Tlc Nursing Center

diversion. No other reportables to ADPH in October, 2025 11/21/25 OCTOBER QAPI Meeting,

reportables to ADPH. No reportables in December, 2025 01/23/26 DECEMBER QAPI Meeting,

02/19/26 January QAPI Meeting, Continued Regulatory Compliance Monitoring for reportables to ADPH.

One (1) reportable in February, 2026 pertaining to abuse (misappropriation).

Review revealed the incident was reported in a timely manner. 02/25/26 Ad hoc QAPI meeting re February reportable held, no concerns identified in reporting to ADPH in a timely manner. No other reportables at this time. ************* Upon review and verification of the information provided in the facility's corrective action plan, in-service/education records, the facility's investigation, as well as staff interviews, the survey team determined the facility implemented corrective actions from 10/01/2025 to 02/25/2026, with on-going monitoring implemented; thus, past noncompliance was cited.

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Tlc Nursing Center 212 Ellen Street Oneonta, AL 35121

missing/highˆrisk orders are clarified with the attending physician and/or discharging provider prior

jeopardy to resident health or clarification are completed, when indicated.

The order verification when complete is signed by the RN safety Nurse Manager/designee and uploaded to the Electronic Health Record (EHR) under documents.

Although order entry is performed by medical records staff as a clerical function, clinical oversight

Manager/designee verification prior to implementation.Nursing clinical meetings held on weekday mornings, reviews of new admissions, including patients admitted or readmitted with a fracture.

Conducted by the nursing leadership team at the morning nursing meeting (may include the IDON, RN Supervisor, MDS Coordinator, MDS/Admissions Nurse, Restorative RN, QAPI/Staff Development Nurse and the wound care nurse).

These reviews include verification that required physician follow-up orders are obtained and documented when hospital orders are discontinued, contraindicated, or incomplete.On weekend days the assigned Nurse Manager/designee will conduct the reviews.

The process the facility will review/monitor newly admitted residents and ensure residents have orders entered to meet their medical needs per standards of practice/care is as follows:Weekly Patients-at-risk (PAR) meetings to review risk concerns including Admissions - Care Plan (CP) - Orders (including anti-coagulant therapy).3/20/26 A PAR meeting was held to review Admissions - CP - Orders (including anti-coagulant therapy)3/27/26 A PAR meeting was held to review Admissions - CP - Orders (including anti-coagulant therapy) 4/1/2026 IDON initiated nursing education - 1:1 with the nurse who called the physician.

Education included Physician Orders and Anticoagulation Therapy, Read Back Verified phone/verbal MD orders, Nursing Documentation and Discontinued Medications4/1/2026 IDON initiated nursing education with nursing staff on:The above processes in #2 and #3 a.Physician Orders and Anticoagulation TherapyRead Back Verified phone/verbal MD ordersNursing DocumentationDiscontinued MedicationsTwenty (20) nursing staff have completed education as of 04/02/2026 and twelve (12) nursing staff are left to complete the training.

The IDON or designee will monitor the schedule and ensure any staff who have not received education will receive the education before beginning their shift. QA Review 3/26/26 a QAPI meeting to review facility quality topics including the circumstances surrounding the anticoagulant and steps taken to address the concern.

Attending included the Administrator, IDON, Social Services, QA Nurse, RN Supervisor, MDS Coordinator, Therapy Director, Wound Nurse, Activities Coordinator, Admissions Coordinator, Restorative RN, MDS/Admissions Nurse.

There were no concerns or recommendations for any changes or additional actions at that point.

This facility asserts that immediacy was removed effective 03/12/2026. ******** After reviewing the facility's immediate actions and information in their Removal Plan, interviewing staff and verifying the corrective actions had been implemented the Immediate Jeopardy was removed on 04/02/2026.

The scope/severity level of F-F684 was lowered to the scope of no actual harm with a potential for no more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

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Tlc Nursing Center 212 Ellen Street Oneonta, AL 35121

in their Removal Plan, interviewing staff and verifying the corrective actions had been implemented

jeopardy to resident health or to the scope of no actual harm with a potential for no more than minimal harm that was not immediate safety jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

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Tlc Nursing Center 212 Ellen Street Oneonta, AL 35121

The facility failed to identify in RI #81's medical record what would be provided in place of the aspirin.

This deficient practice affected RI #81, one of 18 residents for whom records were reviewed. LPN #9's failure to document in RI #81's medical records that RI #9's aspirin had been discontinued by RI #81's attending physician placed RI #81 at risk of not receiving continuity of care.Findings Include: Review of a facility policy titled Discontinued Medications with an effective date of 04/2024 revealed the following: .

Policy Interpretation and Implementation1. A provider's order to discontinue a resident's medication is documented in the resident's clinical record .2.

The nurse receiving the order to discontinue a medication is responsible for recording the information . A facility policy titled Charting and Documentation with an effective date of 01/2024 documented the following:Policy StatementAll services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record.

The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.

Policy Interpretation and Implementation 1.

Documentation in the medical record may be electronic, manual, or a combination.3.

Documentation in the medical record will be objective . complete, and accurate.7.

Documentation of procedures and treatments will include care-specific details, including: .f. notification of . physician or other staff if indicated . RI #81 was admitted to facility on 02/12/2025 and readmitted to the facility on [DATE] with a diagnosis of Displaced Fracture of Base of Neck of Right Femur, Subsequent Encounter for Closed Fracture with Routine Healing. A review of RI #81's February 2026 Order Summary Report (Physician Orders) revealed RI #81's aspirin, 81 mg to be given two times per day for DVT prevention, had been discontinued due to RI #81 being allergic to aspirin.

On 03/12/2026 at 12:01 PM LPN #9 said she notified RI #81's attending physician that RI #81 was allergic to aspirin when RI #81 was readmitted on [DATE].

When asked if she documented in RI #81's medical chart or clinical records when she notified RI #81's physician, LPN #9 said she did not.

When asked why she did not document in RI #81's medical chart that she had notified RI #81's attending physician of RI #81's allergy to aspirin, LPN #9 said, she had given report to another nurse. LPN #9 acknowledged the importance of documenting in the medical chart to make sure other nurses were aware of a resident's allergies and orders given by the physician. On 04/02/2026 at 1:16 PM Registered Nurse (RN) #3 was asked where it would be documented when the nurse communicated with the physician. RN #3 replied, in the chart (nurses notes). RN #3 said it would be important to document the nurse's notes because if it was not documented, it was not done. RN #3 said documenting in the nurses' notes was important for other nurses to see changes that were made. On 04/02/2026 at 1:41 PM an interview was conducted with RN #14.

When asked where it would be documented when the nurse communicated with the physician, RN #14 replied documentation would be under the progress notes.

When asked why it would be important to document the progress notes, RN #14 replied, so other nurses knew what was going on. RN #14 further stated supervisors read the progress notes every morning to see if there had been any change in conditions. On 04/02/2026 at 3:10 PM an interview was conducted with LPN #16.

When asked where it would be documented when the nurse communicated with the physician, LPN #16 said, in the nurses' or progress notes. LPN #16 said it would be important to document the nurses' notes to show continuity of care for the resident