**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure three residents (Resident #1, #2, and #5) received treatment and care in accordance with professional standards of practice when the facility failed to provide timely lab testing with results. Two residents (Resident #2 & #5) were admitted to the hospital with septic shock. The facility also failed to obtain lab testing for one resident (Resident #1) who was without his/her psychotropic medication for fourteen days when the pharmacy would not provide the medication without lab results. The facility also failed to follow physician's orders for the resident when they did not administer psychotropic medication. The sample size was six residents. The facility census was 111. A policy regarding professional standards of care was requested but not provided. Review of the laboratory services agreement, dated 8/1/24, showed: -Lab will travel to location to draw and/or collect patient specimens for duly ordered tests and will transport the specimens to one of the laboratories for testing. -Requisition procedures: -Online: all orders will be submitted via the online order porter for order entry and test results. -Written requisitions: Facility shall use laboratories pre-printed requisition form which must be properly completed by facility and delivered to the laboratory representative by hand at the time of specimen collection. -Reporting procedures: laboratory shall make test results available to facility via the online order portal. Review of facility policy, titled Test Results Notification, dated 12/2024, showed: -Results of laboratory, radiological, and diagnostic tests shall be reported to the facility. The medical practitioner shall be notified of the results. -The medical practitioner shall mark labs as reviewed in the electronic health record. -Director of Nursing or their designee will review results of laboratory, radiological, and diagnostic tests daily. -Any lab result not marked as reviewed by the medical practitioner will be called to the practitioner. Documentation of the notification will be done in the electronic health record. -All other radiological and diagnostic test results will be called to the practitioner. Documentation of the notification will be done in the electronic health record. 1. Review of Resident #2's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 12/13/24, showed: -He/She had severe cognitive impairment; -Total care of all activities of daily living; -Diagnoses included: Alzheimer's disease with late onset (a neurodegenerative disease that affected the brain and caused memory and language problems) dementia, anxiety disorder, depression, insomnia due to other mental disorder, and palliative care (a specialized approach to medical care that focuses on improving the quality of life for people with serious illness). Review of the resident's care plan, revised 12/9/24, showed: -He/She received end of life hospice services; -He/She was at risk for septicemia (a life threatening condition where bacteria or other microorganisms enter the bloodstream and spread throughout the body) and will be minimized and prevented via prompt recognition and treatment symptoms of urinary tract infection (UTI) through review date; -Monitor and document for signs and symptoms of UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns; -He/She was on antibiotic therapy, macrobid until 11/18/24 due to UTI; -Administer antibiotics as ordered; -He/She had communication problem due to hearing deficit and cognitive decline; -Monitor, document for physical or nonverbal indicators of discomfort or distress and follow up as needed. Review of the hospice physician's order showed: -11/12/24 at 2:01 P.M., patient showed signs of UTI - delirium, low grade fever, restless and stated he/she hurt and burns in his/her genital area, the physician ordered macrobid 100 mg twice daily for 5 days; -11/22/24 at 2:15 P.M., patient had persistent diarrhea, the physician ordered a TSH (thyroid-stimulating hormone) test (a test that measures thyroid-stimulating hormone in your blood) and C-diff (clostridioides difficile) (a test that measures a bacterium that can cause diarrhea, colitis, and other intestinal conditions). Review of the facility hospice book showed: -On 11/22/24, hand written note from nurse showed he/she provided facility new orders for C-diff and TSH; -On 11/26/24, hand written note from nurse showed he/she provided facility new order for KUB (kidney, ureter, and bladder (KUB) X-ray) to rule out obstruction; -On 12/3/24, note showed provided facility hand written orders on third party form. Review of lab requisition standing order log from 11/1/24-12/30/24, showed no orders on the requisition log for the resident. Review of the resident's progress notes, dated 12/1/24-12/30/24, showed: -On 12/3/24, Assistant Director of Nursing (ADON) wrote resident had been screaming since yesterday and yelling out and had been incontinent of urine several times; -On 12/18/24, Licensed Practical Nurse (LPN) A wrote he/she spoke to hospice nurse who stated she ordered labs to be completed in November and they were not carried out, so nurse entered lab as they had been ordered. -On 12/22/24, Certified Medication Technician (CMT) B heard resident yelling and found the resident on the floor wedged between the nightstand and side of his/her bed at 7:40 P.M.; -On 12/23/24, ADON wrote alerted of resident's swelling to face. He/She assessed resident and found resident to have significant swelling redness, warmth to right side of face and face was firm to touch. Resident was observed leaning forward in Broda chair moaning. Notified hospice and hospice nurse called charged nurse stating the facility could send the resident to hospital. Charge nurse notified him/her, and he/she contacted nurse practitioner (NP). NP ordered radiographic images (xrays) and to start resident on doxycycline (antibiotic used for bacterial infections) 100 mg twice daily for seven days. Xray orders were entered and physician rounded on resident during the xrays. -On 12/23/24, Physician wrote saw resident after being requested by nursing due to resident having a fall overnight. Facility staff think resident landed on their face first and possibly more on right side. Patient observed bent forward in Broda chair all night. Hospice was notified and instructed facility to place resident in common area. On call was notified and instructed to be sent to hospital. Resident observed yelling help repeatedly. Resident was difficult to reposition in reclining position for full physical, but face had extensive edema and right eye edematous and shut. Nurse indicated they had given resident morphine twice during morning. The xray tech came to evaluate and it took three people to hold resident in reclined position in order to obtain plain films of face. He/She reviewed three views of x-ray at patient's side, but was difficult to study due to movement. He/She saw a possible nasal bone fracture which could have contributed to resident's facial swelling. Discussed giving ativan and morphine together at resident's next dose and reposition. He/She attempted to contact hospice nurse to discuss, but could not get through so evaluated resident independently. -On 12/23/24, ADON wrote resident sent to hospital per hospice; -On 12/23/24, ADON wrote resident had UTI and the hospital was going to start resident on a round (treatment of) of IV antibiotics. He/She spoke to resident's representative and representative shared his/her concern with the amount of UTIs resident had since last hospitalization in September. He/She expressed concern that antibiotic was not doing anything for resident's UTI. -On 12/26/24, Director of Nursing (DON) wrote resident continued hospitalization, receiving IV antibiotics for UTI. Review of hospital medical record, dated 12/27/24, showed: -Resident was admitted to hospital on 12/23 with altered mental status, found to be septic (blood infection), pneumonia, MSSA bacteremia (methicillin-susceptible staphylococcus aureus) (a type of bacteria that is sensitive to antibiotic methicillin), and a UTI; -Hospital labs showed on 12/23/24 at 12:36 P.M. that his/her white blood count (WBC) was 37.21 (above a normal white blood count range is 4.5-11.0 in adults); -He/She was treated with IV antibiotics, ancef (cefazolin) (an antibiotic used to treat bacterial infections); -Anticipated discharge from the hospital was 12/31/24. During an interview on 12/29/24 at 9:16 A.M., the resident's representative said: -He/She told facility and hospice three weeks ago the resident probably had a UTI due to his/her change in mental status of being more foggy; -Hospice staff reported they ordered a test for a urinalysis (UA) three weeks before the facility put lab orders in; -The hospice case worker reported to the resident's representative the hospice orders had not been carried out by the facility. -Now Resident #2 was hospitalized with an infection in his/her blood, UTI, and pneumonia; -The hospital had to place the resident on an antibiotic and stated it was going to take three to six weeks to treat the infection in his/her blood; -The hospital stated they may have to put a PICC line (a long, flexible tube that is inserted into a vein in the arm or neck and threaded into a large vein above the heart) in Resident #2. During an interview on 12/30/24 at 3:54 A.M., Certified Nurse Aide (CNA) A said: -He/She reported to the nurse a change in condition with the resident when his/her speech became unclear and he/she had a different look in the face; -He/She usually had clear speech; -He/She noticed a change in condition on Saturday 12/21/24, the same day resident fell out of his/her bed; -He/She was now in the hospital with a UTI. During an interview on 12/29/24 at 4:01 A.M., Licensed Practical Nurse (LPN) A said: -He/She contacted the hospice nurse one day about the resident; -During a call with the hospice nurse, he/she wanted to know the results of the resident's labs; -He/She could not locate the lab orders or that the labs were ever entered into the electronic medical system; -He/She found orders written in the hospice book; -During the last two weeks the resident's yelling and restlessness had increased significantly; -The resident's family member said when the resident got like this, it was because they usually had a UTI; -A UA was completed a month ago, but they had still not received the results from the lab; -The resident was hospitalized for a UTI and was septic. During an interview on 12/31/24 at 12:36 P.M., the ADON said: -Hospice had collected the resident's urine around 12/23/24; -The UA was ordered 12/23/24 at the same time the KUB was ordered for the resident; -The requested lab was completed before the resident went to the hospital; -The results were never received for these labs; -Hospice staff did not have access to facility electronic medical records or the laboratory results. During an interview on 12/31/24 at 2:33 P.M., the Hospice Registered Nurse (RN) Case Manager, said: -There were several lab orders that he/she had written and provided to a facility nurse and wrote in the resident's hospice binder; -He/She would ask for results and the nurse on duty would not have access to the lab system to provide the results; -He/She requested the UA on 11/12/24 and started empirically (by means of observation) treating the resident due to a low grade fever and restlessness; -He/She placed a request for TSH and second request for C-diff on 11/22/24; He/She had ordered the same testing in October, but the labs had not been done; -He/She would write new orders down on the facility form that was titled facility's third party and that form was handed to the facility charge nurse with any new orders he/she provided the facility with; -He/She made C-Diff lab request on 11/22/24; -He/She ordered TSH and C-Diff on 11/26/24; -He/She never received the results for the TSH or the C-Diff; -He/She did not have access to the facility electronic medical record system or the lab system records. 2. Review of Resident #5's Discharge MDS, dated [DATE], showed: -discharged to short-term general hospital; -Return anticipated. Review of Resident #5's entry tracking record MDS, dated [DATE], showed he/she entered from short-term general hospital stay. Review of Resident #5's admission MDS, dated [DATE], showed: -He/She was cognitively intact; -He/She had clear speech, able to make self-understood and understand others; -He/She was dependent in a wheelchair; -He/She was depending for toileting hygiene; -Diagnosis included UTI, pneumonia (an infection of the lungs), paraplegia (condition resulting in loss of muscle function and sensation in the lower half of the body), sepsis (a life-threatening medical emergency that required immediate medical care), and bacteremia (bacteria in blood stream). Review of the resident's care plan, revised 12/24/24, showed: -Monitor and document for signs and symptoms of UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns; -He/She had hypothyroidism; -Obtain and monitor lab/diagnostic work as ordered. Report results to medical doctor and follow up as indicated; -He/She was on antibiotic therapy-sepsis until 1/29/24; -Administer medications as ordered. Review of lab requisition standing order log from 11/1/24-12/31/24, showed: -On 11/22/24, UA with urine culture was ordered, a note was made that it was not ready by the phlebotomist; -On 11/27/24, UA was picked up and signed for by phlebotomist; -On 12/4/24, UA with urine culture, signed by phlebotomist with note that it was not ready. Review of laboratory reports showed: -On 11/26/24, a UA was collected, it was reported 12/3/24 a problem with sample integrity; -On 12/5/24, a UA was collected and was reported on 12/9/24 report was 5 days after specimen collection. During an interview on 12/31/24 at 11:33 A.M., NP B said: -The resident and his/her spouse came to him/her two weeks before going to the hospital and indicated he/she had foul smelling urine; . -The resident requested a UA so they could ensure they did not have a bladder infection; -He/She developed a plan with facility staff in order to complete straight catheter specimen collection due to complexity of resident's paraplegia and their inability to retain urine during transfers via mechanical lift; -The specimen was collected and something happened with the lab where the specimen was not labeled correctly and the specimen was not processed; -A week and a half later he/she still did not have the lab results; -The resident was hospitalized [DATE]-[DATE] for UTI with sepsis. -Every time the resident had a UTI he/she would go septic and go to hospital; -He/She ended up becoming septic and was hospitalized again; -He/She was currently receiving intravenous line (IV) antibiotics in the hospital. During an interview on 12/31/24 at 12:36 P.M., the ADON said: -The resident could turn septic really quickly; -The resident was sent to hospital before his/her UA results were received; -It can almost be too late by the time the facility collects the UA specimen and results were received from the lab; -He/She was unaware of any delay in collection for this resident's UA samples. 3. Review of Resident #1's Quarterly MDS, dated [DATE], showed: -He/She was cognitively intact; -He/She had clear speech, was able to make self-understood and understand others; -Diagnoses included: Schizoaffective disorder (a mental health condition that combines symptoms of schizophrenia and a mood disorder), overactive bladder, need for assistance with personal care, personality disorder, anxiety disorder (a mental health condition characterized by excessive worry, fear, and nervousness that can interfere with daily life), depression, and bipolar disorder (a chronic mood disorder that causes intense shifts in mood, energy levels, and behavior). Review of the resident's care plan, revised 12/18/24, showed: -He/She had depression, anxiety, bipolar, and schizoaffective disorder; -Clozapine (a medication used to treat schizophrenia) treatment had caused severe neutropenia, defined as an absolute neutrophil count (ANC) (a blood test that measures the number of neutrophils in the blood) less than 500/mm3. Severe neutropenia can lead to serious infection and death. Prior to initiating treatment, a baseline ANC must be at least 1,500/mm3 for the general population and must be at least 1,000/mm3 for patients with documented benign ethnic neutropenia (BEN). During treatment, patients must have regular ANC monitoring. Advise patients to immediately report symptoms consistent with severe neutropenia or infection (fever, weakness, lethargy, sore throat). -Because of risk of severe neutropenia, clozapine is available only through restricted program under a risk evaluation mitigation strategy called Clozapine REMS program. -Administer medications as ordered. Monitor/document for side effects and effectiveness. -Monitor/document/report to NURSE/MD signs and symptoms of depression, including: hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive anxious or health-related complaints, tearfulness. Review of physician's orders, dated 12/30/24, showed: -Ordered 10/11/23, clozapine oral tablet 50 mg tablet, give 1 tablet by mouth daily at bedtime; -Ordered 10/12/23, clozapine oral tablet 25 mg, give 1 tablet by mouth one time a day for schizoaffective disorder; -Ordered 12/17/24, weekly complete blood count with differential (CBCD) lab for clozapine. Review of the resident's electronic progress notes, dated 12/1/24-12/30/24, showed: -On 12/17/24, CMT B wrote, clozapine oral tablet 50 mg, give 1 tablet by mouth at bedtime for schizoaffective disorder, medication was not in stock. Pharmacy was waiting on labs. The ADON was aware; -On 12/17/24, CMT A wrote, clozapine oral tablet 25 mg, give 1 tablet by mouth one time a day for schizoaffective disorder, waiting on pharmacy to deliver medication, charge nurse and unit manager aware; -On 12/18/24, CMT A wrote, clozapine oral tablet 25 mg, give 1 tablet by mouth one time a day for schizoaffective disorder, waiting for lab to draw blood, then needed to fax pharmacy results. Charge nurse and unit manager notified; -On 12/18/24, CMT A wrote, clozapine oral tablet 25 mg, give 1 tablet by mouth one time a day for schizoaffective disorder, medication unavailable, waiting for lab results to send to pharmacy, charge nurse, unit manager, and medical doctor aware; -On 12/19/24, CMT B wrote, clozapine oral tablet 50 mg, give 1 tablet by mouth at bedtime for schizoaffective disorder, this medication was not in stock, pharmacy is waiting for labs. The ADON was made aware; -On 12/19/24, CMT A wrote, clozapine oral tablet 25 mg, give 1 tablet by mouth one time a day for schizoaffective disorder, still waiting for lab results to fax to pharmacy; -On 12/21/24, CMT B wrote clozapine oral tablet 25 mg, give 1 tablet by mouth one time a day for schizoaffective disorder. This medication was not available until the patients' labs were give to the pharmacy, the ADON was made aware; -On 12/22/24, CMT B wrote, clozapine oral tablet 25 mg, give 1 tablet by mouth one time a day for schizoaffective disorder, this medication was not available, labs were needed; -On 12/22/24, CMT B wrote, clozapine oral tablet 50 mg, give 1 tablet by mouth at bedtime for schizoaffective disorder, this medication was not available in stock, pharmacy needed a copy of the labs; -On 12/23/24, CMT A wrote, clozapine oral tablet 25 mg, give 1 tablet by mouth one time a day for schizoaffective disorder, still waiting on pharmacy to deliver, charge nurse, unit manager, and medical doctor aware; -On 12/24/24, CMT A wrote, clozapine oral tablet 25 mg, give 1 tablet by mouth one time a day for schizoaffective disorder, waiting on lab results to fax to pharmacy, charge nurse, unit manager, and medical doctor aware; -On 12/24/24, CMT B wrote, clozapine oral tablet 50 mg, give 1 tablet by mouth at bedtime for schizoaffective disorder. This medication was not available until labs were received, the ADON is aware of this; -On 12/25/24, CMT A wrote, clozapine oral tablet 25 mg, give 1 tablet by mouth one time a day for schizoaffective disorder, still waiting for delivery from pharmacy, charge nurse, unit manager, and medical doctor aware; -On 12/25/24, CMT B wrote, clozapine oral tablet 50 mg, give 1 tablet by mouth at bedtime for schizoaffective disorder, this medication was not available until pharmacy received labs; -On 12/26/24, CMT C wrote, clozapine oral tablet 25 mg, give 1 tablet by mouth one time a day for schizoaffective disorder not available; -On 12/26/24, CMT B wrote, clozapine oral tablet 50 mg, give 1 tablet by mouth for schizoaffective disorder, this medication is not available until labs have been received; -On 12/27/24, CMT A wrote, clozapine oral tablet 25 mg, give 1 tablet by mouth one time a day for schizoaffective disorder, still waiting on pharmacy to deliver, charge nurse, unit manager, and medical doctor aware; -On 12/27/24, CMT B wrote, clozapine oral tablet 50 mg, give 1 tablet my mouth at bedtime for schizoaffective disorder. This medication was not available, until pharmacy has new labs; -On 12/28/24, CMT A wrote, clozapine oral tablet 25 mg, give 1 tablet by mouth one time a day for schizoaffective disorder, waiting on lab results, charge nurse, unit manager, and medical doctor aware; -On 12/28/24, CMT B wrote, clozapine oral tablet 50 mg, give 1 tablet my mouth at bedtime for schizoaffective, this medication was not available at this time, new labs were needed; -On 12/29/24, CMT A wrote, clozapine oral tablet 25 mg, give 1 tablet by mouth one time a day for schizoaffective disorder, still waiting on lab, charge nurse, unit manager, and medical doctor aware; -On 12/29/24, CMT B wrote clozapine oral tablet 50 mg, give 1 tablet by mouth at bedtime for schizoaffective disorder, this medication was not available at that time, the pharmacy was needing updated labs; -On 12/30/24, CMT C wrote, clozapine oral tablet 25 mg, give 1 tablet by mouth one time a day for schizoaffective disorder, not available; -On 12/30/24, CMT B wrote, clozapine oral tablet 50 mg, give 1 tablet by mouth at bedtime for schizoaffective disorder, this medication was not available, new labs were needed. Review of the lab requisition standing order log, dated 12/1/24-12/30/24, showed: -On 12/9/24 a CBC with differential was ordered, there were no initials entered by phlebotomist that these labs were obtained; -On 12/16/24 a CBC with differential was ordered, there were no initials entered by phlebotomist that these labs were obtained; -On 12/28/24 a UA with urine culture was ordered, there were no initials entered by phlebotomist that this specimen was obtained; -On 12/30/24 a CBC with differential was entered and were initialed that had been completed by phlebotomist; Review of laboratory reports, 12/1/24-12/30/24, showed: -On 12/3/24 CMP was collected and CBC with differential, and reported to the facility nursing staff on 12/4/24; -No other lab reports were available for December. During an interview on 12/30/24 at 2:29 P.M., the resident said: -He/She was experiencing itching, burning and his/her urine looked like lemonade; -He/she and needed another lab to be done; -The nurse on duty working on Friday night (12/27) was going to take urine for his/her labs to be complete, but the facility did not have any urine specimen containers; -He/She was put on ciprofloxacin (an antibiotic used to treat infections) a month ago; -He/She did not know if the facility ever received his/her lab results; -He/She had been without his/her clonazepam for two weeks; -He/She saw his/her psychiatric doctor two weeks ago and he/she had been without the medication since then; -He/She had felt more stressed, had not been slept well, had cringed his/her teeth which made his/her jaw and forehead hurt since not having his/her psychotropic medication. During an interview on 12/30/24 at 4:01 A.M., LPN A said: -The resident was to have labs completed one time weekly for psychotropic medication clozapine; -The last lab for the resident was last completed on 12/4/24; -CMT A had reported this to him/her several times; -The lab had still not come out and drawn his/her labs; -The online laboratory system showed nothing in lab reports to be viewed or pulled up for the resident. During an interview on 12/30/24 at 2:47 P.M., the DON said: -The resident had not received his/her psychotropic medications due to the lab never made it on Friday and never collected labs on the resident; -The facility notified the lab regarding the failed pick up and the physician was made aware. During an interview on 12/31/24 at 11:02 A.M., CMT A said: -The resident had been without his/her clonazepam for approximately two weeks; -He/She notified all the nurses; -The pharmacy would only send five medications at a time; -The pharmacy wanted weekly lab draws in order for staff to provide medication; -The resident's last lab draw was on 12/3/24; -The resident had been restless during the night; -He/She had not observed any other behavior changes in the resident; -The psychiatrist was notified regarding the medication; -He/She had contacted the pharmacy every day regarding the medication; -The clonazepam was not available in the facility emergency medication storage system to provide to the resident. During an interview on 12/31/24 at 12:36 P.M., the ADON said: -The NP changed his/her laboratory orders to monthly in November; -He/She talked with the pharmacy and pharmacy said the way the medication was ordered it required weekly laboratory results; -The NP changed the lab orders to weekly; -The labs were on requisition for labs to be obtained on 12/9 and 12/16, but were not drawn by the phlebotomist and there was no reason from the lab on why the requisition was left blank; it was not done. During an interview on 12/31/24 at 1:19 P.M., the Psychiatrist office manager said: -The resident was last seen on 12/16/24 in the office; -The facility had not notified the physician about any issues with the resident being able to obtain his/her clonazepam; -That call was the first time their office was made area aware of any issues with the resident not receiving the clonazepam. During an interview on 1/2/25, the Psychiatrist said: -He/She changed the lab order to be completed monthly during the resident's last appointment; -He/She provided a printed lab order to the resident during his/her visit on 12/16/24; -Possible results of the resident not receiving his/her medication included mood changes, manic episodes, and a risk of psychosis. 4. During an interview on 12/30/24 at 4:01 A.M., LPN A said: -The facility had a new lab, they are supposed to pick up labs 2:00-3:00 A.M. on Mondays, Wednesday, and Friday; -If labs were ordered stat (immediately), the lab was [NAME] (late); -Each unit in the facility has a soiled utility room with a fridge and laboratory staff know to come check refrigerators if there are urine samples to be picked up. on 11/21/24 inquiring why he/she had so many UA orders at the same time. -He/She contacted the nurse practitioner about not having the lab results and if he/she should recollect the UAs; -The DON and ADON contacted him/her via text message on 11/21/24 after she put in new UA orders and wanted to know why all the orders had been entered for so many residents; -He/She notified DON/ADON that residents were still experiencing symptoms and no lab results were found. During an interview on 12/30/24 at 5:48 A.M., RN A said: -There was issues with stat lab orders as the lab did not respond as they should for stat labs. During an interview on 12/31/24 at 9:40 A.M., NP A said: -There had been a delay in treatment for residents in the facility due to issues with the laboratory company; -The delay in laboratory results had especially impacted residents with UTIs having delayed treatments, and even hospitalization. During an interview on 12/30/24 at 2:47 P.M., the DON said: -She was aware of the issues with laboratory services; -The laboratory did not always show up as scheduled; -At times the laboratory phlebotomist will show up and say they only had time to do lab draws on five residents and then leave; -The laboratory company had promised a lot of items they had not been able to commit to. -The corporate facility staff had talked to their management team multiple times; -She expected stat lab orders to take six hours or less; -There were times that stat lab orders will be made and the laboratory will say that they cannot be to the facility until Monday morning; -The facility had advised the laboratory they were willing to pay stat fees and the facility could not get the laboratory to come out even with fees; -NP A had questioned where lab results were located and would contact the laboratory and try to locate specimens; -She expected urine specimens to be picked up within 24 hours; -The facility had to start adding CBC on all UA orders or the laboratory would refuse to pick up the UA; -She did not know where some specimens were, if they had been picked up or if specimens had been thrown away; -The facility was giving the laboratory 48 hours before they would attempt to call and track down results; -There were multiple issues with locating and obtaining laboratory results; -The laboratory came to pick up this afternoon, on Mondays the laboratory was supposed to be arriving between 2-3 A.M.; -There are some dates nothing is ever picked up by the lab company. During an interview on 12/30/24 at 3:14 P.M., the Administrator said: -He/She was aware there was issues with the laboratory including issues with labs being drawn, labs being picked up, and stat labs sometimes taking longer to obtain results; -He/She expected the laboratory to take what specimens were in the refrigerators every time they were in the facility; -He/She believed the lab came to the building [NAME] days a week; -He/She was unsure on expectation of how long stat laboratories should take; -He/She was not aware of any outcomes to residents as a result of not having laboratories drawn or test results back in a timely manner. During an interview on 12/31/24 at 10:31 A.M., Laboratory Account Manager said: -The facility was to order lab work and put in the lab requisition book; -The laboratory technician would go to the facility, get the lab requisition book and then proceed to draw the patient's labs; -Stat labs are put in by the facility and the laboratory customer service was alerted and dispatch out the orders to a technician; -Stat lab orders are processed at a local hospital; -The stat lab results are faxed to the facility, but the system was not perfect and sometimes the lab had to call the hospital to get results because the hospital's patients came first over our stat labs; -UAs are put on lab requisition orders and laboratory technicians pick up the specimens; -The laboratory turn around time for results is same day or the next morning; -If the laborat

Based on record review and interviews, the facility staff failed to maintain a safe environment for one resident (Resident #1) out of three sampled residents when Resident #1 was identified as a high fall risk and fell two times on 11/8/22 fracturing his/her right arm. The facility nurse found the resident on the floor, and told the Certified Nurse Aid (CNA) to pick the resident up from the floor. The nurse failed to assess the resident for injuries before and after the transfer from the floor to the bed. The resident had a second fall immediately after nurse left the resident's room. CNA B found the resident and picked him/her up before a nurse assessed the resident. CNA B failed to alert the nurse to that fall. On 11/14/22 the resident was in his/her room alone with the door closed. The resident fell to the floor, crawled on the floor and picked him/herself up off of the floor and pivoted into the bed. The facility census was 105. The facility did not provide a policy regarding fall prevention or a resident safety policy. 1. Review of Resident #1's quarterly Minimum Data Set (MDS, a federally mandated assessment that is completed by the facility staff) dated 10/21/22 showed: - The resident's diagnoses included: Parkinson 's disease, (a disease of the nervous system that often causes tremors, muscular stiffness, and slow unsteady body movements) and neuro cognitive disorder with Lewy Bodies, (changes in the brain that can affect thinking and movement). - The resident had a Brief Interview of Mental Status (BIMS) score of 2, indicating severe cognitive deficit. - He/she required standby assistance of staff to go to the toilet, transfer and walk. - He/she required the assistance on one staff to get dressed. - He/she had frequent falls. Review of the resident's record showed: - He/she had a fall risk assessment score of 35 on 11/8/22 and 11/14/22, indicating the resident was at high risk for falls. - His/her fall care plan dated 4/23/22 showed the resident was identified at risk for falls due to his/her diagnoses of Parkinson's disease, cognitive loss and incontinent episodes. Ensure the resident was wearing appropriate foot wear and call light was in reach. - 1 on 1 activities while he/she was in COVID isolation. - The staff were to provide hourly visual checks to assure the resident's safety and offer assistance. - 11/8/22 6:00 P.M. Licensed Practical Nurse (LPN) A documented on a nurses note, the resident's family called the facility and reported the resident had fallen twice. The family said that the falls were seen once they reviewed video footage. The falls were reported to happen between 4:50 P.M. and 6:00 P.M. LPN A found the resident lying in his/her bed and visibly crying. The resident reported pain and LPN A administered pain medication to the resident. LPN A assessed the resident was guarding his/her right arm and swelling, and obtained an order from the physician to order an X-ray. - X-ray results dated 11/8/22 showed the resident had a right lower arm fracture. Observation of the video surveillance dated 11/8/22 and 11/14/22 showed: - 11/8/22 4:36 P.M. The resident's door was closed. The resident was in his/her room standing next to his/her bed, bent at the waist and smoothing his/her blanket. The resident then fell to his/her right side, landed on the floor. The resident fall was heard, the resident was moaning. - 4:48 P.M. The resident was still lying on his/her right side on the floor. LPN B knocked on the resident's door, the resident verbalized come in. LPN B holding a medication cup entered the resident's room, saw the resident lying on the floor. CNA A was walking by the resident's door as he/she pushed another resident in his/her wheel chair. LPN B stopped CNA A and instructed him/her to pick the resident up off of the floor. CNA A stepped behind the resident and stood the resident to a half standing position and pivoted the resident from the floor to the end of the bed by placing the resident's legs over the foot of the bed. LPN B remained in the room with the resident, was heard asking the resident if he/she was ok had fallen and if he/she was ok. The resident answered by saying he/she was tired. LPN B administered the resident's medication to him/her and exited the resident's room at 4:51 P.M. leaving the resident's door open. The resident was still sitting with his/her legs over the foot of the bed and leaned forward. The resident stood just as LPN B was out of the view of the camera of the resident's door. The resident fell to the floor a second time and landed on his/her right side with his/her right arm under the resident's right hip and hand behind the resident. The resident's head hit so hard on the floor his/her head recoiled. - 5:10 P.M. The resident was still on the floor attempting to sit up, and leaned to the right side. The resident was sitting half upright with his/her head leaning against his/her television stand. - 5:18 P.M. CNA B entered the resident's room, closed the resident's door and stepped behind the resident. CNA B grasped the resident under his/her arms as he/she stood behind the resident and stood the resident to his/her feet. The resident was unable to straighten his/her legs. The resident was heard telling CNA B that he/she was not able to walk. CNA B scoots the resident to his/her bed and sat him/her with his/her legs hanging over the foot of the bed. - 11/14/22 4:04 P.M. The resident was standing in his/her room with the door closed. The resident had his/her hands on the arms of a straight- back chair and pushed it next to his/her bed. The resident was wearing a splint to his/her right hand and forearm. The resident took a step sideways, lost his/her balance and fell to the floor hitting his/her head on the nearby walker. The resident landed on his/her right side. - 4:05 P.M. The resident pushed him/herself up to his hands and knees and crawled on the floor to the side of his/her bed. - 4:07 P.M. He/she struggled to stand on his her feet, used the straight-back chair and the bed frame and pulled him/herself up, bent at the waist, pivoted his/her hips and sat on the side of the bed. During an interview on 11/16/22 at 11:28 A.M. LPN B said: - He/she passed medications during the evening portion of his/her shift on 11/8/22. - He/she found the resident lying on the floor and instructed CNA A to pick the resident up off of the floor. - He/she quickly looked the resident over, but did not perform a head to toe assessment. - He/she was aware that he/she should have performed a head to toe assessment before the resident was assisted from the floor. - He/she was unaware of the second fall the resident had. During an interview on 11/16/22 at 10:56 A.M. CNA B said: - He/she found the resident lying on the floor in front of his/her television stand. - He/she picked the resident up off of the floor and placed him/her on the end of the bed. - He/she thought the resident was in pain. - He/she told the nurse and a couple of CNA's the resident had fallen. - The resident had frequent falls and the CNA's often picked him/her up off of the floor. During an interview on 11/16/22 at 1:34 P.M. LPN A said: - He/she was the charge nurse for the resident on 11/8/22. - He/she was not notified that the resident had either fall until 6:00 P.M. when the family reported the falls to him/her. - He/she immediately assessed the resident for injuries and found the resident lying in his/her bed, crying. - The resident did not want to move his/her right arm and LPN A saw swelling to that extremity. - LPN A obtained an order to X-ray the resident's right arm. The X-ray showed the resident had a broken right arm. - LPN B did not tell him/her of the resident's first fall until the family reported the falls to LPN A. - He/she expected LPN B to report the fall to him/her s that that he/she could have assessed the resident sooner and addressed the resident's pain sooner. - He/she expected CNA B to report Resident #1's fall immediately to him/her. - CNA B should not have picked the resident off of the floor after he/she fell before the nurse assessed the resident. - He/she expected resident falls to be reported to the charge nurse immediately. During an interview on 11/16/22 at 12:18 P.M. the Director of Nursing (DON) said: - He/she expected LPN B to perform an head to toe assessment after he/she found the resident lying on the floor and before the resident was moved. - He/she expected CNA B to notify the charge nurse immediately when he/she found the resident on the floor and before the resident was moved. During an interview on 11/16/22 at 12:43 P.M. the Administrator said: - He expected LPN B to provide the proper assessment when he/she found the resident lying on the floor. - The resident should not have been moved before the assessments were completed. - He expected CNA B to notify the charge nurse immediately when he/she found the resident on the floor. - CNA B should not have moved the resident before the charge nurse assessed him/her. MO209947