West Woods Of Bridgman

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to adequately assess and respond to an acute change in condition for one resident, including failure to follow provider orders for diagnostic testing and failure to promptly activate 911 EMS when the resident became unresponsive and hypotensive. The resident was an elderly female with bipolar disorder, dementia, and delusional disorder who had been evaluated by a nurse practitioner two days prior for fatigue, poor appetite, right flank/low back pain, and lower abdominal tenderness. The NP suspected a UTI and hand‑wrote orders on a Doctor’s Orders sheet for CBC, CMP, and urinalysis with C&S if indicated. These orders were to be entered into the EMR by clinical care coordinators, but the Infection Prevention Manager later confirmed that no such orders were entered and no labs or UA were completed, and there were no results in the lab system. During the overnight shift, multiple CNAs reported that the resident was her usual self at the beginning of the shift but later became very lethargic, unable to keep her eyes open, and then completely unresponsive. CNAs stated they notified the nurse, and that two RNs (one being newly oriented) repeatedly assessed the resident, took vital signs several times, and made numerous phone calls. One CNA recalled that one RN wanted to send the resident to the hospital while the other RN was not convinced this was necessary. The orienting RN reported that both nurses assessed the resident and noted fluctuating vital signs, pain, lack of responsiveness except to painful stimuli (sternal rub), cold hands, and difficulty obtaining pulse oximetry readings. She contacted the on‑call PA, who agreed the resident required hospital evaluation, and she documented that the focus at that time was on facilitating transport and maintaining safety while awaiting transfer. The orienting RN described that she and the other RN were the only two nurses in the building that night and that she was being trained on the transfer process, including completing a transfer checklist and packet. She stated she had already transferred another resident earlier in the shift and had learned that 911 arrived quickly and would not wait for incomplete paperwork, so for this resident she took extra time to complete all transfer forms, call the family, and call report to the ED before calling 911. She reported asking the other RN whether they should call 911 and being told to finish the packet while the other RN went to eat. She then completed the electronic transfer form, including documenting last vital signs and that report was called to the ED, but she did not call 911 and believed the other RN would do so. EMS and 911 records show an abandoned 911 call from the facility, a return call in which staff stated there was no emergency, and subsequent calls from the local ED and ambulance service indicating the facility had called the ED with report on an unresponsive resident but had not sent the patient. EMS ultimately received a dispatch at approximately 5:37 a.m. for a 77‑year‑old female in cardiac arrest, arrived to find the resident unconscious but with spontaneous respirations and a pulse, and documented that no CPR or ventilations were in progress on arrival. The resident was transported emergently to the hospital, where she was found comatose, hypotensive, tachycardic, cool and cyanotic, and later died the same day. The PA who had been contacted by the facility stated that, based on the nurse’s documentation, the resident should have been sent to the hospital right after their call and that he would not have told staff to delay transfer. Additional interviews with leadership clarified that the DON expected nurses to assess residents with a change in condition, call the on‑call provider, complete transfer forms, and call 911 EMS for transport, with immediate transfer for an unresponsive resident. The DON acknowledged that night shift staffing could be as low as two nurses and that she believed there was little to do after evening med pass. The Infection Prevention Manager stated she did not receive any call from the facility during the overnight hours and arrived at work as EMS was taking the resident out on a stretcher. The Nursing Home Administrator reported there was no phone outage on the dates in question, although the facility’s voice‑over‑IP phone system could go down and be switched to another Wi‑Fi connection, and staff were expected to use personal cell phones if needed. 911 service records documented that when 911 returned the abandoned call from the facility, staff told them there was no emergency, and only after subsequent calls from the ED and ambulance service was EMS dispatched for the resident described as unresponsive and in cardiac arrest.

Removal Plan

• All licensed nurses were re-educated that 911 EMS must be called without delay for any resident exhibiting signs of an acute decline, including but not limited to unresponsiveness, hypotension, altered mental status, respiratory distress, or other emergent conditions.
• Staff were instructed that contacting the emergency department or hospital does not replace activation of 911 EMS.
• Emergency response protocol reeducation requiring immediate activation of 911 followed by notification of the supervisor or administrator on call.
• The monthly on call schedule was posted at the nurse's station.
• The Director of Nursing or designee are available 24 hours a day, 7 days a week to support clinical decision-making during all shifts.
• Re-education will be completed in person or by telephone prior to staff’s next scheduled shift being worked.
• No licensed staff will be allowed to start a shift or give care until education is completed.
• Medical director was notified.
• Facility health care providers will enter their own orders into the electronic medical record.
• A facility wide review of all current residents was initiated to identify those at risk for acute clinical decline.
• All residents exhibiting signs of deterioration were immediately assessed and transferred via EMS per the emergency response protocol.
• A licensed nurse will conduct a chart review of all current residents for change in condition and follow through with health care practitioner orders.
• All licensed nurses will receive education prior to their next worked shift, including those on leave of absence upon return.
• Agency licensed nurses will be educated and will complete a competency test prior to their shift worked.
• The facility change in condition policy was reviewed by the interdisciplinary team and updated to clearly require activation of 911.
• Emergency condition decision-support tools were implemented at the nurse's station.
• Leadership oversight was implemented to review all emergency transfers.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure sufficient licensed nursing staff on the night shift to meet resident needs and maintain residents’ highest practicable well-being, which contributed to a delayed emergency transfer for a resident who experienced an acute change in condition and later died. The facility used a corporate staffing matrix based solely on census, without documented consideration of resident acuity, despite a facility assessment stating that staffing levels would be based on acuity and diagnoses. On the night in question, the census was 75, and the staffing matrix and facility assessment both indicated there should be three nurses on the night shift; however, only two nurses (one of whom was still in orientation) were on duty for the entire overnight shift after a scheduled nurse called in. The DON acknowledged that the facility often worked with only two nurses at night and believed three nurses were not needed after the evening medication pass, and the staffing manager confirmed that when there was a call-in, a day-shift nurse might stay over only long enough to complete the evening medication pass, leaving the night shift short. Resident #1 was a female resident with bipolar disorder, dementia, and delusional disorder. On the cited night, two residents, including Resident #1, required transfer to the hospital. CNA interviews described that staffing on nights was frequently short, with only two nurses and five CNAs at times, and that the south and east (back) units had higher-acuity residents, many of whom required two staff for care. CNAs reported that when CNAs working 8‑hour segments left mid‑shift, remaining CNAs were left with 15–16 residents each, and that residents sometimes waited 20 minutes or more for call lights to be answered, especially when showers were being completed. One CNA stated that once staff were in the back units, they did not go to other parts of the building due to the high acuity and needs of those residents. During the night in question, the two nurses on duty were RN V, who was still completing orientation, and RN P, who was assisting RN V with orientation tasks, including learning how to transfer a resident to the hospital. According to RN V, around 3:00 a.m. two residents, including Resident #1, needed to be transported to the hospital. RN V reported that she had earlier transferred another resident that night and had learned that EMS would not wait if paperwork was not ready, so she took extra time to complete all transfer paperwork correctly for Resident #1. She stated she asked RN P whether they should call 911, and RN P told her to finish the paperwork while RN P went to eat and would help afterward. RN V believed RN P called 911; however, she later stated she did not call 911 herself. RN P, in contrast, initially stated she did not call 911 and then expressed uncertainty about who had called. Documentation by RN V, entered later that morning, indicated that at 3:16 a.m. the PA was notified of Resident #1’s change in condition (hypotension, lethargy, cool skin, significant bilateral lower-extremity edema, and fluid-filled blisters on the heels), that the PA agreed the resident required hospital evaluation, and that the hospital was notified and preparations for transfer were initiated. EMS and 911 records showed that 911 received a call at 3:20 a.m. for another resident, with that call clearing at 5:01 a.m., and that an abandoned call from the facility occurred at 5:24 a.m., which was returned and staff reported no emergency. At 5:29–5:30 a.m., the local emergency department and the ambulance service contacted 911, reporting that the facility had called the hospital with report on a patient over an hour earlier but the patient had not arrived, and that the facility had reported difficulty reaching 911 due to phone issues. A subsequent call detail report documented that 911 initially closed the call after being told there was no emergency, then reactivated it when the ambulance service called back with information that a 77‑year‑old female at the facility was hypertensive, unresponsive, and in cardiac arrest, and that the facility said they could not get through to 911. EMS was dispatched around 5:37 a.m. and arrived to find the resident unconscious but breathing with a pulse, on oxygen via nasal cannula, with no CPR or ventilations in progress. EMS documented severe hypoxia requiring escalation of oxygen support and transported the resident to the emergency department. Hospital records indicated that upon arrival to the emergency department, the resident was comatose, hypotensive, tachycardic, cool, and cyanotic, and was intubated, with crushed pill remnants noted in the back of the throat and concern for polypharmacy versus aspiration of medication. The resident was found to have a UTI and developed complications including unstable SVT, cardiogenic shock on top of sepsis, and DIC, ultimately leading to death later that day. The facility’s own data for the date of the incident showed that, with a census of 75, 35 residents required two or more staff for care such as transfers. Multiple CNAs and nurses reported that night shifts were often short-staffed, that there were not enough nurses to cover nights, and that they frequently did not get lunch breaks. The combination of working with only two nurses instead of the three indicated by the facility’s matrix and assessment, the high acuity and dependency of many residents, and the orientation status of one of the two nurses on duty contributed to delays and confusion in arranging timely EMS transport for Resident #1 after an acute change in condition.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide and monitor an effective training program for a newly hired RN, specifically related to emergency procedures and hospital transfers, which contributed to a delayed response to a resident’s acute change in condition and emergent transfer. The facility’s DON and NHA stated that new nurses receive five days of training and an orientation checklist that includes emergency procedures, hospitalization, transfer forms, and emergency access for rapid transport. However, the DON acknowledged that the checklist does not have to be completed before being returned and that the orientation checklist for the involved RN had not been turned in, leaving the DON unaware of which training items had been completed. The orientation checklist for this RN was not provided to surveyors by the time of exit. The newly hired RN reported that she started at the end of the prior month and had not completed all of her training, including training on transferring a resident to an acute care hospital. On the night in question, she had to transfer two residents to the hospital for changes in condition and stated she had never done this before. She reported that another RN was assisting her with the orientation training checklist and with completing the paperwork, steps, and packet required for a hospital transfer. The assisting RN confirmed that the new RN appeared overwhelmed and unfamiliar with the transfer process and that she tried to help with the required paperwork. The new RN stated that she asked whether they should just call 911 for the resident and was told by the assisting RN to finish the paperwork while the assisting RN went to eat and would help again afterward. During this same shift, EMS and 911 records show multiple calls associated with the facility and a delay in EMS activation for the resident who was ultimately found unresponsive. 911 records documented an abandoned call from the facility, a return call from 911 during which facility staff reported no emergency, and subsequent calls from the local emergency department and ambulance service indicating that the hospital had received report on a patient from the facility but had not yet received the patient. EMS documentation for the resident later transported described dispatch for a cardiac or respiratory arrest, arrival to find the resident unconscious, minimally responsive, hypoxic, and requiring escalating oxygen support and eventual transfer to the emergency department. Hospital records documented that the resident, an older adult with dementia with psychotic features, major depressive disorder, and atrial fibrillation on Eliquis, was brought in unresponsive, hypotensive, tachycardic, cool, and cyanotic, and was intubated for airway protection. The combination of incomplete orientation, lack of verified competency in emergency transfer procedures, and the facility’s failure to ensure the new RN was effectively trained and monitored in these processes led to a delay in treatment and emergent hospital transfer for this resident. The DON confirmed that she did not know which emergency procedure and transfer-related training items the new RN had completed because the orientation checklist had not been returned. The Licensed Nurse Orientation and Skill Check form included items such as emergency procedures, hospitalization, transfer form from the electronic record, and emergency access for rapid transport, but there was no evidence these competencies had been completed or validated for the new RN. The new RN’s own statements that she had never transferred a resident to the hospital before, had not yet completed all of her training, and did not complete the first transfer’s paperwork correctly further demonstrate that the facility did not maintain an effective training and monitoring process for new nurses in critical emergency and transfer procedures, contributing to the deficient practice identified by surveyors.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to develop and implement a person-centered care plan addressing a resident’s C6 cervical fracture and ordered Aspen collar use. The resident, a male admitted with diagnoses including a displaced fracture of the sixth cervical vertebra, syncope, collapse, and weakness, had a history and physical dated 12/6/25 documenting a syncopal episode with a fall, head strike, neck pain, and a scalp laceration requiring sutures. MRI showed an anterior superior vertebral body fracture, and he was stabilized in an Aspen collar with a recommendation for continued collar use and follow-up imaging. An after-visit summary dated 12/12/25 directed that the Aspen collar be worn at all times, and a provider note dated 12/15/25 confirmed the C6 fracture and Aspen collar, noting the resident was seen heading to therapy in the collar. Despite these documented orders and clinical findings, review of the resident’s care plan revealed no care plan related to the cervical fracture or the use of the Aspen collar. Interdisciplinary documentation on 12/16/25 described the resident as alert and oriented with some confusion, continuously removing the Aspen collar despite education to keep it in place per provider orders, and being unsteady, requiring assistance of two for bed mobility, transfers, and ambulation. During interviews, the Infection Prevention Manager/RN and the DON both confirmed there was no care plan in place for the C6 fracture or Aspen collar and stated that a care plan should have been created at admission by the assigned clinical care coordinator/RN responsible for the resident’s unit.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors related to administration of metoprolol succinate ER. The resident, a female with bipolar disorder, dementia, and delusional disorder, had a physician’s order for metoprolol succinate ER 25 mg by mouth once daily for hypertension, with instructions to hold the medication if the systolic blood pressure was less than 110 or the pulse was less than 60, and to notify the physician. Review of the Medication Administration Records (MARs) for October, November, and December 2025 showed multiple instances where the resident’s systolic blood pressure was documented below 110, yet the metoprolol was still administered on those dates. Specific blood pressure readings below the ordered parameter included systolic values of 107, 102, 106, 107, 94, and 107 in October; 103, 106, 100, 100, 108, 105, and 109 in November; and 103, 104, 104, 106, 109, and 104 in December, all with documentation that the medication was given. The resident’s medical record contained no documentation that any provider was notified when blood pressure readings were outside the ordered parameters. In interviews, an LPN stated that medications with hold parameters should not be given if vital signs are outside those parameters. The physician assistant and nurse practitioner both reported that, based on the written order, the metoprolol should have been held whenever the systolic blood pressure was below 110, and the nurse practitioner did not recall being notified of any holds. The DON stated her expectation that medications be given per physician orders and acknowledged that if the provider was not contacted and the medication was given when blood pressure was outside parameters, it constituted a medication error.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to complete required annual performance evaluations for two CNAs out of five reviewed, resulting in potential for unidentified CNA performance concerns, lack of training related to performance review outcomes, and potential unmet care needs. Documentation provided by the NHA showed that one CNA hired on 8/24/24 had no performance evaluation completed, and another CNA hired on 3/9/15 had their last documented performance evaluation on 3/19/24, with no current annual review. During interviews, the NHA acknowledged that these two CNAs did not have completed performance reviews and stated that the DON was responsible for completing evaluations while HR was responsible for tracking due dates. The DON reported she was unaware that she was responsible for CNA performance evaluations and had not completed any since starting in her role about five months earlier. The Regional Clinical Support confirmed that performance evaluations were expected annually on each employee’s hire-date anniversary, and no evaluations for the two CNAs were available by the end of the survey. A cited reference from a healthcare performance review resource noted that performance reviews lead to improved performance, greater productivity, and a better overall experience for patients. No specific residents or their medical conditions were mentioned in relation to this deficiency, and the report focused solely on staff performance evaluation practices and related documentation and interviews.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure a certified nurse assistant (CNA) completed the required 12 hours of in‑service training needed to ensure continued competency. Interview and record review showed that one CNA, identified as CNA F, was hired on 8/24/24 and, as of the time of survey, had completed 0 hours of in‑service training. A list of assigned in‑service trainings for this CNA documented that none of the assigned trainings had been attempted. The Nursing Home Administrator (NHA) reported that in‑services were assigned at the beginning of the year and monthly, and that CNAs were notified electronically when new training was assigned. The NHA confirmed that CNA F did not have 12 hours of completed in‑service trainings and stated that the Human Resources staff member responsible for maintaining the list of employees and training completions was unavailable during the survey. This deficiency resulted in the potential for a decrease in resident safety, as the facility did not ensure that this CNA had the required in‑service education, including dementia care and abuse prevention, as required for ongoing competency.

Penalty

7 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate supervision and implement interventions to prevent falls for two residents. One resident had Alzheimer’s disease, severe cognitive impairment, daily wandering behavior, and required moderate assistance for transfers. Her care plan identified altered functional mobility, impaired judgment due to dementia, a history of attempting independent transfers, and repeated falls. Staff described her as restless, agitated, impulsive, and unable to recognize her physical limitations. Although staff kept her near the nurses’ station and later transferred her to bed when she began to fall asleep, she fell shortly afterward in her room and sustained a pelvic fracture with severe pain. Staff and family reported she was not on 1:1 supervision at the time, and staff stated she would not have fallen if she had been on 1:1 supervision. The record also showed that this resident had a history of falls during early morning hours, including prior falls before the time she was scheduled for 1:1 supervision. Staff interviews indicated that when she was restless or agitated, she needed someone right next to her and sometimes required 1:1 supervision to remain safe. The facility had a timeline showing prior use of 1:1 supervision for increased restlessness, exit-seeking, and unsafe attempts to ambulate, but documentation of the clinical process for starting and stopping 1:1 supervision was not provided. The administrator reported the facility did not provide staff with training specifically related to 1:1 supervision and did not have a policy for it. A second resident was non-ambulatory and had diagnoses including muscle weakness and cognitive communication deficit. His care plan called for dependent ADLs, non-ambulatory status, and assist of two for bed mobility. During a transfer, a CNA attempted to move him without the care plan available and without waiting for the nurse to evaluate his transfer needs. The resident could not stand long enough to transfer, was assisted to the floor, and hit his head, with a blister and bruise noted near his left eye. The incident documentation stated the care plan was not followed, and the fall management assessment noted he could not attempt balance without physical support and had told staff he could not walk or stand.

Penalty

7 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide care and services that promote dignity and respect for multiple residents, as evidenced by prolonged call light response times and unmet personal care needs. Several residents, all with significant physical or cognitive impairments requiring assistance with personal care and toileting, reported waiting extended periods—ranging from 30 minutes to several hours—for staff to respond to their call lights. In some cases, residents remained in soiled briefs or with full urinals for hours, causing discomfort and distress. Family members also observed and reported these delays, noting that staff sometimes turned off call lights before completing the requested assistance and occasionally forgot to return to fulfill the resident's needs. Staff interviews corroborated the residents' and families' accounts, with multiple CNAs and an LPN acknowledging that residents frequently complained about long call light wait times. One CNA admitted to turning off call lights before completing the task, intending to return later, while the facility's orientation materials specifically instructed staff not to turn off call lights until the resident's need was met. Despite these guidelines, the practice of prematurely turning off call lights persisted, leading to further delays and unmet care needs. The affected residents had diagnoses such as major depressive disorder, paraplegia, muscle weakness, paralysis, and cognitive communication deficits, making timely assistance with toileting and hygiene essential. The failure to respond promptly to call lights and to provide necessary personal care services resulted in residents experiencing discomfort and a lack of dignity, as well as frustration and concern from both residents and their families.

Penalty

7 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to employ an Activity Director with the required qualifications. During interview, the NHA stated the Activities Director was still working on certification and was only about 30-40% completed with the required training, and the NHA did not know how much experience she had. The Activity Director reported she had been employed at the facility for a little over a year, had completed about 30% of an activity professional certification course, and did not have 2 years of experience in social or recreational programming. The Activity Director also stated she was not supervised by a qualified Activities Director and felt she needed support and guidance to ensure residents were provided activities that met their needs. Review of the facility's activity calendars for 6/2025, 7/2025, and 8/2025 showed no activity opportunities in the evenings, no structured opportunities for physical activity 2-3 times per week, and no specialized programs for residents with severe cognitive impairments. The job description stated that staff without certification must begin an Activity Professional Certification Course within 90 days of employment and be certified within 12 months, and listed responsibilities including planning individual and group activities, documenting activity interests and needs in the care plan, planning evening functions, and reviewing activity plans for residents with little or no activity.

Penalty

7 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate infection control practices during medication administration for multiple residents. During observation, an RN removed medications from packaging with bare hands for residents with diagnoses including coronary artery disease, dementia, cancer, heart failure, diabetes, chronic lung disease, stroke, and hemiplegia. For one resident, the RN poured pills from a cup onto paper, counted 15 medications with bare hands, and returned them to the cup before administering them. For other residents, the RN was observed removing medications from packages with bare hands and placing them into medication cups before administration. The RN stated she used hand sanitizer before touching each pill and believed that allowed her to use bare hands. The facility also failed to clean resident-shared equipment between uses. After taking a resident's blood pressure and oxygen saturation, the RN placed the blood pressure cuff and pulse oximeter into a resident-shared equipment basket without cleaning either item. Another blood pressure cuff was already in the basket, and the used cuff was placed on top of it. No disinfecting wipes were seen on the cart. Corporate infection control staff stated resident-shared equipment should be cleaned between each resident and that disinfecting wipes are kept on equipment or carts used regularly with residents. The facility further failed to provide adequate Enhanced Barrier Precautions for two residents. One resident had a newly identified wound on the right heel/ankle with dressing changes ordered for day and evening shifts, but the resident reported delayed dressing changes and no EBP sign was posted on the room door or wall. Another resident with paralysis, stroke, dementia, and tube feeding had an EBP sign on the door, but staff entered for hands-on care without gowns, and one LPN was observed with painted fake fingernails while handling the resident's tube feeding equipment and assisting with care. Corporate infection prevention staff stated residents with chronic wounds should be placed on EBP and that gowns and gloves are to be worn for direct contact care.

Penalty

7 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a safe, functional, sanitary, and comfortable environment based on multiple observations and interviews. In the kitchen near the dish machine area, the hand sink had soap and paper towel dispensers located on the opposite wall, and the paper towel dispenser was positioned over an area used for drying clean pots, pans, and utensils. In the clean utility storage area, clean and sanitary items were observed stored on the floor, and the Maintenance Director stated staff sometimes drop items when they are in a hurry. In the East Hall clean linen room, items were also observed stored on the floor, and the room was described as being cleaned nightly. Additional observations showed debris under the mat of the shower bed in the South Hall spa room, including what appeared to be flakes of skin, paper, and plastic debris. On revisit, clean and sanitary linens and briefs were stored on the short shower wall in the South Hall spa rooms and on the half shower wall in the North Hall spa room, leaving them exposed to contamination. The Mechanical Room door in the boiler room had a gap underneath that could allow pest entry, and the double doors used for deliveries and as an employee entrance had a visible gap at the bottom middle. A large trash container was placed in the hall near a resident room to catch dripping water from the ceiling, with multiple wet tiles and tiles beginning to fall apart from excess moisture. The love seat near the courtyard entrance had debris and trash under the cushions, including a dirty folded dollar bill, a used band-aid, and a dirty wadded-up Kleenex. In the therapy room, the parallel bars were loose in their brackets and could be moved back and forth, and the right pedal of the arm bike slowly came off during use and had to be repeatedly retightened.

Penalty

7 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure a PASARR Level II Exemption Form 3878 was completed timely for one resident who had diagnoses including unspecified dementia with behavioral disturbance, recurrent major depressive disorder, delusional disorders, and generalized anxiety disorder. The resident’s PAS/ARR Level I Screening form dated 1/31/25 indicated “Yes” responses for current mental illness or dementia, treatment for mental illness or dementia, and routine use of prescribed antipsychotic or antidepressant medications within the last 14 days, which required distribution of the screening to the local CMHSP with a copy of Form DCH-3878 if an exemption was requested. A review of the medical record on 8/19/25 found no DCH-3878 exemption form. During interview, the VPCS stated the physician did not complete the Level II Exemption Form 3878 when due because the form had not pulled over in the computer for signature at that time, and stated it was the Social Worker’s responsibility to ensure the correct forms were in place. The VPCS also stated she did not know what happened with the resident’s form and reported that the Level II Exemption Form 3878 was completed on 8/20/25. The Social Worker was not available for interview during the survey period.

Penalty

7 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide ADL care, including nail care, for a dependent resident. Resident #36 was a male with spastic quadriplegic cerebral palsy and unspecified intellectual disabilities. His MDS indicated he had problems with both short-term and long-term memory and that he was dependent on staff for showering/bathing and personal hygiene. His care plan identified him as dependent for ADLs and noted he could be combative with care, had episodes of restlessness and agitation, and had a history of placing his hands in his brief when incontinent. During observations on 8/18/25 and 8/19/25, Resident #36 was seen seated in his room and later across from the nurses’ station with the thumb and index finger on his right hand caked with a black substance underneath the nails. On 8/19/25 and 8/20/25, an LPN observed the nails with the surveyor and confirmed they remained dirty, stating it was embarrassing that the resident’s nails were still dirty. The shower assignment task report showed the resident received a shower on 8/20/25 at 3:06 AM. Staff interviewed stated nail cleaning and clipping were part of shower care and that nails should also be cleaned between showers if dirty, and the resident’s family member and RN reported he did not refuse ADL care.

Penalty

7 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide individualized activities designed to support the psychosocial well-being of one resident with Alzheimer’s disease, major depressive disorder, and adjustment disorder. The resident’s MDS showed a BIMS score of 6/15, indicating severe cognitive impairment, and documented daily wandering during the assessment period. The assessment also reflected that the resident’s family member said it was somewhat important for the resident to do things in groups, pursue favorite activities, listen to music, participate in religious activities, go outdoors, and spend time around pets. The resident’s care plan identified a risk for decreased activity pursuits related to anticipated dementia worsening and noted that she enjoyed listening to music and being outside. Interventions included assistance to and from activities of choice, reminiscing items, books and music, outdoor patio activities when weather permitted, and social interventions such as tactile stimulation, sorting objects, appropriate touch, music, and sounds. However, the recreational engagement record for the period reviewed showed only one outdoor activity and six religious activities over 15 weeks, with no documented pet visits, music activities, tactile stimulation, or sorting activities. The record also contained conflicting entries, including simultaneous documentation of refusal and participation in the same activity, duplicate participation entries at the same time, and participation in group activities that were not offered on those days per the activity calendar. Observations showed the resident repeatedly self-propelling her wheelchair through the halls throughout the day on multiple days, without dementia sensory items, tactile sensory items, or music of her choosing available while she attempted to engage in her surroundings. No social interactions between the resident and staff, residents, or visitors were observed during the observation periods. Staff interviews indicated the resident wandered throughout the day, could not focus on group activities, and needed personalized interventions to optimize engagement. The Activity Director stated the resident was not scheduled for regular 1:1 activity visits, had not received training related to activity programming for residents with severe cognitive impairments, and reported difficulty ensuring the resident’s activity needs were met.

Penalty

7 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure adequate care and appropriate treatment for two residents with skin integrity concerns. One resident had diabetes, paralysis affecting the right side, difficulty walking, weakness, joint inflammation, and required assistance with personal care. Her care plan identified impaired skin integrity related to multiple chronic conditions and noted that she had been admitted with a diabetic ulcer to the right heel that had closed but remained at risk to resurface. The care plan also included skin inspections, heel elevation, and sage boots while in bed. For this resident, the record and interviews showed that a wound on the right heel was identified during a shower, and the resident reported telling staff and the wound provider about it. The wound provider later debrided the wound and ordered Medi-honey and calcium alginate dressings to be changed during day and evening shifts. The resident reported delays in dressing changes, including times when the dressing was not changed until later in the day or evening, and she stated there was no treatment or dressing applied from the time the wound was first identified until after the wound provider visit. During observation, no sage boots were noted in use, and the resident reported staff had not placed them on her feet since the wound was discovered. The record also showed the last skin assessment had been completed before the wound was identified, with no skin assessment completed on the date the resident reported discovering the wound and none completed on the following weekly date. The second resident had muscle weakness and cognitive communication deficit and was dependent for ADLs, non-ambulatory, incontinent of bowel and bladder, and required a mechanical lift for transfers. His care plan and interdisciplinary documentation identified him as high risk for skin impairment and noted MASD to the buttock and groin, with interventions including pressure-relieving surfaces, skin inspections, and barrier cream. During observation, a CNA provided a brief change and exposed an open red area approximately the size of a quarter between the buttocks, covered with a sticky white cream-like substance. The CNA stated it looked like a sore. The infection preventionist confirmed a skin assessment had not been completed and no nurse progress note had been entered for the area, and the last skin assessment in the record had been completed weeks earlier. A family member also reported the resident had been left in soiled clothing and described prior drainage from the penis, while staff reportedly checked only the front of the brief and not the back.

Penalty

7 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide services to prevent the development of and promote healing of pressure ulcers/injuries for one resident, who had diagnoses including muscle weakness, stroke, tracheostomy, diabetes, and respiratory failure and required assistance with personal care. The resident’s care plan included heel elevation in bed, inspection of heels with care, an alternating pressure mattress, pressure-relieving wheelchair padding, and Sage boots to reduce the risk of bedsores and keep the heels floated. The care plan also addressed potential impaired skin integrity with instructions to bridge heels in bed if indicated and to use pressure-reducing surfaces and cushions. During observation, the resident was found lying supine in bed without Sage boots or heel bridging, and no bandage was observed on either foot. On another observation, the resident had a pillow under the calves, but it was deflated and the heels were directly on the bed; the Sage boots were not on, and the wedge was positioned on top of the blankets rather than supporting the heels. An LPN stated the boots were in the closet and that CNAs had removed them while getting the resident up, but they should have been on while the resident was in bed. Records showed an open area on the right heel and right lower extremity, and a wound measurement later documented a stage II pressure injury on the right heel with a beefy red wound bed; the HCP note identified a new right heel ulcer and noted the resident had right-sided hemiplegia.

Penalty

7 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide tracheostomy emergency care equipment at the bedside for Resident #8, a male resident with diagnoses including acute respiratory failure with hypoxia and tracheostomy. His care plan, revised on 4/30/25, documented that he had a Shiley Flex uncuffed size 6 trach placed on 3/5/25 due to respiratory failure and inability to protect his airway, and that he required frequent suction, humidifier, and trach mask support. During observations on 08/18/2025 and 08/20/2025, no Ambu bag, tracheostomy tube, or obturator were observed in Resident #8's room, including in the room, drawers, nightstand, closet, and on the wall. Suction tubing was also observed placed directly on the nightstand with no barrier. In interviews, the President of Clinical Services stated the resident should have an Ambu bag, tracheostomy tube, and obturator at the bedside for an emergent situation and identified this as the facility's policy; an LPN also reported the resident used to have an Ambu bag and tracheostomy tube on the wall but none were found in the room.

Penalty

7 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure proper labeling of medications in 1 of 1 medication carts reviewed, the South medication cart. During observations and interview on 8/19/25 and 8/20/25, the RN working from the South medication cart stated she did not know everything that was in the drawer and reported that she kept some personal items there and used the code alert to test wander guard bracelets. The top left drawer was observed to contain cooking timers, glucometers, a code alert tester for wander guard bracelets, a key ring with multiple keys, two vape pens labeled with a resident's name, a Swiss Army knife, glucometer test strips, cuticle cutters, blue roll of tape, thermometers, a candy sucker, scissors, multiple wander guard bracelets, a pill crusher, an empty syringe, probe covers for thermometers, packages of wound dressings, packages of thickening agents, and a tube of manuka honey. During interview on 8/20/2025, Corporate Infection Control stated that only resident medications and treatment items should be kept in the medication cart and that anything else could compromise the medications and/or treatments. The night shift nurses were expected to go through the medication carts to make sure none of the items found in the South medication cart were present and that the carts were clean and organized. Review of the facility policy Medication Storage & Stability, revised April 2021, stated that medications and biologicals are stored safely, securely, and properly, that medication storage areas are kept clean, well-lit, and free of clutter, and that medication storage conditions are monitored monthly.

Penalty

7 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain complete and accurate medical records for Resident #3, a female with diabetes, paralysis affecting the right dominant side, difficulty walking, weakness, joint inflammation, and need for assistance with personal care. Her record also reflected diagnoses including stage 3 kidney disease, congestive heart failure, coronary artery disease, irregular heart rate, high blood pressure, and diabetes, with a history of a diabetic ulcer to the right heel that had closed and remained at risk to resurface. The care plan identified impaired skin integrity and directed skin inspections, heel elevation, and use of Sage boots while in bed. During observation and interview, Resident #3 stated she told the provider about a wound on her right heel during a visit on 8/11/25, and said a wound provider debrided the wound on 8/15/25. She reported repeated requests for dressing changes on 8/16/25 and 8/17/25, stating the dressing was not changed until later in the day and that she only received one dressing change on each of those days. She also reported asking for a dressing change on 8/18/25 before her shower, but it had still not been changed at that time. On 8/19/25, she reported nursing staff had not placed Sage boots on her feet since she discovered the wound, and she found a pair of Sage boots in her closet and put one on her right heel herself. Record review showed the HCP visit on 8/11/25 documented a new wound to the right medial ankle and recommended Medi-honey daily until evaluation. The dressing change order dated 8/15/25 directed treatment during the day and evening shifts, and the TAR for August 2025 listed cleansing with normal saline, applying honey and calcium alginate, and covering the right heel wound every day and evening shift. However, the documentation of treatment showed the first treatment was recorded on 8/16/25, with documentation twice daily on 8/16, 8/17, and 8/18, and no dressing change was noted as completed on the administration record prior to 8/15/25. RN L stated nurses documented yes, no, or refused when entering treatment documentation, and that CNAs did not complete shower sheets for resident skin observations, instead verbally informing nurses of issues. CCSN LL stated treatment records should reflect what was completed and refusals could be charted by exception.

Penalty

7 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to notify the Office of the State Long-Term Care Ombudsman of residents who transferred from the facility, including the reason for each transfer. An email from the Ombudsman stated that only one transfer report had been received for 2025 in May and that this issue had been brought to the facility's attention several times. In response, the Nursing Home Administrator stated that the Administrator was responsible for supplying the transfer report and was looking for them, then later confirmed that there was no record of these reports being sent to the Ombudsman.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a therapy evaluation was completed for a resident upon readmission following an inpatient hospital stay. The resident, who had diagnoses including muscle weakness and required assistance with personal care, was discharged from the facility, hospitalized, and then readmitted. Upon return, the resident reported feeling weaker and more easily fatigued than before her hospitalization. Despite hospital discharge documentation and orders explicitly stating the need for occupational and physical therapy evaluation and treatment at the receiving facility, no therapy evaluation was conducted after her readmission. Interviews with facility staff revealed that the therapy manager and clinical care coordinator did not consider hospitalization alone as a reason to screen for therapy services, and believed that if a resident returned at their baseline, no therapy referral was necessary. However, hospital records indicated the resident required further skilled occupational therapy, and discharge instructions included orders for therapy evaluation and treatment at the facility. The interim director of nursing confirmed that the resident was not evaluated by therapy upon readmission, contrary to expectations.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop a person-centered care plan for two residents, leading to deficiencies in their care. Resident #8, who is bed-bound and requires assistance with personal care, was observed unkempt and unshaven on multiple occasions. Despite being scheduled for showers twice a week, during which shaving was expected to occur, Resident #8 remained unshaven. Interviews with staff revealed that Resident #8 preferred to be shaved by a family member, a preference that was not documented in his care plan. The care plan lacked interventions related to his preferences or refusals for care, and staff were unaware of these preferences, leading to inconsistent care. Resident #32, diagnosed with major depressive disorder, PTSD, and generalized anxiety disorder, had a care plan that did not address his PTSD diagnosis. The care plan focused on the potential for acute condition changes but lacked specific interventions related to PTSD. Interviews with staff indicated a lack of awareness of Resident #32's PTSD diagnosis and the absence of documented triggers or interventions to manage his condition. This oversight resulted in staff being unprepared to address his needs, potentially leading to angry outbursts and stress. The facility's policy on care planning emphasizes the importance of person-centered care, including understanding resident preferences and documenting refusals of care. However, the care plans for both residents did not reflect these principles, resulting in deficiencies in meeting their individual needs. The lack of documentation and communication among staff contributed to the failure to provide appropriate and consistent care for these residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to update the transfer status of a resident, resulting in a skin tear. The resident, who was cognitively intact, was initially admitted with diagnoses including unsteadiness on feet and difficulty walking. After a hospital stay, the resident was readmitted to the facility, and therapy assessed that her transfer status required a change from a one-person assist to a two-person assist due to increased weakness. However, this change was not updated in her care plan, leading to a skin tear during a transfer when a CNA followed the outdated care plan. Interviews revealed that the therapy director communicated the need for a change in transfer status to nursing staff, but the care plan was not updated accordingly. The CNA involved in the transfer was unaware of the change and relied on the care plan, which still indicated a one-person assist. The incident highlighted a breakdown in communication between therapy and nursing staff, as well as a failure to update the care plan to reflect the resident's current needs.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate nail care to a resident who was dependent on staff for activities of daily living. The resident, who was bed-bound and required total care, was observed on multiple occasions with long and soiled fingernails. Despite being scheduled for showers twice a week, during which nail care was supposed to be provided, the resident's nails remained unkempt. Observations on different days confirmed the resident's unshaven and unkempt appearance, indicating a lack of personal care. Interviews with staff, including CNAs and the Director of Nursing, revealed that nail care was expected to be performed during the resident's scheduled showers. However, despite documentation indicating that a shower was completed, the resident's nails were still long and dirty. The Director of Nursing acknowledged the deficiency upon observation, confirming that the resident's nails should have been trimmed during the shower. This indicates a failure in the facility's process to ensure the resident's personal care needs were met as per their care plan.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement the use of gait belts during transfers for two residents, leading to potential injury risks. Resident #268 was admitted with diagnoses including unsteadiness on feet and required assistance with personal care. After a hospital readmission, her care plan indicated a one-person assist for transfers. However, a therapy screen revealed increased weakness, necessitating a two-person assist, which was not updated in her care plan. On a specific date, during a transfer without a gait belt, Resident #268 sustained a skin tear, highlighting the failure to adjust her care plan and use appropriate transfer aids. Resident #61, diagnosed with a neurocognitive disorder and a history of falls, required maximal assistance for transfers. Observations revealed that staff frequently transferred Resident #61 without using a gait belt, despite his impaired mobility. During one instance, a CNA assisted him to the toilet by placing her arms around his torso without a gait belt, as reported by a family member who regularly observed such practices. Interviews with staff, including the Therapy Director and Clinical Care Coordinator, confirmed that gait belts should be used for all transfers unless a mechanical lift is employed. The facility lacked a specific gait belt policy, relying on it as a standard of care. Additionally, a review of staff training revealed gaps in gait belt education, with some staff not receiving current training, contributing to the deficiency in safe transfer practices.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to identify and implement interventions for PTSD triggers for a resident, leading to the potential for retraumatization and mental distress. The resident, who was admitted with diagnoses including major depressive disorder, PTSD, and generalized anxiety disorder, was cognitively intact as per a recent assessment. Despite having a care plan that mentioned the potential for acute condition changes related to PTSD, there were no specific interventions addressing the PTSD diagnosis. Additionally, a trauma-informed care life event screening identified past traumatic events, but no further trauma assessments were conducted by the facility staff. The Social Services Director (SSD) was initially unaware of the resident's PTSD diagnosis and any related triggers, despite the resident's history of physical aggression and past traumatic experiences, including abuse and significant personal losses. The resident had displayed aggressive behavior at the facility, such as breaking a window and threatening staff. The SSD later confirmed the PTSD diagnosis and the resident's history of violence but still lacked knowledge of specific PTSD triggers. This lack of awareness and intervention contributed to the deficiency in providing trauma-informed care.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that the Quality Assessment and Process Improvement (QAPI) meetings included the Medical Director as a mandatory attendee at least quarterly. This deficiency was identified through a review of the QAPI meeting sign-in sheets for January and February 2024, which revealed the absence of the Medical Director. Additionally, the Infection Control Meeting sign-in sheets, used for QAPI meetings in March and April 2024, also showed the Medical Director's absence. During an interview, the Nursing Home Administrator acknowledged that the Medical Director did not attend the meetings for four consecutive months, failing to meet the requirement of attending at least one meeting per quarter. The facility's Quality Assurance Performance Improvement Plan Policy, reviewed in May 2024, lists the Medical Director as a required attendee for these meetings.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the proper use of personal protective equipment (PPE) for enhanced barrier precautions, which was observed in two residents. Resident #1, who had diagnoses including cerebral infarction and type 2 diabetes, was cognitively intact and required enhanced barrier precautions during high-contact care activities. Despite signage indicating the need for PPE, Certified Nurse Assistants (CNAs) L and S did not wear gowns or gloves while providing care to Resident #1. CNA S was unaware of the meaning of the signage, while CNA L acknowledged the requirement but did not comply. Resident #18, diagnosed with cerebral palsy and aphasia, required enhanced barrier precautions due to a gastrostomy tube. However, there was no signage on the door to indicate the need for PPE. Licensed Practical Nurse (LPN) BB confirmed the necessity of PPE when handling the tube. The Clinical Care Coordinator/Registered Nurse (CCC/RN) and the Director of Nursing (DON) both stated that enhanced barrier precautions were expected for residents meeting the criteria, yet these precautions were not properly implemented for Residents #1 and #18.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident received care in accordance with professional standards of nursing practice, leading to an overdose of blood thinner medication. The resident, who had a history of atrial fibrillation and high blood pressure, was admitted with specific medication orders for warfarin. However, the facility transcribed the orders incorrectly, leading to the administration of an incorrect dosage. The hospital discharge summary specified a complex dosing schedule for warfarin, which was not accurately transcribed by the facility. Interviews with facility staff revealed a breakdown in the medication verification process. The nurse practitioner assumed that the pharmacy had correctly dosed the warfarin and did not verify the orders herself. The admission process involved multiple checks by different nurses, but these checks were not documented or retained, leading to a lack of accountability. The Clinical Care Coordinator noted that the order for pharmacy dosing of warfarin was not entered until days after the resident's admission, indicating a delay in the medication review process. Family members expressed concerns about the resident's medication regimen shortly after admission, highlighting the oversight in medication administration. Despite the facility's protocol for triple-checking medication orders, the failure to accurately transcribe and verify the warfarin dosage resulted in a significant medication error. The lack of effective communication and documentation among the healthcare team contributed to this deficiency, as noted in the review of nursing fundamentals.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to administer medications at the correct dose as per the physician's order for a resident, leading to a significant medication error involving an overdose of Warfarin, an anticoagulant. The resident, who had a history of atrial fibrillation and hypertension, was discharged from a local hospital with specific instructions for Warfarin dosing. However, the facility transcribed the orders incorrectly, resulting in the resident receiving 4.5 mg of Warfarin daily instead of the prescribed 2 mg or 2.5 mg. This error was not identified or corrected promptly, leading to a critically high INR level of 8.19, which was reported to the facility. Despite the critical lab results indicating a dangerously high INR, the facility did not take immediate action to address the overdose. The results were faxed to the pharmacy, but there was no documented follow-up with the provider regarding the critical lab results or the pharmacy's recommendation to administer Vitamin K. The resident's INR remained critically high, and there was a delay in obtaining a stat lab draw to reassess the INR levels. The lack of timely intervention and communication with the provider contributed to the resident's prolonged exposure to the risk of bleeding due to the Warfarin overdose. Interviews with facility staff revealed a breakdown in the medication administration and monitoring process. The nurse practitioner did not review the Warfarin orders closely, and the admission process failed to ensure accurate transcription and verification of medication orders. The facility's procedures for handling critical lab results and coordinating with the pharmacy and provider were inadequate, leading to a failure to address the resident's critical condition promptly. This deficiency highlights significant lapses in medication management and communication within the facility.