Every finding on record at Williamsport Nursing and Rehabilitation

Based on observation, interview, and record review, the facility failed to ensure the kitchen was in a sanitary condition and the facility failed to ensure cleaning logs were completed and kept up to date for 1 of 1 initial kitchen observations. This had the potential to affect 64 out of 64 people who consumed food out of the kitchen. Findings include: During the initial kitchen tour on 6/9/25 at 10:00 a.m., the Dietary Cooperate Consultant was present during the initial tour. The convention oven burners were noted to have dark/chard particles caked on them. The grill next to the convention oven had food particles all around the outside rim of the grill. There was no food currently being cooked on the grill or oven at the time. The piping and wall behind the convention oven appeared dirty with old grease. The kitchen floor was dirty with food crumbs and pieces of paper towel throughout. Walk-in freezer contained food crumb/particles on the floor and shelving. During an interview, on 6/9/25 at 10:10 a.m., the Dietary Cooperate Consultant indicated the kitchen had a new dietary manager and she was not aware if the kitchen staff had been following a cleaning schedule. The Consultant opened a binder that had the cleaning schedule logs in it. The logs were dated April 2025 and were completely blank. She was unable to provide documentation that the kitchen cleaning logs were completed for April, May, or June 2025. During an interview, on 6/10/25 at 2:44 p.m., the Dietary Manager indicated she was aware that there were no kitchen cleaning logs completed for the last few months. She started at the facility a few weeks ago and she was aware that some tasks were not being completed as they should have by staff. She was still learning where the breaks in the system were and what staff needed to be re-educated on the tasks. The dietary manager indicated she would just instruct staff to clean something when she noted it needed attention. They had not been following an actual daily or deep cleaning schedule. During an interview, on 6/11/25 at 1:21 p.m., the Director of Nursing (DON) indicated she was aware that the kitchen cleaning logs were not kept up to date and that they have had several changes in management during the last year in the kitchen. On 6/11/25 at 1:25 p.m., the Director of Nursing (DON) provided a document with a revised date of 5/24, titled, Cleaning Schedules, and indicated it was the policy currently being used by the facility. The policy indicated, .The culinary staff will maintain the sanitation of the culinary department through compliance with a written, comprehensive cleaning schedule .2. The cleaning schedule will be posted for all cleaning tasks, and employees will initial tasks as completed. 4. Cleaning schedules are kept on file for a minimum of twelve months but if the time between annual surveys is longer than 12 months, the cleaning schedules must be held until completion of annual survey 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to provide food that was palatable and failed to serve food at the proper temperature for 1 of 1 test tray. This had the potential to affect all residents who received food from the kitchen. Findings include: 1. During an observation of the lunch service, on 6/9/25 at 11:50 a.m., The residents in the dining room were served a chicken salad sandwich, slice of lettuce, slice of tomato, beets, and sliced pears. This menu differed from what was to be served that day. The residents were to be served a bowl of tomato basil soup, hot tuna and cheese sandwich, pickled beets and sliced pears. During a dining room observation, on 6/9/24 at 12:27 p.m., Resident 31 was served her lunch tray, and she indicated she was tired of chicken salad, and they just had a chicken salad sandwich a couple of days ago. The resident also questioned the staff why they were also having chicken again for dinner. During an interview, on 6/10/25 at 2:44 p.m., the Dietary Manager was unsure why there were different foods served on the previous day's menus. She knew they were allowed to serve substitutes if necessary. The chicken salad sandwich, beets, and pears were not enough of a caloric intake for the residents that day, indicated by the manager. The dietary manager indicated she was still trying to get the food council up and running and she knew there were concerns about repeated items on the menu. During an interview, on 6/10/25 at 2:45 p.m., Culinary Aide 18 indicated she saw where soup was to be served with the sandwich, and she was told there was no soup to be served. 2. During an interview, on 6/9/25 at 2:17 p.m., Resident 31 indicated the food was often cold and they had a lot of repeated items on the menu and were not palatable. The resident indicated that she ate most of the time in the dining room and the food was even cold when served from there. During an interview, on 6/10/25 at 9:55 a.m., Resident 12 indicated the food served from the kitchen was the same items week after week and the food was often cold and not palatable. The resident indicated most of the time she ate in the dining room but not always. During an interview, on 6/10/25 at 10:25 a.m., Resident 50 indicated the food from the kitchen was always cold. The resident ate most of his meals in his room and received a hall tray. During an interview, on 6/12/25 at 11:11 a.m., the Dietary Manager indicated she was aware of the cold food complaints from the residents, and she had just started at the facility a few weeks before and was still trying to find out what the issue was. They do not have insulated food carts for the hall trays. A test tray was obtained on 6/12/25 at 1:10 p.m., the food temps were as follows: a. [NAME] dog 130.6 degrees F(Fahrenheit) b. Potato Wedges 113.4 degrees F c. [NAME] Slaw 49.6 degrees F d. Watermelon 48.4 degrees F The potato wedges were noted to not be cooked thoroughly and were crunchy in sections. The warm food was noted to be lukewarm. During an interview, on 6/12/25 at 1:10 p.m., the Dietary Manager indicated the food was not to the correct temperature and the warm food items were too cold and the cold items were too warm per state regulation. On 6/12/25 at 2:10 p.m., the Dietitian Assistant provided a document with a revised date of 5/25, titled, Food Temperatures, and indicated it was the policy currently being used by the facility. The policy indicated, .The facility will maintain proper food temperature control to prevent food borne illness .1. Hot foods will be held for service at or above 135F, and cold foods at or below 41F. 2. All hot and cold food items will be served to the resident at a temperature that is considered palatable at the time the resident receives the food .9. Hot food will be held at or above 135F. If minimum temperature requirements are not maintained, food will need to be reheated to a minimum of 165F for 15 seconds before serving .11. Cold food will be held at or below 41. If cold food temperature is not maintained food item will need to be chilled to less than 41F before serving 3.1-21(a)(1) 3.1-21(a)(2)

Based on observation and interviews, the facility failed to ensure medication was labeled properly for 1 of 2 medication storage rooms reviewed for medication storage. Findings include: On 6/11/25 at 9:15 a.m., observed the North Hall medication storage room with Licensed Practical Nurse (LPN) 17. The refrigerator observed with an opened, undated vial of tuberculin solution. On 6/11/25 at 9:20 a.m., during an interview LPN 17 indicated medications must be dated when opened. On 6/11/25 at 11:30 a.m., during an interview the Director of Nurses (DON) indicated tuberculin solution must be dated when opened. On 6/11/2025 at 10:12 a.m., the DON provided a document, titled, Medication Storage and Expiration policy, dated 11/2024, and indicated it was the policy currently being used by the facility. The policy indicated, .9. Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened 3.1-25(j) 3.1-25(m) 3.1-25(n)

Based on record review and interview, the facility failed to ensure the accurate coding of a Minimum Data Set (MDS) assessment for 1 of 22 residents reviewed for MDS assessment accuracy (Resident 55). Findings include: Resident 55's record was reviewed on 6/11/25 at 11:58 a.m. A quarterly MDS assessment, dated 4/15/25, indicated the resident received an anticoagulant (blood thinner) medication during the look-back period. A Medication Administration Record (MAR), dated April 2025, lacked documentation the resident received an anticoagulant medication. During an interview, on 6/13/25 at 10:17 a.m., the Director of Nursing Services (DNS) indicated she reviewed the MDS assessment, dated 4/15/25, and the resident's record. At the time of the MDS assessment, the resident was not on an anticoagulant medication. He was on an anticoagulant previously, but it was discontinued prior to the MDS assessment's look-back period. The assessment was coded in error. On 6/13/25 at 10:16 a.m., the DNS provided the Centers for Medicare and Medicaid Services (CMS), Resident Assessment Instrument (RAI) manual, section N, and indicated it was the policy currently being used by the facility. The RAI manual indicated, .Steps for Assessment 1. Review the resident's medication administration records for the 7-day look-back period .N0415 High-Risk Drug Classes: Use and Indication: 1. Is taking: Check if the resident is taking any medications by pharmacological classification, not how it is used, during the last 7 days .E. Anticoagulant 3.1-31(c)(13)

Based on interview and record review, the facility failed to ensure a resident's shower preferences were upheld for 1 of 24 residents reviewed for choices (Resident 54). Findings include: During an interview, on 6/9/25 at 11:16 a.m., Resident 54 indicated she wanted a shower every day but had never been asked how often she wanted one. Resident 54's record was reviewed on 6/12/25 at 11:08 a.m. Census information indicated the resident was admitted to the facility on [DATE]. An admission Minimum Data Set (MDS) assessment, dated 4/1/25, indicated the resident had a moderate cognitive impairment, it was very important for her to choose the type of bath she received, and she required partial/moderate staff assistance with bathing. A preferences for customary routines and activities observation, dated 4/8/25, indicated the resident was interviewed to obtain the information in the document. The resident indicated it was very important for her to choose the type of bath she received, and she preferred to be bathed more than twice per week in the AM. An undated shower schedule indicated the resident was scheduled for showers on evening shift twice weekly despite the resident's stated preference of showering more than twice per week in the morning. Shower reports, dated April, May, and June 2025, indicated the resident was offered a shower on 4/3/25, 4/5/25, 4/9/25, 4/10/25, 4/11/25, 4/15/25, 4/21/25, 4/24/25, 4/27/25, 4/28/25, 5/6/25, 5/9/25, 5/16/25, 5/20/25, 5/23/25, 5/27/25, 5/30/25, 5/31/25, and 6/10/25. Of those dates, the resident refused the offered showers on 4/3/25, 4/9/25, 4/10/25, 4/11/25, 5/16/25, 5/23/25, 5/27/25, 5/30/25, and 6/10/25. The shower reports lacked documentation the resident's shower preference was reassessed due to refusals or what shift the showers were offered on as the resident's stated time preference was morning, but she was scheduled for evening showers. Progress notes, dated May and June 2025, lacked documentation the resident was offered a shower daily or the resident's shower preference was reassessed. A care plan, goal target dated, 7/7/25, indicated the resident enjoyed spending time with animals and pets, crocheting, visiting with family and friends, reading, listening to music, and going outside. Interventions included, but were not limited to, the resident preferred to shower every day. During an interview, on 6/12/25 at 11:37 a.m., the Director of Nursing Services (DNS) indicated the Activity Director interviewed residents to determine their preferences and it was documented on the customary routines and activities observation. The resident's shower schedule should have been based on the resident's preference obtained from the customary routines and activities observation. If the resident stated she wanted to be showered more than twice per week then the Activity Director should have followed up to determine how many days a week she preferred to shower. Once the resident's shower preference was determined then the Activity Director should have communicated the preference to the scheduler to add to the resident's shower schedule. During an interview on 6/12/25 at 12:03 p.m., the DNS indicated the resident was scheduled for showers twice weekly. The resident refused showers, but showers should have been scheduled more than twice per week since that was her stated preference. Ideally, if the resident stated a preference, but then refused showers, the resident should have been re-interviewed or reassessed to determine if the resident wanted to be offered a shower daily. The DNS indicated she reviewed the resident's record but was unable to find documentation the resident's shower schedule or preferences had been reassessed or updated. On 6/12/25 at 12:07 p.m., the DNS provided a document titled, Preferences for Daily Routine, last revised in December 2015, and indicated it was the policy currently being used by the facility. The policy indicated, .Purpose: To identify and develop a plan of care that reflects the resident's past and current daily customary routines .Procedure: 1. Activity Director or designee will complete the Preferences for Daily Customary Routines worksheet upon admission of a new resident .3. The information from the worksheet will be shared with the interdisciplinary team so that each department can address the resident's preferences. 3.1-3(u)(1)

3. During an interview, on 6/9/25 at 2:15 p.m., Resident 31 indicated she did not remember being invited to or attending a care plan meeting regularly. She did not recall when the last one was. Resident 31's record was reviewed on 6/11/25 at 11:29 a.m. A quarterly Minimum Data Set (MDS) assessment, dated 4/30/25, indicated the resident was cognitively intact. Census information indicated the resident was admitted to the facility on [DATE]. A Care Plan Summary note, dated 12/12/24, indicated a care plan meeting was conducted on this day for Resident 31. A Care Plan Summary note, dated 6/13/24, indicated a care plan meeting was conducted on this day for Resident 31. Resident 31's record lacked documentation of a quarterly care plan meeting being conducted for the last year from June 2024 to June 2025. The resident had two care plan meetings for the entire year. During an interview, on 6/11/25 at 1:28 p.m., the Social Service Director (SSD) indicated she would document a care plan summary note in the residents' chart when the care plan meetings were conducted, and she would conduct a care plan meeting every 3 months with the resident and or resident representative. She was unable to provide documentation that care plan meetings were conducted quarterly for Resident 31. On 6/11/25 at 2:17 p.m., the Director of Nursing (DON) provided a document with a revised date of 8/23, titled, IDT Comprehensive Care Plan Policy, and indicated it was the policy currently being used by the facility. The policy indicated, .The care plan must include measurable goals and resident specific interventions based on resident needs and preferences to promote the resident's highest level of functioning including medical, nursing, mental, and psychosocial well-being .Resident, resident's representative, or others as designated by resident will be invited to care plan review. The care plan review may be conducted face to face, via phone conference, video conference, or through written communication per resident and/or representative preference. Care plan problems, goals, and interventions must be reviewed and revised by the interdisciplinary team periodically and following completion of each MDS assessment 3.1-35(a) 3.1-35(e) Based on record review and interview, the facility failed to develop a care plan for the long-term use of an antibiotic for 1 of 22 residents reviewed for care plans (Resident 55), and the facility failed to ensure care plan meetings were held and documented for 2 of 22 residents reviewed for care plan meetings (Residents 11 and 31). Findings include: 1. Resident 55's record was reviewed on 6/11/25 at 11:58 a.m. Diagnosis on the resident's profile included, but were not limited to, extended spectrum beta lactamase (ESBL) (multi-drug resistant organism). A quarterly Minimum Data Set (MDS) assessment, dated 4/15/25, indicated the resident had a moderate cognitive impairment, a UTI in the last 30 days, and received an antibiotic during the look-back period. A progress note, dated 3/26/25, indicated the Nurse Practitioner (NP) called about the resident potentially having a peripherally inserted central catheter (PICC) line placed for antibiotic treatment for ESBL. The NP wanted to talk with the resident's wife and the infectious disease doctor before making a decision. The resident had an appointment scheduled with infectious disease on 4/1/25. A written physician's order from the infectious disease doctor, dated 4/1/25, indicated continue Macrobid (antibiotic) twice daily until 4/5/25, and then start Macrobid daily from 4/6/25 for six months for urinary tract infection (UTI) prevention. A physician's order, dated 4/6/25, indicated Macrobid 100 milligrams (mg) by mouth daily for six months for prevention of UTI. The resident's comprehensive care plan lacked documentation a care plan was developed due to the resident's long-term use of the antibiotic for UTI prevention and the resident's history of UTIs and ESBL. During an interview, on 6/12/25 at 9:38 a.m., the Director of Nursing Services (DNS) indicated a care plan should have been developed related to the resident's long-term antibiotic use. 2. During an interview, on 6/9/25 at 11:03 a.m., Resident 11 indicated she did not remember having a care plan meeting. Resident 11's record was reviewed on 6/11/25 at 2:31 p.m. Census information indicated the resident was admitted to the facility on [DATE]. An annual Minimum Data Set (MDS) Assessment, dated 5/21/25, indicated the resident was cognitively intact. Progress Notes, dated 12/1/24 to 6/11/25, lacked documentation the resident or resident representative were invited to a care plan meeting, a response to any invitation, or a care plan meeting was held. On 6/12/25 at 10:40 a.m., the Social Services Director (SSD) provided copies of invitations for a care plan meeting on 5/21/25 at 10:30 a.m. One invitation was addressed to the resident's representative and one had the resident's name on it. The invitations did not indicate if the resident or the representative accepted the invitation, refused, or documentation the care plan meeting was held at the indicated time. During an interview, on 6/12/25 at 10:43 a.m., the SSD indicated she reviewed the resident's chart and was unable to find documentation the resident or the representative responded to the invitation or documentation the care plan meeting was held. She was only able to provide documentation an invitation was mailed. The SSD indicated the resident or representative's response to the invitation should have been documented. The care plan meeting should have been documented when it was completed.

Based on observations, interviews and record reviews, the facility failed to ensure residents were administered showers and shaved per resident preference for 2 of 24 residents reviewed for Activities of Daily Living (ADL), (Resident 50), (Resident 29). Findings include: 1. On 6/10/25 at 10:32 a.m., during initial observation and interview, Resident 50 observed to have extensive facial hair. The resident indicated he preferred to be shaved but the staff does not shave him, and due to poor vision he is unable to shave himself. The resident indicated he was scheduled to receive a shower on Monday and Friday, but he was not being administered regular showers. On 6/10/25 at 10:45 a.m., during an interview the Assistant Director of Nursing (ADON) indicated she was unsure how often the residents were shaved. On 6/10/25 at 10:46 a.m., during interview Certified Nurse Aide (CNA) 5, indicated residents were shaved on the days they received a shower. She indicated they record administered showers on a shower sheet. On 6/11/25 at 1:45 p.m., the medical record of Resident 50 was reviewed. The resident was admitted to the facility on [DATE]. Admitting diagnoses included but were not limited to Hypertension (high blood pressure), Diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high), and Hemiplegia (a loss of strength in the arm, leg, and sometimes face on one side of the body). A Minimum Data Assessment (MDS) dated [DATE] indicated the resident was cognitively intact and required assistance for Activities of Daily Living (ADL) (activities related to personal care such as bathing and grooming). A care plan dated 8/30/24 indicated the resident required assistance with ADLs including bed mobility, transfers, eating and toileting related to: CVA (stroke), and hemiplegia. Intervention included but were not limited to assist with bathing as needed per resident preference. Offer showers two times per week, partial bath in between. Current preference for bathing/shower/bed bath and AM/PM. The record indicated the resident was scheduled to be administered two showers per week, on Mondays and Fridays. The point of care documentation in the medical record (documentation recorded by the CNA indicating care that was provided to the resident), indicated the resident was scheduled to have 22 showers administered from 4/1/25 to 6/11/25. The record indicated the resident was administered a shower 10 times. The record lacked documentation the resident refused showers. On 6/12/25 at 10:45 a.m., during a routine observation the resident was laying down in his room. The resident indicated he still had not been shaved. Resident noted to have full beard facial hair. 2. On 6/9/25 at 10:15 a.m. during initial observation Resident 29 was sitting in a wheelchair in his room. The resident was dressed, and clothing was clean. The residents fingernails observed with brown debris under the nails, and a heavy beard growth. On 6/9/25 at 12:00 p.m., during a second observation, resident was in the assistant dining room. The resident had not been shaved, and brown debris were under the nails. On 6/10/25 at 11:30 during a third observation. Resident sitting in wheelchair in his room. The resident had not been shaved. On 6/11/25 at 2:00 pm the medical record of resident 29 was reviewed. The resident was admitted to the facility on [DATE]. Diagnoses included but not limited to Parkinsons disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), and diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high). A quarterly Minimum data set assessment dated [DATE] indicated the resident was not cognitively intact and was dependent for all personal care. A care plan dated 1/14/25 indicated the resident required assistance with ADLs including bed mobility, transfers, eating and toileting related to Parkinson's disease. Intervention included but was not limited to assist with bathing as needed per resident preference. Offer showers two times per week. Assist with dressing/grooming/hygiene as needed. The point of care documentation indicated the resident was scheduled to have been administered 22 showers from 4/1/25 to 6/11/25. The documentation indicated that the resident was administered 6 showers. The medical record lacked documentation of the resident refusing showers. On 6/11/25 at 2:30 p.m. the Director of Nursing (DON) provided copies of shower sheet records for the residents. She indicated the shower sheets were an internal document and were not retained as part of the medical record. She indicated the residents were scheduled for a shower two times weekly. On 6/12/25 at 10:40 a.m., during a fourth observation the resident observed sitting in a wheelchair in his room. The resident nails observed to have brown debris under nails and had not been shaved. On 6/12/2025 at 11:04 a.m., the Director of Nursing (DON) provided a document, titled, AM Care, dated, 3/2023 and indicated it was the policy currently being used by the facility. The policy indicated, .6. Assist resident to ash face, hands .8. Shave resident, if needed or requested On 6/12/2025 at 11:04 a.m., the DON provided a document, titled, Fingernail care, dated, 9/2023 and indicated it was the policy currently being used by the facility. The policy indicated, .9. Clean under nails with orange stick The DON did not provide a policy specific to administering showers or bathing. 3.1-38(a)(3)

Based on observation, record review, and interview, the facility failed to prevent potential accidents by ensuring medications were administered and disposed of according to medication professional standards for 2 of 5 residents reviewed (Residents 8 and 20). Findings include: 1. On 6/9/25 at 11:15 a.m., during an initial observation and resident interview, Resident 8 sat on side of bed. Two plastic medication cups containing several pills were observed. The resident indicated she had a rough night, and the nurse did not want to wake her up and left her medications on her overbed table. On 6/10/25 at 2:33 p.m., the medical record of Resident 8 was reviewed. The resident was admitted to the facility on [DATE]. Admitting diagnoses included but not limited to chronic obstructive pulmonary disease (COPD) (a group of diseases that cause airflow blockage and breathing-related problems), alcoholic cirrhosis (a severe liver condition where healthy liver tissue is replaced by scar tissue due to long-term, excessive alcohol consumption), diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high), gastroesophageal reflux disease (GERD) (a condition where stomach contents flow back up into the esophagus, causing irritation and discomfort), and heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs). A physician order, dated 5/23/25, indicated to administer acetaminophen 1000 mg (milligrams), three times daily for pain. A physician order, dated 6/27/25, indicated to administer adult low does aspirin 81 mg, daily for aftercare. A physician order, dated 5/8/25, indicated to administer clopidogrel 75 mg daily for aftercare. A physician order, dated 4/21/25, indicated to administer docusate sodium 100 mg twice daily for aftercare. A physician order, dated 3/29/25, indicated to administer famotidine 20 mg twice daily for GERD. A physician order, dated 5/3/25, indicated to administer Jardiance 25 mg once daily for diabetes. A physician order, dated 3/29/25, indicated to administer Metoprolol ER 12.5 mg twice daily for hypertension. A physician order, dated 4/11/25, indicated to administer Omeprazole 20 mg once daily for GERD. A physician order, dated 4/18/25, indicated to administer Oxybutynin 5 mg twice daily for aftercare. A physician order, dated 4/30/25, indicated to administer Propranolol 10 mg twice daily for hypertension. A physician order, dated 5/8/25, indicated to administer Sertraline 100 mg once daily for depression. A physician order, dated 5/3/25, indicated to administer Spironolactone 25 mg once daily for hypertension. A Minimum Data Set assessment (MDS), dated [DATE], indicated the resident was cognitively intact. A care plan, dated 1/23/23, indicated the resident had behaviors which included rejection of medications and hiding medications in her top drawer. On 6/10/25 at 2:37 p.m., during an interview Registered Nurse (RN) 6, indicated she did not leave medications at a resident's bedside. She indicated if a resident refused to take medications she advised the resident she could not leave them and would bring them back later. On 6/10/25 at 2:43 p.m. during an interview, the Licensed Practical Nurse (LPN) 7 indicated she did not leave medications at a resident's bedside. She indicated she would explain to the resident she was unable to leave medications at the bedside and would bring them to the resident later. On 6/11/25 at 9:43 a.m., during an interview the Director of Nursing (DON) indicated the nurses were not permitted to leave medications at the residents' bedside. 2. On 6/11/25 at 9:20 a.m., observed medication administration with Licensed Practical Nurse LPN 17. The nurse attempted to administer Sertraline HCL 100 mg 2 tablets, Amlodipine 5 mg 1 tablet, Benazepril 10 mg 1 tablet, Centrum Silver Vitamin 1 tablet, Memantine HCL 10 mg 1 tablet, Senna tablet 8.6 mg 2 tablets to Resident 20. The resident refused to take the medications. The nurse disposed of medications into the sharps (used needles) container. On 6/11/25 at 9:30 a.m., during an interview Nurse 17 indicated she only disposed of narcotic medications in the Drug Buster disposal system (a solution to neutralize the active chemicals in medications). She acknowledged she should have disposed of refused medications into the disposal solution. On 6/11/2025 at 9:45 a.m., the DON provided a document, titled, Medication Pass Procedure, dated 4/2025, and indicated it was the policy currently being used by the facility. The policy indicated, .14. Wasted, dropped or discarded medications disposed of in Drug Buster disposal system 3.1-45

Based on interview and record review, the facility failed to ensure a resident had received a requested medication for muscle spasms (sudden involuntary powerful contraction of a muscle or muscle group) for 1 of 1 resident reviewed for pain management (Resident 112). Findings include: During the initial pool interview, on 6/9/25 at 2:22 p.m., Resident 112 indicated she had requested an as needed (PRN) dose of her tizanidine (medication to treat muscle spasms) earlier in the morning when she had been given her pain medication. The nurse asked if she would consider waiting until after lunch due to the high risk of falling as the medication was known to lower blood pressure. The resident was confused as to why the nurse was concerned about her falling as she was in a wheelchair and was non-weight bearing (when no weight should be placed on an affected limb, usually after a surgical procedure). She indicated she reluctantly agreed, and requested, and was given, a Xanax (anti-anxiety medication). The nurse had not returned, after lunch, to check on her and offer the tizanidine, and now her spasms were increasing, and she was in pain. She believed the nurse had already left for the day. At the same time, the resident was observed with facial grimacing and clutching at her lower back area. During a telephone interview, by the Director of Nursing (DON), on 6/10/25 at 2:38 p.m., Licensed Practical Nurse (LPN) 4, indicated after lunch, she went back to the resident and offered her the tizanidine. The resident did not want the tizanidine but wanted a Xanax instead. During an interview, on 6/11/25 at 9:39 a.m., the DON indicated she had placed a follow-up call to LPN 4 later in the afternoon of 6/10/25, because the LPN had told her when she initially spoke with her on the phone, she had a headache. During the follow-up call, the LPN admitted she had failed to return to the resident, on the date in question, to see if she had needed the tizanidine. At the same time, the DON indicated the expectation was, if a resident requested medication to help with muscle spasms causing pain, and the nurse didn't give it, the nurse should have come back to follow up to see if the resident still wanted the medication. LPN 4 should have followed up to see if the resident still wanted the tizanidine. Resident 112's record was reviewed on 6/11/25 at 10:05 a.m. The profile indicated the resident's diagnoses included, but were not limited to, stress fracture of right ankle (small crack in the bone due to repetitive stress or overuse) and stage 3 chronic kidney disease (moderate damage to the function of the kidneys). A care plan, dated 6/10/25, indicated the resident was at risk for pain. Interventions included, but were not limited to, administer medications as ordered and observe for non-verbal signs of pain. A care plan, dated 6/10/25, indicated the resident was non-weight bearing status due to stress fracture of right ankle. A physician's order, dated 6/6/25, indicated to administer 1 tablet of 5-325 milligram (mg) hydrocodone-acetaminophen (pain medication) every 4 hours PRN for moderate to severe pain. The June 2025 Medication Administration Record (MAR) indicated the resident had received her hydrocodone-acetaminophen tablet at 1:02 a.m., 8:44 a.m., and 6:07 p.m., on 6/9/25. A physician's order, dated 6/6/25, indicated to administer a 1 mg tablet of Xanax three times a day PRN, for anxiety. The June 2025 MAR indicated the resident had received her Xanax at 10:20 a.m., and 6:07 p.m., on 6/9/25. A physician's order, dated 6/6/25, indicated to administer one, 4 mg capsule of tizanidine every 8 hours PRN for muscle spasms/cramping. The June 2025 MAR indicated the resident had received a dose of tizanidine on 6/9/25 at 1:02 a.m., but lacked documentation that the resident had received any further doses of the medication on 6/9/25. A nurse progress note, dated 6/9/25 at 10:21 a.m., LPN 4 indicated the resident had requested a Xanax. The note lacked documentation of that the nurse had followed up with the resident on her need for the tizanidine. On 6/11/25 at 10:12 a.m., the DON provided a document, with a revision date of 7/2024, titled, Pain Management Policy, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure .3 .Pain medication will be .given based on the intensity of the pain .11. The licensed nurse will monitor the efficacy .as it relates to the resident's pain management 3.1-37(a)

Based on record review and interview, the facility failed to ensure a wound vacuum-assisted closure (vac) was placed properly for 1 of 3 residents reviewed for wound treatment (Resident B). Findings include: Resident B's closed record was reviewed on 11/21/24 at 11:53 a.m. The profile indicated the resident's diagnoses included, but were not limited to, acute osteomyelitis (a serious bone infection that occurs when bacteria or other infectious agents spread to the bone) of the left ankle and foot, type 2 diabetes (a chronic disease that causes high levels of blood sugar, because the body doesn't produce enough insulin or doesn't use it properly) and diabetic foot ulcer (an open sore or wound that develops on the foot of a person with diabetes). An admission Minimum Data Set (MDS) assessment, dated 10/18/24, indicated the resident had no cognitive deficit and required extensive assistance with daily living skills (the routine tasks that people perform to care for themselves and their surroundings). A care plan, dated 10/13/24, indicated the resident required implementation of services related to left toe amputations (surgical removal) and wound vac (a medical treatment device that uses negative pressure to help wounds heal). Interventions included, but were not limited to, provide special treatments or devices including wound care and devices. A physician's order, dated 10/11/24, with a discontinuation dated of 10/19/24, indicated the apply a wound vac to the resident's left bottom foot area. Set wound vac pressure setting to 125 millimeters of mercury (mmhg) (a standard suction pressure used in wound vac therapy to treat wounds) and check every shift for proper functioning. A physician's order, dated 10/11/24, with a discontinuation dated of 10/20/24, indicated to change the resident's wound vac dressings three times weekly and as needed for soilage or dislodgement. A physician's order, dated 10/21/24, with a discontinuation date of, 10/29/24, indicated per the physician, the wound vac was to be changed Wednesday and Sunday by the facility. The physician would change at the clinic appointment on Fridays. A wound clinic visit note, dated 10/18/24, indicated the resident's wound to his left plantar foot was a diabetic ulceration. The wound was not healed. The periwound area (the skin directly surrounding a wound) moisture and color were normal. The supplies for the wound treatment had been delivered to the resident's home. A wound clinic note, dated 10/25/24, indicated the resident's wound to his left plantar foot was not healed. The periwound area was macerated (skin that has softened and broken down due to prolonged exposure to moisture, such as water, urine, sweat, or other fluids) and moist which was not normal for the patient. The foot was macerated due to the wound vac foam was against the resident's skin. A Social Services progress note, dated 10/25/24 at 4:45 p.m., indicated the resident and his wife had returned from the wound clinic appointment and requested to discharge from the facility. The Podiatrist (a doctor who specializes in diagnosing and treating conditions affecting the foot, ankle, and lower leg) at the appointment had sent an order for the resident to discharge to home. The Social Services Director (SSD) and the Director of Nursing Services (DNS) explained to the resident and his wife that it would be considered discharging against medical advice (AMA) because the facility's Medical Director had not ordered the discharge. The resident and his wife were adamant about discharging back to his home. A progress note, dated 10/25/24 at 5:03 p.m., indicated the resident was discharged from the facility and the physician was notified. During an interview, on 11/21/24 at 1:01 p.m., the Medical Records Director indicated the resident had been admitted to the facility with the wound vac, orders for the wound vac, and supplies. The facility had all the supplies for the wound vac in stock, but they were not the same brand name as the original wound vac supplies. The supplies worked the same as the originals, but the resident's wife was concerned that because they were not the original brand, they would not work properly. The wound vac was hard to keep in place due to the area of the foot that it was placed on. The DNS had placed the wound vac when the resident arrived at the facility. There were orders to change the wound vac dressings three times a week and as needed if it came off or got dirty. Any nurse could change the dressings and replace the wound vac. No specific education had been provided, but if a nurse wanted education, the DNS would provide. She understood that education had been given to one nurse, who she believed was a new nurse. She had heard that the resident had gone to a wound clinic appointment at the end of October and the wound clinic staff had suspected the foam from the wound vac had not been properly placed and was touching the resident's skin. She had no further knowledge of the situation. During an interview, on 11/21/23 at 1:25 p.m., the Executive Director (ED) indicated she was aware of Resident B's wife's concern of the facility's lack of supplies. Her understanding was that the supplies that the facility had in stock worked fine with the wound vac. She was also aware that the DNS had re-educated Licensed Practical Nurse (LPN) 7 about proper placement of the wound vac. During a telephone interview with the DNS, on 11/21/24 at 1:39 p.m., she indicated due to Resident B's wife's concerns about the wound vac being placed improperly, she had re-educated LPN 7. She had not documented the education. She was unsure if the wound vac had been placed improperly or not. She checked the placement of the wound vac daily. During an interview, on 11/21/24 at 2:04 p.m., the MDS Coordinator indicated it was very important to ensure that the foam used in wound vacs was not left in contact with the skin, as it could cause skin breakdown. On 11/21/24 at 2:16 p.m., the Admissions Director provided a document, with a revision dated of 5/22, titled, Skin Management Program, and indicated it was the policy currently being used by the facility. The policy indicated, Policy: It is the policy .that each resident receives care, consistent with professional standards or practice .and a resident .receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing This citation relates to complaint IN00446310. 3.1-37(a)

Based on observations, interview, and record review, the facility failed to ensure proper food handling for 1 of 2 dining observations and the facility failed to ensure proper hand sanitization was performed during meal service for of 1 of 2 dining observations. This had the potential to affect 50 out of 50 residents who ate meals from the kitchen. Findings include: 1a. During a dining observation, on 5/8/24 at 11:36 a.m., Certified Nurse's Aide (CNA) 12 was preparing drinks for the residents. She scooped the ice into 2 glasses and returned the ice scoop into the ice bucket. At 11:37 a.m., the Housekeeping Supervisor prepared a glass of fruit punch for a resident and placed the ice scoop back into the ice bucket that contained ice. At 11:56 a.m., the ice scoop remained in the ice bucket. At 11:57 a.m., another staff member approached the ice bucket and placed the ice scoop into an empty behind the ice bucket. 1b. During an observation of hall trays being served on 5/8/24 at 12:17 a.m., CNA 3 grabbed two empty plastic glasses off the cart and scooped ice into them. She obtained the ice from a plastic container that contained pitchers of water, milk, juice, and tea. The container of the pitchers was used to keep the drinks cold. The CNA served the two glasses to a resident with their lunch tray. During an interview, on 5/13/24 at 11:11 a.m., the Dietary Manager indicated the ice scoop was to be placed in the clear plastic container on the cart. The ice scoop should not be placed in the ice bucket when not in use. She indicated the staff should not use the ice from the container that had the pitchers in it. The ice in the containers was not for consumption and is only used to keep the drinks cold. She indicated staff had been educated before and the facility was working on a solution. On 5/13/24 at 2:05 p.m., the Administrator provided a document, dated 2/02 with a revised date 5/23, titled, Food Storage, and indicated it was the policy currently used by the facility. The policy indicated, .Scoops are not to be stored in the food. Scoops can be stored within the container using designated scoop storage space of they should be kept covered in a protected area near the containers 48226 2. On 5/08/24 at 11:37 a.m., during initial observation of the restorative dining room noon meal service. Observed Certified Nurse Aide (CNA 3) assisting residents with repositioning and with feeding residents. Observed CNA 3 assisting resident 47 by repositioning her and her wheelchair and setting up meal. CNA 3 assisted Resident 21. She applied a clothing protector to the chest, repositioned the residents wheel chair and prepared meal tray. CNA 3 assisted resident 21 to eat and reached over with the same hand and continued to assist resident 47 by feeding the residents. She then placed a clothing protector over the residents chest and assisted the resident to eat. CNA 3 failed to sanitize her hands between residents. She continued to assist both residents to eat without sanitizing her hands between assisting each one and after repositioning each resident. On 5/08/24 at 11:46 a.m., during interview with CNA 4. She indicated she would sanitize her hands between residents while assisting them with their meal and when repositioning. On 5/08/24 at 12:10 p.m., observed CNA 5 deliver a meal tray to resident 18. The CNA failed to sanitize her hands prior to passing meal tray. On 5/13/2024 at 2:45 p.m., the Director of Nursing (DON) provided a document, titled, Hand Hygiene Policy, dated 12/2021, and indicated it was the policy currently being used by the facility. The policy indicated, .Definitions .Alcohol-based hand rub (ABHR) (hand rubbing)- alcohol-containing preparation based designed for application for the hands to reduce number of viable microorganisms .5. Moments of hand hygiene .After touching a resident .Healthcare personnel should use an alcohol based hand rub or wash with soap and water for the following clinical indications .Immediately before touching a resident .before having direct contact with a resident and or equipment .After each resident contact and after contact with a residents belongings, environmental surfaces, touching items on the floor, and resident care equipment .[NAME] touching self or clothing during meal service 3.1-21(i)(1) 3.1-21(i)(3)

Based on observation and interview, the facility failed to ensure hot water temperatures were maintained within safe range for 5 of 7 residents reviewed for accidents (Resident 49, 36, 5, 29, and 208). Findings include: During random observation on 5/9/24 at 9:30 a.m., the public bathroom sink water was too hot to hold hands under for more than a few seconds without burning the skin. During random observation on 5/9/24 at 11:01 a.m., Residents 49's and 36's sink water was too hot to hold hands under for more than a few seconds without burning the skin. The water temperature after running at one and two minutes read 130.1 degrees Fahrenheit (F). During an interview on 5/9/24 at 11:19 a.m., Resident 5 indicated the water was too hot when she washed her hands. Residents 5's and 29's sink water was too hot to hold hands under for more than a few seconds without burning the skin. The water temperature after running one minute read 132.3 degrees F, and after running two minutes read 134.2 degrees F. During random observation on 5/9/24 at 11:31 a.m., Resident 208's sink water was too hot to hold hands under for more than a few seconds without burning the skin. The water temperature after running one minute read 128 degrees F, and after two minutes read 130 degrees F. During an interview on 5/9/24 at 11:55 a.m., the Administrator (ADM) indicated they recently had the water heater replaced that provided hot water to the Resident rooms and indicated they would need to adjust the hot water temperatures right away. She also indicated that their Maintenance Supervisor was new and had just started on 5/8/24. During an interview on 5/9/24 at 11:59 a.m., the Maintenance Supervisor indicated he was not able to locate temperature logs yet and indicated he had checked the water temperatures that morning, noticed they were running high but did not document them. He indicated there were two water heaters in the building, one for kitchen and laundry, one for resident rooms and the temperatures should read below 120 degrees F. During the interview, the ADM provided login information to access TELS (an online platform used to track maintenance tasks) to the Maintenance Supervisor. On 5/9/24 at 12:09 p.m., the faucet water temperatures were checked with the Maintenance Supervisor. He indicated he was not sure how to calibrate the thermometer and the water temperatures were to be between 100-120 degrees F. He read Residents 49's and 36's water temperature, in less than one minute, reached 134.4 degrees F. Resident 208's water temperature reached 129 degrees at one minute. On 5/14/24 at 11:52 a.m., the Maintenance Supervisor indicated he was still unable to locate temperature logs from before 5/8/24 but learned there were three hot water heaters in the building, one for each resident wing, after having a plumber come out the evening of 5/9/24. On 5/14/24 at 1:18 p.m., the Maintenance Supervisor provided water temperature logs for the last 30 days. No temperature logs were provided for between 4/23/24-5/9/24. During an interview on 5/14/24 at 1:50 p.m., the ADM indicated they did not have a policy related to monitoring water temperatures or temperature guidelines and that the TELS program notifies maintenance when temperatures should be checked weekly. During an interview on 5/15/24 at 10:27 a.m., the ADM indicated the former Maintenance Supervisors last day was 4/26/24 and that nobody had been checking the water temperatures after he left until the new Maintenance Supervisor started she was not sure how long the temperatures had been running high. 3.1-45 (a)(1) 3.1-45 (a)(2)

Based on observation, interview, and record review, the facility failed to ensure respiratory services were provided to 2 of 2 residents reviewed for respiratory services (Residents 15 and 8). Findings include: A. On 5/09/24 at 10:52 a.m., during an observation and interview, Resident 15 was sitting in a wheel chair in his room. The portable oxygen tank meter flow gauge was set on 2 L (Liters) and being administered to the resident by a nasal canula (NC). The resident indicated it should have been on 3 L. The resident indicated he was not getting any air. CNA 7 remove portable oxygen tank from the resident and failed to place resident on an oxygen concentrator (a device that converts ambient room air to a higher concentration of level of oxygen) that was in his room. Certified Nurse Aide (CNA) 7 spoke to Licensed Practical Nurse (LPN) 9. The CNA failed to inform the nurse the residents oxygen concentrator was not on. On 5/09/24 at 10:56 a.m., during an interview with CNA 7, she indicated she would normally not remove a resident from portable oxygen without placing the resident on an oxygen concentrator. She continued to proceed to fill station to refill portable oxygen tank. On 5/09/24 at 10:58 a.m., during an interview with LPN 9 she indicated CNA 7 did not inform her she had removed the portable oxygen tank from Resident 15. She indicated she observed the CNA with the portable tank, and she knew the resident would not be receiving oxygen until she turned the concentrator on. She indicated she was going to place Resident 15 on the concentrator, but she was busy with medication pass. She acknowledged a resident should be changed to a concentrator when the portable tank was removed. On 5/13/24 at 11:30 a.m., during a routine observation, the resident was sitting in the dining room. The portable oxygen tank meter flow gauge was set on 2L and being administered by a NC. On 5/14/24 at 10:19 a.m., during routine observation, the resident was sitting in his wheelchair in his room. The portable oxygen meter flow gauge was set on 2L and being administered through a NC. On 5/14/24 at 10:22 a.m., during an interview with LPN 9, the LPN indicated she was not sure what the oxygen should be set at. On 05/14/24 at 10:27 a.m., during an interview with the Director of Nurses (DON), the DON verified the oxygen for Resident 15 was ordered to be set on 3L per NC and administered continually. On 5/14/24 at 10:35 a.m., the medical record for Resident 15 was reviewed. Diagnoses included but were not limited to. Hypoxemia (low levels of oxygen in your body tissues. It causes symptoms like confusion, restlessness, difficulty breathing, rapid heart rate, and bluish skin) dated 2/28/24, Type 2 diabetes mellitus with hyperglycemia (a disease that occurs when your blood glucose, also called blood sugar, is too high) dated 2/24/24, Obstructive sleep apnea (a common condition in which your breathing stops and restarts many times while you sleep) dated 2/28/24. Physician orders included but were not limited to: Change oxygen tubing and humidity. Clean concentrator and filter. Once A Day on Sunday dated 2/23/2024, and oxygen at 3 liters per nasal cannula every shift dated 5/07/2024. Admission care plan, dated 2/26/24, lacked documentation of a care plan for oxygen use. On 5/13/24 at 10:00 a.m., during an interview with Registered Nurse (RN) 23, she indicated the resident did not have a care plan for oxygen use or impaired gas exchange. An admission Minimum Data Set Assessment (MDS) dated [DATE] indicated the resident was on oxygen during the initial look back period. B. On 5/10/24 at 10:40 a.m., during an observation and interview with Resident 8, observed the resident lying in bed with head of bed elevated. Resident had removed nebulizer mask and laid it on the bed. LPN 6 removed the nebulizer treatment mask from the residents bed and placed it in a bag without cleaning the medication chamber. LPN 6 failed to assess the resident after the administration of the breathing treatment. The resident indicated the nurse did not assess her lungs before or after nebulizer treatment and indicated sometimes the nurses did assess and sometimes they did not. On 5/10/24 at 10:55 a.m., during an interview with LPN 6, she indicated she provided a nebulizer treatment to Resident 8 and indicated she did not assess the resident after the treatment. She did not wear personal protective equipment (PPE) to administer the treatment and she did not stay in the room during the treatment. On 5/13/24 at 11:46 a.m., during an interview with LPN 16 she indicated when nebulizer treatment completed she wiped out the nebulizer medication chamber with a paper towel and then placed it in a bag after it had dried. She indicated she assessed the resident before and after nebulizer treatment. On 5/13/24 at 11:57 a.m., during routine observation and interview with Resident 8, observed the resident lying down in bed. The nebulizer mask and medication chamber was laying on top of a dry paper towel. The nebulizer equipment was not bagged. The resident indicated the nurse did not assess her before or after nebulizer treatment today. On 5/13/24 at 1:00 p.m., the medical record for Resident 8 was reviewed. Diagnoses included but were not limited to: Chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems). Dated 10/02/2018, pulmonary hypertension (a condition that affects the blood vessels in the lungs), Type 2 diabetes mellitus with unspecified complications (a disease that occurs when your blood glucose, also called blood sugar, is too high) dated 2/19/2024, Generalized anxiety disorder (a feeling of fear, dread, and uneasiness. It might cause you to sweat, feel restless and tense, and have a rapid heartbeat), Acute and chronic respiratory failure (a serious condition that makes it difficult to breathe on your own. Respiratory failure develops when the lungs can't get enough oxygen into the blood) dated 5/18/2023, and chronic pain syndrome dated 6/04/2020. Physician orders included but were not limited to: Albuterol sulfate solution for nebulization; 2.5 mg /3 mL (milliliters)(0.083 %); amount: 1 unit dose inhalation as needed at bedtime for shortness of breath or respiratory distress daily 2/01/2024, Ipratropium-albuterol solution for nebulization; 0.5 mg (milligrams)-3 mg (2.5 mg base)/3 mL; amount: 0.5 mg - 3 mg; inhalation, three Times A Day dated 2/01/2024, Change nebulizer tubing/set, Once A Day on Sunday dated 2/22/2022, Change oxygen tubing and humidity and clean concentrator and filter once a day on Sunday dated 4/09/2020. Oxygen at 5 liters per nasal cannula every shift dated 6/01/2023. A quarterly Minimum Data Set (MDS) assessment, dated 2/27/24, indicated the resident received oxygen and respiratory treatments during the look back period. A care plan, dated 10/4/18, indicated the resident has impaired gas exchange and received continual oxygen and nebulizer treatments as ordered. On 5/10/24 at 1:27 p.m., the Director of Nursing provided an undated document, titled, Oxygen Concentrator, and indicated it was the policy currently being used by the facility. The policy indicated, .Purpose .To provide oxygen for therapeutic use by utilizing a concentrator that converts ambient air to a higher concentration of level of oxygen. It is commonly used to provide oxygen therapy .Procedure .1. Verify and understand the physicians order .9. Adjust the flow meter control to the knob to the flow stetting prescribed by the physician On 5/10/24 at 1:27 p.m., the Director of Nursing (DON) provided a document, titled, Nebulizer (small volume Nebulizer-SVN Medicated Aerosol Therapy), dated 9/2023, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure steps .12. Stay with the resident during the entire medication administration .14 b. Rinse with saline or wipe with alcohol c. Air dry on paper towel d. Once dry, place in plastic bag 3.1-47(a)(4) 3.1-47(a)(5) 3.1-47(a)(6)

Based on observations, interview, and record review, the facility failed to provide mental health services to 1 of 4 residents reviewed (Resident 48). Findings include: On 5/09/24 at 2:30 p.m., during an observation and interview with Resident 48, the resident was very confused, crying indicated she was not supposed to be married to her husband and she wanted to leave the facility. The staff indicated she was an elopement risk and had been trying to leave the facility. She often went to the front but did not attempt to leave the exit next to her room. The resident became more agitated while interviewing and distressed about wanting to leave. Ended the interview due to evident distress of the resident. On 5/14/24 at 1:45 a.m., the medical record for Resident 48 was reviewed. Diagnoses included but were not limited to: Essential (primary) hypertension (high blood pressure) dated 9/19/2023, dementia, severe, with other behavioral disturbance (the loss of cognitive functioning thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities) dated 9/19/2023, Depression dated 9/19/2023, Hyperlipidemia (high cholesterol) dated 9/19/2023, Psychotic disorder with delusions due to known physiological condition (a collection of symptoms that affect the mind, where there has been some loss of contact with reality) dated 9/19/2023. Physician Orders included but were not limited to: Donepezil at Bedtime 9/19/2023, Sertraline tablet; 100 mg (milligrams); amount: 100 mg; oral Twice A Day 4/23/2024, Wander-guard- check every shift for placement and proper functioning. Check skin under wander guard every shift. A care plan, dated 2/13/2024, indicated behavioral symptoms. Resident experiences the following behavior expressions: tearfulness, paranoia, short temper, history of delusions, yelling at others, exit seeking. Resident has a diagnosis of depression with a treatment of psychoactive medication. A quarterly Minimum Data Set (MDS) assessment, dated 3/27/24, indicated the resident had not shown any behavior symptoms during the look back period. Documentation within the medical record indicated several entries of behaviors including agitation and exit seeking. On 5/14/24 at 1:16 p.m., during an interview with the Social Services Director, regarding Resident 48, she indicated the resident did not try to exit any of the side doors she only tries to go out the front door. She indicated the facility was in the process of getting her seen by Psychiatric Services. She indicated the primary physician was apprehensive about working with psychological medications and prefers psychiatric services to oversee the medications. She indicated the family has been reluctant to allow psychiatric services to see her. She acknowledged the resident needed to be seen but she did not have any documentation regarding discussion with the family about services. The medical record lacked documentation of consultation with family. On 5/15/2024 at 9:00 a.m., the Director of Nursing (DON) provided a document, titled, Behavioral Health, dated 10/22, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy .It is the policy of this facility to ensure that each resident receive the necessary behavioral healthcare and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being .Procedure .2. Residents will be assessed for Behavioral Health needs using Social Services Assessment, which is completed upon admission, annually and with significant change. Residents will be referred to Behavioral Health providers when needed for situations such as, mental health disorders, psychotropic medication management, behavior intervention development .and or adjustment or mood issues 3.1-37 3.1-43

Based on observation, record review, and interview, the facility failed to ensure a medication error rate of less than 5%, related to not administering medications in a safe and sanitary manner and failed to follow manufacturer's guidelines for 2 of 9 residents observed for medication administration (Residents 31 and 159), 2 errors were observed during 31 opportunities resulting in an error rate of 6.45%. Findings include: 1. On 5/13/24 at 12:50 p.m., Licensed Practical Nurse (LPN) 16 was observed administering medications to Resident 31. While dispensing the resident's Creon (a medication to assist with pancreatic enzyme [protein that help speed up metabolism, or the chemical reactions in the body] ) from the medication bottle, the LPN touched the capsule with her ungloved finger, and continued to administer the medication to the resident. On 5/14/24 at 1:13 p.m., Resident 31's record was reviewed. The profile indicated the resident's diagnoses included, but were not limited to, other chronic pancreatitis (a condition where the pancreas becomes permanently damaged from inflammation). A physician's order, dated 8/16/22, indicated Creon (lipase-protease-amylase-pancreatic enzymes) capsule, delayed release (DR) 12,000-38,000-60,000 units, 1 capsule by mouth three times a day. Special instruction: To be given with food. During an interview, on 5/14/24 at 1:09 p.m., the Director of Nursing (DON) indicated medications should never be administered if touched by the nurse with a bare hand. On 5/14/24 at 1:26 p.m., the DON provided a document, with a revision date of 7/2023, titled, Medication Administration (Medication Pass Procedure), and indicated it was the skills competency for the nurses currently being used by the facility. The skill competency indicated, .Procedure Steps: .5. Medications are opened without contaminating On 5/14/24 at 1:57 p.m., the DON provided a document, dated January 2022, titled, General Dose Preparation and Medication Administration. and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure: .3 .3.4. Facility staff should not touch the medication when opening a bottle or unit dose package 2. On 5/14/24 at 11:00 a.m., Licensed Practical Nurse (LPN) 9 was observed performing a blood sugar reading on Resident 159. At the same time, the LPN indicated the resident blood sugar reading was 245 and per the physician's order, 3 units of insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) were to be administered. On 5/14/24 at 11:10 a.m., 3 units of insulin lispro (a rapid acting insulin) were verified and administered in the right upper arm to the resident by LPN 9. On 5/14/24 at 11:13 a.m., the resident was taken to the dining room for his lunch meal and provided a glass of water. A continuous meal service observation indicated the resident did not receive his lunch meal until 11:52 a.m. On 5/14/24 at 1:18 p.m., Resident 159's record was reviewed. The profile indicated the resident's diagnoses included, but were not limited to, type 2 diabetes (a disease that occurs when the blood glucose is too high) with hyperosmolarity (occurs in people with type 2 diabetes who experience very high blood glucose levels). A physician's order, dated 5/3/24, indicated insulin lispro solution; 100 units/milliliter (ml), administer subcutaneous (SQ-under all layers of the skin), four times daily, per sliding scale. If Blood Sugar is less than 70, call physician. If Blood Sugar is 161 to 200, give 1 Unit. If Blood Sugar is 201 to 240, give 2 Units. If Blood Sugar is 241 to 280, give 3 Units. If Blood Sugar is 281 to 320, give 4 Units. If Blood Sugar is 321 to 360, give 5 Units. If Blood Sugar is greater than 360, call physician. During an interview, on 5/14/24 at 1:09 p.m., the Director of Nursing (DON) indicated residents who receive fast-acting insulin should get their meal within 15 minutes of receipt of the insulin. On 5/14/24 at 1:26 p.m., the DON provided a document, with a revision date of 9/2023, titled, Highlights of Prescribing Information, and indicated it was the manufacture's guidelines for the insulin lispro solution. The guidelines indicated, .Dosage and Administration .Subcutaneous Injection: Administer Insulin Lispro by subcutaneous injection .within 15 minutes before a meal or immediately after a meal 3.1-48(c)(1)

Based on observation, record review, and interview, the facility failed to ensure residents were treated with dignity for 1 of 1 resident reviewed for dignity (Resident 4). Findings include: During a dining observation on 5/8/24 at 11:50 a.m., the Speech Language Pathologist (SLP) was observed to be standing at Resident 4's left side, assisting him with eating and drinking. She was not observed to sit down while assisting him. Resident 4's record was reviewed on 4/15/24 at 11:21 a.m. His diagnoses included, but were not limited to, paraplegia (loss of muscle function in the lower body), lack of coordination (poor muscle control), contracture of muscles (permanent shortening of a muscle causing deformity), abnormal posture (involuntary abnormal position of the body), and mild cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). A comprehensive care plan, last reviewed 5/13/24, indicated resident had a problem with activities of daily living (ADL) that started 1/19/23 and needed assistance with ADL's, including eating, with an intervention approach to assist resident with eating as needed. During an interview on 5/15/24 at 11:50 a.m., the Director of Nursing (DON) indicated that on 5/8/24, during lunch, Resident 4 was receiving his quarterly screening to determine if there was a need for therapy services. When he was being assisted with eating it was not a swallow study and if anyone was assisting him with eating, she hoped that they would be sitting in a chair like they would with normal assisting. She indicated that the SLP answers should not be any different. During an interview on 5/15/24 at 1:15 p.m., the SLP indicated when she completed quarterly evaluations, she would occasionally assist residents with eating and drinking and she would be sitting down next to them while working with them. It was an evaluation just to lay eyes on them to see how they are doing and determine if there were any indicators that would warrant them to be picked up for therapy. On 5/15/24 at 1:51 p.m., the DON provided a document, updated 3/15/17, titled, Resident Rights, and indicated it was the policy currently being used by the facility. The policy indicated, .Respect and dignity. You have the right to be treated with respect and dignity, including . the right to reside and receive services in the facility with reasonable accommodation of your needs and preferences 3.1-3(v)(1)

Based on interview and record review, the facility failed to ensure care plan meetings were conducted quarterly for 1 of 3 residents reviewed for care plan meetings (Resident 7), and the facility failed to ensure an oxygen care plan was implemented for 1 of 3 residents reviewed for care plans (Resident 15). Findings include: 1. During an interview, on 5/10/24 at 10:22 a.m., Resident 7 indicated he did not remember being invited to or attending a care plan meeting. He did not recall when the last one was. Resident 7's record was reviewed on 5/14/24 at 9:45 a.m. A quarterly Minimum Data Set (MDS) assessment, dated 2/22/24, indicated the resident had moderate cognitive impairment. Census information indicated the resident was admitted to the facility on [DATE]. A Social Service Director (SSD) note, dated 8/29/23, indicated a care plan meeting was conducted on this day for Resident 7. A SSD note, dated 2/22/24, indicated a care plan meeting was conducted on this day for Resident 7. Resident 7's record lacked documentation of a quarterly care plan meeting being conducted for the last year from May 2023 to May 2024. The resident had two care plan meetings for the entire year. During an interview, on 5/14/24 at 10:33 a.m., the SSD indicated she could not find where Resident 7 had quarterly care plan meetings for the last year. She indicated they should be conducted quarterly, and she would normally send invites to the resident representatives via mail or by phone. During an interview, on 5/14/24 at 11:45 a.m., the Director of Nursing (DON) indicated care plan meetings should be conducted quarterly. 48226 2. A. On 5/09/24 at 10:52 a.m., during an observation and interview, Resident 15 was sitting in a wheel chair in his room. The portable oxygen tank meter flow gauge was set on 2 liters (L) and being administered to the resident by a nasal canula (NC). The resident indicated it should have been on 3 L. On 05/13/24 at 11:30 a.m., during routine observation, the resident was sitting in the dining room. The portable oxygen tank meter flow gauge was set on 2L and being administered by a NC. On 5/14/24 at 10:19 a.m., during routine observation, the resident was sitting in his wheelchair in his room. The portable oxygen meter flow gauge was set on 2L and being administered through a NC. On 5/14/24 at 10:22 a.m., during an interview with LPN 9, the LPN indicated she was not sure what the oxygen should be set at. On 05/14/24 at 10:27 a.m., during an interview with the Director of Nurses (DON). The DON verified the oxygen for Resident 15 is ordered to be set on 3L per NC and administered continually. On 5/14/24 at 10:35 a.m., the medical record for Resident 15 was reviewed. Diagnoses included but were not limited to. Hypoxemia (low levels of oxygen in your body tissues. It causes symptoms like confusion, restlessness, difficulty breathing, rapid heart rate, and bluish skin) dated 2/28/24, Type 2 diabetes mellitus with hyperglycemia (a disease that occurs when your blood glucose, also called blood sugar, is too high) dated 2/24/24, Obstructive sleep apnea (a common condition in which your breathing stops and restarts many times while you sleep) dated 2/28/24. Physician orders included but were not limited to: Change oxygen tubing and humidity. Clean concentrator and filter. Once A Day on Sun dated 2/23/2024, oxygen at 3 liters per nasal cannula every shift dated 5/07/2024. An admission care plan dated 2/26/24 lacked documentation of a care plan for oxygen use. On 5/13/24 at 10:00 a., During an interview with Registered Nurse (RN) 23, she indicated the resident did not have a care plan for oxygen use or impaired gas exchange. An admission Minimum Data Set Assessment (MDS) dated [DATE] indicated the resident was on oxygen during the initial look back period. On 5/14/2024 at 1:26 p.m., the Director of Nursing (DON) provided a document titled, IDT Comprehensive Care Plan Policy, dated 8/23, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy .It is the policy of this facility that each resident will have an interdisciplinary comprehensive person-centered care plan developed and implemented based on Resident Assessment Instrument (RAI) process .Purpose .Improve relationships between resident, families and or representative, and facility caregivers through understanding of resident's social history, culture and preferences to enhance the resident's life .Procedure .Resident, resident's representative, or others as designated by the resident will be invited to care plan review .Care plan problems, goals and interventions must be reviewed and revised by the interdisciplinary team periodically and following completion of each MDS assessment 3.1-35(d)(2)(B)

Based on observation, interview, and record review, the facility failed to ensure catheter care and placement of catheter equipment for 1 of 1 residents reviewed for catheter care. (Resident 15) Findings include: On 5/8/24 at 11:07 a.m., during main dining room meal observation, Resident 15 sat in his wheelchair. The catheter bag was completely in contact with floor touching wheel of wheelchair dignity bag (a cloth bag covering the urinary drainage bag) was not completely covering bag and urine was visible. On 5/08/24 at 11:21 a.m., during routine observation, observed catheter bag had continued to be in contact with the floor coming out of the dignity bag resident continues to pull on tubing causing bag to go up and down. touching the floor, his shoes, and wheel of wheelchair. On 5/08/24 at 11:28 a.m., during routine observation, observed Resident 15 pick up catheter bag and placed it in his lap. The resident continued to touch the drainage bag tubing with hands while in the drainage bag continued to be in his lap. On 5/08/24 at 11:34 a.m. during routine observation, Licensed Practical Nurse (LPN) 9 picked up the drainage bag from Resident 15's lap and placed drain bag into the dignity bag and left dining room with resident to fix the placement of the bag and tubing. On 5/13/24 at 11:43 a.m., observed Resident 15 sitting in dining room waiting on meal. The urinary drainage bag was within the dignity bag under the wheelchair. The dignity bag was touching floor. On 5/13/24 1:00 p.m., interview with the Director of Nurses (DON). She indicated the foley catheter drainage bag and tubing must not be touching the floor and the drainage dignity bag should be off the floor. On 5/14/24 at 10:00 a.m., during an observation and interview with Resident 15 noted he no longer had a urinary drainage bag. The resident indicated he had a urinary leg drainage bag, but he liked the other one better. He indicated he did not like the feeling of the straps from the leg bag around his leg. On 5/14/24 at 11:00 a.m., the medical record for Resident 15 was reviewed. Diagnosis included but were not limited to: Essential (primary) hypertension (high blood pressure) dated 2/23/24. Hypoxemia (low levels of oxygen in your body tissues. It causes symptoms like confusion, restlessness, difficulty breathing, rapid heart rate, and bluish skin) dated 2/28/24, Type 2 diabetes mellitus with hyperglycemia (a disease that occurs when your blood glucose, also called blood sugar, is too high) dated 2/24/24, Obstructive sleep apnea (a common condition in which your breathing stops and restarts many times while you sleep) dated 2/28/24. Physician orders included but were not limited to: 02/26/2024 Store collection bag inside a protective dignity pouch dated 2/26/24, Suprapubic Catheter dated 4/24/2024. Catheter orders: Change Super Pubic Foley catheter and urinary drainage bag as needed for dislodgement, leakage or occlusion dated 2/23/24, Cath orders: Foley catheter care, Catheter securement device in place, Every Shift dated 2/23/24. A care plan, dated 2/26/2024, indicated the Resident requires an indwelling urinary related to bladder/prostate mass. Interventions included but were not limited to: Do not allow tubing or any part of the drainage system to touch the floor dated 2/26/24. An admission Minimum Data Set Assessment (MDS), dated [DATE], indicated the resident had a foley catheter during the initial look back period. On 5/13/24 at 2:45 p.m., the DON provided a document titled, Suprapubic Catheter Care, dated, 12/2012 and indicated it was the policy currently being used by the facility. The policy indicated, .Established suprapubic catheter .6. Check drainage bag and tubing placement On 5/13/24 at 2:45 p.m., the DON provided a document titled, Catheter Care (Urinary), dated, 05/2023, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure steps .14. Replace catheter in securement device 3.1-41(a)(1)

Based on observation, interview, and record review, the facility failed to ensure a scoop was not stored in the powdered thickener canister, expired food was not stored in the walk-in refrigerator, pureed food items were prepared in a sanitary manner, and staff sanitized their hands appropriately for 2 of 2 kitchen observations with the potential to effect 6 of 6 residents who received pureed food from the kitchen. Findings include: 1. During the initial kitchen tour with the Dietary Manager (DM), on [DATE] at 10:29 a.m., a scoop was observed in the powdered thickener canister and in the walk-in refrigerator a large bag of diced potatoes was observed with an expiration date of [DATE]. On [DATE] at 10:56 a.m., the DM indicated, a scoop should not have been stored in the thickener canister and the bag of diced potatoes was expired and should have been discarded into the garbage. 2. During an observation of pureed foods with the DM in the kitchen, on [DATE] at 10:18 a.m., Dietary Aide (DA) 10 indicated the facility had 6 residents who received pureed diets from the kitchen, as she was observed pureeing spiced peaches for dessert in the food processor. DA 10 wiped her hands with a paper towel, then wiped her hands onto her pants, grabbed the processor container and a scoop and dished the pureed peaches into dessert dishes. DA 10 then washed the processor container in the three-compartment sink, placed the processor container onto a drying rack, wiped her hands onto a large bath towel that was located on the food preparation counter. She then obtained a tray of clean cups, placed the cups onto a wheeled drink cart, pulled down her shirt with both hands, picked up a scoop and a pitcher, placed ice into the pitcher from the ice machine, pulled down her shirt with both hands, then grabbed a stack of cloth napkins, placed the napkins onto the front counter, wiped her hands onto her pants, then rolled silverware into the cloth napkins with no handwashing observed. On [DATE] at 10:28 a.m., Cook 9 placed chicken pot pie and broth into the food processor, pureed the pot pie, and then placed the pureed food into a pan. Cook 9 washed the processor container in the three-compartment sink, placed the processor container onto the drying rack, dried her hands with the same bath towel DA 10 had used which was located on the food preparation counter, then picked up the pan with the pureed pot pie and placed the pan onto the steam table. Cook 9 removed a pan of cooked cauliflower from the steamer, temped the cauliflower with a thermometer, wiped the thermometer with an alcohol wipe, then placed the pan of cauliflower onto the steam table, scooped some of the cauliflower into a pan, then pureed the cauliflower and powdered thickener in the food processor. She placed the pureed cauliflower into a pan, then washed the food processor container in the three-compartment sink, and wiped her hands on the same soiled large bath towel that was located on the food preparation counter with no handwashing observed. On [DATE] at 10:41 a.m., Cook 9 pureed breadcrumbs, powdered thickener, and oil in the food processor, washed the food processor container in the three-compartment sink and wiped her hands with the same soiled large bath towel that was located on the food preparation counter. On [DATE] at 11:01 a.m., DA 10 prepared orange juice at the sink into a gallon jug, wiped the jug off with the same soiled large bath towel that was located on the food preparation counter that had been used to dry hands, carried the jug against her clothing to the refrigerator, pulled out of the refrigerator three other gallon jugs, placed the three containers directly onto the floor, put the freshly made gallon jug into the refrigerator, then the three other jugs back into the refrigerator, and then wiped her hands on her pants without handwashing observed. Cook 9 temped the steam table food with a thermometer, wiped the thermometer off with an alcohol pad, and began plating the food. DA 10 pulled up her pants with her bare hands then placed lids onto the plated food. DA 10 then washed her hands for less than (<) 20 seconds, turned off the water faucet with her bare hand, pushed up her eyeglasses with her bare hand, pulled up her pants with her bare hands, and then retrieved a tray of dessert dishes from the refrigerator and placed the dessert dishes onto the trays with the plated food without handwashing observed. On [DATE] at 11:14 a.m., DA 11 entered the kitchen and washed her hands for <10 seconds, turned off the faucet with her bare hand, then went to the dishwasher area and grabbed clean dessert dishes and stacked the dishes onto other clean dessert dishes on a shelf. On [DATE] at 11:32 a.m., DM indicated staff were supposed to wash and dry their hands at the handwashing sink for a minimum of 20 seconds and dry their hands with a paper towel and turn off the faucet with a paper towel, when they are soiled, after washing items in the three-compartment sink, after touching their clothing or eyeglasses, and after temping the food with the thermometer. She was not sure why the bath towel was on the preparation counter. The bath towels were supposed to be used for the drink cart for condensation, not to dry or wipe their hands with nor wipe off the drink containers. Staff were not supposed to place the drink containers up against their bodies nor placed the containers onto the floor. Staff were not supposed to wash or dry their hands with a bath towel. The DM, on [DATE] at 12:15 p.m., provided and identified a document as a current facility policy, titled Food Storage, dated ,d+[DATE]. The policy indicated, .Policy: Sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing. Food is stored at an appropriate temperature and by methods designed to prevent contamination .Procedure: .4. Individual scoops must be provided for flour, sugar, cereals, and other dried food items. Scoops are not to be stored in the food .5. All stock must be rotated with each new order received. Rotation should be based on the First In, First Out method or rotated based on the product expiration date .6. Food is stored a minimum of 6 above the floor and 18 below the sprinkler heads on clean racks or other clean surfaces, and is protected from contamination .8. Refrigerated, ready-to-eat, potentially hazardous food purchased from approved vendors shall be clearly marked with the date the original container is opened and the date which the food shall be consumed or discarded .the date marked may not exceed the manufacturer's use-by date . On [DATE] at 12:15 p.m., DM provided and identified a document as a current facility policy, titled Hand Washing in the Kitchen, dated ,d+[DATE]. The policy indicated, Policy .Culinary staff will wash hands after using the restroom, touching clothing, aprons, hair, face or body parts other than clean hands and clean, exposed portions of arms; after taking out the garbage; after clearing tables or busing dirty dishes .after handling soiled surfaces, equipment, or utensils .when returning to the kitchen/food prep area .and after engaging in other activities that contaminate the hands .Procedure .1. Turn on faucet .2. Wet hands with water and apply enough soap to cover all hand surfaces .4. Rinse hands with water .5. Dry hands with single use towel, turn off faucets with towel and discard .6. The entire process should take ,d+[DATE] seconds to complete 3XXX,d+[DATE](i)(1) 3XXX,d+[DATE](i)(3)

Based on interview and record review, the facility failed to ensure a care plan was developed for a resident who had no natural teeth for 1 of 17 residents' care plans reviewed (Resident 31). Finding includes: During an interview, on 3/21/23 at 10:49 a.m., Resident 31 indicated, he had all his teeth pulled in 2015 and was edentulous (having no teeth). Resident 31's record was reviewed on 3/24/23 at 9:49 a.m. The census information indicated the resident had been admitted to the facility, on 11/23/22, with the diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (a mini stroke caused by a temporary disruption in the blood supply to part of the brain) and chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs). A significant change in status Minimum Data Set (MDS) assessment, dated 3/1/23, indicated the resident was cognitively intact, had no swallowing issues, received a mechanically altered diet, and was not edentulous. A care plan, started on 12/19/22, indicated the resident was at risk for impaired dental hygiene, interventions on the care plan included, but not limited to, natural teeth, assist resident with oral care, and observe document red/bleeding gums, lesions, loose teeth, and symptoms of pain with the goal target dated 5/24/23 of the resident will be free from mouth pain, red or bleeding gums or oral lesions. During an interview, on 3/24/23 at 11:06 a.m., the Director of Nursing (DON) indicated Resident 31's care plan was not correct. Resident 31 did not have any teeth and the care plan should have been individualized to reflect the resident was edentulous. On 3/24/23 at 11:28 a.m., the DON provided and identified a document as a current facility policy, titled IDT Comprehensive Care Plan Policy, dated 10/2019. The policy indicated, .Policy: It is the policy of this facility that each resident will have a comprehensive person-centered care plan developed based on comprehensive assessment. The care plan will include measurable goals and resident specific interventions based on resident needs and preferences to promote the resident's highest level of functioning including medical, nursing, mental, and psychosocial needs .Care plan problems, goals, and interventions will be updated based on changes in resident assessment/condition, resident preferences or family input 3.1-35(a) 3.1-35(b)(1) 3.1-35(b)(2)

Based on interview and record review, the facility failed to ensure a resident was transferred with a mechanical stand up lift according to the manufacturer's directions and the resident's plan of care to prevent accidents resulting in the resident sustaining a fracture for 1 of 4 residents reviewed for transfers (Resident B). Finding includes: On 7/3/19 at 9:45 a.m., a facility reported incident was reviewed. The report indicated Resident B had fallen from a mechanical stand up lift. Resident B was interviewed on, 7/3/19 at 10:40 a.m. The resident was in bed with her left arm in a sling. She indicated at the time of the accident she had been in a stand up lift in the bathroom, unattended, and fell from the lift. She had experienced pain in her left arm. Certified Nursing Assistant (CNA) 7 was interviewed on, 7/3/19 at 12:30 p.m. She indicated she had transferred the resident from her wheelchair in her room, to the bathroom. She indicated she had been the only CNA on the floor and the resident was anxious to go to the bathroom. She had gotten the Sara stand up lift, positioned the sling around the resident. The resident had refused to allow the waist belt to be fastened. The resident's feet had been placed on the lift, and the resident refused the belt utilized for residents' legs to be fastened except on the resident's affected leg. The resident had been transferred into the bathroom and lowered onto the stool, CNA 7 indicated she left the resident and went to the nurses' station to obtain a fresh battery for the lift. When she returned she raised the resident to a standing position in the bathroom, the resident had complained of a back rash. The resident's clothing had been adjusted and the CNA attempted to transfer the resident back into her room. The resident grabbed the grab bar near the stool in the bathroom and refused to be moved until the nurse looked at her back. The CNA exited the resident's room, relayed the message to the nurse that had been close by, and met CNA 5 at the doorway. At that time CNA 7 left for her break. She indicated she had been gone 10 minutes and when she returned found the resident in bed and learned she had fallen from the lift and been transferred with a Hoyer mechanical lift into bed. She indicated the resident had removed her unaffected arm from the sling and had reached for the controls of the lift and fallen. The CNA indicated the resident would get the controls to the lift and use them all the time to raise herself up and down. The resident would frequently refuse use of the safety straps utilized on the lift. CNA 7 indicated she had frequently transferred the resident without another staff to assist. She had reported the resident's refusal of use of the safety straps to nurses who worked second shift on the unit. Documentation in the facility's fall investigation, dated, 6/22/19, provided by the Director of Nursing (DON) on 7/3/19 at 11:30 a.m., indicated it had been discovered during the investigation the resident would refuse proper placement of safety belt and leg straps at times during the lift transfers. The Administrator was interviewed on, 7/3/19 at 11:30 a.m., and indicated had that been known other interventions would have been used to transfer the resident. The resident's clinical record was reviewed on 7/3/19 at 12:18 p.m. [DIAGNOSES REDACTED]. A nurse's note in the Event section of the electronic clinical record, dated 6/22/19, indicated the resident had been transferred to the hospital, returned the same day with pain medications, a left arm immobilizer, and was not to be transferred with the stand up lift until fracture healed. The resident had a [DIAGNOSES REDACTED]. An annual Minimum Data Set (MDS) assessment, dated 5/2/19, coded the resident with no cognitive impairment, and she required extensive assistance of two people for transfers. A plan of care dated, 9/14/16, indicated the resident was not to be left alone while toileting. Staff were to remain with the resident or in the resident's room while toileting to help prevent fall with injury. A facility's policy titled Stand Lift, dated 4/2012, provided by the DON on, 7/3/19 at 10:03 a.m., included but was not limited to, NOTE: The stand up lift is to be used by two staff members with resident's that are able to stand and bear weight. Always follow manufacturer's guidelines for lifts. Documentation in the Manufacturer's directions, no date, for the Sara 3000 stand up lift reviewed on, 7/3/19 at 1:38 p.m. The directions included, but were not limited to, Sara 3000 shall always be handled by a trained caregiver, continuously attending to the resident, and in accordance with the instructions outlined in these Operating and Product Care Instructions. This Federal deficiency relates to Complaint IN 947. 3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to ensure supervision to prevent an elopement on a heat advisory day, resulting in a transfer to the emergency room (ER) to receive intravenous (IV) fluids for a diagnosed of heat exhaustion versus early heat stroke for 1 of 3 residents reviewed for elopement (Resident B). Findings include: Review of a report, titled, Indiana State Department of Health Survey Report System, dated 7/1/18, was completed on 7/18/18 at 8:30 a.m. The report indicated, (Resident B) was outside in the courtyard and staff went to check on him and he had left the courtyard .the Executive Director (ED) called the police .the resident was located 50 yards into the woods .EMS on scene and transferred the resident to the ER for evaluation .the resident had heat exhaustion and was given one (1) bag of IV fluids . On 7/18/18 at 1:10 p.m., the Director of Nursing Services (DNS) provided a report, titled, Incident/Accident log for (YEAR). The log indicated, 6/30/18 at 2:30 p.m., Resident B in the courtyard, and got out the gate. 2:45 p.m. noticed he was not in the courtyard and search done. Resident found, taken to ER for evaluation by emergency medical services (EMS). Returned that evening. On 7/18/18 at 9:50 a.m., Resident B was observed lying in bed with his eyes closed. He was dressed in a sweatshirt, long pants, ball cap and brown sneakers. On 7/18/18 at 10:15 a.m., Resident B was observed lying in bed, fully dressed with ball cap and brown sneakers, eyes closed. Calm and appeared to be sleeping. On 7/18/18 at 12:44 p.m., Resident B was observed sitting at a table in the main dining room alone, head down at times, food partially eaten. Dressed in long sleeves, pants, and brown sneakers. On 7/19/18 at 10:28 a.m., Resident B was observed sitting on the side of his bed, quiet, pleasant when spoken to. Wanderguard (an electronic wander management monitor) bracelet was observed on his right ankle tucked underneath his sweat pants. Record review was completed for Resident B on 7/18/18 at 10:20 a.m. The record indicated the resident had current [DIAGNOSES REDACTED]. Review of Progress Notes, dated 6/11/18 - 7/2/18, indicated the following: On 6/11/18 at 2:26 p.m., the Social Service Director (SSD) indicated, (Resident B) was seen by (physician's name) and the behavioral team on 6/8/18 .More paranoia was evident. Resident was happy but stated he didn't want to go outside, didn't want to go on outings, and didn't want to watch television. On 6/30/18 at 8:44 a.m., Registered Nurse (RN) 9 indicated, Resident B was confused that day, he had been wandering/walking all through the facility, going room to room, and not sitting still for long. Resident B stated he was going to Florida. He was looking for his dad's things and going to get his next. On 6/30/18 at 2:30 p.m., RN 9 indicated, Resident B was observed going out into the patio area. On 6/30/18 at 2:50 p.m., RN 9 indicated, Resident B was not in courtyard/patio area and the gate was unlocked and opened. All staff were notified of the open gate. An immediate search was started inside and outside the facility. On 6/30/18 at 3:30 p.m., Licensed Practical Nurse (LPN) 8 indicated, after searching inside and outside of facility she called the ED to inform her of the incident. Staff continued to search for Resident B. On 6/30/18 at 4:00 p.m., LPN 8 indicated, the police and EMS were notified and came to assist in searching for the resident. Resident B was found outside the back of the facility, about 50 yards into the wooded area, and was taken by EMS to the ER for evaluation. On 6/30/18 8:34 p.m., LPN 8 indicated, Resident 8 returned from the ER at this time. Alert and verbal, his skin was warm, dry, and intact. No skin issued noted. Wanderguard placed on right ankle. Review of an event form for Resident B, titled, New/Worsening Behavior Communication Event, and dated 6/30/18. LPN 8 indicated, Wandering outside in courtyard and out through the gate into the surrounding woods .At 3:30 p.m. after searching inside and outside of facility this writer called the executive director (ED) to inform her of incident, staff continues to search. 4:00 p.m. police and EMS were notified and came to assist in search. Resident was found outside the back of the facility about 50 yards into the woods area and was taken by EMS to the ER for evaluation .8:34 p.m. Resident returned from ER at this time .Wanderguard placed on right ankle. Band-Aid removed from left wrist from IV site in ER . Review of a quarterly Elopement Risk Assessment, dated 4/26/18, indicated, Resident B had the ability to move about freely and easily which would allow the resident the capability of leaving the facility unassisted. Resident did not often request to go home/and or search for home, no history of eloping from home or facility, did not wander aimlessly, and he was not often seen pushing on/trying to open/ or pacing near exit doors. The resident was not assigned a security bracelet. Assessment Notes: resident used to be at risk when he first came to facility but no longer exhibits any behaviors. Resident has a set routine he sticks to. A Social Service Director note, dated 4/27/18, indicated, Resident B was not at risk for elopement per assessment. On 6/30/18 at 8:38 p.m., an Elopement Risk Assessment, completed by LPN 8, indicated, Resident B had the ability to move about freely and easily which would allow the resident the capability of leaving the facility. Resident often requests to go home and/or is searching for home, has a history of eloping from home or facility, is often seen wandering aimlessly/without purpose, often seen pushing on/trying to open/or pacing near exit doors, and had been assigned a security bracelet. On 7/2/18 at 11:00 a.m., an interdisciplinary team (IDT) elopement assessment, completed by the SSD, indicated, last elopement assessment was inaccurate. Resident B does not wander and does not push on doors. He does not request going home. Resident usually stays in room and comes out for meals. Resident had been assigned a security bracelet. On 7/2/18 at 11:00 a.m., the SSD indicated, new IDT elopement assessment completed. Resident B's previous assessment incorrect. Resident did not usually wander hallways, ask to go home or was seen pushing on doors. The resident usually stayed in his room and came out for meals. Behavior on 6/30/18 was out of norm. Review of Resident B's Physicians Orders, dated, 6/30/18, indicated, Wanderguard, check placement and function every shift, replace transmitter every 3 months. A quarterly Minimum Data Set (MDS) assessment, dated 4/27/18, indicated Resident B had the ability to make himself understood and the ability to understand others. His Brief Interview for Mental Status (BIMS) score was 7, indicating severe cognitive impairment. There were no signs or symptoms of [MEDICAL CONDITION], hallucinations, delusions, behaviors, rejection of care, or wandering. The resident required supervision with no physical assistance for ambulating in his room and corridor, and for locomotion on and off the unit. Review of Resident B's Care Plans, last reviewed/revised 7/9/18, indicated: 1. Problem: Resident is at risk for elopement per the Elopement Risk Assessment as evidenced by (aeb) leaving facility unattended. Goal: Resident will remain safely in the facility through next review. Approach: Resident at risk for Elopement, All facility exits secured, Provided 1:1 attention and conversation - ask about the farm, living in (home town), sister (sisters name), Wanderguard per medical doctor (MD) order .2. Behavior: Resident may have anxiety towards others i.e.: aggression, agitation, believing he knows what to do with them, where they should be, threatening others, delusions. Goal: Resident will be free of anxiety or redirected within 10 minutes by staff intervention. Approach: .Redirect resident by asking if he can help you do a task. Resident likes helping others .Talk to him about farming and working in (name of city) .Offer resident a coffee. Ask him how his day is .Encourage resident to discuss his life with his sister and mother. Ask resident about going to (home town) daily .3. Resident is at risk for fluid imbalance due to impaired cognition, diuretic use, and dementia with behaviors .The resident wears long sleeve shirts/coat and pants/sweats even during the summer. Resident is currently at greater risk due to recent behaviors. Fluids are being encouraged as resident likes to drink coffee at meals. Goal: Resident will be free of signs and symptoms of fluid volume deficit. Approach: encourage extra water at meals, vital signs as ordered, administer medications as ordered, document and notify MD of signs and symptoms of fluid volume deficit: dry mucous membranes, thirst, weight loss, decreased blood pressure, weak rapid pulse, change in mental status, decreased urine output, abnormal labs, poor skin turgor, encourage fluids, labs as ordered, offer an additional 120 ml (milliliters) of fluids each meal, record intake . On 7/19/18 at 3:30 p.m., the ED provided reports, and indicated, they were reports from Resident B's ER visit, dated 6/30/18. The reports indicated, the resident's primary reason and ER [DIAGNOSES REDACTED]. The ER physical exam indicated, [AGE] year old man was silver alert about 1 and a half hours prior to arrival .It is a very hot day with a heat index of about 100 degrees Fahrenheit. He was found sitting next to a tree .he had been dressed and long shirt, long pants, socks. Was found to be hypotensive at 86/52, heart rate 104, temperature 99.3 Fahrenheit .Patient has signs and symptoms consistent with both heat exhaustion and early heat stroke. He is hypotensive, [MEDICAL CONDITION] (elevated heart rate), with no sweating at the time. We will gently hydrate the patient and evaluate his laboratory study looking especially for any evidence of rhabdomyolysis (kidney failure). Orders included: [MEDICATION NAME] Ringers (IV fluids to replace fluids and electrolytes) 1000 ml/hour (milligrams per hour), complete blood count) with differential, CMP (complete metabolic panel monitoring the kidneys, liver, blood glucose levels), CPK ([MEDICATION NAME] phosphokinase monitoring for heart damage), and troponin 1 (monitoring for a [MEDICAL CONDITION] infarction), urinalysis, and monitor cardiac .Additional instructions: You should stay indoors on very hot days. Increase your hydration for the next several days to help with your dehydration and heat related injuries On 7/11/18 12:01 p.m., the DON indicated, there had not been a change in Resident B's behavior causing him to elope. His eloping was due to his dementia and walking throughout the facility at will. The resident naturally exited out the back gate of the courtyard, which had been left open by the contractors, without staff knowing about it. The resident was sent to the ER for evaluation upon being found, with fluids provided in the ER prior to his return, due to being outside in very hot weather and him being at risk for dehydration during this period. On 7/18/18 at 12:48 p.m., the Business Office Manager (BOM) demonstrated how to access the courtyard, and indicted, a code was required to enter the fenced inner courtyard, and a code was required to re-enter the facility. On 7/18/18 at 3:41 p.m., LPN 8 indicated, she was in the facility on the day Resident B eloped. She was not sure how he got into the courtyard as he was already out when she arrived to work, but she was working upon his return from the ER. The resident was given IV fluids in the ER, and had no new orders when he returned. The code to the courtyard was not posted. The courtyard gait was supposed to have been kept locked, and it should have been locked on the date of the incident. On 7/18/18 at 3:42 p.m., Registered Nurse (RN) 15 indicated, a staff member would have to let a resident or visitor out into the courtyard as there was a key pad beside the door and the code was not posted. The codes to re-enter the facility from the courtyard were posted by the door outside to allow entrance. On 7/18/18 at 4:17 p.m., the DNS indicated, Resident B was let out into the courtyard per staff's normal routine. The staff did not know contractors had taken the hasp (a slotted hinged metal plate that forms part of a fastening and is secured by a pin or padlock) lock off the back of the gate while fixing the courtyard awning to bring in equipment. When staff checked, they found the resident gone, and the lock had been taken off the back of the gate. The resident was missing about an hour and a half, police were called, and he was taken to the ER after being found. There was no routine checking of the courtyard gate lock before the incident. To her knowledge, the resident had no history of exit seeking or elopement risk, she did not think he was attempting to get away, he just wandered out the open gate. On 7/18/18 at 4:25 p.m., the ED indicated, Resident B had been let out into the courtyard by one of the nurses because he was wandering and looking for his truck. The hasp had been taken off of the outside of the gate while construction was taking place in the courtyard, and the construction crew forgot to fix the gate when they were finished. Resident B was found about 50 feet into the woods and sat down due to being tired. The EMS team helped to bring him out of the woods, and then per EMS protocol took him to the ER for treatment. His elopement raised concern as he always wore long sleeved shirts and long pants. He was not on elopement precautions before the incident. Signs regarding heat precautions were posted the day of the incident, although there is no facility protocol for heat advisory days. There was no action plan for checking of the courtyard gate before this incident. On 7/19/18 at 11:05 a.m., the Maintenance Director indicated, before Resident B's elopement, the Maintenance Director did not go in and out with the contractors. But, since the contractors had taken the hasp off the gate allowing the resident to get out, he now escorts them in and out. There was a key in a lock box outside the fence for the lawn company to get in, and they have never left the gate open during his employment this year. That was how he identified who had taken the hasp off of the gate. On 7/19/18 at 3:30 p.m., the ED provided a policy, titled, Elopement (Risk and Missing Residents), revised 10/13. The policy indicated, It is the policy of the facility that staff who have residents under their care are responsible for knowing the location of those residents, and in the case of a missing resident, ensuring appropriate action is taken Procedure: 1. Resident identified to be at risk for elopement will be identified as follows: a. The facility will utilize an Elopement Risk Assessment to identify residents at risk to leave the facility unattended. B. A list of residents at risk for elopement is maintained in a book with corresponding pictures . This Federal tag relates to Complaint IN 891. 3.1-45(a)(1) 3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to ensure residents who received anti-coagulant therapy received adequate monitoring and follow-up from the physician to prevent bleeding risk which resulted in residents requiring medical intervention to reverse the effects of the anti-coagulant medication. This deficient practice directly affected 2 of 5 residents reviewed who received anti-coagulant therapy and had critical bleeding times in a total sample of 14 residents. (Resident # 45 and # 36) This deficient practice resulted in an immediate jeopardy. The immediate jeopardy was identified on 12/17/10 and began on 11/23/10. The Director of Nursing, Assistant Director of Nursing, Corporate Nurse Consultant, and Regional Vice President of Operations were notified of the immediate jeopardy on 12/17/10. The immediate jeopardy was removed on 12/19/10, but the facility remained out of compliance at the level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy because of the continued need for follow-up related to anti-coagulant monitoring, continued inservicing of new staff, and ongoing medication monitoring throughout the facility. Findings Include: 1. During medication administration observation for Resident # 45 with RN # 1, on 12/15/10 at 3:50 P.M., the following was observed: RN # 1 administered [MEDICATION NAME] (an anti-coagulant medication) 5 milligrams by mouth to Resident # 45. The clinical record for Resident # 45 was reviewed on 12/16/10 at 3:00 P.M. [DIAGNOSES REDACTED]. A nurse's note, dated 11/13/10 at 5:00 A.M., indicated, "In bed screaming, 'Help me, Help me. Fire! Fire! My leg is on fire! + 2 [MEDICAL CONDITION] (swelling) LLE (left lower extremity). Hot to touch (positive) Homen's (SIC) sign (a test to determine the presence of a blood clot) (with) loud moaning facial grimacing present. Tyl (Tylenol) given...." There was no documentation in the clinical record to indicate the physician was notified of the resident's condition at that time. The next entry in the nurse's notes, dated 11/13/10 at 7:30 A.M., indicated, "(name of physician) called (and) notified of cont. (continued) c/o (complaint of) pain in LLE (with) [MEDICAL CONDITION]. Condition report given (with) N.O. (new order) received (SIC) to send to ER (emergency room ) for eval (and) tx (evaluation and treatment)...." A physician's order, dated 11/13/10 at 7:30 A.M., indicated, "send to ER for eval (and) tx d/t (due to) possible [MEDICAL CONDITION] or [MEDICAL CONDITION] (a skin infection)..." A nurse's note, dated 11/13/10 at 8:45 A.M., indicated, "amb (ambulance) here (and) care transferred...." A nurse's note, dated 11/13/10 at 2:00 P.M., indicated, "Report called from (name of hospital) Doppler showed chronic old [MEDICAL CONDITION] ([MEDICAL CONDITION] treat (with) [MEDICATION NAME], to cont (continue) [MEDICATION NAME] (and) start [MEDICATION NAME]. (arrow pointing up) WBC (white blood cells) so poss (possible) [MEDICAL CONDITION] (a skin infection) will start keflex (an antibiotic)...." An emergency medicine report form, dated 11/13/10 at 9:42 A.M., indicated, "...deep vein [MEDICAL CONDITIONS], contusion..." A nurse's note, dated 11/13/10 at 3:30 P.M., indicated, "Res (resident) returned from hospital-new orders received (and) noted. ... LLE remains red (with) [MEDICAL CONDITION] warm to touch..." A physician's order, dated 11/13/10 at 3:30 P.M., indicated the following orders: Keflex (a cephalosporin antibiotic) 500 milligrams by mouth three times daily for 10 days. [MEDICATION NAME] (an anti-coagulant medication) 5 milligrams by mouth daily. [MEDICATION NAME] (an anti-coagulant medication) 100 milligrams/milliliter-1 milligram/kilogram subcutaneously every 12 hours for three days. Follow up with physician in 1-2 days. A current care plan for the resident, initially dated 11/13/10, indicated the resident was at risk for bleeding tendency secondary to [MEDICATION NAME] treatment. Interventions related to this concern indicated staff were to administer the medication as ordered, perform labs as ordered, and notify the physician of increased problems. There was no documentation on the physician's orders to indicate the initial laboratory monitoring of the resident related to the initiation of the [MEDICATION NAME] therapy. Review of the 11/10 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A nurse's note, dated 11/15/10 at 7:30 A.M., indicated, "Call placed to (physician's name) for condition update. N.O. (new order) for PT([MEDICATION NAME] time) (a lab used to evaluate to the ability of blood to clot properly) /INR (a lab to monitor the effectiveness of blood thinning drugs)-CBC (complete blood count) today..." A physician's order, dated 11/15/10 at 7:30 P.M., indicated "Get PT/INR (and) CBC today..." A laboratory results form, dated 11/15/10, indicated the resident's PT level was 12.2 (normal range 10.1-11.6) and the INR level was 1.14 (normal range 0.97-1.12). There was no documentation in the clinical record to indicate the physician was notified of the laboratory results on 11/15/10. There were no physician's orders obtained at that time related to the need for further laboratory testing and the resident's continued use of [MEDICATION NAME]. A nurse's note, dated 11/23/10 at 2:05 P.M., indicated, "...Last dose of Keflex given for LLE [MEDICAL CONDITION] ... continue [MEDICATION NAME] for LLE chronic [MEDICAL CONDITION]. MD called this AM (SIC) (and) ordered CBC (and) PT/INR if she has not had one. Was done on the 15th results to MD (and) awaiting clarification for labs to be done...." A nurse's note, dated 11/24/10 at 4:30 P.M., indicated, "Noted left eye to be bloodshot-teary-...c/o eye feeling little funny ... (name of physician) notified...." The next nurse's note entry that addressed the resident's bloodshot eye was dated 11/27/10 at 5:00 P.M. The note indicated, "Res left eye improving (with) redness resolving-Denies vision problems, pain or discomfort...." A nurse's note, dated 11/29/10 at 9:00 P.M., indicated, "MD called (with) N.O. for CBC PT/INR for 11/30/10. He also wants results sent to him on 11/30/10. Labs put on calendar..." A physician's order, dated 11/29/10, indicated "CBC PT/INR do on 11/30/10..." The reason for the laboratory order indicated "[MEDICAL CONDITION] therapy." A nurse's note, dated 11/30/10 at 1:30 P.M., indicated, "Lab (laboratory) had called (with) critical PT/INR MD notified. Vit K (vitamin K) 10 mg (milligrams) given per order. Hold [MEDICATION NAME] PT/INR in AM (SIC)...." A laboratory results form, dated 11/30/10, indicated the resident's PT level was >114.2 (normal range 10.1-11.6) and the INR level was >12.00. A physician's order, dated 11/30/10, indicated, "Hold [MEDICATION NAME] until further notice Vit K 10 mg SQ (subcutaneously) 1 x (time) only PT INR on 12/1/10" The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the physician's order summary for 12/10, indicated an order for [REDACTED]. A nurse's note, dated 11/30/10 at 8:45 P.M., indicated, "N.O. (new order) monitor stools et (and) blood. If any more bloody stools notify MD. N.O. to D/C (discontinue) aspirin et (and) draw PT-INR (and) CBC 12/1/10...." A physician's order, dated 11/30/10, indicated "D/C aspirin 81 mg once daily PT-INR (and) CBC on 12/1/10" A laboratory results form, dated 12/1/10, indicated the resident's PT level was 95.7 (normal range 10.1-11.6) and the INR level was 9.88. A nurse's note, dated 12/1/10 at 4:55 P.M., indicated, "Lab called-critical INR-9.88-results called to (name of physician) office-awaiting return call-no visible s/s of bleeding noted...." A nurse's note, dated 12/1/10 at 5:30 P.M., indicated, "(name of physician) returned call-new order received (and) noted for Vit K (and) repeat lab in AM...." A physician's order, dated 12/1/10, indicated, "Vit K 10 mg SQ x 1 only for (arrow pointing up) INR...PT INR in A.M...." A nurse's note, dated 12/2/10 at 4:00 P.M., indicated, "... Noted bruising to res rt (right) arm/elbow area-Denies pain or discomfort. [MEDICATION NAME] remains on hold-No active bleeding noted...." There was no documentation in the note to indicate the physician was notified of the resident's bruise. A non-pressure ulcer monitoring form, dated 12/2/10, indicated the resident had a bruise just above the elbow on the back side of the right arm. The bruise measured 20 centimeters x 15 centimeters. A laboratory results form, dated 12/2/10, indicated the resident's PT level was 30.5 and the INR level was 2.97. The form had a hand-written note which indicated, "called to MD 12/5/10 11:30 P (P.M.) new orders noted" A nurse's note, dated 12/5/10 at 11:30 P.M., indicated "Called (physician's name) with PT (and) INR results new orders noted..." A physician's order, dated 12/5/10, indicated, "[MEDICATION NAME] 2.5 mg PO (by mouth) Q Day (once daily)...PT INR 12/9/10..." A nurse's note, dated 12/6/10 at 8:30 P.M., indicated, "N.O. received for labs in A.M. Hold [MEDICATION NAME] until N.O. from (physician's name) (after) labs tomorrow..." A laboratory results form, dated 12/7/10, indicated the resident's PT level was 12.5 (normal range 10.1-11.6) and the INR level was 1.17. A nurse's note, dated 12/8/10 at 7:30 P.M., indicated, "(physician's name) notified of critical lab results N.O. received and implemented..." A physician's order, dated 12/8/10, indicated, "[MEDICATION NAME] 5 mg po qd W (Wednesday), Thu (Thursday) [MEDICATION NAME] 2.5 mg po qd on Monday, Tuesday, Friday, Sat. (Saturday) (and) Sun (Sunday)..." A laboratory results form, dated 12/9/10, indicated the resident's PT level was 13.4 (normal range 10.1-11.6) and the INR level was 1.25. A physician's order, dated 12/11/10, indicated, "CBC, PT INR Tuesday 12/14/10..." A laboratory results form, dated 12/14/10, indicated the resident's PT level was 48.4 (normal range 10.1-11.6) and the INR level was 4.83. The form indicated the lab was drawn at 6:00 A.M. on 12/14/10. The facility did not obtain any orders from the physician related to the elevated PT/INR results on 12/14/10. The orders from the physician were not obtained until 7:30 P.M. on 12/15/10. A nurse's note, dated 12/15/10 at 7:30 P.M., indicated "N.O. hold [MEDICATION NAME] until further notice et (and) (check) PT-INR on 12/17/10...." Review of the 12/10 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. During an interview with the Assistant Director of Nursing on 12/17/10 at 9:30 A.M., she indicated the resident did not have any bleeding in her stools during the time of the critical PT/INR levels. She further indicated the facility sometimes has a 24 hour turn around time for getting laboratory results back. She indicated there has been recent problems related to the Medical Director not responding to the facility's concerns with laboratory results. She indicated the Medical Director had a new nurse, and they were not sure if that is the problem. She indicated the facility has the Medical Directors cell and home phone numbers, but he does not always answer when contacted. She indicated the administrator had spoken with him about the lack of immediate response. The resident's primary physician was identified as the Assistant Medical Director, but staff would need to contact the Medical Director if additional follow-up was needed. She indicated laboratory results are sent to the physician and facility at the same time, but the only way to verify the physician has obtained the labs is during his weekly visits when his nurse brings in signed copies. During an interview with the Director of Nursing on 12/17/10 at 9:32 A.M., she indicated staff should look at stools, bruising, pain, gums, nose for signs and symptoms of bleeding. She indicated bloodshot eyes could be a sign of bleeding. She indicated the physician should be notified within and hour or two of laboratory results. She also indicated the laboratory always calls with critical lab results. She indicated the facility did not receive the 12/2/10 laboratory results until 12/5/10, and that is when the physician was notified. She indicated the staff should have followed-up to make sure the laboratory report was obtained. She indicated the facility lab draw days are Tuesday and Thursday, and medical records does the lab tracking to make sure the labs are done. She indicated it would be a nursing measure to hold [MEDICATION NAME] if the PT/INR results were elevated and there was no response from the physician at the time of the next dose. During an interview with the Assistant Director of Nursing on 12/17/10 at 11:20 A.M., she indicated the nursing staff should have gotten back with the MD between 11/23/10 and 11/29/10 in order to clarify when the physician wanted to obtain additional laboratory results. During an interview on 12/17/10 at 3:00 P.M., the Assistant Director of Nursing indicated she had spoken with Resident # 45's physician and he indicated he was notified of the laboratory results on 11/15/10. The Lippincott Manual of Nursing Practice, 9th edition pages 441-443, includes the following information on anticoagulation therapy using [MEDICATION NAME]: "[MEDICATION NAME] time (PT) and INR are the coagulation tests used to monitor the anticoagulation effects of [MEDICATION NAME] (generic name for [MEDICATION NAME]). The patient's INR should be 2 to 3 1/2 times the control. Note the desired levels of INR are determined by protocol for condition and risk factors being followed or by the health care provider. Administering [MEDICATION NAME]: Give orally at the same time each day. Best time to check INR is at least 16 hours after last dose. Monitor frequently until stable, with any medication changes, and then monthly." In addition, "Be aware of drug - drug and food -drug interactions that may alter the effects of [MEDICATION NAME]." Box 14-1 is a list of Selected Substances That Interact with [MEDICATION NAME]. [MEDICATION NAME] and Cephalosporins are listed as substances that increase the INR. 2. The clinical record for Resident # K was reviewed on 12/16/2010 at 11:25 A.M. [DIAGNOSES REDACTED]. A care plan (not dated) listed a [MEDICAL CONDITION] (blood clot) on 10/03/2009 and indicated Resident # K was on [MEDICATION NAME] (a blood thinning drug). Nursing interventions included, but were not limited to, "...give ASA (aspirin) per order, do (SIC) labs per order, notify (SIC) MD (medical doctor) of complications...." A physician's telephone order, dated 11/11/2010, indicated, "Hold [MEDICATION NAME] until further notice. PT/INR (labs used to evaluate the ability of blood to clot properly and to monitor the effectiveness of blood thinning drugs) QD (every day) x (times) 3 days. Vit (vitamin) K 1 ml (milliliter) IM (intramuscular injection) 1 x now." A lab, dated 10/26/2010, indicated PT ( a lab used to evaluate the ability of blood to clot properly) of 11.8 (normal value is 10.0-11.6) and INR ( a lab to monitor the effectiveness of blood thinning drugs) of 1.10 (normal value is 0.9-1.12). An order was hand written on the laboratory report by (name of physician) on 10/28/2010. The order indicated, "(1) [MEDICATION NAME] 2 mg (milligram) QD 6 days per week and 4 mg QD ( symbol for "one) day per week. (2) Weekly PT/INR x 4 weeks." Additional hand written notes on the laboratory report included: "[MEDICATION NAME] 2 mg QD " and "2 mg QD 3 days per wk (week) 4 mg QD 4 day (SIC) wk." Another hand written note on the laboratory report indicated, "MD notified." There was no documentation to clarify the meaning of the additional hand written notes. The additional hand written notes did not include the writer's signature. A lab, dated 11/04/2010, indicated PT of 31.9 and INR of 3.12. A hand written note on the laboratory report indicated, "(name of physician)-Please advise any new orders..." A lab, dated 11/11/2010, indicated PT of 84.0 and INR of 8.2. A hand written note on the laboratory report indicated, "MD notified. Vit (vitamin) K (medical symbol for "one") ml (milliliter) IM (intramuscular injection). PT INR QD x 3 days. Hold [MEDICATION NAME]." The note did not include a writer's signature. A lab, dated 11/12/2010, indicated PT of 34.1 and INR of 3.34. A lab, dated 11/16/2010, indicated PT of 10.8 and INR of 1.00. A hand written note indicated, "[MEDICATION NAME] on hold. WOW (Waters of Williamsport). MD notified." The note did not include a writer's signature. A nurse's note, dated 11/13/2010, indicated, "Unable to get blood sample for PT/INR due to poor veins-(name of physician) notified and undated order received and noted lab order (symbol for changed) to 11/16/2010 and hold [MEDICATION NAME]." During an interview on 12/16/2010 at 1:20 P.M., the ADoN (Assistant Director of Nursing) indicated the resident's physician did not respond to the request for advice related to the lab obtained on 11/04/2010. She indicated the facility should have followed up on the lab and continued pursuing a physician response. The ADoN indicated that the facility staff had implemented a procedure last week where staff fax [MEDICATION NAME] related labs directly to the nurse practitioner due to the delayed responses from the physician. A current facility policy, dated 1/07, titled "Lab Scheduling and Tracking" was provided by the ADoN on 12/16/10 at 3:35 P.M. The policy indicated, "...all laboratory test ordered by the physician will be systematically scheduled and tracked to ensure all lab work ordered is obtained and results are received....The Unit Nurse will review the lab results and notify the physician of any abnormal results or as ordered by the physician and document notification....Medical Records Department will review all lab scheduling routinely to ensure all scheduled labs have been drawn and results have been received. If a lab result is found to be missing, Medical Records/Unit Nurse will contact the lab to obtain outstanding results...." At the time the above policy was provided, the Assistant Director of Nursing indicated the facility did not have a policy/procedure related to the facility's monitoring of residents who receive [MEDICATION NAME] therapy. A current facility policy, dated 4/06, titled "Physician Notification of Resident Change of Condition" provided by the Assistant Director of Nursing on 12/16/10 at 3:35 P.M. The policy indicated, "...The attending physician will be notified of a change in a resident's condition by licensed personnel as warranted....Physician notification is to include but is not limited to:...abnormal lab findings....Make an entry into Nurse's notes regarding condition/physician notification/physician's orders." An immediate jeopardy was identified on 12/17/10 P.M. The immediate jeopardy began on 11/23/10, when staff failed to ensure residents with anticoagulant medications received adequate monitoring. The Regional Vice President, Corporate Nurse Consultant, Director of Nursing, and Assistant Director of Nursing were notified of the immediate jeopardy on 12/17/10 related to the failure to monitor and report laboratory values for residents taking anticoagulant medications. The immediate jeopardy was removed on 12/19/10, when through record review and interview, it was determined the facility had implemented the plan of action to remove the immediate jeopardy. The steps taken removed the immediacy of the problem, and the steps taken were as follows: A. A 100% audit of laboratory results was completed. The physician was notified of any labs as needed. B. All CNA's and licensed staff were inserviced regarding signs and symptoms of bleeding. C. All licensed staff were inserviced regarding the appropriate steps to take when a resident is on anti-coagulant medication. Even though the facility's corrective action removed the immediate jeopardy, the facility remained out of compliance at a reduced scope and severity level of isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy. 3.1-48(a)(3)