**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for 1 of 3 residents (Resident #1) reviewed unnecessary drugs. The facility failed to ensure PT/INR laboratory tests (to measure blood clotting time and thus ensure safe blood levels of the anticoagulant, warfarin) were obtained weekly as ordered for Resident #1 on 04/14/25, 04/28/25, 05/05/25, 05/12/25, 05/26/25, 06/09/25, 06/16/25 and 06/30/25. Resident #1 was presented with multiple, unexplained bruising to her face, tongue, and extremities on 07/05/25 and was hospitalized for a warfarin overdose on 07/07/25. An Immediate Jeopardy (IJ) was identified on 07/09/25. While the IJ was removed on 07/11/25, the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of adverse effects from high-risk medication such as bruising, uncontrolled bleeding, and death.Findings include: Record review of Resident #1's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included chronic atrial fibrillation (irregular heartbeat), congestive heart failure (long term condition in which the heart cannot pump blood well enough to meet the body's needs), chronic respiratory failure with hypoxia (breathing problems with low blood oxygen), chronic obstructive pulmonary disease (chronic breathing disorder), asthma, hypertension (high blood pressure), major depressive disorder, unsteadiness on feet, abnormalities of gait and mobility, dementia, fibromyalgia (long-term condition that involves widespread body pain), hyperlipidemia (high cholesterol), muscle weakness, lack of coordination, dependence on supplemental oxygen, obstructive sleep apnea (sleep-related breathing disorder), anxiety disorder, cochlear implant (electronic hearing device that provides a sense of sound to people with severe hearing loss) status, chronic migraine (headache), and mild cognitive impairment of uncertain or unknown etiology (origin). Record review of Resident #1's annual MDS reflected a BIMS score of 15, which indicated intact cognition. Resident #1 received anticoagulant medication during the 7-day lookback period. Record review of Resident #1's care plan, dated 01/10/25, reflected the following: The resident is on Anticoagulant therapy r/t A-fib. The resident will be free from discomfort or adverse reactions related to anticoagulant use through the review date. Daily skin inspection. Report abnormalities to the nurse. Labs as ordered. Report abnormal lab results to the MD. Monitor/document/report to MD PRN s/sx of anticoagulant complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, , diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB, Loss of appetite, sudden changes in mental status, significant or sudden changes in v/s. Resident/family/caregiver teaching to include the following: Take/give medication at the same time each day, Use soft toothbrush, Use electric razor, Avoid activities that could result in injury, Take precautions to avoid falls, Signs/symptoms of bleeding, Avoid foods high in Vitamin K. These include greens such as spinach and turnips, asparagus, broccoli, cabbage, Brussels sprouts, milk and cheese. Review medication list for adverse interactions. Avoid use of aspirin or NSAIDS. Record review of physician orders for Resident #1 reflected the following:-Warfarin Sodium oral tablet 4 mg- take 2 tablets one time per day for chronic atrial fibrillation start date 03/18/25-PT/INR on Mondays- one time a day every Monday due to anticoagulant use send lab order Sunday start date 06/22/25-PT/INR on Mondays- one time a day every Monday due to anticoagulant use start date 09/30/24 end date 06/21/25-Side effects to anti-coagulant medication 1) Discolored urine 2) black tarry stools 3) muscle/joint pain 5) lethargy 6) increased bruising 7) sudden changes in mental status/vitals 8) shortness of breath 9) nosebleeds. Every shift for preventative measure if side effects were noted, documentation and physician notification were required.-Diphenhydramine HCl 25 mg Benadryl, one time administration 07/07/25 Record review of Resident #1's MAR/TAR from April 2025 to July 2025 reflected the following dates were marked as complete for PT/INR04/14/25 (no corresponding laboratory test)04/28/25 (no corresponding laboratory test)05/05/25 (no corresponding laboratory test)05/12/25 (no corresponding laboratory test)05/19/25 (correlating lab test on 05/20/25)06/02/25 06/09/25 (no corresponding laboratory test)06/16/25 (no corresponding laboratory test)06/23/2506/30/25 (no corresponding laboratory test, documented by LVN K)The following dates were not marked as complete for PT/INR:04/07/2504/21/25 Record review of PT/INR results for Resident #1 reflected the following:04/07/25 PT 23.3 and INR 2.104/21/25 PT 34.5 and INR 3.405/20/25 PT 28.1 and INR 2.606/02/25 PT 35 and INR 3.506/23/25 PT 30 and INR 2.8(Note: A normal INR range for people who take warfarin is 2-3 but can vary from patient to patient. Patients who tend to clot more easily may have an INR target range of 3-4.) Review of pharmacy consultant reports for Resident #1 from January 2025 to July 2025 reflected her drug regimen was reviewed by the consultant pharmacist each month, and no recommendations were made related to her drug regimen. Record review of Resident #1's nursing progress notes reflected the following:07/05/25 at 06:15 PM, written by LVN B, resident states she has been complaining of discomfort to Left lower leg, states when she went to the restroom she noticed a dark red/purple bruise. Resident states she did not hit or bump it while transferring states where the bruise is where she had been hurting all week. Notified NP of findings no new orders at this time.07/06/25 at 02:04 PM, written by LVN E notified by family that resident had bruising on her face, left dorsal hand, thumb, wrist, LLE both front and back. Resident does not remember falling. She states I'm always in this chair. Residents VS are with in normal limits, speaks normally, but says it hurts to open her mouth and her leg hurts. Leg has some swelling refused ice pack.07/06/25 at 02:14 PM, written by LVN E resident took Tylenol with no issues07/06/25 at 05:06 PM, written by LVN E PT/INR in the morning NP checked on resident. Coumadin on hold. No Xray or hospital visit was needed at this time.07/07/25 at 01:56 AM, written by RN A Resident complained of glossitis (inflammation and swelling of the tongue). Purplish bruising on right side of tongue. Bruising also noted to left chin area, left hand, left lower posterior leg. Resident denies falling. No history recent falls noted. Vitals stable 120/69, P62, RR20, O2-94%-2L with dyspnea[shortness of breath]. EMS in route. MD, family, DON notified. Called report to ER.07/07/25 at 02:27 AM, written by RN A Benadryl Allergy Oral Tablet 25 MG (Diphenhydramine HCl) Give 1 tablet by mouth one time only for Skin Irritation for 1 Day route. MD, family, DON notified. Called report to ER.07/07/25 at 04:28 AM, written by LVN D RN called from [hospital] to ask how long we had held the resident's coumadin. Writer answered all her questions. She informed writer that the patient was receiving a dose of IV Vitamin K as we spoke and if the head CT came back negative she will be discharged . [RN] also provided me with patient's lab results. PTT: 158.9 RANGE: 22.9-36.1INR: 12.6 RANGE: CRITICAL IS GREATER THAN 6PT:96 RANGE: 12-14.707/07/25 at 10:04 AM, written by the DON Resident assessed by nurse, this nurse spoke with resident, resident denies fall, denies feeling ill, denies headache, denies SOB. Resident states her tongue is bigger than her mouth but has gotten smaller she thinks. Resident was observed drinking her coffee without difficulty stated by resident. Resident informed we would like to send her to the hospital for monitoring, resident stated she did not want to go that they won't do nothing for her. NP notified, hospital called spoke with ER nurse, she stated that her tongue was swollen while she was there, she received Vit K, and discharged back to[the facility]. PT/INR ordered for daily, Coumadin held and removed from medication cart and placed in medication room unit 4.07/07/25 at 04:35 PM, written by LVN F Warfarin Sodium Oral Tablet 4 MG, Give 2 tablet by mouth one time a day related to Chronic Atrial Fibrillation, Unspecified (I48.20) med on hold07/07/25 at 04:43 PM, written by LVN F Res has been without c/o pain/discomfort, SOB, dizziness, headache since return from ER. Drank 2 bowls of tomato soup and drank glass of tea for lunch without incident/difficulty. Res cont. to state she feels as if her tongue swelling is going down. Sitting up in [sic] recliner chair in room per usual routine. Will cont. to monitor closely for changes in condition.07/08/25 at 11:44 AM, written by RN B Patient is on bleeding precautions related to anticoagulant therapy. Daily PT/INR to monitor levels. Coumadin on hold. Patient noted to have bruising to left chin, left hand, bilateral ankles, scattered bruising on trunk, and tongue. Swelling to tongue has subsided, no issues with swallowing/eating/breathing. Patient denies any pain. VSS. 143/83 87 97.8 18 93% on RA. Record review of hospital records for Resident #1, dated 07/07/25, reflected the following: Communications: critical lab value, received at 0327 [03:27 AM], received from lab, critical results: INR 12.6/PTT158. Triage notes: from (facility); diffuse bruises. Tongue bruising/swelling. Bruise to left hand. Bruise to left jaw. Dried blood behind right ear. Bruising to left foot. Denies injury. Does not remember falling. Doctor Notes: This is a 91 Y/O F with a PMHx of dementia, afib, HTN, polyosteoarthritis, osteoporosis, urinary incontinence, HLD, COPD, asthma, abd sx, and GERD presenting to the ED via EMS from NH with a CC/O multiple bruises throughout the body. EMS reports BP of 122/83 and SP02 of 95%. EMS does not know the etiology beyond her bruises, falling, tripping, or any other trauma related injury. Diagnosis final: primary: overdose - Coumadin warfarin, additional: Ecchymosis [flat area of discolored skin], elevated INR. During observation and an interview on 07/09/25 at 07:30 AM, Resident #1 was sitting in her recliner chair having breakfast. She had a very dark bruise stretching across her left cheek and jaw and one on the wrist and thumb of her left hand. She stated, I'm doing better than I look. She said the bruises just showed up on her because she had too much blood thinner. She said she went to the hospital for two days and that was what the hospital told her. She said the bruises did not hurt anymore, though the ones on her legs did hurt at first. She lifted her pants leg and had more bruising on her left, lower leg. An attempted interview with RN A was made on 07/09/25 at 08:10 AM to by telephone. A voicemail was left. An attempted interview with LVN C was made on 07/09/25 at 08:11 AM to by telephone. The outgoing message stated the wireless customer you are trying to reach is not available. Please try again later. A second attempt was made on 07/11/25 at 09:00 AM. During an interview on 07/09/25 at 08:30 AM, LVN D stated she worked the night Resident #1 was sent to the hospital. She stated the nurses on that shift decided together to send Resident #1 to the hospital. She stated the nursing team knew Resident #1 was on Warfarin, and when they came in, Resident #1 was covered in bruises, her tongue was really swollen, and she had difficulty breathing. LVN D stated she had checked the PT/INR results and discovered that the lab test had not been done as ordered since 06/23/25. She stated they had no idea whether Resident #1 had safe levels of warfarin, and she stated she looked up the swollen and bruised tongue and saw online that it could be a symptom of warfarin overdose. The charge nurse on Resident #1's hall, LVN C, administered Benadryl (diphenhydramine HCl) thinking it might have been an allergic reaction, but the Benadryl did not help. She said Resident #1 could barely talk. LVN D stated she took some pictures of the bruising and swollen tongue for the DON. She stated they tried to find information on the shift change report, but there was nothing definite- only to hold the warfarin. LVN D stated there was an order for a PT/INR to be done the following day (Monday 07/07/25) but the lab requisition had not been completed. LVN D stated the nurses decided to call EMS and send Resident #1 out. She said she got a call from the nurse at the ER about 04:00 AM that morning (07/07/25) letting them know Resident #1's PTT was over 150 and her INR was 12.6. LVN D stated those levels were very elevated. She stated the normal reference range for someone not on warfarin was around 2 or 3. She stated the hospital RN told them Resident #1 received an infusion of vitamin K to bring the levels down. A telephone interview was attempted on 07/09/25 at 11:59 AM with LVN B (was charge nurse for administered Benadryl to Resident #1 on 07/07/25). A voicemail was left and not returned prior to 07/12/25. During an interview on 07/09/25 at 12:05 PM, the DON stated LVN E was in the facility working and a request was made for an interview. The DON stated LVN E was at an appointment. LVN E did not present herself for an interview. A telephone interview was attempted on 07/10/25 at 10:03 AM and a voicemail was left, but there was no response as of 07/12/25. The DON was asked why Resident #1's PT/INR levels were not checked weekly as ordered, and she did not answer. A telephone interview was attempted on 07/09/25 at 12:12 PM with LVN K (documented a PT/INR on Resident #1's MAR on 06/30/25). A voicemail was left and not returned prior to 07/12/25. During an interview on 07/09/25 at 02:53 PM, the NP stated she received a call from LVN E on Sunday 07/06/25 notifying her Resident #1 had unexplained bruising. The NP said she came to the facility, saw the bruising, and knew right away it was a reaction to the warfarin. She stated the bruises were small, they were not hardened, and Resident #1 stated she was not in discomfort. The NP stated she felt there was no need for emergent care, ordered a hold on the warfarin, and ordered a PT/INR to be taken the following day. She stated she was not aware Resident #1 had gone to the hospital and had not seen the results of the hospital PT/INR test. She amended her statement to say she was aware Resident #1 had gone to the hospital, but she was not aware of the results of the hospital visit. She stated the bruises looked much worse today than they had on 07/06/25. She stated the PT/INR tests should have been performed as ordered, but it was a fluke that her PT/INR values had gone up so much and so quickly. She laughed and said they could not have known there would be high PT/INR levels and the bruising and high PT/INR levels were not adverse effects, and the surveyor may not know what adverse effects meant. When asked if the increase in lab values might have been detected sooner if the PT/INR test was run on 06/30/25 as ordered, she did not answer verbally but shrugged and nodded her head yes. During an interview on 07/09/25 at 03:02 PM, the MD stated Resident #1 was on the same dose of warfarin since 03/18/25, which meant her PT/INR was stable. He stated the standard of practice was to test for PT/INR once per month in a stable patient on warfarin. He stated the goal INR for Resident #1 was 2-4. The MD stated if the PT/INR was ordered once per week, it should have been done once per week. He stated he was not notified of Resident #1 going to the ER with bruising and a swollen tongue or of her critically high PT/INR levels. He stated Resident #1 had an adverse reaction, but he still thought monthly was frequently enough to check PT/INR levels. During an interview on 07/09/25 at 04:02 PM, the DON stated prior to the investigation entrance, she had not received any hospital documentation for Resident #1 and was not aware of what had occurred. She stated she was aware Resident #1 went to the hospital, but she did not know the outcome. She stated her expectation was all orders were followed. She stated she did not know why the PT/INRs were not done as ordered for Resident #1 and she did not know why they were documented as done. She stated she did not know who was responsible for making sure the labs were done, and the side effect monitoring was completed for high-risk medications. She stated she guessed it was her job. She did not answer any more questions. During an interview on 07/29/25 at 01:46 PM, RN A stated she had left employment at the facility in mid-July 2025. She stated the procedure for intervention in a change of condition or a medical emergency was to call the NP, and if there was no answer to call the MD. She stated if there was still no answer, they were to call the NP hotline for an on-call nurse practitioner. RN A stated she spoke to the NP about sending Resident #1 to the hospital on the night of 07/07/25, so she did not need to call the MD. RN A stated that night she relied on LVN D to help her through the process, because she was new at the facility and did not know the residents as well. RN A stated what was in her progress note about that night was what was done. She stated she did not want to answer more questions.During an interview on 07/29/25 at 02:14 PM, the PHARM stated she was not aware of any problems with Resident #1's drug regimen or with the warfarin side effects that sent Resident #1 to the ER. She stated she reviewed Resident #1's meds in May/June but made no nursing or physician recommendations for follow up on PT/INR. She stated she typically looked for labs done at least monthly and Resident #1 had not had any issues with results or not getting the labs done at least monthly. During an interview on 07/29/25 at 02:42 PM, a laboratory technician stated they had an outreach group that went to the facility and picked up the requisitions in the lab books and then noted in the lab book after lab draws were completed. She stated her supervisor would be able to access details about all the other labs that had been drawn for Resident #1. She stated her supervisor was not available and took a message, which was not returned as of 08/04/25. Record review of the National Library of Medicine's website, accessed on 07/11/25, at the web address medlineplus.gov/lab-tests/prothrombin-time-test-and-inr-ptinr reflected the following definition for PT/INR: PT/INR is a blood test that measures how long it takes for a clot to form in a blood sample. PT stands for prothrombin time, which is a protein made by the liver and one of the clotting factors. INR stands for internationalized normalized ratio, which is a calculation based on PT test results. PT/INR test can be used to check for bleeding problems or to monitor the effect of medicine to prevent blood clots. Record review of an article titled Practical tips for warfarin dosing and monitoring, accessed on 07/11/25, at the web address www.ccjm.org /content/ccjom/70/4/361.full.pdf reflected the following: PATIENTS WHO TAKE WARFARIN (Coumadin) walk a tightrope between bleeding and clotting- and a hundred things can tip the balance. It's a difficult drug to use, with a narrow therapeutic index, but 60 years after it was introduced it is still the mainstay of oral anticoagulant treatment . The INR was developed in 1982 by the World Health Organization's Expert Committee on Biologic Standardization in response to variations in thromboplastin sensitivity and different ways of reporting the prothrombin time across the world.8 Inappropriate management can lead to subtherapeutic or supratherapeutic INR values, increasing the risk of acute or recurrent thromboembolic episodes or bleeding episodes, respectively. For most indications, the therapeutic INR range is 2.0 to 3.0. Exceptions are when warfarin is used for secondary prevention after a myocardial infarction or for patients with high-risk mechanical prosthetic heart valves, in which case the range is 2.5 to 3.5. Record review of an article, accessed on 07/11/25, at the web address my.clevelandclinic.com/health/diagnostics/prothrombin-time-test reflected the following: Labs measure prothrombin time in seconds based on how long it takes your blood to clot, or (more commonly) as the International Normalized Ratio (INR). The World Health Organization (WHO) developed the INR as a standardized measurement that accounts for differences in lab testing processes.The normal ranges for PT/INR results are:11 to 13.5 seconds.INR of 0.8 to 1.1.INR of 2.0 to 3.0 if you're taking warfarin. (There are some conditions for which a higher or lower target PT range is desired.). Record review of the facility's, undated, policy titled Laboratory Services and Reporting reflected the following: The facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law.Policy explanation and compliance guidelines:The facility must provide or obtain laboratory services to meet the needs of its residents.The facility is responsible for the timeliness of the services. Record review of the facility's, undated, policy titled High Risk Medications- Anticoagulants reflected the following: Policy: this facility recognizes that some medications, including anticoagulant, are associated with greater risks of adverse consequences than other medications. This policy addresses the facilities collaborative, systematic approach to managing anticoagulant therapy for efficacy and safety.Policy explanation and compliance guidelines:Anticoagulant shall be prescribed by a physician, authorized practitioner with clear indications for use. Examples include prevention and treatment of deep vein thrombosis, pulmonary embolism, atrial fibrillation with embolization, stroke, or management of myocardial infarction.Target symptoms, (i.e. lab values) and goals for use (i.e. prevention or treatment) of anticoagulant shall be documented in the residence medical record. Duration of use shall be appropriate to the resident's condition and indication for use.Routine labs, including baseline, and subsequent labs, shall be ordered for each resident requiring anticoagulant medication. Results shall be communicated to the physician in a timely manner. This was determined to be an Immediate Jeopardy (IJ) on 07/09/25 at 5:30 PM. The ADM and DON were notified. The ADM and DON were provided with the IJ template on 07/09/25 at 05:30 PM.The following Plan of Removal submitted by the facility was accepted on 07/10/25 at 04:04 PM: Plan of RemovalUnnecessary Drugs, F-757 1. On 7/9/2025, an abbreviated survey was initiated at the facility. On 7/9/2025 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. Action: Resident #1 (R1) was assessed upon return from the hospital following diagnosis of Coumadin (Warfarin) overdose. Physician was notified, and R1's Warfarin order was discontinued. PT/INR monitoring updated to reflect daily labs per new order.Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, Regional Clinical Support Nurse ConsultantDate/Time: 7/9/2025 by 11PM Action: R1's care plan updated to include risk for medication-related adverse effects, monitoring for bleeding/bruising, and ongoing INR surveillance.Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, Regional Clinical Support Nurse ConsultantDate/Time: 7/9/2025 by 11PM 2. How the Facility Identified Other Possibly Affected Residents: Action: Action: Conducted audit of all residents receiving anticoagulants (e.g., Warfarin) to review appropriateness of medication, frequency of PT/INR monitoring, and compliance with physician orders. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, Regional Clinical Support Nurse ConsultantDate/Time: 7/9/2025 by 11PM Action: Reviewed pharmacy consultant reports and prior medication regimen reviews to ensure unnecessary medications were not continued without indication.Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, Regional Clinical Support Nurse ConsultantDate/Time: 7/10/2025 by 12PM Action: The Director of Nursing and the Assistant Director of Nursing will utilize the Clinical Meeting form (includes section for laboratory and diagnostic studies) to list all laboratory studies that were to be drawn that day. The Director of Nursing and the Assistant Director of Nursing will put a check next to the laboratory study once the test is resulted. The Director of Nursing and the Assistant Director of Nursing will then validate that the MAR/TAR reflect accurate documentation that the laboratory study was collected. 3. Measures Put into Place/System Changes to Remove the Immediacy Action: The Director of Nurses was educated on the Side Effects of High-Risk Medications and recognition of adverse effects and High-Risk Medications-Anticoagulant Policy and Laboratory Services and Reporting Policy. The Director of Nursing will validate understanding of the training material by summarizing the information she was educated on. This will allow for re-education and clarification at that moment and facilitate re-education immediately. Person(s) Responsible: Regional Clinical Support Nurse ConsultantDate/Time: 7/9/2025 by 7PM Action: All licensed nursing staff, all new staff that are currently in the onboarding process, agency nurses who are scheduled to work in the facility, and all PRN nurses were re-educated on Side Effects of High-Risk Medications and recognition of adverse effects prior to working their next shift. Any new hires, agency nurses and new PRN nurses will be educated prior to working their first shift in the facility. All staff educated will be required to verbalize in his/her own words what they learned from the education provided. This will allow for re-education and clarification at that moment and facilitate re-education immediately. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, Regional Clinical Support Nurse ConsultantDate/Time: 7/9/2025 - 7/10/2025 by 12 noon Action: Facility policies on High-Risk Medications-Anticoagulant Policy and Laboratory Services and Reporting Policy reviewed by VP of Clinical Operations with no changes identified. All licensed nursing staff, all new staff that are currently in the onboarding process, agency nurses who are scheduled to work in the facility, and all PRN nurses were re-educated on High-Risk Medications-Anticoagulant Policy and Laboratory Services and Reporting Policy prior to working their next shift. Any new hires, agency nurses and new PRN nurses will be educated prior to working their first shift in the facility. All staff educated will be required to verbalize in his/her own words what they learned from the education provided. This will allow for re-education and clarification at that moment and facilitate re-education immediately.Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, Regional Clinical Support Nurse ConsultantDate/Time: 7/10/2025 Action: QAPI meeting held with the Medical Director to discuss the Immediate Jeopardy template, F757, and the facility's plan of action to remove the immediacy. Person(s) Responsible: Administrator and Director of Nursing Date/Time: 7/9/2025 by 11PM Monitoring of the POR included the following: During an interview on 07/11/25 at 09:56 AM, the RNC stated she in-serviced the ADON and the DON on high-risk medications, lab services, nurse staff daily posting and quality of care. She said the DON and ADON conducted all the in-services for the nurses. She stated an example of high risk medications was anticoagulants which were important to monitor. She stated they should be doing the PT/INR every Monday without fail and do side effects monitoring every day every shift for adverse effects, example bruising, swelling of the tongue. She stated they made sure they are checking each shift for bruising or any complaints of difficulty swallowing. She stated staff was instructed to monitor the resident's diet, educated on how other medications can interfere with high-risk medications. The RNC stated she reviewed the facility policy that spoke about anticoagulants and monitoring for the main side effects of bruising to ensure it was thorough, and it was. She stated it was important that they do the PT/INRs scheduled as ordered because that showed if the resident had a safe level of anticoagulant in her system. She stated the process for lab services was when they received the order it was placed in the lab tracker/binder along with a requisition. She stated they then waited for results, and if any were missed they followed up with the lab. She stated the requirement for the DON and ADON was to print out the labs from the EMR that were ordered for the day and before they went home to make sure labs had been completed as ordered or find out why they had not. She stated they had conducted in-services on weekly labs for warfarin users unless ordered sooner by the NP/MD. She stated the lab tech who drew the labs needed to be contacted if the labs were not signed off. She stated the lab binder should remain at each nurse's station and when nurses received an order, they were to fill out the requisition and place it in the book. She stated staff were required to give residents the basic standard of care they deserved and needed. During an interview on 07/11/25 at 08:30 AM, LVN D stated she worked 6 AM-6 PM. She stated she felt like she already was pretty comfortable with the procedure. She stated it was just a matter of it getting done. She stated they needed to be conducting the PT/INR labs weekly. PT/INR results for anybody who's on strong anticoagulant needed to be checked. She stated they needed to check PT/INR results anytime they administered an anticoagulant. She stated she really did not administer on her shift, but she has the clinical knowledge to know that warfarin was a dangerous drug and somebody could die so it had to be monitored. They also had to monitor for side effects, which is in the TAR, such as unexplained, bruising or bleeding. They did a bunch of in-servicing over the last couple of days on adverse effects of medication, high risk medications, and lab services. She stated she had to take a quiz to show her knowledge. She stated they were now checking over lab orders at shift change and it's been included in the 24-hour report. She stated it should have already been in the 24-hour report, but it was not, but it was now. She stated there was a binder at each nurse's station that had the labs that were supposed to be done in the next few days listed out as well as requisition forms. She stated she had been double checking the lab binder every time she worked even though she did not usually have responsibility for lab requisitions as an overnight staff. During an interview on 07/11/25 at 08:41 AM, LVN B stated she was PRN so she sometimes worked overnight, but she worked mostly day shifts. She stated she was the person who first noticed the bruising on Resident #1 on 07/05/25, and she was concerned about it, but she did not think to look at the labs at the time. She stated she just called the nurse practitioner. She stated they had to be able to rely on the nurse practitioner to make clinical decisions for the residents. She didn't know the outcome for Resident #1 until she came back to work to get this in-service. They talked about symptoms of anticoagulants, including some of the lesser-known symptoms. They talked about making sure that labs were done as ordered. She stated they talked about what the procedure already was that she was doing. During an interview on 07/11/25 at 08:47 AM, LVN C stated she had received in-servicing on side effects of anticoagulant and the process for making sure PT/INR was done. It was not something she was responsible for very often because she just picked up on the overnight shift sometimes, and those were usually done during the day but now she had to check the binder at

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure laboratory services were provided or obtained to meet the needs of its residents for 1 of 3 residents (Resident #1) reviewed for laboratory services. The facility failed to ensure PT/INR laboratory tests were obtained weekly as ordered for Resident #1 on 04/14/25, 04/28/25, 05/05/25, 05/12/25, 05/26/25, 06/09/25, 06/16/25 and 06/30/25. Resident #1 was presented with multiple, unexplained bruising to her face, tongue, and extremities on 07/05/25 and was hospitalized for a warfarin overdose on 07/07/25. An Immediate Jeopardy (IJ) was identified on 07/09/25. While the IJ was removed on 07/11/25, the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of adverse effects from high-risk medication such as bruising, uncontrolled bleeding, and death. Findings include: Record review of Resident #1's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included chronic atrial fibrillation (irregular heartbeat), congestive heart failure (long term condition in which the heart cannot pump blood well enough to meet the body's needs), chronic respiratory failure with hypoxia (breathing problems with low blood oxygen), chronic obstructive pulmonary disease (chronic breathing disorder), asthma, hypertension (high blood pressure), major depressive disorder, unsteadiness on feet, abnormalities of gait and mobility, dementia, fibromyalgia (long-term condition that involves widespread body pain), hyperlipidemia (high cholesterol), muscle weakness, lack of coordination, dependence on supplemental oxygen, obstructive sleep apnea (sleep-related breathing disorder), anxiety disorder, cochlear implant (electronic hearing device that provides a sense of sound to people with severe hearing loss) status, chronic migraine (headache), and mild cognitive impairment of uncertain or unknown etiology (origin). Record review of Resident #1's annual MDS reflected a BIMS score of 15, which indicated intact cognition. Resident #1 received anticoagulant medication during the 7-day lookback period. Record review of Resident #1's care plan, dated 01/10/25, reflected the following: The resident is on Anticoagulant therapy r/t A-fib. The resident will be free from discomfort or adverse reactions related to anticoagulant use through the review date. Daily skin inspection. Report abnormalities to the nurse. Labs as ordered. Report abnormal lab results to the MD. Monitor/document/report to MD PRN s/sx of anticoagulant complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, , diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB, Loss of appetite, sudden changes in mental status, significant or sudden changes in v/s. Resident/family/caregiver teaching to include the following: Take/give medication at the same time each day, Use soft toothbrush, Use electric razor, Avoid activities that could result in injury, Take precautions to avoid falls, Signs/symptoms of bleeding, Avoid foods high in Vitamin K. These include greens such as spinach and turnips, asparagus, broccoli, cabbage, Brussels sprouts, milk and cheese. Review medication list for adverse interactions. Avoid use of aspirin or NSAIDS. Record review of physician orders for Resident #1 reflected the following:-Warfarin Sodium oral tablet 4 mg- take 2 tablets one time per day for chronic atrial fibrillation start date 03/18/25-PT/INR on Mondays- one time a day every Monday due to anticoagulant use send lab order Sunday start date 06/22/25-PT/INR on Mondays- one time a day every Monday due to anticoagulant use start date 09/30/24 end date 06/21/25-Side effects to anti-coagulant medication 1) Discolored urine 2) black tarry stools 3) muscle/joint pain 5) lethargy 6) increased bruising 7) sudden changes in mental status/vitals 8) shortness of breath 9) nosebleeds. Every shift for preventative measure if side effects were noted, documentation and physician notification were required.-Diphenhydramine HCl 25 mg Benadryl, one time administration 07/07/25 Record review of Resident #1's MAR/TAR from April 2025 to July 2025 reflected the following dates were marked as complete for PT/INR04/14/25 (no corresponding laboratory test)04/28/25 (no corresponding laboratory test)05/05/25 (no corresponding laboratory test)05/12/25 (no corresponding laboratory test)05/19/25 (correlating lab test on 05/20/25)06/02/25 06/09/25 (no corresponding laboratory test)06/16/25 (no corresponding laboratory test)06/23/2506/30/25 (no corresponding laboratory test, documented by LVN K)The following dates were not marked as complete for PT/INR:04/07/2504/21/25 Record review of PT/INR results for Resident #1 reflected the following:04/07/25 PT 23.3 and INR 2.104/21/25 PT 34.5 and INR 3.405/20/25 PT 28.1 and INR 2.606/02/25 PT 35 and INR 3.506/23/25 PT 30 and INR 2.8(Note: A normal INR range for people who take warfarin is 2-3 but can vary from patient to patient. Patients who tend to clot more easily may have an INR target range of 3-4.) Review of pharmacy consultant reports for Resident #1 from January 2025 to July 2025 reflected her drug regimen was reviewed by the consultant pharmacist each month, and no recommendations were made related to her drug regimen. Record review of Resident #1's nursing progress notes reflected the following:07/05/25 at 06:15 PM, written by LVN B, resident states she has been complaining of discomfort to Left lower leg, states when she went to the restroom she noticed a dark red/purple bruise. Resident states she did not hit or bump it while transferring states where the bruise is where she had been hurting all week. Notified NP of findings no new orders at this time.07/06/25 at 02:04 PM, written by LVN E notified by family that resident had bruising on her face, left dorsal hand, thumb, wrist, LLE both front and back. Resident does not remember falling. She states I'm always in this chair. Residents VS are with in normal limits, speaks normally, but says it hurts to open her mouth and her leg hurts. Leg has some swelling refused ice pack.07/06/25 at 02:14 PM, written by LVN E resident took Tylenol with no issues07/06/25 at 05:06 PM, written by LVN E PT/INR in the morning NP checked on resident. Coumadin on hold. No Xray or hospital visit was needed at this time.07/07/25 at 01:56 AM, written by RN A Resident complained of glossitis (inflammation and swelling of the tongue). Purplish bruising on right side of tongue. Bruising also noted to left chin area, left hand, left lower posterior leg. Resident denies falling. No history recent falls noted. Vitals stable 120/69, P62, RR20, O2-94%-2L with dyspnea[shortness of breath]. EMS in route. MD, family, DON notified. Called report to ER.07/07/25 at 02:27 AM, written by RN A Benadryl Allergy Oral Tablet 25 MG (Diphenhydramine HCl) Give 1 tablet by mouth one time only for Skin Irritation for 1 Day route. MD, family, DON notified. Called report to ER.07/07/25 at 04:28 AM, written by LVN D RN called from [hospital] to ask how long we had held the resident's coumadin. Writer answered all her questions. She informed writer that the patient was receiving a dose of IV Vitamin K as we spoke and if the head CT came back negative she will be discharged . [RN] also provided me with patient's lab results. PTT: 158.9 RANGE: 22.9-36.1INR: 12.6 RANGE: CRITICAL IS GREATER THAN 6PT:96 RANGE: 12-14.707/07/25 at 10:04 AM, written by the DON Resident assessed by nurse, this nurse spoke with resident, resident denies fall, denies feeling ill, denies headache, denies SOB. Resident states her tongue is bigger than her mouth but has gotten smaller she thinks. Resident was observed drinking her coffee without difficulty stated by resident. Resident informed we would like to send her to the hospital for monitoring, resident stated she did not want to go that they won't do nothing for her. NP notified, hospital called spoke with ER nurse, she stated that her tongue was swollen while she was there, she received Vit K, and discharged back to[the facility]. PT/INR ordered for daily, Coumadin held and removed from medication cart and placed in medication room unit 4.07/07/25 at 04:35 PM, written by LVN F Warfarin Sodium Oral Tablet 4 MG, Give 2 tablet by mouth one time a day related to Chronic Atrial Fibrillation, Unspecified (I48.20) med on hold07/07/25 at 04:43 PM, written by LVN F Res has been without c/o pain/discomfort, SOB, dizziness, headache since return from ER. Drank 2 bowls of tomato soup and drank glass of tea for lunch without incident/difficulty. Res cont. to state she feels as if her tongue swelling is going down. Sitting up in [sic] recliner chair in room per usual routine. Will cont. to monitor closely for changes in condition.07/08/25 at 11:44 AM, written by RN B Patient is on bleeding precautions related to anticoagulant therapy. Daily PT/INR to monitor levels. Coumadin on hold. Patient noted to have bruising to left chin, left hand, bilateral ankles, scattered bruising on trunk, and tongue. Swelling to tongue has subsided, no issues with swallowing/eating/breathing. Patient denies any pain. VSS. 143/83 87 97.8 18 93% on RA. Record review of hospital records for Resident #1, dated 07/07/25, reflected the following: Communications: critical lab value, received at 0327 [03:27 AM], received from lab, critical results: INR 12.6/PTT158. Triage notes: from (facility); diffuse bruises. Tongue bruising/swelling. Bruise to left hand. Bruise to left jaw. Dried blood behind right ear. Bruising to left foot. Denies injury. Does not remember falling. Doctor Notes: This is a 91 Y/O F with a PMHx of dementia, afib, HTN, polyosteoarthritis, osteoporosis, urinary incontinence, HLD, COPD, asthma, abd sx, and GERD presenting to the ED via EMS from NH with a CC/O multiple bruises throughout the body. EMS reports BP of 122/83 and SP02 of 95%. EMS does not know the etiology beyond her bruises, falling, tripping, or any other trauma related injury. Diagnosis final: primary: overdose - Coumadin warfarin, additional: Ecchymosis [flat area of discolored skin], elevated INR. During observation and an interview on 07/09/25 at 07:30 AM, Resident #1 was sitting in her recliner chair having breakfast. She had a very dark bruise stretching across her left cheek and jaw and one on the wrist and thumb of her left hand. She stated, I'm doing better than I look. She said the bruises just showed up on her because she had too much blood thinner. She said she went to the hospital for two days and that was what the hospital told her. She said the bruises did not hurt anymore, though the ones on her legs did hurt at first. She lifted her pants leg and had more bruising on her left, lower leg. An attempted interview with RN A was made on 07/09/25 at 08:10 AM to by telephone. A voicemail was left. An attempted interview with LVN C was made on 07/09/25 at 08:11 AM to by telephone. The outgoing message stated the wireless customer you are trying to reach is not available. Please try again later. A second attempt was made on 07/11/25 at 09:00 AM. During an interview on 07/09/25 at 08:30 AM, LVN D stated she worked the night Resident #1 was sent to the hospital. She stated the nurses on that shift decided together to send Resident #1 to the hospital. She stated the nursing team knew Resident #1 was on Warfarin, and when they came in, Resident #1 was covered in bruises, her tongue was really swollen, and she had difficulty breathing. LVN D stated she had checked the PT/INR results and discovered that the lab test had not been done as ordered since 06/23/25. She stated they had no idea whether Resident #1 had safe levels of warfarin, and she stated she looked up the swollen and bruised tongue and saw online that it could be a symptom of warfarin overdose. The charge nurse on Resident #1's hall, LVN C, administered Benadryl (diphenhydramine HCl) thinking it might have been an allergic reaction, but the Benadryl did not help. She said Resident #1 could barely talk. LVN D stated she took some pictures of the bruising and swollen tongue for the DON. She stated they tried to find information on the shift change report, but there was nothing definite- only to hold the warfarin. LVN D stated there was an order for a PT/INR to be done the following day (Monday 07/07/25) but the lab requisition had not been completed. LVN D stated the nurses decided to call EMS and send Resident #1 out. She said she got a call from the nurse at the ER about 04:00 AM that morning (07/07/25) letting them know Resident #1's PTT was over 150 and her INR was 12.6. LVN D stated those levels were very elevated. She stated the normal reference rage for someone not on warfarin was around 2 or 3. She stated the hospital RN told them Resident #1 received an infusion of vitamin K to bring the levels down. A telephone interview was attempted on 07/09/25 at 11:59 AM with LVN B (was charge nurse for administered Benadryl to Resident #1 on 07/07/25). A voicemail was left and not returned prior to 07/12/25. During an interview on 07/09/25 at 12:05 PM, the DON stated LVN E was in the facility working and a request was made for an interview. The DON stated LVN E was at an appointment. LVN E did not present herself for an interview. A telephone interview was attempted on 07/10/25 at 10:03 AM and a voicemail was left, but there was no response as of 07/12/25. The DON was asked why Resident #1's PT/INR levels were not checked weekly as ordered, and she did not answer. i A telephone interview was attempted on 07/09/25 at 12:12 PM with LVN K (documented a PT/INR on Resident #1's MAR on 06/30/25). A voicemail was left and not returned prior to 07/12/25. During an interview on 07/09/25 at 02:53 PM, the NP stated she received a call from LVN E on Sunday 07/06/25 notifying her Resident #1 had unexplained bruising. The NP said she came to the facility, saw the bruising, and knew right away it was a reaction to the warfarin. She stated the bruises were small, they were not hardened, and Resident #1 stated she was in not discomfort. The NP stated she felt there was no need for emergent care, ordered a hold on the warfarin, and ordered a PT/INR to be taken the following day. She stated she was not aware Resident #1 had gone to the hospital and had not seen the results of the hospital PT/INR test. She amended her statement to say she was aware Resident #1 had gone to the hospital, but she was not aware of the results of the hospital visit. She stated the bruises looked much worse today than they had on 07/06/25. She stated the PT/INR tests should have been performed as ordered, but it was a fluke that her PT/INR values had gone up so much and so quickly. She laughed and said they could not have known there would be high PT/INR levels and the bruising and high PT/INR levels were not adverse effects and the surveyor did not know what adverse effects meant. When asked if the increase in lab values might have been detected sooner if the PT/INR test was run on 06/30/25 as ordered, she did not answer verbally but shrugged and nodded her head yes. During an interview on 07/09/25 at 03:02 PM, the MD stated Resident #1 was on the same dose of warfarin since 03/18/25, which meant her PT/INR was stable. He stated the standard of practice was to test for PT/INR once per month in a stable patient on warfarin. He stated the goal INR for Resident #1 was 2-4. The MD stated if the PT/INR was ordered once per week, it should have been done once per week. He stated he was not notified of Resident #1 going to the ER with bruising and a swollen tongue or of her critically high PT/INR levels. He stated Resident #1 had an adverse reaction, but he still thought monthly was frequently enough to check PT/INR levels. During an interview on 07/09/25 at 04:02 PM, the DON stated prior to the investigation entrance, she had not received any hospital documentation for Resident #1 and was not aware of what had occurred. She stated she was aware Resident #1 went to the hospital, but she did not know the outcome. She stated her expectation was all orders were followed. She stated she did not know why the PT/INRs were not done as ordered for Resident #1 and she did not know why they were documented as done. She stated she did not know who was responsible for making sure the labs were done, and the side effect monitoring was completed for high-risk medications. She stated she guessed it was her job. She did not answer any more questions. Record review of the National Library of Medicine's website, accessed on 07/11/25, at the web address medlineplus.gov/lab-tests/prothrombin-time-test-and-inr-ptinr reflected the following definition for PT/INR: PT/INR is a blood test that measures how long it takes for a clot to form in a blood sample. PT stands for prothrombin time, which is a protein made by the liver and one of the clotting factors. INR stands for internationalized normalized ratio, which is a calculation based on PT test results. PT/INR test can be used to check for bleeding problems or to monitor the effect of medicine to prevent blood clots. Record review of an article titled Practical tips for warfarin dosing and monitoring, accessed on 07/11/25, at the web address www.ccjm.org /content/ccjom/70/4/361.full.pdf reflected the following: PATIENTS WHO TAKE WARFARIN (Coumadin) walk a tightrope between bleeding and clotting- and a hundred things can tip the balance. It's a difficult drug to use, with a narrow therapeutic index, but 60 years after it was introduced it is still the mainstay of oral anticoagulant treatment . The INR was developed in 1982 by the World Health Organization's Expert Committee on Biologic Standardization in response to variations in thromboplastin sensitivity and different ways of reporting the prothrombin time across the world.8 Inappropriate management can lead to subtherapeutic or supratherapeutic INR values, increasing the risk of acute or recurrent thromboembolic episodes or bleeding episodes, respectively. For most indications, the therapeutic INR range is 2.0 to 3.0. Exceptions are when warfarin is used for secondary prevention after a myocardial infarction or for patients with high-risk mechanical prosthetic heart valves, in which case the range is 2.5 to 3.5. Record review of an article, accessed on 07/11/25, at the web address my.clevelandclinic.com/health/diagnostics/prothrombin-time-test reflected the following: Labs measure prothrombin time in seconds based on how long it takes your blood to clot, or (more commonly) as the International Normalized Ratio (INR). The World Health Organization (WHO) developed the INR as a standardized measurement that accounts for differences in lab testing processes.The normal ranges for PT/INR results are:11 to 13.5 seconds.INR of 0.8 to 1.1.INR of 2.0 to 3.0 if you're taking warfarin. (There are some conditions for which a higher or lower target PT range is desired.). Record review of the facility's, undated, policy titled Laboratory Services and Reporting reflected the following: The facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law.Policy explanation and compliance guidelines:The facility must provide or obtain laboratory services to meet the needs of its residents.The facility is responsible for the timeliness of the services. Record review of the facility's, undated, policy titled High Risk Medications- Anticoagulants reflected the following: Policy: this facility recognizes that some medications, including anticoagulant, are associated with greater risks of adverse consequences than other medications. This policy addresses the facilities collaborative, systematic approach to managing anticoagulant therapy for efficacy and safety.Policy explanation and compliance guidelines:Anticoagulant shall be prescribed by a physician, authorized practitioner with clear indications for use. Examples include prevention and treatment of deep vein thrombosis, pulmonary embolism, atrial fibrillation with embolization, stroke, or management of myocardial infarction.Target symptoms, (i.e. lab values) and goals for use (i.e. prevention or treatment) of anticoagulant shall be documented in the residence medical record. Duration of use shall be appropriate to the resident's condition and indication for use.Routine labs, including baseline, and subsequent labs, shall be ordered for each resident requiring anticoagulant medication. Results shall be communicated to the physician in a timely manner. This was determined to be an Immediate Jeopardy (IJ) on 07/09/25 at 5:30 PM. The ADM and DON were notified. The ADM and DON were provided with the IJ template on 07/09/25 at 05:30 PM.During an interview on 07/29/25 at 01:46 PM, RN A stated she had left employment at the facility in mid-July 2025. She stated the procedure for intervention in a change of condition or a medical emergency was to call the NP, and if there was no answer to call the MD. She stated if there was still no answer, they were to call the NP hotline for an on-call nurse practitioner. RN A stated she spoke to the NP about sending Resident #1 to the hospital on the night of 07/07/25, so she did not need to call the MD. RN A stated that night she relied on LVN D to help her through the process, because she was new at the facility and did not know the residents as well. RN A stated what was in her progress note about that night was what was done. She stated she did not want to answer more questions.During an interview on 07/29/25 at 02:14 PM, the PHARM stated she was not aware of any problems with Resident #1's drug regimen or with the warfarin side effects that sent Resident #1 to the ER. She stated she reviewed Resident #1's meds in May/June but made no nursing or physician recommendations for follow up on PT/INR. She stated she typically looked for labs done at least monthly and Resident #1 had not had any issues with results or not getting the labs done at least monthly. During an interview on 07/29/25 at 02:42 PM, a laboratory technician stated they had an outreach group that went to the facility and picked up the requisitions in the lab books and then noted in the lab book after lab draws were completed. She stated her supervisor would be able to access details about all the other labs that had been drawn for Resident #1. She stated her supervisor was not available and took a message, which was not returned as of 08/04/25.The following Plan of Removal submitted by the facility was accepted on 07/10/25 at 04:04 PM: Plan of RemovalLaboratory Services, F-770 1. On 7/9/2025, an abbreviated survey was initiated at the facility. On 7/9/2025 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. Action: Resident #1's (R1) care plan was immediately updated to reflect enhanced monitoring for signs/symptoms of bleeding, adherence to anticoagulant lab schedules, and dietary precautions. All current lab orders were reviewed, and a daily PT/INR was obtained.Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, Regional Clinical Support Nurse ConsultantDate/Time: 7/9/2025 @ 11PM 2. How the Facility Identified Other Possibly Affected Residents: Action: An audit of all residents receiving anticoagulant therapy (including Warfarin) was completed. Orders were reviewed to ensure that laboratory monitoring, including PT/INR, was in place and being followed. Any discrepancies were corrected immediately. No other residents were identified to have missed required labs.Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, Regional Clinical Support Nurse ConsultantDate/Time: 7/9/2025 @ 8 PM 3. Measures Put into Place/System Changes to Remove the Immediacy Action: Lab audit performed facility wide to ensure no other labs were missed. If any other labs are identified, the physician will be notified, and the facility will follow orders. No other laboratory studies were missed. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, Regional Clinical Support Nurse ConsultantDate/Time: 7/9/2025 @ 11PMAction: Laboratory, Radiology, and Diagnostic Testing Service Policy reviewed by VP of Clinical Operations and Sr. VP of Operations and no changes are identified as needed at this time.Person(s) Responsible: VP of Clinical Operations and Sr. VP of OperationsDate/Time: 7/9/2025 by 10PM Action: All licensed nursing staff, all new staff that are currently in the onboarding process, agency nurses who are scheduled to work in the facility, and all PRN nurses were re-educated over reviewing scheduled laboratory tests and validating that the lab requisition is completed and placed in the laboratory binder at each of the nursing stations. If the laboratory requisition is not located in the laboratory binder the Charge Nurse is responsible for completing the laboratory requisition immediately and notifying the Director of Nurses. Any new hires, agency nurses and new PRN nurses will be educated prior to working their first shift in the facility. All educated staff will be required to verbalize in his/her own words what they learned from the education provided. This will allow for re-education and clarification at that moment and facilitate re-education immediately.Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, Regional Clinical Support Nurse ConsultantDate/Time: 7/9/2025 11PM Action: Director of Nursing and Assistant Director of Nursing have been educated regarding reviewing all scheduled clinical labs in daily clinical meeting, Monday thru Friday, to ensure labs that were ordered have been drawn and that results for labs have been received prior to leaving their scheduled shift, that appropriate lab communication to the MD and/or their extender have occurred when labs have been received, and any labs that were scheduled and not drawn will be drawn by the Director of Nursing or the Assistant Director of Nursing immediately and transported to the laboratoryPerson(s) Responsible: Regional Clinical Support Nurse ConsultantDate/Time: 7/9/2025 @ 11PM Action: QAPI meeting held with the Medical Director to discuss the Immediate Jeopardy template, F770, and the facility's plan of action to remove the immediacy. Person(s) Responsible: Administrator and Director of Nursing Date/Time: 7/9/2025 by 11PM Monitoring of the POR included the following: During an interview on 07/11/25 at 09:56 AM, the RNC stated she in-serviced the ADON and the DON on high-risk medications, lab services, nurse staff daily posting and quality of care. She said the DON and ADON conducted all the in-services for the nurses. She stated an example of high risk medications was anticoagulants which were important to monitor. She stated they should be doing the PT/INR every Monday without fail and do side effects monitoring every day every shift for adverse effects, example bruising, swelling of the tongue. She stated they made sure they are checking each shift for bruising or any complaints of difficulty swallowing. She stated staff was instructed to monitor the resident's diet, educated on how other medications can interfere with high-risk medications. The RNC stated she reviewed the facility policy that spoke about anticoagulants and monitoring for the main side effects of bruising to ensure it was thorough, and it was. She stated it was important that they do the PT/INRs scheduled as ordered because that showed if the resident had a safe level of anticoagulant in her system. She stated the process for lab services was when they received the order it was placed in the lab tracker/binder along with a requisition. She stated they then waited for results, and if any were missed they followed up with the lab. She stated the requirement for the DON and ADON was to print out the labs from the EMR that were ordered for the day and before they went home to make sure labs had been completed as ordered or find out why they had not. She stated they had conducted in-services on weekly labs for warfarin users unless ordered sooner by the NP/MD. She stated the lab tech who drew the labs needed to be contacted if the labs were not signed off. She stated the lab binder should remain at each nurse's station and when nurses received an order, they were to fill out the requisition and place it in the book. She stated staff were required to give residents the basic standard of care they deserved and needed. During an interview on 07/11/25 at 08:30 AM, LVN D stated she worked 6 AM-6 PM. She stated she felt like she already was pretty comfortable with the procedure. She stated it was just a matter of it getting done. She stated they needed to be conducting the PT/INR labs weekly. PT/INR results for anybody who's on strong anticoagulant needed to be checked. She stated they needed to check PT/INR results anytime they administered an anticoagulant. She stated she really did not administer on her shift, but she has the clinical knowledge to know that warfarin was a dangerous drug and somebody could die so it had to be monitored. They also had to monitor for side effects, which is in the TAR, such as unexplained, bruising or bleeding. They did a bunch of in-servicing over the last couple of days on adverse effects of medication, high risk medications, and lab services. She stated she had to take a quiz to show her knowledge. She stated they were now checking over lab orders at shift change and it's been included in the 24-hour report. She stated it should have already been in the 24-hour report, but it was not, but it was now. She stated there was a binder at each nurse's station that had the labs that were supposed to be done in the next few days listed out as well as requisition forms. She stated she had been double checking the lab binder every time she worked even though she did not usually have responsibility for lab requisitions as an overnight staff. During an interview on 07/11/25 at 08:41 AM, LVN B stated she was PRN so she sometimes worked overnight, but she worked mostly day shifts. She stated she was the person who first noticed the bruising on Resident #1 on 07/05/25, and she was concerned about it, but she did not think to look at the labs at the time. She stated she just called the nurse practitioner. She stated they had to be able to rely on the nurse practitioner to make clinical decisions for the residents. She didn't know the outcome for Resident #1 until she came back to work to get this in-service. They talked about symptoms of anticoagulants, including some of the lesser-known symptoms. They talked about making sure that labs were done as ordered. She stated they talked about what the procedure already was that she was doing. During an interview on 07/11/25 at 08:47 AM, LVN C stated she had received in-servicing on side effects of anticoagulant and the process for making sure PT/INR was done. It was not something she was responsible for very often because she just picked up on the overnight shift sometimes, and those were usually done during the day but now she had to check the binder at each shift and check that lab requisitions had been done and labs completed. The binder was for lab services and there was one at the nurse's station. The nurse who received the order wrote the lab order in the binder and then filled out a requisition form. She stated then the lab tech looked at that and determined who to draw labs for. She stated side effects of anticoagulant medicine would be unexplained bruising, pain, bleeding especially, sometimes diarrhea, sometimes shortness of breath. She stated she learned that tongue swelling, and bruising could be an adverse effect. She stated she no longer had any patients receiving warfarin, but if she did, she knew she had to check for side effects every shift. During an interview on 07/11/25 at 09:03 AM, LVN J stated she worked exclusively overnight on the lower level and she was not the nurse for Resident #1 although she did know her. She stated she did not have any residents on warfarin or high-risk anticoagulant. She stated they did in-servicing at the