Health inspection·May 22, 2025

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain physician ordered laboratory testing in 1 of 3 residents (R2), reviewed for medication monitoring in the sample of 9. This failure resulted in R2 being admitted to the hospital on [DATE], where he remains. R2 was diagnosed in the hospital with Supratherapeutic INR (Initial Normalized Ratio) with a level greater than 10 (target range is between 2-3) and had to receive medication to reverse the effects from the anticoagulant, Warfarin, that R2 was receiving in the facility for a diagnosis of Pulmonary Embolism. This failure resulted in an immediate jeopardy when the facility failed to obtain laboratory testing to monitor R2's anticoagulant levels to ensure a therapeutic level was obtained. Residents Affected - Few The Immediate Jeopardy began on 4/23/24, when the facility failed to obtain a PT(Prothromin Time)/INR to ensure a therapeutic level was obtained due to the use of an anticoagulant. On 5/21/25 at 9:35 AM, V1, Administrator, V7, Regional Director of Operations, and V8, Chief Operating Officer, were notified of the Immediate Jeopardy. The surveyor confirmed by observation, interview and record review, the Immediate Jeopardy was removed on 5/22/25, but remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: On 5/20/25 at 10:30 AM, V5, R2's Sister, stated R2 is currently in the hospital preparing for surgery to remove a large cancerous mass in his intestines. V5 stated she is concerned about R2's Coumadin not being checked at the facility like it is supposed to be, it is to be checked weekly and hasn't been checked since March 2025. V5 stated when R2 was in the ER (Emergency Room) his blood count was 3 and his INR which is supposed to be between 1-2 was greater than 10. V5 stated this is not acceptable and whoever is to be checking to make sure his INR is being checked failed, the bedside care and the nurses are good at the facility and have saved R2's life a few times, but this is unacceptable. R2's ER (Emergency Room) Notes, dated 5/8/25, document R2's INR was greater than 10, R2 was started on Vitamin K and Kcentra (medication used to reverse the effects of Warfarin). Admit to ICU (Intensive Care Unit) for multiple problems, critically ill patient. Impression: Sepsis, Leukocytosis, GI (Gastrointestinal) Bleed, Elevated Lactic Acid Level, Elevated INR. R2's History and Physical, dated 5/8/25, documents the following: Impression - Acute Blood Loss Anemia, Probable GI Bleed, Supratherapeutic INR, Hx of PE. Reversal of Coumadin with Kcentra. R2's Hospital Laboratory Results, dated 5/8/25, document R2's Hgb (Hemoglobin) level was 3.8 (normal range is 14 - 18); PT (Prothrombin Time) level of greater than 80 seconds (normal range is Page 1 of 4 145783 145783 05/22/2025 Sunrise Skilled Nur & Rehab 333 South Wrightsman Street Virden, IL 62690

F 0757 Level of Harm - Immediate jeopardy to resident health or safety 11.6-14.5); INR level of greater than 10 (normal range is 0.9-1.1 with a suggested therapeutic range of 2-3); FOB (Fecal Occult Blood) was positive. R2 received four blood transfusions on 5/9/25 and one on 5/13/25. R2's Final pathological diagnosis from the colon biopsies, dated 5/15/25, documents a colon/cecal mass that is an invasive moderately differentiated adenocarcinoma, the colon showed fragments of tubulovillous adenoma. Residents Affected - Few R2's Colorectal Surgery Consult, dated 5/15/25, documents R2 has a history of DVT(Deep Vein Thrombosis)/PE on Warfarin, Hgb 3.8, Supratherapeutic INR greater than 10, reversal with Kcentra. admitted to ICU. EGD (Esophagogogastroduodenoscopy) and colonoscopy revealed a large cecal mass as well as a foreign body within the cecum, likely a bone. R2's Cardiology Consult, dated 5/17/25, documents R2 has a history of subsegmental PE (Pulmonary Embolism), admitted for acute blood loss anemia with a Supratherapeutic INR greater than 10. Continue holding Coumadin (Warfarin). R2's Face Sheet, Undated, documents R2 has a diagnosis of Pulmonary Embolism and Atherosclerosis of the Arteries of the Bilateral Lower Extremities. R2's Physician Order Sheet (POS), has the following orders: 3/6/25 Warfarin 6 mg (milligrams) every evening for Pulmonary Embolism and 4/23/25 Check a PT/INR (Prothrombin Time/Initial Normalized Ratio) weekly on Mondays. R2's Care Plan, dated, 9/23/22, documents R2 is at high Risk For Abnormal Bruising or Bleeding Related to Anticoagulant Therapy with Warfarin and an intervention to conduct therapeutic lab monitoring and report results as ordered by physician or anticoagulant clinic. R2's last PT/INR was completed on 3/26/25. There were no other PT/INR results completed after this date. A fax to V6, R2's Physician, dated 4/23/25, from V2, DON (Director of Nurses), documents that R2 had not had a PT/INR since 3/26/25 and V6 ordered a PT/INR to be completed weekly. On 5/20/25 at 11:50 AM, V6, R2's Physician, stated verified that he gave an order on 4/23/25 to check R2's PT/INR weekly. V6 stated R2 is on Warfarin and a residents therapeutic INR level is dependent on what they are on it for. V6 stated he would need to re-evaluate R2's Warfarin. V6 stated an INR of 10 is not ideal because it allows bleeding and could lead to a person bleeding to death. V7, RDO (Regional Director of Operations), stated V2, DON, identified a problem with the PT/INR's not being drawn so they did a past non-compliance, have in-serviced and are completing audits. On 5/20/25 at 12:49 PM, V2, DON, stated R2's PT/INR's should have been drawn weekly after 4/23/25 as they were routine. V2 stated R2 should have been drawn on 5/5/25 and wasn't. V2 stated she called the lab and was told that it wasn't drawn because there was no carbon copy with the lab requisition, but that it still should have been drawn. The Anticoagulant Policy/Procedure, dated 11/4/20, documents the following: The facility shall provide anticoagulation medications and perform surveillance as directed by the primary care physician 145783 Page 2 of 4 145783 05/22/2025 Sunrise Skilled Nur & Rehab 333 South Wrightsman Street Virden, IL 62690

F 0757 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few and/or facility medical director. The Physician should adjust the anticoagulant dose or stop, taper, or change medications that interact with the anticoagulant, and/or monitor the PT/INR very closely while the individual is receiving Warfarin, to ensure that the PT/INR stabilizes within a therapeutic range. They physician will order appropriate lab testing to monitor anticoagulant therapy and potential complications; for example, periodically checking hemoglobin/hematocrit, platelets, PT/INR, and stool for occult blood. If Warfarin is used the staff should use a Warfarin flow sheet or come comparable means to follow trends in anticoagulant dosage and response in individuals on Warfarin. The Immediate Jeopardy that began on 4/23/25 was removed on 5/22/25, when the facility took the following actions to remove the immediacy: 1) Immediate actions taken for residents identified: R2 was hospitalized for Supratherapeutic INR on May 7th, 2025, and received medication to reverse the effects from the anticoagulant, Warfarin. An audit of all resident laboratory orders was completed on May 9th, 2025, by V2, Director of Nursing. An audit of all residents that have physician orders for Warfarin were identified and have active lab orders for PT/INRs to monitor for therapeutic effectiveness was completed by V2, Director of Nursing, on May 9th, 2025. 2) How the facility identified other residents who could potentially be affected: All residents have the potential to be affected by the alleged deficient practice. 3) Measures put into place/ System changes: Facility licensed nursing staff were educated by phone or in person in the following categories: Obtaining laboratory testing as ordered by the physician, with special consideration for those residents on Warfarin on May 9th, 2025, by V2, Director of Nursing. Audit of all scheduled labs was completed on May 9th, 2025, including PT/INRs by V2, Director of Nursing. Audit of all residents with Warfarin medication orders were ensured to have scheduled laboratory testing of PT/INRs to monitor for therapeutic effectiveness by V2, Director of Nursing on May 9th, 2025. 145783 Page 3 of 4 145783 05/22/2025 Sunrise Skilled Nur & Rehab 333 South Wrightsman Street Virden, IL 62690

F 0757 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few V2, Director of Nursing, initiated a Warfarin tracking system that consists of reviewing the Electronic Medical Record to ensure that any resident with new orders for Warfarin have orders in place for monitoring therapeutic effectiveness with a PT/INR laboratory testing and results are obtained and the resident's physician are notified of those results with new orders obtained as necessary. Licensed agency staff will not work at the facility until they are educated by the Director of Nursing/Designee on the importance of ensuring PT/INR levels are ordered with Warfarin to monitor for therapeutic effectiveness. The facility will educate all Agency and Facility licensed nursing staff on a quarterly basis and during orientation on the order process for labs, with emphasis on the need for therapeutic monitoring for effectiveness for residents with medication orders for Warfarin, by the Director of Nursing or Designee. 4) Those that reviewed policies were: V19, Chief Nursing Officer, V7, Regional Director of Operations, and V8, Chief Operating Officer 5) How the corrective actions will be monitored: The Director of Nursing or designee has put into place a Warfarin tracking system that consists of reviewing the Electronic Medical Record to ensure that any resident with new orders for Warfarin have orders in place for monitoring therapeutic effectiveness with a PT/INR laboratory testing and results are obtained and the resident's physician are notified of those results with new orders obtained as necessary. The Director of Nursing or designee will complete random audits of scheduled laboratory testing as ordered by the physician, with special consideration for those residents on warfarin for 12 weeks until compliance is achieved. Results of the above reviews will be discussed at a weekly quality assurance meeting that the Administrator is the head of/holds for a period of 12 weeks and will provide additional education as needed and implement interventions for improvement until resolution. 145783 Page 4 of 4