**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to adequately manage a resident's Coumadin (anticoagulant medication) dosage to ensure the medication was reaching therapeutic levels, develop a policy on anticoagulant medication management, and obtain treatment adjustment from the physician for a non-therapeutic INR (International Standardized Ratio for clotting in the blood) lab result for a resident with a history of a high risk blood clotting disorder for one of three residents (R3) reviewed for High Risk Medications. This failure resulted in R3 requiring emergency medical services followed by a medical transfer and admission to a tertiary critical care (higher level/specialized) hospital for treatment of Acute Ischemic Stroke Left MCA (Middle Cerebral Artery) territory with right facial droop and weakness, Lactic Acidosis (lactic acid in the bloodstream) and Subtherapeutic INR, resulting in R3 experiencing aphasia, dysphagia, right sided weakness, mental anguish, and hospitalization for 17 days. These failures resulted in an Immediate Jeopardy. Findings include: The Immediate Jeopardy started on 1/26/24 when the facility received R3's Laboratory result of a subtherapeutic INR and failed to inform the resident's primary Physician of the result and need to alter the current anticoagulant medication dosage, and did not record the INR result on the Protime flowsheet, resulting in R3 suffering a change in cognition and being transferred to the emergency room then subsequently transferred the a tertiary critical care hospital for treatment of Acute Ischemic Stroke Left MCA territory with right facial droop and weakness, Lactic Acidosis and Subtherapeutic INR. V1 (Administrator in Training) was notified of the Immediate Jeopardy on 2/27/24 at 1:07 PM. While the immediacy was removed on 2/27/24, the facility remains out of compliance at a severity Level II as the facility continues to have members of the IDT (Inter-Disciplinary Team) including a nurse review all admissions for anticoagulant medication and ensure proper lab orders during Quality Assurance meetings, review all current admitted residents with anticoagulant medication for lab orders during Quality Assurance meeting weekly, and audit all other residents with high-risk medications for adequate lab monitoring. R3's Physician Order Sheet, dated 11/1/23-2/29/24, documents R3 has diagnoses including but not limited to Hypertension, History of Pulmonary Embolism, History of other Venous Thrombosis and Embolism, Antiphospholipid Syndrome and Heart Failure. This order sheet documents R3 has a laboratory order for PT (Prothrombin)/INR one time only related to Personal History of Pulmonary Embolism, Personal History of other Venous Thrombosis and Embolism, until 1/25/24. This order has a start date of 1/25/24. This order sheet also documents a medication order for Warfarin Sodium (Coumadin) two and a half milligrams to give 1 tablet by mouth one time a day every Monday, Wednesday, and Friday for blood thinner, start date 1/12/24. This order sheet also documents a medication order for Warfarin Sodium five milligrams to give 1 tablet by mouth one time a day every Tuesday, Thursday, Saturday, and Sunday for blood thinner, start date 1/11/24. No other Warfarin orders were started after 1/12/24 for R3. R3's Laboratory report, dated 1/26/24, documents R3's INR result was 1.3. This report also documents an INR range for Standard Anticoagulant is 2.0-3.0 and Aggressive Anticoagulant is 2.5-3.5. On 2/21/24 at 12:10 PM, V13 (R3's Family Member) stated I am going off what the neurologist doctor said to me. When we were in the emergency room, I don't know his name but after she was taken there, I asked specifically what caused her stroke and he said likely medication management. Her level was too low for the Coumadin to be considered therapeutic. (R3) is still having left side weakness, aphasia (difficulty formulating thoughts into words and speaking) and dysphagia (difficulty swallowing). She has to eat soft foods only which she cries about. She was able to eat regular food before this. (R3) also has suffered memory loss with her stroke. On 2/21/24 at 1:40 PM, V1 (Administrator in Training) stated I don't know if (V8 R3's Primary Physician) was notified of the 1/26/24 laboratory result for (R3's) PT/INR. If he was notified it should be in the progress note or a new updated order would be in place. On 2/21/24 at 2:00 PM V9 (V8's Medical Office Licensed Practical Nurse) stated I do not see where we (doctor office) were ever notified of the PT/INR results for (R3) on or after 1/26/24. R3's Physician visit history, provided by V1 on 2/21/24, documents that the last visit from V8 was on 12/12/23. R3's Nursing Progress notes, dated 1/11/24-2/9/24 do not document that V8 was ever notified of R3's PT and INR results that were completed on 1/26/24. R3's Nursing Progress note, dated 2/10/24 at 8:15 AM, documents R3 was transferred to a local hospital after appearing to have experienced a change in Cognitive Ability. R3's Nursing Progress note, dated 2/10/24 at 1:27 PM, documents Informed by emergency room nurse That (R3) had Stroke with Left sided weakness and sepsis. Resident will be re-transferred to (tertiary critical care hospital). R3's emergency room provider notes, dated 2/10/24 at 9:22 AM, documents This [AGE] year-old woman sent from (the facility) because mental status change concerning for possible stroke. The (facility) said that the right sided face is drooping compared to normal, and (R3) is not speaking as she normally does. R3's emergency room hospital record, dated 2/10/24 at 12:15 PM, documents R3 is being transferred to a tertiary hospital for Acute ischemic stroke left MCA (Middle Cerebral Artery) territory with right facial droop and weakness, Lactic acidosis rule out sepsis and Subtherapeutic INR. This record also documents Brief Summary: Work up in emergency room shows INR subtherapeutic at 1.3. Patient had a CTA (Computed Tomography Angiography) of the head which showed acute ischemic infarct in the left MCA territory in the left temporal lobe region, no hemorrhage. On 2/26/24 at 11:20 AM V19 (Pharmacist) stated, (R3's) INR of 1.3 is not within therapeutic range. A physician should have been notified to possibly adjust (R3's) Warfarin dose. On 2/26/24 at 12:45 PM V15 (R3's Primary Hospital Physician) stated, (R3) is currently in the hospital being treated for the effects of her stroke. (R3's) sub-therapeutic INR levels contributed to (R3's) stroke. (R3) had a history of developing blood clots. On 2/26/24 at 12:55 PM V16 (R3's Neurologist) stated, (R3) had a history of a disorder called Anti-Phospholipid Syndrome which is a disorder that puts (R3) at a high risk for developing blood clots. (R3) also has a history of a Pulmonary Embolism and Venous Thrombosis. (R3's) INR levels should have been watched closely and as soon as the facility knew (R3's) INR levels were 1.3 (sub-therapeutic) on 1/26/24 the facility should have notified the physician to get (R3's) Warfarin (anti-coagulant) dose adjusted to ensure (R3's) INR levels were therapeutic to prevent blood clots. Sub-therapeutic INR levels would have caused a clot to throw and caused (R3's) stroke. On 2/27/24 at 10:15 AM, V1 (Administrator in Training) stated We do not have a Coumadin specific policy or one for anticoagulant monitoring. We use the Protime (PT) Flowsheet for residents on Coumadin and that is where nurses will document INR results and then dose changes and when the Physician was notified of them. V1 confirmed R3's Protime flowsheet has not been documented on since December of 2023. The facility's Notification of Change in Resident Condition or Status policy, dated 10/12/05, documents The facility and/or facility staff shall promptly notify appropriate individuals (i.e., Administrator, Director of Nursing, Physician, Guardian, Health Care Power of Attorney, etcetera) of changes in the resident's medical/mental condition and or status. The nurse supervisor/charge nurse will notify the resident's attending physician or on call physician when there has been; A need to alter the resident's medical treatment significantly, Abnormal lab findings. The facility's Laboratory Tests policy, dated 9/27/17, documents Appropriate laboratory monitoring of disease processes and medication requires consideration of many factors including concomitant disease(s) and medication(s), wishes of the resident and family and current standards of practice. On 2/29/24 the surveyor confirmed through interview, and record review that the facility took the following actions to remove the immediacy: 1. All nursing staff including agency nurses in-serviced on proper monitoring of anticoagulant use and ensuring high risk medication labs are reported and adjusted to ensure the resident reaches therapeutic levels by V1 on 2/27/24. 2. Staff In-service on the policy to monitor and complete the PT/INR flow sheet by V1 on 2/27/24. 3. All nursing staff including agency educated on notification to physician immediately with lab results by V1 on 2/27/24. 4. R3 no longer lives at facility, all other charts reviewed for any residents receiving anticoagulant therapy by V3 (Care Plan/MDS Coordinator) on 2/27/24. 5. MD reviewed policy for lab monitoring and signed off on policy on 2/27/24.

Based on observation, interview and record review, the facility Administration and Governing Body failed to ensure the facility heating system was in working order after being made aware of significant issues with the heating system in residential areas for (R1, R2, R4, R5, R6, R7, R8 and R9), since November 2022. The facility failed to develop a plan for a cold weather emergency during a weather event where temperatures were negative 7 to 8 degrees and with windchill factor was negative 40 degrees with sustained winds at 31 miles/hour and temperatures in facility resident rooms were 55 to 64 degrees. These failures resulted in residents (R1, R2, R4, R5, R6, R7, R8 and R9) to experience uncomfortable and unsafe ambient air temperatures, which placed them at risk for loss of body heat and risk of hypothermia. R1, R2, R4, R5, R6, R7, R8 and R9 are one of 10 residents reviewed for safe, comfortable heating conditions, in a sample of 10. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 12/23/22 when residents were found to be residing in rooms where ambient temperatures were 63 degrees. On 12/25/22 at 10:45 A.M. V1 (Administrator in Training) was notified of the Immediate Jeopardy. While the immediacy was removed on 12/27/2022, the facility remains out of compliance at a Severity Level Two, as the facility implements the following: continued education of all facility staff on the facility Cold Weather Policy and Evacuation Plan. Every 15-minute ambient room air temperature checks and documentation. Continued monitoring of all residents for safety and comfort level. A review of the facility Heating System and implementation of necessary recommendations by a licensed Heating/Plumbing Company. The development of a facility QAPI plan to address Cold Weather Advisory and facility continued compliance. FINDINGS INCLUDE: The (undated) facility policy, Cold Weather Policy and Procedure directs staff, It is the policy of (Company) to provide continuing, safe and comfortable care to its residents in the event the facility power source becomes non-operational or the facility heating, and furnace systems fail during periods when unseasonably cold outside temperatures are present and such systems are required for resident safety and comfort. If the heating systems fail, facility personnel shall take the following action: Either the Administrator, DON (Director of Nurses) or nurse in charge will coordinate the response. A staff member will be designated to call the local Electric Department to determine the cause of the problem and the duration of the outage. If the problem is determined to be in the facilities own heating systems, the Maintenance Man or the Administrator will determine the appropriate course of action. Staff will be assigned to bring all residents to the central core of the building. Staff will collect all blankets in the facility and distribute extra blankets to all residents as needed. Staff will keep all doors and windows closed to retain as much heat as possible. Staff will be assigned to do 10-minute checks on all residents to determine their safety and comfort level. Staff will be assigned to do 15-minute temperature checks throughout all areas of the building. If the core temperatures of the area occupied by the residents and staff drops below 65 degrees, the facility will immediately implement the evacuation procedures outlined in the Facility disaster Plan. The (State Agency), Physicians, Families and Responsible parties will be notified as required by statue. On 12/23/22 at 3:10 P.M., R3 was seated in wheelchair in the facility B/C Hall Dining Room/Family Room with a coat on, watching the facility television. At that time, the air temperature was recorded as 59 degrees. R3 stated, It's cold in here (facility). It has been since earlier this week, but it's really bad now. Even though it's cold, I watch television out here, so I don't disturb my roommate. On 12/23/22 at 3:20 P.M., R3 was seated in a wheelchair in (Room AAA) resident room, on the facility C-Wing and stated, I know it's cold out there. The bathroom that we have to use, is freezing. It gets cold in this room, too. Only half of my register gets warm. Current air temperature recorded as 68 degrees. R3's roommate (R10) was seated on his bed wearing a hooded sweatshirt, pants, and socks. R10's hooded sweatshirt had the hood pulled up, covering R10's head. R10 had his hands in the pockets of his sweatshirt. At that time R10 stated, I'm freezing. It is so cold in here. On 12/23/22 at 3:21 P.M., the air temperature in the shared C-Hall Bathroom/Shower room was recorded as 67 degrees. On 12/23/22 at 3:25 P.M., the air temperature in facility Main Dining Room was recorded as 68 degrees. At that time, R2 was seated at table in MDR with two shirts on, pants, socks, shoes, and a winter coat. R2's hands were cold to the touch. R2 kept repeating, It's cold. I'm cold. On 12/23/22 at 3:26 P.M., V3 (Maintenance Director) stated, I have been the (facility) Maintenance Director for the past four months. We have been having some problems with cold (resident) rooms and even hallways, since about Monday or Tuesday (December 20, 2022/December 21, 2022). I have spent the night, the past two nights to make sure we don't lose heat altogether. Some of the windows are old and the cold air comes in. I have been putting up plastic on windows to try and cut down on some of that. Some of the PTAC Units (Packaged Terminal Air Conditioners- a type of single unit in a resident room that provides air conditioning or heat) on the Pathways Unit, have blown motors. The Heating and Cooling Company was out here in November and diagnosed the problem. The estimate to replace the units has been sent to the Corporate Maintenance Director (V5). I haven't heard anything more on it. I have been checking the generator periodically, but I haven't kept any records of those checks. I didn't know I needed to. I don't know anything about a Facility Cold Weather policy or what that involves. On 12/23/22 at 3:32 P.M., the air temperature at facility Pathways Hall Nurse's Station was recorded as 68 degrees. On 12/23/22 at 3:35 P.M., the air temperature in (facility) room AAB was currently 71 degrees. R5 was dressed in pants, shirt, coat, socks, and shoes. At that time, R5 stated, It has been so cold in here (facility) for the past three days. My room (Room AAC) was freezing. I just got moved. I was in one of the rooms where the register (heat) didn't work. I finally got moved, but the hallways are still cold. And nobody has had a shower because it's too cold. They need to get this fixed. On 12/23/22 at 3:46 P.M., the Pathways Hall Therapy Room air temperature was recorded as 65 degrees. And at 3:47 P.M., the Pathways Hall Dining Room air temperature was recorded as 64 degrees. On 12/23/22 at 3:48 P.M., the Pathways Hall, Room (AAD) air temperature was recorded as 67 degrees. R4 was seated in wheelchair at the side of the bed with a long-sleeved top, long pants, slippers and a thick coat that was zipped up with the hood pulled up. At that time, R4 stated, It's cold in here. It's been cold for the past few days. The register in my room doesn't work. On 12/23/22 at 3:49 P.M., the Pathways Hall, Room (AAE) air temperature was recorded as 67 degrees. R9 was seated in a wheelchair in the room with a tablet in her hand. R9 was wearing a shirt, pants, winter coat with hood up, shoes and socks . At that time, R9 stated, It's too cold. On 12/23/22 at 3:55 P.M., V1 (Administrator in Training) stated, We knew we were having some heating problems, back in November. We called (heating company) and they came out but said because we have boiler heat that we needed to call (another heating company). The tech (technician) came out some time in November and said the reason those first few rooms (room AAD- room AAF) were so cold is that the heater motors were bad. I don't have a copy of the visit. I forwarded it on to (V5 Corporate Maintenance Director). Evidently, they have been having trouble getting the motors for those units. I have never heard back from them. I think (V5 Corporate Maintenance Director) is taking care of it. It was cold in some of those rooms, and we started moving residents today, to other rooms. (V3 Maintenance Director) has been putting plastic on some of the resident room windows. I don't know if we have a cold weather policy. I will check and see. On 12/23/22 at 4:38 P.M., V4 (Heating Company Technician) stated, I am aware of the situation at (facility) with the PTAC (Packaged Terminal Air and Heating Units) in the resident rooms, back on the south hall (Pathways Hall). They are older and most of them have the motors blown. They won't produce any warm air for those rooms. The boss of the company has been working on trying to locate some used units. We gave the facility an estimate for new units for three rooms. They run around thirty-five hundred dollars each. No one has given us the go ahead to order new ones yet. We were out to the facility in November, I can't remember the exact date. I can get you a copy of the invoice from that visit, but it won't be until Tuesday (December 27, 2022). On 12/23/22 at 4:55 P.M., V1 (Administrator in Training) stated, I guess we do have a cold weather policy. Evidently (V8) sent it out to all of us, earlier this week. I haven't been having my staff do 10-minute checks on residents for safety and comfort, but I can start that. I also haven't been doing 15-minute temperature checks throughout the building. I can start that, too. On 12/23/22 at 5:20 P.M., V8 (Registered Nurse/Regional Corporate Staff) stated, This (facility) does have a Cold Weather policy. I sent them out to all the facilities earlier this week. When the heating system in the facility isn't working properly, staff are to do 10-minute checks on all residents for safety and comfort level and 15-minute temperature checks throughout all areas of the facility. I don't know why this policy wasn't began when we noticed how cold some of the resident rooms were. On 12/23/22 at 5:28 P.M., the Pathways Hall, Room AAF air temperature was recorded as 63 degrees. R6 was seated in an electric wheelchair, in the hallway, outside of room AAF. At that time R6 stated, It's been cold in this building all week. It's miserable. The unit in my room doesn't work. I only go in there to sleep. On 12/24/22 at 7:20 A.M. the air temperature in the B/C Hall Dining Room was recorded as 66 degrees. The air temperature in the facility C Hallway as recorded as 66 degrees. At that time, V9 (Certified Nursing Assistant/CNA) was seated in the B/C Hall Dining Room. V9 (CNA) was dressed in clothing, with a winter coat with the pulled hood up and boots. V9 stated, I worked 12 hours last night, starting at 6:00 P.M. I am waiting for my ride to pick me up. It is cold in here. It has been cold for a few days now. We try and keep the residents as bundled up as we can. We only have so many blankets to give them. We encourage them to stay in bed and eat. On 12/24/22 at 7:25 A.M., the facility thermostat in the Main Dining Room, was set at 73 degrees, and currently registered 68 degrees. The thermostat in the Pathways Hallway, across from the Nurse's Station was set on 79 degrees, and currently registered 68 degrees. On 12/24/22 at 7:28 A.M., the Pathways Hall, Room AAD air temperature was recorded as 67 degrees. R4 was in bed sleeping with multiple blankets on the bed. A portable, electric space heater was running in the room, with the temperature set at 81 degrees. On 12/24/22 at 7:30 A.M., the Pathways Hall, Room AAF air temperature was recorded as 64 degrees. The room PTAC Unit was cold to the touch. R1 was up in a wheelchair in the room. At that time, R1 stated, I am cold. This room is too cold. I would move to a different room, if someone asked me. On 12/24/22 at 7:32 A.M., V6 (Licensed Practical Nurse/LPN) was taking air temperatures with a gray/orange inferred thermometer on the Pathways Hall. At that time, V6 stated, I have been told to use this thermometer to check random room temperatures every 15 minutes and write them on this log. This is the first time I have done this. I don't know if I'm supposed to call (V1 AIT) with the results or not. I was just told to log them. At that time a review of the facility Room Temp (temperature) Log, dated 12/23/22 beginning at 6:00 P.M. documents that at 10:00 P.M. on 12/23/22 the air temperature in the Pathways Hall, Room AAD as 60.8 degrees. At 10:15 on the same date, the air temperature of the Pathways Hall, Room AAF was recorded as 55.4 degrees. Both of these temperatures were obtained by a staff member. This same staff member recorded the air temperature on 12/24/22 at 3:15 A.M. on the Pathways Hall, Room AAG as 61.4 degrees; at 4:00 A.M. on the Pathways Hall, Room AAF as 63.7 degrees and on 12/24/22 at 4:30 A.M. on the Pathways, room AAF as 63.8 degrees. These recorded temperatures were verified with V6. On 12/24/22 at 7:33 A.M., the Pathways Hall, Room AAH air temperature was recorded as 64 degrees. On 12/24/22 at 7:55 A.M., V1 (Administrator in Training) was reviewing the Pathways Hall Room Temperature Log and was observed with an ink pen, writing on the document. AT 7:58 A.M., V1 left the Pathways Hall. A review of the Pathways Room Temperature Log, at that time with V6 (LPN) present, documents the recorded temperatures on 12/23/22 at 10:00 P.M. and 10:15 A.M. were changed to 68.8 degrees and 65.4 degrees, respectively. The recorded air temperatures for 12/24/22 at 3:15 A.M. had been changed to 68.4 degrees, the 4:00 A.M. air temperature was changed to 68.7 degrees and the 4:30 A.M. recorded air temperature had been changed to 68.8 degrees. At that time V6 stated the Pathways Room Temperature Log had been in her possession from 6:00 A.M., until V1 (AIT) took possession of the document at 7:55 A.M., while V6 was present. V6 denied changing the recorded temperatures on the Pathways Hall Room Temperature Log. On 12/24/22 at 8:30 A.M., V7 (CNA) verified she had taken air temperatures for the facility Pathways Hall rooms on 12/23/22 at 10:00 A.M. and 10:15 A.M. and on 12/24/22 at 3:15 A.M., 4:00 A.M. and 4:30 A.M. and the current air temperature recordings had been changed to reflect warmer temperatures. V7 states, It was 55 degrees at 10:15 (P.M.) in room AAF. I reported it to the nurse. You can see where someone changed the temperatures on the log. On 12/24/22 at 8:45 A.M., V1 (Administrator In Training) stated, I was called three times in the night, last night, for different things. I don't remember if I was notified of fifty-five-degree air temperatures in a resident's room. I looked at the Pathways Room Temperature Log this morning. We are planning to move (R1 and R4) today. Their rooms are too cold. We moved (R9) yesterday. On 12/28/22 a letter to the facility from the (local HVAC) company documents, In reference to the service call we were called out on to (facility), on 11/18/2022, we have not invoiced the job yet but offer the following information. #1. The original call was for a boiler problem. I don't know if this was just a miscommunication, or what, but it wasn't the boiler. What we found was some PTAC units were not heating properly. #2. We pulled the blower motor from the unit in the dining room, with the intentions of either getting replacement motors. The local repair shop told us that they could not find a replacement motor, and the one we had could not be repaired. We suggested to the maintenance man at the time that we could take some of the motors out of PTACS that were working in some of the nonresident areas and put them in rooms that were occupied by residents. We were told that this work was going to be put out to bid, which suggested to us that this wasn't an emergency in their minds. #3. In the meantime, we have been trying to find a replacement unit that would fit the openings of the existing PTAC units. We did find a vendor in Tennessee that quoted us a unit that appeared as though it would fit the wall sleeve of the existing PTACS. Our superintended went to the job site on 12/27/2022 to discuss the matter further with the maintenance man and found another contractor on site working on the units, so we are no longer involved with the situation. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: * All facility staff in-serviced on the facility Cold Weather Policy on 12/23/22, 12/24/22 and on 12/25/22. by Administrator. * All facility staff in-serviced on the Facility Evacuation Plan on 12/23/22, 12/24/22 and on 12/25/22 by Administrator. * Ambient room temperature checks will be initiated on 12/23/22 every 15 minutes throughout the facility and recorded by assigned facility staff. * The facility B/C Hall Dining Room will be temporarily closed due to ambient room temperatures and all residents seating arrangements for dining and Activities will be moved to the facility Main Dining Room. * Rooms AAD-AAF, on the facility Pathways Hall were taken out of operation on 12/24/22 until a review of the facility heating system by a licensed Heating/Plumbing Company and implementation of necessary recommendations. * Residents who were residing in rooms AAD-AAF were relocated to appropriate rooms on 12/23/22 and 12/24/22. * A review of the facility Emergency Preparedness Plan and Tabletop Discussion on Cold Weather Policy and Evacuation Plan was performed on 12/23/22 with the Regional Clinical Director and facility IDT. * Residents are continually being monitored by IDT and Staff throughout 12/23/22 and 12/24/22. * The facility Governing Body was notified of the facility concerns on 12/23/22 by Administrator. * On 12/27/22 Licensed Heating/Plumbing Company did a review of the facility heating system. * On 12/27/22 Necessary parts needed for Rooms AAI, AAJ, and AAF are being ordered. AAI, AAJ, and AAF will remain out of operation until said parts are delivered, installed, and in working order. * Residents returned to rooms AAD, AAE, and AAC on 12/28/2022. * Ambient room temperatures on affected rooms to continue x 3 days to assure adjustments made maintain, and then IDT to monitor during facility daily rounds for a week to be completed by assigned staff member. *In servicing of nursing staff to notify Administrator immediately if room temperatures thought to be at a less than desired temperature on 12/28/2022 by Administrator.