident currently on multiple anticoagulants including [MEDICATION NAME], and [MEDICATION NAME] subcutaneous injection (SQ). Resident states she is unsure of when the discolored area appeared. Call placed to family to inform of resident's current condition as well as side effects of medications. Will continue to monitor for changes throughout shifts. " There was no further documentation of monitoring of bruises and skin discoloration. The nurse did not document that an assessment was conducted. The measurements and description of the discolorations were not documented. There was no documentation in the resident's medical record that the physician was notified of the bruises/discoloration. Review of the physician's orders [REDACTED]. [MEDICATION NAME] was ordered on [DATE] and the [MEDICATION NAME] and [MEDICATION NAME] were ordered on [DATE]. An interview was conducted with CNA #B on 12/27/13 at 8:55 a.m. She stated she works part time on Fridays and Sundays on the 7-3 shift and floats to different wings every time she works. On Sunday, 12/01/13, she said she was assigned to the resident, and saw bruises on the abdomen and inner thighs, and immediately reported it to nurse #C. She could not tell if it was new discoloration because it was the first time she saw the resident. Nurse #C was interviewed on 12/27/13 at 9:05 a.m. and stated it was the first time she saw the discolorations/bruises on the abdomen and inner thighs. She said she had not assessed the resident's skin before. She said she reported the observation to the weekend supervisor. She said she did not conduct a skin assessment but left it to the supervisor to assess the resident. In an interview conducted with the weekend supervisor 7-3 shift nurse #D on 12/27/13 at 11:20 a.m., she indicated that nurse #C called her to report the bruises/discolorations on the inner thighs and the abdomen. She went to see the resident and looked at the areas. She said the color of the bruises in the abdomen were dark purple and the inner thighs were purplish in color. She stated she did not conduct a complete assessment and did not obtain any measurements in order to obtain a baseline for monitoring the bruises in order to determine any increase in size. She also said she did not document any of the findings in the resident's medical record. She reviewed the resident's medications and assumed that the bruises in the abdomen were caused by the [MEDICATION NAME] injections. She assumed the possible cause of the bruising on the inner thighs occurred when staff used the Hoyer lift to weigh the resident. The resident's medical record did not have any documentation of a fall and she said the resident was able to verbalize if she had a fall or if somebody caused the bruises. A review of the weekly skin checks, dated 11/28/13, 11/19/13, 11/15/13, and 11/12/13, were conducted by the wound care nurse and there was no documentation about any discolorations on the abdomen or inner thighs. The wound care progress notes did not have any documentation of bruises in any other areas of the resident's body. The readmission skin assessment, dated 11/08/13 read,"Bilateral heels remain with dry eschar, unstageable ulcers. Heels are floated a stage 3 ulcer in the sacral area. Bilateral upper extremities with multiple bruises. Right hip with old surgical scar." There was no other documentation that the discolored areas/bruises on the abdomen and inner thighs were identified prior to the nurses' notes of 12/01/13. In an interview with the wound care nurse on 12/23/13 at 11:45 a.m., she stated she did not see any unusual bruises on the thighs and abdomen when she conducted the daily wound care treatment on the sacral area. Upon readmission from the hospital on [DATE], she said she assessed the resident with multiple bruises on both upper extremities. She did not mention any discoloration to the abdomen or inner thighs. An interview was conducted with unit manager (UM) nurse #A on 12/27/13 at 9:15 a.m. She stated she received a call from the nursing supervisor about the resident's skin discolorations on 12/01/13 but did not come to the facility to investigate and assess the resident. The next day , Monday 12/02/13, the issue of the discolorations were discussed in the interdisciplinary team (IDT) meeting. She admitted that she did not go to the resident to assess the skin condition but did complete an incident report. Review of the incident report, dated 12/02/13 at 3 p.m., described the injury as discoloration to inner thighs. It indicated in the report that the physician was notified of the skin discolorations/bruises on 12/02/13 at 1:20 p.m. The narrative read, "Resident was weighted with a Hoyer lift on 11/30/13. Resident was noted with a small amount of discoloration to bilateral inner thighs from Hoyer pad against thighs." The UM completed and signed the incident report without conducting an investigation and a thorough skin assessment of the resident. She made her report based on what the nursing supervisor told her. Both the UM and the nursing supervisor did not document the discolorations/bruises in the resident's medical record. Corrective Action to remove Immediate Jeopardy was conducted by the facility after the incident. Based on the facility's corrective action, Immediate Jeopardy was removed on 12/27/2013. Corrective Action was conducted by the facility after the incident. In-service education was conducted by the director of nursing to the licensed staff on 12/25/2013, 12/26/2013, and 12/27/2013. The education consisted of the following: Step 1 Educate with 1:1 (on to one) in-service for nurses on C wing day shift working on 11/21/13 that they need to do the following: 1. When using the coagulant machine, must record results in the medical records. 2. Must notify the physician if the PT/INR level is out of range. 3. Must document the notification to the physician. Step 2 1. Audited customers (residents) on anti-coagulant therapy to ensure PT/INR were complete, were in range, and documented in the medical records. 2. If not, results are documented in the medical record and physician was notified if level is out of range. Step 3 In-service nurses with the following: 1. When using the coagulant machine, must record the results in the medical records 2. Must notify the physician if PT/INR is out of range. 3. Must document the notification to the physician. 4. Follow the system for pulling and recording lab requisitions, make sure labs are received, and necessary follow-up is complete. 5. When assessing a customer related to a bruise, follow-up as necessary. Assessment, and notification to family, physician, and abuse coordinator if there is a bruise of unknown origin, and document in the medical record. 6. Follow-up care plan as laid out for anti-coagulant medications. Step 4 1. Unit manager/designee will conduct QI monitoring, and continue until substantial compliance is met. Step 5 1. The medical director confirmed the attending physician has the responsibility of writing the orders and following up on the results of the laboratory orders. 2. The medical director will discuss the issues with the attending physician who failed to follow-up on his orders. 3. The medical director will follow-up closely and educate the physician. 4. The medical director will discuss these issues in the facility's Quality Assurance (QA) meeting and the QA committee will be advised of outcome with the primary physician. In an interview with the DON and administrator on 12/27/13 at 12:30 p.m., they presented steps for their plan to address the noncompliance. Although the DON indicated no licensed staff will be allowed to begin their shift until they have been educated, as of 12/27/13, 6 licensed staff members had yet to be educated on assessment for residents receiving anti-coagulant medications if there is a bruise of unknown origin, observing for abnormal bleeding, increased bruising, hematuria, petechiae, bleeding gums, black/tarry stools, hematemesis. The facility had not completed a QA meeting in which the medical director will discuss the findings of the deficiencies with the QA committee and implement a plan for monitoring to prevent reoccurrence. The immediate jeopardy was removed as on 12/27/13 and the severity and scope was reduced to D, isolated no actual harm with potential for more than minimal harm.

Based on interview and record review, the facility failed to ensure care plans were implemented related to the problem of potential for complications of anti-coagulant therapy for 1 of 13 sampled residents (#1). Failure to implement the plan of care resulted in the resident requiring emergency transport to the hospital when laboratory blood work for [MEDICATION NAME] time (PT) and international normalized ratio (INR) were above the normal levels. PT/INR are measures of the extrinsic pathway of coagulation. These tests, called PT/INR, are used to determine the clotting tendency of blood, in the measure of [MEDICATION NAME] ([MEDICATION NAME]) dosage. Immediate Jeopardy was identified for resident #1 starting on 12/01/2013 and it was removed at the survey completion on 12/27/13. The facility's practice caused, or is likely to cause serious injury, harm, impairment, or death to an isolated number of residents receiving anticoagulant medications. Anticoagulant medications, commonly called "blood thinners" prevent the blood from clotting and can cause a person to bleed more easily, which can be severe and/or life threatening. Some signs of bleeding may include: unusual bleeding or bruising, pin point red spots on the skin, bleeding from the gums, and bleeding or oozing from wounds or needle injections (www.drugs.com). The number of residents in the facility was 133 and 10 of them were currently receiving the anticoagulant [MEDICATION NAME]. The administrator and the director of nursing were notified of Immediate Jeopardy on 12/27/2013. Non-compliance continues to exist at a lower severity and scope of D, isolated no actual harm with potential for no more than minimal harm to other residents who receive services from staff who were not educated and the need to implement a QA plan to monitor and prevent reoccurrence. Cross Reference to F329 Findings: Review of resident #1's care plan, dated 11/07/13 upon readmission from the hospital, assessed the resident with the problem for potential for complications related to anti-coagulant therapy. Interventions included: follow physician's orders [REDACTED]. Labs as indicated/ordered with report of results to MD for review. The last minimum data set (MDS), dated [DATE], assessed the resident's cognition as alert and oriented and able to verbalize her needs. The resident was also assessed as requiring assistance with all activities of daily living (ADLs). Review of the physician's orders [REDACTED]. In an interview with the director of nursing (DON) at 5:30 p.m. on 12/23/13, she verified that she could not find the results of the PT/INR ordered on [DATE] and admitted she was not sure if it was done because there was no documentation in the nurses' notes that indicated it was completed or the physician was informed about the results. There was no record in the laboratory log book that a blood test was conducted on 11/21/13. The DON also stated at that time that staff might have done it in their new machine (PT waive test) that checks for INR. She provided the anti-coagulant flow sheet log and indicated that on 11/21/13, the result of the INR was 1.6. However, there was no documentation or signature of who did it and if the results were called in and reported to the physician. On 12/01/13 at 4:04 p.m., the nurses' progress notes indicated the resident's assigned CNA (certified nursing assistant) #B "reported to the nurse of multiple discolored areas to the resident's inner thighs and abdominal area. Resident currently on multiple anticoagulants including [MEDICATION NAME], and [MEDICATION NAME] subcutaneous injection (SQ). Resident states she is unsure of when the discolored area appeared. A call was placed to family to inform of resident's current condition as well as side effects of medications." There was no further documentation of the monitoring of bruises and skin discoloration to check for increase in size. The nurse did not document if an assessment was conducted and there was no documentation in the resident's medical record that the physician was notified. Review of the physician's orders [REDACTED]. [MEDICATION NAME] was ordered on [DATE] and the [MEDICATION NAME] and [MEDICATION NAME] were ordered on [DATE]. This care plan was not implemented based on the following. PT/INR labs ordered for on 11/21/13 were not done. The physician was not informed when a newly identified discoloration/bruising on the abdomen and inner thighs on 12/01/13. Care plan interventions indicated not to give [MEDICATION NAME] and [MEDICATION NAME] concurrently. This was not reviewed by the interdisciplinary team with the physician and there was no written rationale in the progress notes to justify the use of medications with similar effects. The resident was sent out to the hospital unresponsive on 12/03/13. Corrective Action to remove Immediate Jeopardy was conducted by the facility after the incident. Based on the facility's corrective action, Immediate Jeopardy was removed on 12/27/2013. Corrective Action was conducted by the facility after the incident. In-service education was conducted by the director of nursing to the licensed staff on 12/25/2013, 12/26/2013, and 12/27/2013. The education consisted of the following: Step 1 Educate with 1:1 (on to one) in-service for nurses on C wing day shift working on 11/21/13 that they need to do the following: 1. When using the coagulant machine, must record results in the medical records. 2. Must notify the physician if the PT/INR level is out of range. 3. Must document the notification to the physician. Step 2 1. Audited customers (residents) on anti-coagulant therapy to ensure PT/INR were complete, were in range, and documented in the medical records. 2. If not, results are documented in the medical record and physician was notified if level is out of range. Step 3 In-service nurses with the following: 1. When using the coagulant machine, must record the results in the medical records 2. Must notify the physician if PT/INR is out of range. 3. Must document the notification to the physician. 4. Follow the system for pulling and recording lab requisitions, make sure labs are received, and necessary follow-up is complete. 5. When assessing a customer related to a bruise, follow-up as necessary. Assessment, and notification to family, physician, and abuse coordinator if there is a bruise of unknown origin, and document in the medical record. 6. Follow-up care plan as laid out for anti-coagulant medications. Step 4 1. Unit manager/designee will conduct QI monitoring, and continue until substantial compliance is met. Step 5 1. The medical director confirmed the attending physician has the responsibility of writing the orders and following up on the results of the laboratory orders. 2. The medical director will discuss the issues with the attending physician who failed to follow-up on his orders. 3. The medical director will follow-up closely and educate the physician. 4. The medical director will discuss these issues in the facility's Quality Assurance (QA) meeting and the QA committee will be advised of outcome with the primary physician. In an interview with the DON and administrator on 12/27/13 at 12:30 p.m., they presented steps for their plan to address the noncompliance. Although the DON indicated no licensed staff will be allowed to begin their shift until they have been educated, as of 12/27/13, 6 licensed staff members had yet to be educated on implementation of the care plan related to potential complications with anticoagulant therapy. The facility had not completed a QA meeting in which the medical director will discuss the findings of the deficiencies with the QA committee and implement a plan for monitoring to prevent reoccurrence. The immediate jeopardy was removed as on 12/27/13 and the severity and scope was reduced to D, isolated no actual harm with potential for more than minimal harm.

Based on interview, and record review, the facility failed to ensure physician's orders to conduct laboratory test to monitor the [MEDICATION NAME] time (PT) and international normalized ratio (INR) were followed for 1 of 13 residents on anti-coagulant therapy (#1). Failure to monitor blood test (no labs conducted for PT/INR x 18 days), and failure to assess resident's skin condition resulted in the resident requiring emergency transport to the hospital when laboratory blood work for PT/INR were above the normal levels. PT/INR are measures of the extrinsic pathway of coagulation. These tests, called PT/INR, are used to determine the clotting tendency of blood, in the measure of [MEDICATION NAME] ([MEDICATION NAME]) dosage. Hemorrhage is the most serious risk of therapy and anticoagulation must be monitored carefully. Immediate Jeopardy was identified for resident #1 starting on [DATE] and it was removed at the survey completion on [DATE]. The facility's practice caused, or is likely to cause serious injury, harm, impairment, or death to an isolated number of residents receiving anticoagulant medications. Anticoagulant medications, commonly called "blood thinners" prevent the blood from clotting and can cause a person to bleed more easily, which can be severe and/or life threatening. Some signs of bleeding may include: unusual bleeding or bruising, pin point red spots on the skin, bleeding from the gums, and bleeding or oozing from wounds or needle injections (www.drugs.com). The number of residents in the facility was 133 and 10 of them were currently receiving the anticoagulant [MEDICATION NAME]. The administrator and the director of nursing were notified of Immediate Jeopardy on [DATE]. Non-compliance continues to exist at a lower severity and scope of D, isolated no actual harm with potential for no more than minimal harm to other residents who receive services from staff who were not educated and the need to implement a QA plan to monitor and prevent reoccurrence. Cross Reference to F157, F272, F282, and F386 Findings: Record review revealed resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was sent to the hospital on [DATE] for altered mental status, sluggishness, lethargy, and possible [MEDICAL CONDITIONS]-blood clot in lung. The resident returned to the facility with a [DIAGNOSES REDACTED]. The admission minimum data set (MDS), dated [DATE], assessed the resident on cognition as alert and oriented and able to verbalize her needs. The resident also required assistance with all activities of daily living (ADLs). She required extensive assistance with 2 persons for bed mobility and transfers. She was not steady with her balance. A review of the nurses' notes dated [DATE] at 1:50 p.m. indicated the resident was very sluggish and difficult to arouse. Her blood sugar was checked and was high at 380 milligrams/deciliter (mg/dl). Vital signs included blood pressure (B/P) of ,[DATE] millimeters Mercury (mm Hg), pulse of 74, respirations of 22, and temperature of 97 degrees. The physician was notified and ordered stat (immediately)laboratory blood work including a complete blood count (CBC), complete metabolic panel (CMP), urinalysis (UA), PT/INR, and ammonia level. The blood work results were: PT >100.0 seconds elevated, critical level (normal value 11XXX,[DATE].1), INR >12.22 (normal value 0XXX,[DATE].09 & normal therapeutic level 2XXX,[DATE].0) elevated ; ammonia level 47 micrograms per deciliter (mcg/dL) elevated (normal value ,[DATE]). The unit manager documented "There were abnormal readings reported, PT/INR was elevated and positive for urinary tract infection. Orders were given to give the resident [MEDICATION NAME] 5 mg. (milligrams) po (orally) give 2 tablets." [MEDICATION NAME] has similar qualities as Vitamin K which can counteract the effect of [MEDICATION NAME] (www.drugs.com). When the nurse went to give the medications, the resident was unresponsive to verbal stimuli, touch, pain stimuli, pupils were fixed and constricted. Her B/P was ,[DATE], pulse 72, respirations 14, temperature 98.9, oxygen saturation was 97% (normal). 911 was called and the resident was sent to the hospital with the emergency medical services (EMS). Readmission medications dated [DATE] included the following: [MEDICATION NAME] (anti-coagulant medication) 5 milligrams (mg.) 1 tablet daily, [MEDICATION NAME] (low molecular weight [MEDICATION NAME], anti-coagulant medication) 40 mg. subcutaneous injection (SC) daily (ordered [DATE] in the hospital), and [MEDICATION NAME] (anti-platelet agent -precautions use with caution in patients who maybe at risk for increased bleeding) 75 mg. 1 tablet daily. Because the side effects of these 3 medications are increased bleeding and hemorrhage, the resident's blood levels must be closely monitored. The Institute for Safe Medication Practices (SMP) includes [MEDICATION NAME] and [MEDICATION NAME] among the list of drugs which have heightened risk of causing significant patient harm when used in error. The attending physician ordered PT/INR tests. On [DATE], results were PT 31 seconds and INR 3.0. On [DATE], results were PT 16.4 seconds and INR 1.3. On [DATE], results were PT 22.4 seconds and INR 2.0. There were no specific orders from the physician to conduct weekly or daily PT/INR but the resident's laboratory blood tests were ordered based on results of the previous results. The next order written on [DATE] was PT/INR to be done on [DATE]. Results of the PT/INR for this date were not found in the resident's medical record. Review of nurses' notes did not find documentation that the lab ordered was completed. Review of the physician's progress notes dated [DATE], [DATE] and [DATE] found documentation which read, "Patient was seen at bedside, [MEDICAL CONDITION]. assessment plan, on [MEDICATION NAME] see orders." The physician's notes did not mention follow-up on the orders written on [DATE] for the results of the PT/INR. He did not order further blood tests for the resident. On [DATE] at 4:04 p.m., nurse #C documented, "The resident's assigned CNA (certified nursing assistant) #B reported to the nurse of multiple discolored areas to the resident's inner thighs and abdominal area. Resident currently on multiple anticoagulants including [MEDICATION NAME], and [MEDICATION NAME] subcutaneous injection (SQ). Resident states she is unsure of when the discolored area appeared. Call placed to family to inform of resident's current condition as well as side effects of medications. Will continue to monitor for changes throughout shifts." There was no further documentation of monitoring for increased bruises and skin discoloration. The nurse did not document that an assessment was conducted. The measurements and descriptions of the bruises/discolorations were not documented. Review of the physician's orders revealed the resident was also receiving an antiplatelet medication, [MEDICATION NAME], which also prevents the blood from clotting. [MEDICATION NAME] was ordered on [DATE] and the [MEDICATION NAME] and [MEDICATION NAME] were ordered on [DATE]. An interview was conducted with CNA #B on [DATE] at 8:55 a.m. She stated she works part time on Fridays and Sundays on the ,[DATE] shift and floats to different wings every time she works. She said on Sunday, [DATE], she saw the bruises on resident #1's abdomen and inner thighs and immediately reported it to nurse #C. She could not tell if it was new discoloration because it was the first time she saw the resident. Nurse #C was interviewed on [DATE] at 9:05 a.m. and stated she floats to all 3 wings of the facility and on all 3 shifts. It was the first time she saw the discolorations/bruises on the abdomen and inner thighs. She had not assessed the resident's skin condition before. She said she reported this to the weekend supervisor. She said she denied conducting a skin assessment but left it for the supervisor to assess the resident. An interview was conducted with the weekend supervisor ,[DATE] shift, nurse #D, on [DATE] at 11:20 a.m. She indicated that nurse #C called her to report the bruises/discolorations in the inner thighs and the abdomen. She looked at the areas and indicated the color of the bruises on the abdomen were dark purple and the inner thighs were purplish in color. She further stated she did not conduct a complete assessment and did not measure the areas of discoloration in order to obtain a baseline for monitoring the bruises to determine if the areas increase in size. She said she did not document any of the findings in the resident's medical record. She said she reviewed the resident's medications and assumed that the bruises in the abdomen were caused by the [MEDICATION NAME] injections. Because the resident was lifted with a Hoyer lift on [DATE], she assumed that was the cause of the thigh bruising. She said she called the responsible party family member about the discolorations on the abdomen and the inner thighs and then she called the registered nurse (RN) on call, who was the C wing unit manager (UM) and informed her of the observation. She admitted that she did not call the attending physician about the newly identified bruises/discolorations on the abdomen and the inner thighs. A review of the weekly skin checks, dated [DATE], [DATE], [DATE], and [DATE] did not reveal any documentation about discoloration on the abdomen or inner thighs. The wound care progress notes did not have documentation of bruises in other areas of the body. Upon return from the hospital, the readmission skin assessment conducted on [DATE] read, "Bilateral heels remain with dry eschar, unstageable ulcers. Heels are floated a stage 3 ulcer in the sacral area. Bilateral upper extremities with multiple bruises. Right hip with old surgical scar." Eschar is dead tissue that occurs in pressure wounds (www.healthline.com). There was no other documentation that the discolored areas/bruises on the abdomen and inner thighs were identified prior to the nurses' notes on [DATE]. An interview was conducted with the UM nurse #A on [DATE] at 9:15 a.m. She stated she received a call from the nursing supervisor about the discolorations on [DATE] but did not come to the facility to investigate and assess the resident. The next day, Monday [DATE], the issue of the discolorations was discussed in the interdisciplinary team (IDT) meeting. She admitted she did not assess the resident's skin condition but made out an incident report. Review of the incident report dated [DATE] at 3 p.m. described the injury as discoloration to inner thighs. The report indicated that the physician was notified of the skin discolorations/bruises on [DATE] at 1:20 p.m. The narrative read, "Resident was weighed with a Hoyer lift on [DATE]. Resident was noted with a small amount of discoloration to bilateral inner thighs from Hoyer pad against thighs." The UM completed and signed the incident report without conducting an investigation and without conducting a thorough skin assessment of the resident. She said she made her report based on what the nursing supervisor told her. Both the UM and the nursing supervisor did not document the discolorations/bruises in the resident's medical record. A telephone interview was conducted with the attending physician on [DATE] at 9:40 a.m. He stated he does not recall that he had written orders for PT/INR ordered for [DATE] but verified that this laboratory order was "not run or documented." He further stated, "This was not done (PT/INR), was missed." When asked if he received a call on [DATE] at approximately 1:20 p.m. about the identified discolorations on the resident's inner thighs and abdomen of the resident, he stated he did not recall....but definitely would give an order to obtain PT/INR for this resident once he was informed about bruising or discolorations." The physician was also asked about the progress notes he wrote on [DATE], [DATE] and [DATE] and why he did not follow up on his previous order dated [DATE] for a PT/INR. He did not offer any explanation. In an interview with the UM on [DATE] at 12 noon, she stated the resident was alert and oriented and was able to make needs known. The resident was assisted with 2 staff for transfers and does not know if they used a Hoyer lift or not. In an interview with CNA #E on [DATE] at 1:20 p.m., she stated they do not use a Hoyer lift for the resident. She indicated 2 staff will assist the resident from the bed to the wheelchair. She also stated she has not seen any bruises on the abdomen or the thighs when taking care of the resident as far she could recall. In another interview with the director of nursing (DON) and the UM at 5:30 p.m. on [DATE], they verified that she could not find the results of the labs PT/INR ordered on [DATE] and admitted she was not sure if it was done because there was no documentation in the resident's medical record that it was completed or the physician was informed about it. There was no record in the laboratory log book that a blood test was conducted on [DATE]. The DON also stated that they might have done it in their new machine, a PT waive test that checks for INR. She provided a log named "anti-coagulant flow sheet" and indicated that on [DATE] the results was 1.6. However, there was no documentation or signature of staff who did it or if the results were reported to the physician. The DON also stated that she keeps the log but was unable to provide any policy and procedure for the use of the machine. On [DATE] at 9:30 a.m., the DON provided a policy and procedure named "CoaguChek XS System. Systematic Anticoagulation Management program". The purpose of the program is to monitor anti-coagulation medication identified as a high risk treatment that can lead to adverse events due to the complexity of dosing anticoagulation medications, and monitoring their effects associated with the use of [MEDICATION NAME]." The quality control (QC) procedures indicated the machine has a built in quality control function that controls the analytical process. It also indicated that acceptable patient test results will be reported. The policy also requires a "coaguchek XS patient test log" where the date and time of specimen collection would be recorded as well as the name of the operator and the test results. These steps were not completed on the test claimed by the DON that was done on [DATE]. The orders were for a PT/INR but there was no results of the PT. The DON also stated that the PT waive test machine is used only for residents who refuse to be stuck by a lab technician and in cases of emergency. They have a contract with a laboratory company that conducts blood draws every morning. In further interview with the DON on [DATE] at 2:30 p.m., she stated that based on her investigation, the lab test ordered on [DATE] was not done. They reviewed the lab log and nobody was able to trace who carried out the order and why it was not done. She indicated they had a change of laboratory provider effective [DATE]. She stated their procedure is for the nurse who picks up the physician's orders will enter the laboratory orders in the laboratory computer provided by the laboratory. Every night the night nurse would check the computer and make laboratory requisitions for the specific orders and place those requisitions in the laboratory log book situated at each nursing station. The technician will come every morning, go through all the requisitions, and collect the blood specimens. If a resident refuses or the technician was unable to obtain the blood, a form in the log book is to be completed indicating the reason. A review of the facility policy regarding use of [MEDICATION NAME] ([MEDICATION NAME]) was conducted. It indicated monitoring is to be done to achieve optimal coagulation. "[MEDICATION NAME] is a narrow therapeutic range index drug, and its action may be affected by factors such as other drugs and dietary Vitamin K. Therefore, anti-coagulation must be carefully monitored during [MEDICATION NAME] therapy. Determine the INR daily after the administration of the initial dose until INR results stabilize in the therapeutic range by performing periodic INRs. The frequency of INR determinations are ,[DATE] weeks. Perform additional INR tests when other [MEDICATION NAME] ([MEDICATION NAME]) products are interchanged with [MEDICATION NAME], as well as whenever other medications are initiated, discontinued, or taken irregularly. [MEDICATION NAME]. increases the INR." The resident was both on [MEDICATION NAME] and [MEDICATION NAME], a low dose [MEDICATION NAME]. Additional PT/INRs should have been conducted based on the facility policy or physician explanation as to why the policy would not be followed. Further review of the facility policy for "Drug Regimen Review by the Pharmacist" indicated that, "Duplicate therapy defined as 2 or more medications from the same class or use of medications from the same class or use of medications from different therapeutic categories that have similar effects or properties, must have a written rationale for benefits of and monitoring or duplicate therapy." Review of the physician's progress notes did not indicate any documentation of the rationale for the 3 medications he ordered with similar effects which would increase risk of bleeding/hemorrhage. In an interview with the pharmacist on [DATE] at 2 p.m., she stated that they do not have specific policies for obtaining blood work for PT/INR, it depends on the attending physician monitoring and can go up to 4 weeks without blood work for [MEDICATION NAME], depending on the last PT/INR results. The resident can have 2 anti-coagulant medications ([MEDICATION NAME] & [MEDICATION NAME]) while obtaining a bridge therapy and once results of blood work are stable, [MEDICATION NAME] can be discontinued. For this resident's anti-coagulant medication, she stated she did not make recommendations to the physician to conduct a PT/INR because it was not 4 weeks from the last PT/INR, which was conducted [DATE] and results were normal. Review of the resident 's care plans dated [DATE] upon readmission revealed the resident was assessed with [REDACTED]. Interventions included to follow physician's orders, pharmacy review as needed, labs as ordered, avoid giving NSAIDS, aspirin, [MEDICATION NAME] and [MEDICATION NAME] concurrently, observe for abnormal bleeding, hematuria, petechiae, bleeding gums, black/tarry stools, hematemesis, keep resident/responsible party informed; labs as indicated/ordered with report of results to MD for review. This care plan were not followed based on no results were found for the lab ordered on [DATE] (test was not completed) and when there was increase discoloration/bruises on the abdomen and inner thighs on [DATE], the physician was not informed. The care plan indicated not to give [MEDICATION NAME] and [MEDICATION NAME] concurrently. This was not reviewed by the interdisciplinary team with the physician and there was no written rationale in the progress notes to justify the use of medications with similar effects. The resident was sent to the hospital when she became unresponsive on [DATE]. Her admitting [DIAGNOSES REDACTED]. The resident subsequently expired 10 days later on [DATE] in the hospital. Corrective Action to remove Immediate Jeopardy was conducted by the facility after the incident. Based on the facility's corrective action, Immediate Jeopardy was removed on [DATE]. Corrective Action was conducted by the facility after the incident. In-service education was conducted by the director of nursing to the licensed staff on [DATE], [DATE], and [DATE]. The education consisted of the following: Step 1 Educate with 1:1 (on to one) in-service for nurses on C wing day shift working on [DATE] that they need to do the following: 1. When using the coagulant machine, must record results in the medical records. 2. Must notify the physician if the PT/INR level is out of range. 3. Must document the notification to the physician. Step 2 1. Audited customers (residents) on anti-coagulant therapy to ensure PT/INR were complete, were in range, and documented in the medical records. 2. If not, results are documented in the medical record and physician was notified if level is out of range. Step 3 In-service nurses with the following: 1. When using the coagulant machine, must record the results in the medical records 2. Must notify the physician if PT/INR is out of range. 3. Must document the notification to the physician. 4. Follow the system for pulling and recording lab requisitions, make sure labs are received, and necessary follow-up is complete. 5. When assessing a customer related to a bruise, follow-up as necessary. Assessment, and notification to family, physician, and abuse coordinator if there is a bruise of unknown origin, and document in the medical record. 6. Follow-up care plan as laid out for anti-coagulant medications. Step 4 1. Unit manager/designee will conduct QI monitoring, and continue until substantial compliance is met. Step 5 1. The medical director confirmed the attending physician has the responsibility of writing the orders and following up on the results of the laboratory orders. 2. The medical director will discuss the issues with the attending physician who failed to follow-up on his orders. 3. The medical director will follow-up closely and educate the physician. 4. The medical director will discuss these issues in the facility's Quality Assurance (QA) meeting and the QA committee will be advised of outcome with the primary physician. In an interview with the DON and administrator on [DATE] at 12:30 p.m., they presented steps for their plan to address the noncompliance. Although the DON indicated no licensed staff will be allowed to begin their shift until they have been educated, as of [DATE], 6 licensed staff members had yet to be educated on monitoring residents receiving anticoagulant medications to include observing for abnormal bleeding, increased bruising, hematuria, petechiae, bleeding gums, black/tarry stools, hematemesis, completion of PT/INR per physicians orders either by the laboratory or the use of the CoagChek XS System, notification of the physician, and documentation in the medical record. The facility had not completed a QA meeting in which the medical director will discuss the findings of the deficiencies with the QA committee and implement a plan for monitoring to prevent reoccurrence. The immediate jeopardy was removed as on [DATE] and the severity and scope was reduced to D, isolated no actual harm with potential for more than minimal harm.

Based on interview and record review, the facility failed to ensure attending physician followed up on orders for a blood test for anti-coagulant therapy and monitor continued appropriateness of medications for 1 of 13 sampled residents (#1). Immediate Jeopardy was identified for resident #1 starting on [DATE] and it was removed at the survey completion on [DATE]. The facility's practice caused, or is likely to cause serious injury, harm, impairment, or death to an isolated number of residents receiving anticoagulant medications. Anticoagulant medications, commonly called "blood thinners" prevent the blood from clotting and can cause a person to bleed more easily, which can be severe and/or life threatening. Some signs of bleeding may include: unusual bleeding or bruising, pin point red spots on the skin, bleeding from the gums, and bleeding or oozing from wounds or needle injections (www.drugs.com). The number of residents in the facility was 133 and 10 of them were currently receiving the anticoagulant [MEDICATION NAME]. The administrator and the director of nursing were notified of Immediate Jeopardy on [DATE]. Non-compliance continues to exist at a lower severity and scope of D, isolated no actual harm with potential for no more than minimal harm to other residents who receive services from staff who were not educated and the need to implement a QA plan to monitor and prevent reoccurrence. Cross Reference to F329 Findings: Review of readmission medications for resident #1, dated [DATE], included: [MEDICATION NAME] (anti-coagulant medication) 5 milligrams (mg.) 1 tablet daily, [MEDICATION NAME] (low molecular weight [MEDICATION NAME], anti-coagulant medication) 40 mg. subcutaneous injection (SC) daily (ordered [DATE] in the hospital), and [MEDICATION NAME] (anti-platelet agent -precautions use with caution in patients who maybe at risk for increased bleeding) 75 mg. 1 tablet daily. Because the side effects of these 3 medications are increased bleeding and hemorrhage, the resident's blood levels must be closely monitored. The Institute for Safe Medication Practices (SMP) includes [MEDICATION NAME] and [MEDICATION NAME] among the list of drugs which have heightened risk of causing significant patient harm when used in error. Review of the medical record for resident #1 revealed the resident was very sluggish, and difficult to arouse on [DATE]. The attending physician was immediately called at 1:50 p.m. and ordered stat (immediate) laboratory blood tests including a complete blood count, complete metabolic profile, PT/INR, ammonia levels and urinalysis. The results came back abnormal, with PT/INR results over the normal levels. The resident was sent to the hospital at 4 p.m. when the condition declined and was she unresponsive. A telephone interview was conducted with the attending physician on [DATE] at 9:40 a.m. The physician stated he did not recall that he had written PT/INR orders for [DATE] but verified that this laboratory order was, "not run or documented." He further stated, "one thing happened/something, this was not done, was missed." When asked if he received a call on [DATE] at approximately 1:20 p.m. about the identified discolorations on the resident's inner thighs and abdomen, he stated he did not recall.... but definitely would give an order to obtain PT/INR for this resident once he was informed about bruising or discolorations." The physician was also asked about the progress notes he wrote on [DATE], [DATE] and [DATE]. On these days, he did not follow up on his previous order,dated [DATE], for a PT/INR. He did not offer any explanation. A review of the facility policy regarding use of [MEDICATION NAME] ([MEDICATION NAME]) revealed monitoring is needed to achieve optimal coagulation. [MEDICATION NAME] is a narrow therapeutic range index drug, and its action may be affected by factors such as other drugs and dietary Vitamin K. Therefore, anti-coagulation must be carefully monitored during [MEDICATION NAME] therapy. Determine the INR daily after the administration of the initial dose until INR results stabilize in the therapeutic range by performing periodic INRs. The frequency of INR determinations are ,[DATE] weeks. Perform additional INR tests when other [MEDICATION NAME] ([MEDICATION NAME]) products are interchanged with [MEDICATION NAME], as well as whenever other medications are initiated, discontinued, or taken irregularly. [MEDICATION NAME], a common concomitant drug, increases the INR. Review of the facility policy for "Drug Regimen Review by the Pharmacist" indicated that, "Duplicate therapy defined as 2 or more medications from the same class or use of medications from the same class or use of medications from different therapeutic categories that have similar effects or properties, must have a written rationale for benefits of and monitoring or duplicate therapy." Review of the physician's progress notes did not indicate any documentation of close monitoring of the labs and of the rationale for the 3 medications ordered, that have similar effects which would increase risk of bleeding/hemorrhage. The resident's hospital admitting [DIAGNOSES REDACTED]. The resident subsequently expired on [DATE]. In an interview conducted with the medical director on [DATE] at 10 a.m., he stated the attending physician has the responsibility of writing the orders and following up on the results of the laboratory orders. He stated he will discuss the issues/scenario with the attending physician who failed to follow-up on his orders. He said he will follow-up closely and educate the physician, he indicated the attending physician is new to long term care. The medical director also stated that this situation will be discussed in the quality assurance (QA) of the facility and the QA committee will be advised. Corrective Action to remove Immediate Jeopardy was conducted by the facility after the incident. Based on the facility's corrective action, Immediate Jeopardy was removed on [DATE]. Corrective Action was conducted by the facility after the incident. In-service education was conducted by the director of nursing to the licensed staff on [DATE], [DATE], and [DATE]. The education consisted of the following: Step 1 Educate with 1:1 (on to one) in-service for nurses on C wing day shift working on [DATE] that they need to do the following: 1. When using the coagulant machine, must record results in the medical records. 2. Must notify the physician if the PT/INR level is out of range. 3. Must document the notification to the physician. Step 2 1. Audited customers (residents) on anti-coagulant therapy to ensure PT/INR were complete, were in range, and documented in the medical records. 2. If not, results are documented in the medical record and physician was notified if level is out of range. Step 3 In-service nurses with the following: 1. When using the coagulant machine, must record the results in the medical records 2. Must notify the physician if PT/INR is out of range. 3. Must document the notification to the physician. 4. Follow the system for pulling and recording lab requisitions, make sure labs are received, and necessary follow-up is complete. 5. When assessing a customer related to a bruise, follow-up as necessary. Assessment, and notification to family, physician, and abuse coordinator if there is a bruise of unknown origin, and document in the medical record. 6. Follow-up care plan as laid out for anti-coagulant medications. Step 4 1. Unit manager/designee will conduct QI monitoring, and continue until substantial compliance is met. Step 5 1. The medical director confirmed the attending physician has the responsibility of writing the orders and following up on the results of the laboratory orders. 2. The medical director will discuss the issues with the attending physician who failed to follow-up on his orders. 3. The medical director will follow-up closely and educate the physician. 4. The medical director will discuss these issues in the facility's Quality Assurance (QA) meeting and the QA committee will be advised of outcome with the primary physician. In an interview with the DON and administrator on [DATE] at 12:30 p.m., they presented steps for their plan to address the noncompliance. Although the DON indicated no licensed staff will be allowed to begin their shift until they have been educated, as of [DATE], 6 licensed staff members had yet to be educated on physician follow up for orders. In an interview with the medical director on [DATE] at 10:00 a.m., he had not yet spoken to the attending physician regarding the responsibility to follow up on written orders, especially those for anticoagulant monitoring. The facility had not completed a QA meeting in which the medical director will discuss the findings of the deficiencies with the QA committee and implement a plan for monitoring to prevent reoccurrence. The immediate jeopardy was removed as on [DATE] and the severity and scope was reduced to D, isolated no actual harm with potential for more than minimal harm.