Every finding on record at Vernon Manor

Based on interview and record review the facility did not ensure a thorough investigation of elopement was completed for 1 of 3 Residents (R1) reviewed for elopement.R1 eloped from the facility on 6/25/26 and the facility did not complete a thorough investigation. Evidenced by:The facility's policy titled Mistreatment, Neglect, or Misappropriation of Resident Property Policy dated 10/13/16 states in part . VI. Investigation.C. The charge nurse will assist the witness to document information at the direction of the Administrator, Director of Nursing or designee, and provide it to Resident Services. D. The Social Worker will review the information and discuss the incident with the involved parties as necessary. R1 was admitted to the facility on [DATE] with diagnoses that include Alzheimer's Disease, dementia, anxiety disorder, and major depressive disorder. On 6/25/26, R1 eloped from the facility. The facility's self-report states in part On 6/25/26 at 2:55 AM, [Sheriff Officer name and Sheriff Department name] contacted [Facility Name] and asked of a resident named [R1's name] resided at the facility. [LPN (Licensed Practical Nurse) name] confirmed that [R1's name] was a resident. [[NAME] Officer's name] reported that R1 had been found on [Location address] .It was discovered that R1 had exited the facility through her bedroom window. On 8/11/26 Surveyor reviewed the facility's self-report. Surveyor requested staff statements/ interviews regarding this incident, and none were provided. On 8/12/16 at 1:11 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if they participated in the investigation regarding R1's elopement. DON B stated yes and that they did the investigation. Surveyor asked DON B if they obtained staff interviews or statements, DON B stated no. On 8/12/26 at 1:35 PM, Surveyor interviewed NHA A (Nursing Home Administrator). Surveyor asked NHA A if there were any staff statements or interviews completed regarding R1's elopement, NHA A stated no. Surveyor asked NHA A if they would expect that interviews/ statements would have been obtained, NHA A stated yes.

Based on interview and record review, the facility did not ensure a comprehensive care plan was developed and implemented so that residents can attain their highest practicable physical, mental, and psychosocial well-being for 1 (R3) of 3 residents reviewed.R3 was admitted to the facility on hospice services. R3 experienced anxiety and restlessness. R3's comprehensive care plan did not indicate R3 was receiving hospice services or that R3 experienced anxiety and restlessness.Evidenced by:The facility policy, Comprehensive Care Plans, dated 6/25, states, in part;.The comprehensive care plan will describe, at a minimum, the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.R3 was admitted to the facility on [DATE] with a diagnoses including encounter for palliative care, major depressive disorder, and anxiety disorder.On 8/12/26 at 10:45 AM, Certified Nursing Assistant C (CNA) indicated she is very familiar with R3. CNA C indicated R3 experienced anxiety and restlessness and was on hospice services. CNA C indicated staff had to check on R3 often because they were all over the place. R3 would walk on own with oxygen tubing around them and would pull off colostomy bag.On 8/12/26 at 12:20 PM, Licensed Practical Nurse D (LPN) indicated nursing staff struggled to keep R3 calm as R3 was often very anxious and restless. LPN D indicated R3 would pull off colostomy bag and attempt to walk around.On 8/12/26 at 2:00 PM, Nursing Home Administrator A (NHA) indicated R3 was on hospice services and did experience anxiety and restlessness when R3 resided at the facility. NHA A indicated R3's care plan should include hospice services, anxiety, and restlessness.

Based on interview and record review, the facility did not ensure 1 of 1 resident (R3) who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident.R3 was admitted to the facility with a diagnosis of Post-Traumatic Stress Disorder (PTSD). The facility failed to complete a trauma informed assessment and R3's care plan did not include R3's PTSD diagnosis.Evidenced by:The facility policy, Comprehensive Care Plans, dated 06/25, states, in part;.The comprehensive care plan will describe, at a minimum, the following:.Individualized interventions for trauma survivors that recognize the interrelation between trauma and symptoms of trauma, as indicated. Trigger-specific interventions will be used to identify ways to decrease the resident's exposure to triggers which re-traumatize the resident as well as identify ways to mitigate or decrease the effect of the trigger on the resident.The facility policy, Behavioral Health Services and Trauma Informed Care, dated 1/20, states, in part;.Each resident is to be screened for mood, behavior, psychosocial, and trauma needs prior to admission.Any indications of past trauma or known triggers for negative experiences are to be appropriately documented in the plan of care along with approaches that help to support and calm the resident if experiencing symptoms of trauma or other negative mood or behavioral symptoms.R3 was admitted to the facility on [DATE] with a diagnoses including encounter for palliative care, post-traumatic stress disorder, major depressive disorder, and anxiety disorder.On 8/12/26 at 10:45AM, Certified Nursing Assistant C (CNA) indicated she is very familiar with R3. CNA C indicated R3 experienced anxiety and restlessness and was on hospice services. CNA C indicated she did not know any specifics of R3's PTSD diagnosis and was unaware of possible triggers for R3.On 8/12/26 at 2:00PM, Nursing Home Administrator A (NHA) indicated R3 was on hospice services and did experience anxiety and restlessness when R3 resided at the facility. NHA A indicated the facility does have a system in place for trauma informed assessments, but one was not completed for R3. NHA A indicated an assessment should have been completed, and the results should have been care planned.

Based on document review, interview and policy review, facility failed to ensure that when COVID-19 vaccine is available to the facility, each resident and staff member is offered the COVID-19 vaccine unless the immunization is medically contraindicated or the resident or staff member has already been immunized for 4 of 4 staff reviewed. This has the potential to affect all 46 residents residing within the facility.Facility failed to have documentation of staff COVID-19 vaccination status, that staff were educated about the COVID-19 vaccine, the COVID-19 vaccine was offered and signed consents of accepting the vaccine or declining the vaccine for the following four staff Director of Nursing (DON), Licensed Practical Nurse (LPN)1, Resident Care Assistant (RCA)1 and Certified Nurse Aide (CNA)1 Findings include:Review of the facility's policy titled COVID-19 Vaccinations dated 07/03/2025 revealed, 1. It is the policy of this facility, in collaboration with the medical director, to have an immunization program against infectious diseases in accordance with national standards of practice.3. Residents and staff will be offered immunizations against infectious diseases.5. Copies of the Vaccine Information Statement (VIS) or Emergency Use Authorization (EUA) will be given and explained to the staff member.prior to receiving a specified vaccine(s).7. Following assessment for potential medical contraindications, the specified vaccination(s) may be administered.8. Staff.will be required to sign a consent form prior to administration of the vaccine. The completed, signed, and dated record will be filed in the.staff.medical file.Review of the DON, LPN1, CNA1 and RCA1' s employee files and infection control records revealed there was no documentation of the staff's COVID-19 vaccination status, that staff had been educated regarding the COVID-19 vaccine, signed consent form for staff requesting vaccination, or signed declination statement for staff refusing the COVID-19 vaccine.During an interview on 02/26/26 at 3:01 PM, the IP (Infection Preventionist) stated that she had posted informational posters in the break room regarding COVID-19 vaccination; however, she acknowledged she does not document which staff received education, The IP stated that she does not maintain employee records for any staff regarding their COVID-19 vaccination status, consent for vaccination and providing the vaccine or staff's declination of the vaccine.During an interview on 02/27/26 at 12:45 PM, the DON stated she was not aware that the IP was not maintaining documentation for any staff regarding the staff 's COVID-19 vaccination status, education regarding the COVID-19 vaccine, consent, or declination.

Based on observation, interview, record review, and policy review, the facility failed to document and respond to residents' grievance regarding removal of their bedrails for five of five residents (R6, R8, R23, R26 and R42). R6, R8, R23, R26 and R42 voiced grievances regarding their bedrails, and the facility did not follow their grievance policy. Findings include: Reviewed facility's undated policy titled, Grievance indicated, Facility will make prompt efforts to resolve grievances a resident may have. The intent of the grievance process is to support each resident's right to voice grievances (e.g., those about treatment, care, management of funds, lost clothing, or violation of rights) and to assure that after receiving a complaint/grievance, the facility actively seeks a resolution and keeps the resident appropriately apprised of its progress toward resolution. 1.Review of R26's admission Record, located in the EMR (electronic medical record) under the Profile tab revealed the resident was admitted to the facility on [DATE]. Review of R26's annual MDS (Minimum data set) with ARD (assessment reference date) of 02/20/23 revealed a BIMS (brief interview of mental status) score of 14 out of 15, indicating the resident was cognitively intact. Interview on 02/24/26 at 3:34 PM, R26 stated the facility removed the side rails. He expressed frustration and stated he was unable to turn himself in bed. 2.Review of R8's admission Record in the EMR under the Profile tab revealed the resident was admitted on [DATE]. Review of R8's annual MDS with an ARD of 01/07/26 and located in the resident's EMR under the MDS tab revealed a BIMS score of 13 out of 15 which indicated the resident was cognitively intact. Interview on 02/24/26 at 3:52 PM, R8 stated the facility removed the side rails. R8 stated he was unable to turn himself in bed, had difficulty sitting on the side of the bed, and feared he may fall without the rails to hold onto. He stated he now must call staff to assist with repositioning and sitting up. 3.Review of R6's undated admission Record located in the resident's EMR under the Profile tab revealed R6 was admitted to the facility on [DATE]. Review of R6's quarterly MDS with an ARD of 12/17/25 and located in the EMR under the MDS tab revealed R6 had a BIMS score of 15 out of 15 which indicated he was cognitively intact. During an interview and observation on 02/24/26 at 11:14 AM, R6 stated, They took my rails away and told me they are not allowed. R6 stated she wanted the bed rails back because she had no use of her left hand and she had used her right hand to hold onto the rails for positioning in the bed. R6 stated she had expressed her concerns about the bed rails being removed to the Administrator, Director of Nursing (DON and had asked for a written response regarding the bed rails being removed. R6 stated she had not received anything regarding the rationale for the bed rails being removed. 4.On 02/26/26 at 10:00AM, the Resident Council meeting was held with five residents, R6, R8, R23, R26 and R42, in attendance. R42, the Resident Council President, stated that the bed rails were taken away because the facility's Administrator stated that the Federal Regulations (F 700) prohibits any use of bed rails. All the residents present were visibly upset and stated that they received no prior notice that the bed rails were being removed. The Resident Council President filed a grievance asking management if there was an intention to remove resident bed rails. All five residents stated that the Administrator never responded to their grievance either verbally or in writing. During an interview on 02/26/26 at 2:17 PM, the Activity Director (AD) stated there was discussion at the December Resident Council Monthly meeting about bedrails being removed sometime in December 2025. The AD stated the process for concerns voiced in Resident Council Meetings was that the concerns were recorded and documented in the minutes if the issue could not be addressed during the meeting. If the concern was not resolved in the meeting, the concern was documented as a grievance, and the grievance form would be initiated. The AD stated the concerns from the previous meeting would be addressed in the next resident council meeting until residents no longer voiced the concern and this would be documented. The AD verified that no process for addressing bed rails concerns were reported back to the resident group. During an interview on 02/26/26 at 2:31 PM, Licensed Practical Nurse (LPN) 3 and LPN4 stated that they had been informed by Administration that all bed rails had to be removed due to regulation. LPN3 and LPN4 stated the bed rails had been removed around 12/25/25. LPN3 and LPN4 stated numerous residents and families had expressed and continued to express concerns to them regarding the rails being removed. Review of a letter from the Administrator to residents and families dated 02/05/26 that was provided by the facility indicated, We would like to share an important update regarding resident safety at [facility name]. In accordance with guideline F700 related to bed rails, [facility name] will no longer be able to offer or use bed rails for residents. As a result, any bed rails currently in place will be removed by our maintenance team . During an interview on 02/27/26 at 12:29 PM, the DON stated R6 came to Administration and asked if they were going to remove bed rails. The DON verified none of the residents currently had bed rails. The DON stated there had been an upheaval from the residents about the rails being removed. During an interview on 02/27/26 at 8:32 AM, the Administrator stated bed rails had been installed on all the beds, and they had all been removed. The Administrator stated they started this process around 01/01/26. The Administrator stated she had met with residents personally including R6; however, denied providing anything in writing to the resident to address her concerns. The Administrator stated the letter dated 02/025/26 was sent to families but not to residents. The Administrator verified that a response should be provided when a grievance was filed.

Based on interview, record review, and policy review, the facility failed to ensure all incidents and/or allegations of abuse were reported immediately but no later than two hours to the State Survey Agency (SSA) for two of three residents (R55 and R43) reviewed for abuse.Allegations were made that R9 hit R43 on 05/03/25 and R9 hit R55 on 05/08/25; these instances were reported to the State Agency more than eight months later on 02/19/26. Findings include:Review of the Vulnerable Adult' policy dated 11/03/25 and provided by the facility read, All residents have the right to be free from neglect, verbal, sexual, and mental abuse . Residents must not be subjected to abuse by anyone, including but not limited to: facility staff, other residents . Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish . All alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property are reported immediately, but not later than two hours after the allegation is made .1. Review of R9's undated admission Record in the Electronic Medical Record (EMR) under the Profile tab revealed R9 was admitted to the facility on [DATE] with diagnoses which included dementia with agitation and anxiety disorder.Review of R43's undated admission Record in the Electronic Medical Record (EMR) under the Profile tab revealed R43 was admitted to the facility on [DATE] with diagnoses which included schizophrenia and intellectual disability.Review of the facility' Investigation Summary, dated 05/03/25, provided by the facility, revealed [Certified Nursing Assistant (CNA) 3] was in room [ROOM NUMBER] when she heard resident yelling out.[CNA3] was in the middle of performing peri care. It took about a minute to be able to safely leave the resident to investigate the yelling. When CNA [3] arrived in sunroom resident [R43] was in the middle of the sunroom and resident [R9] was in the purple-colored chair with her wheelchair by the pink colored chair. [R43] explained to [CNA3] that [R9] had hit her on her right upper arm and was trying to push her wheelchair into the hallway. [CNA3] stayed with both residents in the sunroom until another CNA [CNA4] arrived.The other CNA [CNA4] on the hall was unaware of any screaming that occurred. When she came out of another resident's room, the [CNA3] that heard the screaming told her that [R9] slapped [R43] . [CNA4] told [CNA3] to tell the nurse right away. [The] Nurse [was] working the hallway in the nurses' station at the time of the incident. She did not hear any noises or yelling. [R43] stated that [R9] walked from her wheelchair to a purple chair. On the way [R9] said that [R9] slapped her on the right upper arm and tried to push her wheelchair into the hallway. The Investigation Summary dated 05/03/25 indicated the State Agency had not been notified of the allegation.Review of the facility's Misconduct Incident Report dated 02/18/26 and provided by the facility revealed, .staff were directed by the Chief Executive Officer in place at that time not to submit the required external report to the Department of Health Services. As a result, mandatory reporting component was not completed. Since that time there has been a change in leadership, and the former Chief Executive Officer is no longer employed by the organization.During an interview on 02/25/26 at 2:46 PM, CNA4 stated she was working on 05/08/25 when R43 alleged that R9 hit her. CNA4 stated she did not see what occurred and was working with a different resident at the end of the hall when she heard R43 yell. CNA4 reported that R43 was sitting near a table in her wheelchair. CNA5 said she heard screaming from R43 who reported R9 was hitting her. CNA4 stated she was not able to get to R43 right away because she was providing care to a different resident. During an interview on 02/25/26 at 4:11 PM, CNA3 stated she was working on 05/08/25 and heard [R43] yelling. CNA3 stated she went into the hallway and R43 reported to her that R9 hit her. R9 was on the opposite side of the room and had walked herself over there or used her wheelchair. During an interview on 02/27/26 at 12:05 PM, the Director of Nursing (DON) stated this allegation was not reported to the State Agency because the Administrator at the time decided not to report it. The DON stated R4'3s allegation of being hit was an allegation of physical abuse. 2. Review of R55's undated admission Record in the EMR under the Profile tab revealed R55 was admitted to the facility on [DATE]with diagnoses which included dementia. R55 passed away and her closed record was reviewed. Review of the Investigation Summary dated 05/08/25 and provided by the facility revealed, [R9] wheeled herself to the activity room where other residents were watching TV. [Activity Assistant (AA)] asked [R9] if she wanted to participate and [R9] responded no. [R9] then wheeled up to another resident [R55] and started to hit her wheelchair. [AA] stepped in between the two residents. [AA] asked [R9] to stop and [R9] told staff to 'get out of here.' [R9] wheeled away from [R55] but stayed in the activity room. [AA] went back to leading activity. [R9] wheeled back and hit [R55] on the right arm under the shoulder. [AA] went to the nurses' station and got nurse [Licensed Practical Nurse (LPN)6]. [LPN6] was told when arriving at activity room that [R9] had slapped [R55]. [R55] was wheeling around the activity room. [Licensed Practical Nurse (LPN)6] directed [R9] out of the activity room and towards the resident's room. [LPN6] notified 400 nurse of the incident and started one-on-one with [R9] . State agency not contacted. Review of the Misconduct Incident Report dated 02/18/26 and provided by the facility revealed, staff were directed by the Chief Executive Officer in place at that time not to submit the required external report to the Department of Health Services. As a result, mandatory reporting component was not completed. Since that time there has been a change in leadership, and the former Chief Executive Officer is no longer employed by the organization.During an interview on 02/27/26 at 12:09 PM, the Director of Nursing (DON) stated she was working on 05/08/25 when the incident occurred between R9 and R55. The DON stated R9 was initially smacking the arm of R55's wheelchair, then AA moved R9 but R9 came back and hit R55. The DON stated R9 was very mobile in her wheelchair at the time.During an interview on 02/25/26 at 3:16 PM, Social Services (SS )2 stated abuse allegations went to the Administrator and DON. SS2 stated if an allegation involved abuse, it should be reported to the State within two hours. During an interview on 02/27/26 at 2:11 PM, the [NAME] President (VP) of Health Services stated the Administrator (current during the survey) was a student in May 2025 and was training at the facility. The VP of Health Services stated the Previous Administrator in place in May 2025 and decided not to report the 05/03/25 or the 05/08/25 incidents to the State Agency. The VP of Health Services stated once the Previous Administrator left and was no longer an employee, current administration staff reviewed the incidents on 05/03/25 and 05/08/25 and felt there were allegations of abuse and the incidents were reported in February 2026.

Based on observation, interview, and facility policy review, the facility failed to ensure one of one medication storage room was free of expired COVID-19 tests.This practice fails to ensure that biologicals stored in the medication storage room efficacy is maintained.Findings include:Review of the facility's policy titled Medication Administration Policy reviewed 02/2019, revealed under procedure, 3.Check that medication are labeled with open date and not expired before administrating.On 02/26/26 at 10:54 AM, Surveyor observed the only medication storage room with the facility's Infection Preventionist (IP). Surveyors' observation revealed three of three boxes of iHealth COVID -19 Antigen Rapid Test with expiration dates of 09/02/25. The IP confirmed at this time that the tests were expired. Observation revealed one box of COVID-19 tests was opened and three tests had been used. The IP stated three test from the expired boxed were used the previous day. During an interview on 02/26/2026 at 10:56 AM, the IP stated it was her expectation there would not have been any expired medications and/or biologicals in the facility.

Based on interview, record review, and policy review, the facility failed to ensure 2 of 3 Residents (R58 and R59) reviewed for beneficiary notices received the Skilled Nursing Facility (SNF) Advanced Beneficiary Notice (ABN) of Non-Coverage forms when skilled therapy was being discontinued.This failure did not allow residents/responsible parties to decide whether to receive the care that might not be paid for by Medicare if they chose to assume financial responsibility for R58 and R59.Findings include:Review of the Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) Form CMS-10055, dated 2020, provided by the facility, and served as the facility's policy for completion of the SNF ABN revealed, Medicare requires SNFs to issue the SNF ABN to Original Medicare, also called fee-for-service (FFS), beneficiaries prior to providing care that Medicare usually covers, but may not pay for in this instance because the care is: not medically reasonable and necessary; or is considered custodial. SNF ABN provides information to the beneficiary so that s/he can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility.1. Review of R58's admission Record, from the electronic medical record (EMR) Profile tab, showed an admission date of 01/19/26 with diagnoses due to aspiration pneumonia. Review of R58's EMR Census tab showed he started Medicare A benefits on 01/19/26 with an end date of 01/30/26.Review of the form titled Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) showed R58 was not issued a SNF ABN that advised the cost of skilled services if he desired to continue when Medicare discharged from skilled services. 2. Review of R59's admission Record, from the EMR Profile tab showed an admission date of 12/19/25 with medical diagnoses of sepsis due to pneumonia, urinary tract infection, and paroxysmal atrial fibrillation. Review of R59's EMR Census tab showed R59 started Medicare A benefits on 12/19/25 with an end date of 01/16/26.Review of the form titled NOMNC and Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) showed R59 was not issued a SNF ABN that advised the cost of skilled services if he desired to continue when Medicare discharged from skilled services. Interview on 02/26/26 at 11:30 AM, Social Services (SS)2 verified that no ABN had been issued to R58 or R59. SS2 stated, The facility has not issued ABN Forms.During an interview on 02/26/26 at 1:29 PM, SS2 stated SS2 was not aware of the SNF ABN form or the need to issue to residents in the event they were staying in the facility beyond the termination of skilled services. During an interview on 02/27/22 at 2:57 PM, the Administrator stated SS2 brought to her attention during the survey that SS2 was not doing SNF ABN notice. The Administrator stated she had spoken with the SS2 that it is required for SS2 to compete the SNF ABN notice. The Administrator stated if a resident were to stay in the facility for a post Medicare stay, the resident should be issued the SNF ABN so the resident would know they could pay for continued services if desired.

Based on interview, record review, and policy review, the facility failed to ensure one of two residents (R43) reviewed for advanced directives had a valid advanced directive in place. R43's Physician's Orders Scope of Treatment (POST) form had not been signed by the Guardian when R43's code status was changed from Full Code to Do Not Resuscitate (DNR). Findings include:Review of the facility's policy titled, Advance Directive, dated 08/2017 revealed, [Facility name] will encourage residents to exercise their right to formulate an advance directive at their option. Staff will inform and educate resident of their rights to accept or refuse medical treatments, refuse to participate in experimental research and to formulate an advanced directive to express their health care wishes .Upon admission, identify if the resident has an advanced directive and if not, determine if the resident wishes to formulate an advanced directives . Examples include a pre-existing medical order for do not resuscitate.POST, or other document directing the resident's health care wishes . All advance directive documents will be reviewed to ensure complete with signatures, etc . All advance directive copies will be obtained and located under the advance directive section in the medical record .During the quarterly RAI process and with any significant changes in condition, [name of facility] staff will: identify, clarify, and review the existing care instructions and whether the resident wishes to change or continue instructions from the advance directive .Review of the R43's undated admission Record in the Electronic Medical Record (EMR) under the Profile tab revealed R43 was admitted to the facility on [DATE]. Review of the R43's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/04/26 in the EMR under the MDS tab revealed R43 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated the resident was moderately cognitively impaired. Review of R43's Order for Appointment of Successor Guardian of the Person dated 11/20/15 in the EMR under the Misc [Miscellaneous] tab revealed Family Member (F) 2 was R43's legal guardian.Review R43's POST dated 04/24/25 and located in the resident's paper chart under the Advance Directive tab revealed the form had been signed by the Physician Assistant (PA); however, it had not been signed by F2, R43's guardian. The POST form indicated R43's status was DNR.Review of R43's current physician Order Summary Report dated 02/26 in the EMR under the Orders tab revealed the DNR physician order originated on 09/28/25. During an interview on 02/26/26 at 2:20 PM, Licensed Practical Nurse (LPN) 3 reviewed R43's paper chart and stated there was a POST form signed by the PA on 04/24/25 that indicated R43's code status was DNR. LPN3 stated the form had not been signed by F2, R43's guardian. LPN3 stated that F2 should have signed the POST form. During an interview on 02/26/26 at 2:29 PM, Social Services (SS) 2 stated it was her responsibility to ensure the POST forms were complete upon admission, but after that time if changes were made, she would not be aware of it. SS2 stated she did not review POST forms after the initial POST was completed at admission. SS2 reviewed R43's paper chart and stated she did not know where the original POST form was, but it should be in the paper chart. SS2 stated the POST dated 04/24/25 was not signed by F2, R43's guardian, therefore was not valid without the responsible party signature. On 02/26/26 at approximately 4:30 PM, the surveyor requested from the Administrator to review a signed and valid POST for R43. During an interview on 02/27/26 at 9:59 AM, the Administrator stated R43's guardian had requested the code status be changed from Full Code to DNR and that was why the POST form with DNR was signed by the PA on 04/24/25 and placed into R43's paper chart. The Administrator stated the social service department was responsible for getting the resident/guardian signatures for the POST forms. The following additional documents were provided to the surveyor by the Administrator:Review of R43's POST, form dated 10/17/23 revealed R43's previous code status was Full Code, and the form was signed by the PA and F2.Review of R43's Physician's History and Physical, dated 02/22/24 revealed, I spoke with Guardian [F2] over the phone. All questions answered to satisfaction. Requesting a call back with any changes in clinical status. Requested DNR.Review of R43'sCare Plan Notes and Social Service Notes from 05/09/24 - 02/27/26 revealed no documented evidence that R43's code status had been reviewed. During an interview on 02/27/26 at 11:29 AM, F2 stated the Physician had talked to her a while ago about changing the code status from Full Code to DNR and she had decided over the course of time that DNR was the best option. F2 stated she attended most Care Plan meetings but did not remember staff discussing R43's code status. During an interview on 02/27/26 at 12:25 PM, the Director of Nursing (DON) stated Social Service staff were responsible for ensuring POST forms were completed and placed in the paper chart upon admission. If changes were made later, the resident/decision maker would sign the new form along with the Physician and it would be placed into the paper chart. The DON stated she attended some Care Plan meetings but did not remember staff discussing code status at the meetings. The DON stated the POST form for R43 should have been signed and placed into the paper chart. During an interview on 02/27/26 at 12:46 PM, the Administrator stated that POST forms should have both signatures (Physician and resident/responsible party) before being placed in the chart. The Administrator stated there had not been an auditing process in place to review advanced directives.

Based on record review, interview, and policy review, the facility failed to ensure residents (R) were free from physical abuse for 1 (R22) of 3 residents reviewed for abuse out of 18 sample residents. R15 threw a metal spoon and hit R22 on the back of the head during an activity. Findings include: Review of R15's ''Admission Record,'' located in the ''Profile'' tab of the electronic medical record (EMR) revealed the resident was admitted to the facility on [DATE] with diagnosis including unspecified dementia. Review of R15's significant change ''Minimum Data Set (MDS)'' with an assessment reference date (ARD) of 07/07/24 located in the EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of two out of 15 which indicated the resident was severely cognitively impaired. Further review revealed R15 exhibited physical and verbal behaviors towards others. Review of R15's Care Plan, located under the ''Care Plan'' tab of the EMR and dated 08/26/24, revealed a care plan related to altered behaviors and that resident strikes out. Interventions in place were to watch for signs of increasing anxiety and agitation. Review of R22's ''Admission Record,'' located in the ''Profile'' tab of the EMR, revealed R22 admitted to the facility on [DATE] with diagnosis including Alzheimer's disease. Review of R22's quarterly ''MDS'' with an ARD of 09/04/24 and located in the EMR under the MDS tab revealed the facility a BIMS score of 13 out of 15 which indicated the resident was cognitively intact. Review of R15's Incident report, dated 08/25/24 at 10:00 AM, provided by the facility revealed there was an incident with R15 during activities. No additional description was listed. Review of R15's Incident Summary dated 08/25/24 at 10:00 AM completed by Activities Assistant 1 (ACT) revealed ACT1 removed R15 from the group circle in the activity room due to R15 trying to hit another resident. (It did not identify the resident) It further documented while ACT1 was trying to redirect R15 with magazines, R15 tried to hit ACT1 with a spoon but was unsuccessful. R15 kept talking to ACT1 and then moved her chair to see in the direction of the group of other residents and then threw the spoon at another resident. During an interview on 11/18/24 at 2:33 PM, ACT1 stated Certified Nurse Aide 1 (CNA) brought R15 into the activities room from the dining room. ACT1 stated R15 already had a spoon with her when she came to activities. She stated that CNA1 placed R15 beside other residents. She said R15 seemed off, appeared upset and had an angry face. R15 was sitting beside R22 and R15 attempted to hit R22 on her arm with the spoon but she was unable to reach her. ACT1 further stated she moved R15 to another table in the activity room. She gave R15 some magazines to read and she seemed fine, but she did not take the spoon away from R15. A short time later R15 turned her wheelchair around in the direction of the other resident and was mumbling something and she threw the spoon. She did not see the spoon being thrown but she heard the noise it made when it hit the ground, and she heard R22 say Ouch. Continued interview revealed she looked up and saw R22 who appeared upset. ACT1 stated she asked R22 if she was okay, and she stated yes. At that time, she took R15 out of the activity room and reported it to Licensed Practical Nurse 1 (LPN), who took R15 with her while she filled out an incident report and wrote a statement. During an interview on 11/18/24 at 2:59 PM, LPN1 stated back in August, ACT1 reported to her during an activity that R15 became upset and threw a spoon at R22. She took R15 to the nurse's station after it happened to keep an eye on her. She stated she was aware that R15 had another incident in the past of hitting another resident. She stated R15 should not have been allowed to take a metal spoon out of the dining room. She said no residents are allowed to take utensils out of the dining room. During an interview on 11/19/24 at 12:12 PM the Director of Nursing (DON) stated the facility substantiated the incident that occurred between R15 and R22. She stated staff witnessed the incident when R15 threw a spoon at R22 and hit her in the head. She stated ACT1 should have intervened and notified a nurse as soon as she observed R15 trying to hit R22 on the arm. Review of the facility's policy titled Resident Abuse revised 01/15/24 revealed, the facility believes all residents have the right to be free from abuse including metal, verbal, and sexual: neglect, maltreatment, exploitation, corporal punishment, involuntary seclusion, and misappropriation of property.

Based on record review, document review, interviews, and policy review, the facility failed to timely report an allegation of verbal abuse to the State Agency (SA) for 1 of 3 residents (R33) reviewed for abuse out of a total sample of 18 residents. Findings include: Review of the facility's Grievance Log for September 2024 revealed a grievance dated 09/17/24 that indicated R33 reported that Certified Nurse Aide 5 (CNA) had verbally abused her. Review of R33's Face Sheet located in the electronic medical record (EMR) under the Face Sheet tab revealed admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, heart failure, and chronic obstructive pulmonary disease (COPD). Review of the EMR quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/04/24 under the MDS tab indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. Review of the facility's investigative file revealed that CNA6 (Certified Nursing Assistant) and CNA5 entered R33's room on 09/14/24 to answer her call light. R33 requested to be removed from the bedpan. CNA5 began to yell at R33. CNA7 came across the hall and stated that she heard CNA5 yelling at R33. The investigation documented that CNA6 reported to RN1 the verbal abuse on 09/15/24. However, Registered Nurse 1 (RN) did not report to the Social Service Director (SSD) or Director of Nursing (DON) until 09/17/24 the allegation of verbal abuse. On 09/17/24, the SA and Local Law Enforcement were notified. Review of the facility's policy titled Resident Abuse revised 01/15/24 revealed, Nursing Home Administrator will determine whether or not the alleged incident or offense is reportable. Reportable incidents are to be reported immediately, and not to exceed 24 hours with the exception of suspicion of serious bodily injury which will be reported immediately, but no later than 2 hours after forming the suspicion. During an interview with the DON on 11/19/24 at 04:14PM, she confirmed that she and the SSD work as the facility's Abuse Coordinators. She was asked why the facility failed to report the incident timely to the SA regarding R33's allegation of abuse and she stated that she was not made aware of the situation until the day it was reported 09/17/24.

Based on record review, interview, and policy review, the facility failed to thoroughly investigate an incident of resident-to-resident abuse for 1 of 3 residents (R22) reviewed for abuse out of 18 sample residents. Findings include: Review of R15's ''Admission Record,'' located in the ''Profile'' tab of the EMR, revealed R15 admitted to the facility on [DATE] with diagnoses of unspecified dementia, anxiety disorder and depression. Review of R15's significant change ''Minimum Data Set (MDS)'' with an Assessment Reference Date (ARD) of 07/07/24, revealed a Brief Interview for Mental Status (BIMS) score of two out of 15, which indicated severe cognitive impairment. Further review revealed R15 exhibited physical and verbal behaviors towards others. Review of R22's ''Admission Record,'' located in the ''Profile'' tab of the EMR, revealed R22 admitted to the facility on [DATE] with diagnosis of Alzheimer's disease. Review of R22's quarterly ''MDS'' with an ARD (Assessment Reference Date) of 09/04/24 revealed a BIMS (Brief Interview of Mental Status) score of 13 out of 15, which indicated no cognitive impairment. Review of R15's Incident Summary dated 08/25/24 at 10:00 AM completed by Activities Assistant 1 (ACT) revealed ACT1 removed R15 from the group circle in the activity room due to R15 trying to hit another resident. (It did not identify the resident). The summary further stated while ACT1 was trying to redirect R15 with magazines and that R15 tried to hit ACT1 with a spoon but was unsuccessful. R15 kept talking to ACT1 and then moved her chair in the direction of the group of other residents. R15 threw a spoon at another resident. During an interview on 11/18/24 at 2:33 PM, ACT1 stated that Certified Nurse Aide 1 (CNA) brought R15 into the activities room from the dining room and that R15 was carrying a spoon. R15 was seated beside R22 and R15 attempted to hit R22 on her arm with the spoon but she was unable to reach her. ACT1 moved R15 to another table in the activity room. A short time later R15 turned her wheelchair around in the direction of the other resident and was mumbling something. R15 threw the spoon. ACT1 stated that she didn't see the spoon being thrown but she heard the noise it made when it hit the ground, and she heard R22 say Ouch. During an interview on 11/19/24 at 12:12 PM, the Director of Nursing (DON) confirmed that she did not interview any staff or other residents who were witnesses to the incident. The DON stated that she should have completed a thorough investigation by conducting the interviews. Review of the facility's policy titled Resident Abuse revised 01/15/24 revealed, the facility believes all residents have the right to be free from abuse including metal, verbal, and sexual: neglect, maltreatment, exploitation, corporal punishment, involuntary seclusion, and misappropriation of property. The policy of the facility is to investigate any suspicious events of the above nature. The investigation will include Interviewing alleged victim(s) and witnesses. Interviewing other residents to determine if they have been abused. Interview staff that work same shift as the accused and interview staff who worked other shifts to determine if they are aware of an injury or incidents. Interview family or others who may know about any injury, incident, or significant care issues.

Based on observation, interview, record review, and policy review, the facility failed to develop a person-centered care plan to include pertinent diagnoses and care areas for 2 residents (R28 and R59) of 18 sampled residents. Findings include: Review of R28's Admitting and Discharge Record located in the electronic medical record (EMR) under the Face Sheet tab, revealed an admitted [DATE] with diagnosis of malignant carcinoid tumor of the ileum. Review of R28's admission Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 09/04/24, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R28 was cognitively intact. Review of the Care Area Assessments (CAAs) revealed urinary incontinence, psychotropic drug use, and pain were triggered by the MDS and had a checkmark for Addressed in Care Plan. Review of R28's EMR under the Care Plan tab revealed no mention of pain, incontinence, and psychotropic drug use in the Care Plan. Review of R28's Guidelines for Daily Care, located in R28's room revealed no plan of care for pain, incontinence, and psychotropic drug use. On 11/19/24 at 1:17 PM, MDS Coordinator (MDSC) said the interdisciplinary team determined what went on the comprehensive care plan. A Registered Nurse (RN) worked on the admission and was responsible to start the care plan. The MDSC stated that she reviewed the care plan and updated it as needed. She stated that R28's care areas were expected to be on the care plan. The MDSC verified R28's Care Plan did not address the care areas. Example 2 Review of R59's Admitting and Discharge Record located in the EMR under the Face Sheet tab, revealed an admitted [DATE] with diagnosis of unspecified dementia. Review of R59's EMR under the Nurses Notes tab revealed a 10/01/24 Nurse Notes which indicated, It was reported from staff that resident has been wandering into other residents' room on 300 wing, disturbing other residents. Per IDT (Interdisciplinary Team), alarm will be placed on door to notify staff of residents whereabouts at night and encourage resident from wandering into other rooms. Review of R59's quarterly MDS located in the EMR under the MDS tab with an ARD of 10/16/24, revealed a BIMS score of 7 out of 15, indicating severe cognitive impairment. Review of R59's Care Plan in the EMR under the Care Plan tab revealed an approach, dated 10/28/24, door alarm on door at night only under the self-care deficit problem. The Care Plan did not document that R59 wandered. Review of R59's Guidelines for Daily Care, located in R59's room revealed it did not mention R59's wandering or use of an alarm. During an observation on 11/17/24 at 9:21 AM, a motion sensor alarm was mounted to the top of R59's door frame. During an interview on 11/18/24 at 9:49 AM, LPN3 stated the alarm over the door was in place because R59 was confused and started to wander into other residents' rooms. During an interview on 11/18/24 at 2:10 PM, Certified Nurse Aide 3 (CNA) stated she used the care cards located inside the residents' closets and daily report to know how to care for the residents. During an interview on 11/19/24 at 9:00 AM, the Assistant Director of Nursing (ADON) stated the floor nurses were instructed to update the Care Plan for new infections. For other care items, the MDS nurse was responsible. During an interview on 11/19/24 at 12:49 PM, CNA4 reported she used a paper located in residents' closets which stated how to provide care. During an interview on 11/19/24 at 1:02 PM, Licensed Practical Nurse 3 (LPN) said that she only updated the care cards in the residents' rooms with changes. On 11/19/24 at 1:17 PM, MDS Coordinator (MDSC) stated she thought the nurses had updated R59's care plan when he began wandering. MDSC verified the care plan did not contain any wandering behavior. During an interview on 11/19/24 at 3:07 PM, the Director of Nursing (DON) stated that RNs were responsible for the care plans and that the MDSC was expected to check them when completing the MDS assessments. The DON expected triggered care areas and pertinent diagnoses were addressed on the care plan. The DON stated that changes, such as wandering behavior, were also expected to be on R59's care plan. Review of the facility's policy titled, Development - Implementation and Maintaining Comprehensive Care Plans, updated 06/01/22, revealed, RN and other interdisciplinary team members will create an overall care plan reflecting the individual needs, strengths, and preferences of the resident . The care plan should continue to reflect resident's individual needs, strengths and preferences. It will be evaluated and revised with quarterly, annual, and significant change status assessments, and as needed with changes in resident condition and functioning.The care plan should show evidence of the resident's triggered areas Care Area Assessments (CAAs) . The care plan should be followed by all staff providing care to the resident. Portions of the care plan pertinent to the CNAs should be located inside the resident closet door.

Based on observation, interview, and record review, the facility failed to ensure it maintained an infection prevention and control program designed to help prevent the development and transmission of communicable disease and infections such as COVID-19. This had the potential to affect all residents residing within the facility at the time of the outbreak on 7/25/24. As of 7/25/24, the facility was in a COVID-19 outbreak with 1 staff positive for COVID-19. - The facility line listings were not completed contemporaneously, and the line lists did not contain symptomology. - During the survey, staff were observed throughout the facility not wearing source control. - The facility did not track community transmission rates and hospital admissions. - The facility did not recognize the outbreak and did not implement their COVID-19 procedures. - The facility did not recognize or ensure they screen all residents for signs and symptoms of COVID-19 once the outbreak was identified. - The facility did not ensure staff who were positive for COVID-19 did not work. - The facility did not test residents once confirmed case of COVID-19 was identified. - The facility infection control policies and procedures have not been updated. - The Medical Director was not notified of outbreak. This is evidenced by: The facility policy titled, COVID-19 Testing, last reviewed 1/13/23, states in part . Policy: The facility will follow the guidance in the CMS QSO-20-38-NH memo in order to provide framework for routine, symptomatic and outbreak testing of staff and residents. Utilizing this guidance will allow the facility to quickly identify and limit the transmission of this highly contagious illness in a setting where we care for a vulnerable population. Procedure: The facility will ensure testing of residents, staff, vendors, and visitors for COVID-19 as outlined in QSO-20-38-NH Memo. Table 1: Testing Summary Testing Trigger: Newly identified COVID-19 positive staff or resident in a facility that can identify close contacts. Staff: Test all staff, regardless of vaccination status, that had a higher-risk exposure with a COVID-19 positive individual. Residents: Test all residents, regardless of vaccination status, that had close contact with a COVID-19 positive individual. Testing Trigger: Newly identified COVID-19 positive staff or resident in a facility that is unable to identify close contacts. Staff: Test all staff, regardless of vaccination status, facility wide or at a group level if staff are assigned to a specific location where the new case occurred (e.g., unit, floor, or other specific area(s) of the facility.) Residents: Test all residents, regardless of vaccination status, facility-wide or at a group level (e.g., unit, floor, or other specific area(s) of the facility.) 1. Any NEW positive COVID test result, resident or staff, must be immediately reported to the Infection Prevention RN and the Director of Nursing so that further notifications and actions can be anticipated/completed per DHS (Department of Health Services) and CMS (Centers for Medicare and Medicaid Services) guidance. 2. The facility will notify the public health department to coordinate facility wide testing if an outbreak occurs, as defined as one or more staff or residents that test positive. The facility policy titled, Respiratory Illness, last reviewed 6/07/24, states in part . Policy: To protect residents and staff from outbreaks of respiratory illness through early recognition, isolation, and testing of exposed or ill residents or staff. Procedure: - Any staff member with any of the above symptoms, should be COVID antigen tested . - Send home if COVID positive and notify DON and Infection Prevention RN. Staff need to be off for 7 days from symptom onset and may return to work on day 8 if fever free for 24 hours. If the staff member remains antigen positive, they are required to wear a N95 mask. - All exposed residents and staff will require immediate testing and then repeat testing per direction of Infection Prevention RN/DON after contact tracing completed. The facility policy titled, Respiratory Illness Outbreak, revised 5/06/24, states in part . Definition: An acute respiratory illness outbreak is defined as three or more residents and/or staff from the same wing with illness onset within 72 hrs. (hours) of each other. - Residents/staff who test positive for Sars-CoV-2 will remain on COVID/airborne precautions for a minimum of 20 days or home isolation (for staff) until a minimum of 7 days from positive test, with a decrease in symptoms and at least 24 hrs. have passed since last fever without the use of fever reducing medications. A negative COVID antigen test may be used as a requirement for returning to work. Staff who are antigen positive that meet all other criteria may return with the use of a N95 respirator for source control. Residents will require 2 negative COVID antigen tests at least 48 hours apart before COVID/airborne precautions are discontinued. The facility policy titled, Pandemic COVID-19 Preparedness and Response, updated 9/27/23, states in part . Policy: As part of [facility name] overall Emergency Preparedness (EP) plan, the EP committee has established critical action steps to prepare, respond and communicate in the event COVID-19 virus is suspected or confirmed in the community or State, or within [facility name]. The committee's action steps are based on 2020 Guidance provided by the Wisconsin Department of Public Health (WIDPH) and the Centers for Disease Control (CDC). IV. Monitoring staff a. Ensure staff are aware of sick leave policies and the necessity of staying home if they are ill with fever or respiratory symptoms. b. Advise employees to check for any signs of illness before reporting to work each day and notify the Administrator, Infection Preventionist, Director of Nursing (DON) or designee if they become ill. c. Advise employees to notify the Administrator, Infection Preventionist, DON, or designee if they encounter person(s) who have traveled to high-risk countries or are suspected or confirmed with COVID-19, and whether the encounter was at a distance of 6 feet or less and less than 15 minutes. Implementation-Respond f. All exposed residents will be monitored routinely for fever or respiratory symptoms. The Infection Preventionist, in collaboration with the multidisciplinary EP committee, will determine the frequency of monitoring. h. [Facility name] will report all possible outbreaks of respiratory illness (when two or more residents or staff report fever or respiratory illness) to WI DPH (Wisconsin Department of Public Health). Upon notifying, [Facility name] will follow the WI DPH Recommendations. iv. Keep residents, their families, and employees informed. Describe what actions the facility is taking to protect residents and educate them on what they can do to protect themselves and prevent spread. Appendix A: Infection Control Guidance COVID-19 Background: Infection control procedures including administrative rules and engineering controls, environmental hygiene, correct work practices, and appropriate use of personal protective equipment (PPE) are all necessary to prevent infections from spreading during healthcare delivery. Prompt detection and effective triage and isolation of potentially infectious patients are essential to prevent unnecessary exposures among patients, healthcare personnel, and visitors at the facility. All healthcare facilities must ensure that their personnel are correctly trained and capable of implementing infection control procedures; individual healthcare personnel should ensure they understand and can adhere to infection control requirements. Personal Protective Equipment: Employers should select appropriate PPE and provide it to HCP (healthcare personnel) in accordance with OSHA's (Occupational Safety and Health Administration) PPE standards. Of Note: The facility's policy is out of date and does not reflect the current CDC guidance and recommendations for COVID-19. According to the CDC at https://www.cdc.gov/covid/hcp/infection-control/guidance-risk-assesment-hcp.html . HCP who were asymptomatic throughout their infection and are not moderately to severely immunocompromised could return to work after the following criteria have been met: - At least 7 days have passed since the date of their first positive viral test if a negative viral test* is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7). *Either a NAAT (molecular) or antigen test may be used. If using an antigen test, HCP should have a negative test obtained on day 5 and again 48 hours later. HCP who are not symptomatic could return to work after the following criteria are met: - Results are negative from at least two consecutive respiratory specimens collected 48 hours apart (total of two negative specimens) tested using an antigen test or NAAT. Exposures that might require testing and/or restriction from work can occur both while at work and in the community. Higher-risk exposures generally involve exposure of HCP's eyes, nose, or mouth to material potentially containing SARS-CoV-2, particularly if these HCP were present in the room for an aerosol-generating procedure. Other exposures not classified as higher risk, including having body contact with the patient (e.g., rolling the patient) without gown or gloves, may impart some risk for transmission, particularly if hand hygiene is not performed and HCP then touch their eyes, nose, or mouth. When classifying potential exposures, specific factors associated with these exposures (e.g., quality of ventilation, use of PPE and source control) should be evaluated on a case-by-case basis. These factors might raise or lower the level of risk; interventions, including restriction from work, can be adjusted based on the estimated risk for transmission. For the purposes of this guidance, higher-risk exposures are classified as HCP who had prolonged close contact with a patient, visitor, or HCP with confirmed SARS-CoV-2 infection and: - HCP was not wearing a respirator (or if wearing a facemask, the person with SARS-CoV-2 infection was not wearing a cloth mask or facemask) - HCP was not wearing eye protection if the person with SARS-CoV-2 infection was not wearing a cloth mask or facemask. - HCP was not wearing all recommended PPE (i.e., gown, gloves, eye protection, respirator) while present in the room for an aerosol-generating procedure. - Follow all recommended infection prevention and control practices, including wearing well-fitting source control, monitoring themselves for fever or symptoms consistent with COVID-19, and not reporting to work when ill or if testing positive for SARS-CoV-2 infection. HCP with travel or community exposures should consult their occupational health program for guidance on need for work restrictions. In general, HCP who have had prolonged close contact with someone with SARS-CoV-2 in the community (e.g., household contacts) should be managed as described for higher-risk occupational exposures above. Source control is recommended for individuals in healthcare settings who: - Had close contact (patients and visitors) or a higher-risk exposure (HCP) with someone with SARS-CoV-2 infection, for 10 days after their exposure. Routine cleaning and disinfection procedures (e.g., using cleaners and water to pre-clean surfaces prior to applying an EPA-registered, (Environmental Protection Agency) hospital-grade disinfectant to frequently touched surfaces or objects for appropriate contact times as indicated on the product's label) are appropriate for SARS-CoV-2 in healthcare settings, including those patient-care areas in which AGPs (Aerosol Generating Procedure) are performed. Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2 per the CDC, updated 9/23/22 documents in part: HCP with mild to moderate illness who are not moderately to severely immunocompromised could return to work after the following criteria have been met: At least 7 days have passed since symptoms first appeared if a negative viral test* is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7), and At least 24 hours have passed since last fever without the use of fever-reducing medications, and Symptoms (e.g., cough, shortness of breath) have improved. Either a NAAT (molecular) or antigen test may be used. If using an antigen test, HCP should have a negative test obtained on day 5 and again 48 hours later. HCP with severe to critical illness who are not moderately to severely immunocompromised could return to work after the following criteria have been met: At least 10 days and up to 20 days have passed since symptoms first appeared, and at least 24 hours have passed since last fever without the use of fever-reducing medications, and Symptoms (e.g., cough, shortness of breath) have improved. The test-based strategy as described below for moderately to severely immunocompromised HCP can be used to inform the duration of work restriction. Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic per the CDC, updated May 8, 2023, documents in part: Implement Source Control Measures: Source control refers to use of respirators or well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. Masks and respirators also offer varying levels of protection to the wearer. Further information about types of masks and respirators, including those that meet standards and the degree of protection offered to the wearer, is available at: Masks and Respirators. People, particularly those at high risk for severe illness, should wear the most protective mask or respirator they can that fits well and that they will wear consistently. Source control options for HCP include: - A NIOSH Approved(R) particulate respirator with N95(R) filters or higher. - A respirator approved under standards used in other countries that are similar to NIOSH Approved N95 filtering facepiece respirators (Note: These should not be used instead of a NIOSH Approved respirator when respiratory protection is indicated). - A barrier face covering that meets ASTM F3502-21 requirements including Workplace Performance and Workplace Performance Plus masks, OR - A well-fitting facemask. When used solely for source control, any of the options listed above could be used for an entire shift unless they become soiled, damaged, or hard to breathe through. If they are used during the care of patient for which a NIOSH Approved respirator or facemask is indicated for personal protective equipment (PPE) (e.g., NIOSH Approved particulate respirators with N95 filters or higher during the care of a patient with SARS-CoV-2 infection, facemask during a surgical procedure or during care of a patient on Droplet Precautions), they should be removed and discarded after the patient care encounter and a new one should be donned Source control is recommended for individuals in healthcare settings who: - Have suspected or confirmed SARS-CoV-2 infection or other respiratory infection (e.g., those with runny nose, cough, sneeze); or - Had close contact (patients and visitors) or a higher-risk exposure (HCP) with someone with SARS-CoV-2 infection, for 10 days after their exposure Source control is recommended more broadly as described in CDC's Core IPC Practices in the following circumstances: - By those residing or working on a unit or area of the facility experiencing a SARS-CoV-2 or other outbreak of respiratory infection; universal use of source control could be discontinued as a mitigation measure once the outbreak is over (e.g., no new cases of SARS-CoV-2 infection have been identified for 14 days); or NIOSH Approved particulate respirators with N95 filters or higher used for: o All aerosol-generating procedures. o All surgical procedures that might pose higher risk for transmission if the patient has SARS-CoV-2 infection (e.g., that generate potentially infectious aerosols or involving anatomic regions where viral loads might be higher, such as the nose and throat, oropharynx, respiratory tract). o NIOSH Approved particulate respirators with N95 filters or higher can also be used by HCP working in other situations where additional risk factors for transmission are present, such as when the patient is unable to use source control and the area is poorly ventilated. They may also be considered if healthcare-associated SARS-CoV-2 transmission is identified and universal respirator use by HCP working in affected areas is not already in place. - Eye protection (i.e., goggles or a face shield that covers the front and sides of the face) worn during all patient care encounters. Environmental Infection Control - Dedicated medical equipment should be used when caring for a patient with suspected or confirmed SARS-CoV-2 infection. o All non-dedicated, non-disposable medical equipment used for that patient should be cleaned and disinfected according to manufacturer's instructions and facility policies before use on another patient. Example 1: Facility line listings were not completed contemporaneously and there were no line lists for residents or staff from July 2023. On 7/31/24 at 1:30 PM, ADON/IP C (Assistant Director of Nursing/Infection Preventionist) approached Surveyor with line listing for staff and residents. ADON/IP C stated, R4 was the only resident that had any symptoms of COVID-19 and tested negative. R4 ended up having bilateral pleural effusions. R5 was diagnosed with pneumonia but no symptoms are listed on the line list and line list does not indicate if R5 was ever tested for COVID-19. On 7/31/24 at 3:30 PM, Surveyor interviewed ADON/IP C via phone. Surveyor asked ADON/IP C if infection control line lists should be updated daily. ADON/IP C stated, infection control should be conducted daily for tracking. Surveyor asked ADON/IP C if line listings should be completed contemporaneously. ADON/IP C stated, yes, I was just following what the following IP was doing before she left. Of Note: During chart review surveyors noted at least two residents that were not placed on the line list who were experiencing symptoms. One of those residents was tested and tested negative but was never added to the line list. Example 2: During the survey, staff were observed throughout the facility not wearing any type of PPE. On 7/31/24 at 12:25 PM, Surveyor interviewed ADON/IP C. Surveyor asked ADON/IP C if facility staff should be wearing PPE or utilizing source control during an outbreak. ADON/IP C stated, yes staff should be wearing masks if we are in an outbreak. Example 3: The facility did not track community transmission rates and hospital admission rates. On 7/31/24 at 11:10 AM, Surveyor interviewed ADON/IP C. Surveyor asked ADON/IP C if she was aware of what the community transmission rate was. ADON/IP C stated, the local health department advised to use the state transmission rates and those are below baseline. ADON/IP indicates she does not track hospital rates. Note: Surveyor reviewed current transmission rates in the region and state. Surveyor notes that the entire state is listed in as growing number of COVID-19 hospitalization across the State. Wastewater and hospital admission rates growing for the Western part of the State where the facility is located. Example 4: The facility failed to identify the outbreak and implement their COVID-19 policies and procedures. On 7/31/24 at 11:10 AM, Surveyor interviewed ADON/IP C. Surveyor asked ADON/IP C if the facility was currently in a COVID-19 outbreak as the facility had a positive staff member. ADON/IP C stated no. Surveyor asked ADON/IP C how many staff or residents need to positive to facilitate an outbreak. ADON/IP C stated, three. Surveyor showed ADON/IP C current guidance. Surveyor asked ADON/IP C based on current guidance would the facility be in an outbreak? ADON/IP C stated, yes. Example 5: The facility did not ensure they screened all residents for signs and symptoms of COVID-19 once a staff member tested positive. On 7/31/24 at 11:10 AM, Surveyor interviewed ADON/IP C. Surveyor asked ADON/IP C if the facility was screening residents for signs and symptoms of COVID-19. ADON/IP C stated not at this time as we did not believe we were in an outbreak. Example 6: The facility failed to ensure that staff who tested positive for COVID-19 did not work. On 7/31/24 at 11:10 AM, Surveyor interviewed ADON/IP C. Surveyor asked ADON C when the DON B (Director of Nursing) tested positive for COVID-19. ADON/IP C stated, last Thursday (7/25/24). Surveyor asked ADON/IP C when the last time DON B worked prior to testing positive. ADON/IP C stated DON B worked Thursday morning from 2:00 AM to 6:00 AM on the floor. DON B tested at 6:00 AM prior to leaving from her shift and was positive at that time. Surveyor asked if DON B had worked since testing positive. ADON/IP C stated DON B worked on Sunday (7/28/24) after testing positive due to Med Tech working and needing an RN (Registered Nurse) in the building. ADON/IP C states DON B worked from her office and did not come out on the floor. Surveyor asked ADON/IP C if an RN needed to be in the building with the Med Tech. ADON/IP C stated according to the facility policy an RN needs to be in the building. ADON/IP C pulled out policy and read, Med Tech to be supervised in the building by an LPN or RN. ADON/IP C stated, I guess she didn't need to be. Example 7: Facility policies and procedures have not been reviewed or updated. Surveyor reviewed facility policies provided which are undated and do not reflect current guidance from the CDC. On 7/31/24 at 11:50 AM, Surveyor interviewed ADON/IP C. Surveyor asked ADON/IP C how often policies should be reviewed and updated. ADON/IP C stated, policies should be reviewed yearly at a minimum. Surveyor asked ADON/IP C should the infection control policies and procedures be up to date. ADON/IP stated she is new to the role and was going by what was done previously. Example 8: The facility failed to test residents and staff once there was a confirmed case of COVID-19. On 7/31/24 at 11:10 AM, Surveyor interviewed ADON/IP C. Surveyor asked ADON/IP C if the facility is currently doing any testing of resident or staff. ADON/IP C stated, we are not testing widespread just staff and residents who would show signs and symptoms. Note: Facility began testing residents and staff prior to survey team's exit with no positive residents or staff identified. Example 9: The facility Medical Director was not notified of outbreak of COVID-19. On 7/31/24 at 11:10 AM, Surveyor interviewed ADON/IP C. Surveyor asked ADON/IP C if there has been any contact with the Medical Director regarding the outbreak. ADON/IP C stated, no contact has been made to anyone as we did not believe we were in an outbreak. The facility failed to complete screening of residents for signs and symptoms of COVID-19 during the current outbreak, line listings did not include residents with symptoms and was not completed contemporaneously. Staff were not wearing the appropriate PPE. The facility did not ensure staff who were COVID-19 positive did not work. The facility does not track community transmission rates and hospital rates. The facility did not ensure policies and procedures were up to date and reflect the current CDC recommendations.

Based on interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 1 of 3 reportable incidents involving (R1 and R2) On 3/19/24, R2 had a physical altercation with another resident (R1). This allegation of abuse was not reported to local law enforcement. Evidenced by: The facility policy titled, Resident Abuse: Investigating and Reporting Allegations of abuse, neglect, mistreatment, injuries of unknown source, misappropriation of resident property and resident to resident altercations, last reviewed 1/15/24, states in part . Policy: [Facility Name] believes all resident have the right to be free from abuse including mental, verbal, and sexual; neglect, maltreatment, exploitation, corporal punishment, involuntary seclusion, and misappropriation of property. The policy of [Facility Name] is to immediately investigate and report any suspicious event of the above nature. [Facility Name] shall implement the following procedures in a manner consistent with the requirements of all regulatory agencies of jurisdiction and with facility standards of conduct. Procedure: The following definitions will be used to determine incidents of Neglect/Abuse/Injuries of Unknown Source/Misappropriation of Resident Property. Physical Abuse includes hitting, slapping, pinching, and kicking. This also includes controlling behavior through corporal punishment. The Investigation will include: 3. Other protection steps to consider. h. Determine need to notify local law enforcement or other official agencies, i.e. APS (Adult Protective Services), etc. According to S483.12(c) of the State Operations Manual; all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. R2 was admitted to the facility on [DATE] with diagnosis that include dementia without behavioral disturbance, coronary artery disease (CAD), chronic obstructive pulmonary disease (COPD), and trans ischemic attack (TIA). R1's quarterly Minimum Data Set (MDS) dated [DATE] indicates R1 was assessed as having a Brief Interview for Mental Status score of 3 which indicates R1 has severe cognitive impairment. The facility self-report dated 3/19/24 indicates LPN (Licensed Practical Nurse) heard R1 hollering as she was passing medications. LPN entered room of R1 to see R2 hitting R1 with a closed fist in the back of the head. LPN removed R2 from R1's room and ensured the safety of both residents. R2 stated that she was stabbing R1 for no known reason. R1 has diagnosis of dementia and is quite confused most of the time. R2 has also been having delusions noted recently. R1 stated she was not hurting in any way from the incident. On 7/31/24 at 3:30 PM, Surveyor interviewed SW D (Social Worker). Surveyor asked SW D if the police were notified of resident-to-resident abuse. SW D stated, no police were not called. I had asked the previous NHA (Nursing Home Administrator) about calling them but was she didn't feel it was necessary. Police should have been called. On 7/31/24 at 3:50 PM, Surveyor interviewed NHA A. Surveyor asked NHA A if the facility should have notified the police of observed allegation of abuse. NHA A stated, yes, they should have been notified.

Based on interview and record review, the facility did not ensure residents were free from significant medication errors for 2 of 2 sampled residents (R65 and R265) reviewed for medication errors. R65 had an order to receive 12.5 mcg (micrograms) of levothyroxine. The medication was transcribed into the facility's Electronic Health Record (EHR) as 125mcg. R65 received 45 doses in 46 days of the incorrect dose of levothyroxine. R65 died in the hospital as a result of the medication error which caused Thyrotoxicosis. The facility's failure to ensure that residents were free from a significant medication error created a finding of immediate jeopardy that began on [DATE]. NHA A (Nursing Home Administrator) was notified of the immediate jeopardy on [DATE] at 3:00 PM. The immediate jeopardy was removed [DATE]; however, the deficient practice continues at a scope/severity level of D as the facility continues to implement its action plan and as evidenced by: R265 did not receive the correct dosage of pain medication (hydromorphone) on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], AM dose. R265 received 1 mg instead of 2 mg of hydromorphone. This is evidenced by: The facility's Policy and Procedure titled Medication Administration Policy with a reviewed date of February 2019 states, in part: .Administration: .2. Medications are administered in accordance with written orders of the attending physician or physician extender. 3. If a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current diagnosis or conditions, the nurse called the provider pharmacy for clarification prior to the administration of the medication of is necessary contacts the prescriber for clarification. This interaction with the pharmacy and/or prescriber and the resulting order clarification are documented in the nursing notes and elsewhere in the medical record as appropriate . National Library of Medicine (NIH), National Center of Biotechnology Information (NCBI) article titled Thyrotoxicosis dated [DATE], states in part: Thyrotoxicosis is the clinical state associated with excess thyroid hormone activity, usually due to inappropriately high-circulating thyroid hormones. The clinical presentation varies, ranging from asymptomatic to life-threatening thyroid storm. Symptoms are due to the hypermetabolic state induced by excess thyroid hormones and include weight loss, heat intolerance, and palpitations. There are many different causes of thyrotoxicosis. It is important to determine the cause since treatment is based on the underlying etiology. Thyrotoxicosis can lead to serious complications when not diagnosed and treated appropriately, including delirium, altered mental status, osteoporosis, muscle weakness, atrial fibrillation, congestive heart failure, thromboembolic disease, cardiovascular collapse, and death . Untreated or undiagnosed thyrotoxicosis can lead to thyroid storm. Patients present with tachycardia, fever, altered mental status, agitation, features of cardiac failure, and impaired liver function . The NIH, NCBI article titled Thyroid Storm dated [DATE], states in part: Thyroid storm, also known as thyrotoxic crisis, is an acute, life-threatening complication of hyperthyroidism that presents with multi-system involvement. The mortality associated with thyroid storm is estimated to be 8 to 25% despite modern advancements in its treatment and supportive measures. Thus, it is very important to recognize it early and start aggressive treatment to reduce mortality . Levothyroxine package insert found at https://www.rxabbvie.com/pdf/synthroid.pdf states in part: Recommended Dosage and Titration Primary, Secondary, and Tertiary Hypothyroidism in Adults The recommended starting daily dosage of SYNTHROID (levothyroxine) in adults with primary, secondary, or tertiary hypothyroidism is based on age and comorbid cardiac conditions, as described in 1. For patients at risk of atrial fibrillation or patients with underlying cardiac disease, start with a lower dosage and titrate the dosage more slowly to avoid exacerbation of cardiac symptoms. SYNTHROID Dosing Guidelines for Hypothyroidism in Adults* Patient Population Starting Dosage Dosage Titration Based on Serum TSH or Free-T4. Adults diagnosed with hypothyroidism Full replacement dose is 1.6 mcg/kg/day. Some patients require a lower starting dose. Titrate dosage by 12.5 to 25 mcg increments every 4 to 6 weeks, as needed until the patient is euthyroid (normal thyroid level). Adults at risk for atrial fibrillation or with underlying cardiac disease Lower starting dose (less than 1.6mcg/kg/day) Titrate dosage every 6 to 8 weeks, as needed until the patient is euthyroid. Geriatric patients Lower starting dose (less than 1.6 mcg/kg/day) WARNINGS AND PRECAUTIONS Serious risks related to overtreatment or undertreatment with SYNTHROID: Titrate the dose of SYNTHROID carefully and monitor response to titration. (5.1) Cardiac adverse reactions in the elderly and in patients with underlying cardiovascular disease: Initiate SYNTHROID at less than the full replacement dose because of the increased risk of cardiac adverse reactions, including atrial fibrillation. (2.3, 5.2, 8.5) ADVERSE REACTIONS Adverse reactions associated with SYNTHROID therapy are primarily those of hyperthyroidism due to therapeutic overdosage: arrhythmias, myocardial infarction, dyspnea, muscle spasm, headache, nervousness, irritability, insomnia, tremors, muscle weakness, increased appetite, weight loss, diarrhea, heat intolerance, menstrual irregularities, and skin rash. R65 was admitted to the facility on [DATE] with diagnoses that include: Alzheimer's Disease, Vascular dementia, Cerebral Palsy, and Atherosclerotic heart disease. On [DATE], R65's Thyroid Stimulation Hormone (TSH) level was drawn, which resulted at 8.21 (high meaning the thyroid was not working effectively) Normal TSH levels are 0XXX,d+[DATE].50 uU/ml (units/ milliliter). Of note, a high TSH level requires initiating replacement thyroid hormone with medication such as levothyroxine. On [DATE], R65 received an order from NP I (Nurse Practitioner). NP I wrote an order to Start Levothyroxine 12.5mcg daily P.O. (by mouth) for hypothyroidism .Recheck TSH in ,d+[DATE] weeks . The order written by NP I was clearly written as 12.5 mcg and .5 was even written darker. This order was noted as received by RN L (Registered Nurse). The order was entered into R65's EHR (Electronic Health Record) by HUC J (Health Unit Coordinator) on [DATE] as Levothyroxine 125mcg Capsule by mouth (this is ten times the prescribed dose written by NP I). Take 1 daily AM (morning) first date: [DATE] FOR: Hypothyroidism. The telephone order was sent to the pharmacy, the pharmacy transcribed the order as 125 mcg, and sent the medication to the facility. R65 began taking levothyroxine 125 mcg, ten times the prescribed dose, on [DATE]. On [DATE] at 10:05 AM, Surveyor interviewed NP I. Surveyor asked NP I if she darkened the .5 for the 12.5 mcg? NP I stated yes, she darkened it so they could see the .5. Surveyor asked NP I if she reconciles residents' monthly orders with the MAR? NP I stated that when she gets monthly orders, she tries to reconcile them with EPIC (electronic health record charting system), if she doesn't have time, the nurses at the clinic reconcile them for her. On [DATE] at 3:01 PM, Surveyor interviewed HUC J. Surveyor asked HUC J what the process is when a resident receives a new order? HUC J stated that she puts the order into ECS (facility's EHR) and then places it in the 1st check cart for the nurses to check to make sure she entered it correctly. Surveyor asked HUC J how long the facility has used this process? HUC J stated that she has been working at the facility since May, and it has been the process since she started. HUC J stated that once she puts an order in the computer, she puts her initials along with comp for computer in the corner and then faxes the order to the pharmacy. On [DATE] at 4:11 PM, Surveyor interviewed RN K (Registered Nurse). Surveyor asked RN K if she knew what the process was when a resident received a new order? RN K stated that she started at the facility the previous week, and that she did not know what the process was. On [DATE] at 7:58 AM, Surveyor interviewed RN L. Surveyor asked RN L what the process is when the pharmacy delivers the medications? RN L stated that they bring the tub into the med room and sign off that all the medications are in the tub. Surveyor asked RN L if they check the blister pack of medications against the actual order? RN L stated yes. Surveyor asked RN L if she recalls the levothyroxine order for R65? RN L stated that she noted that they received the order from NP I. Surveyor asked RN L if she checked the order once it was entered into ECS? RN L stated no. Surveyor asked RN L if she knew whether the order was checked by 2 nurses? RN L stated that it was, but she was unsure who the nurses were. On [DATE] at 8:12 AM, Surveyor interviewed LPN N (Licensed Practical Nurse). Surveyor asked LPN N what the process is when a resident receives a new medication? LPN N stated that the nurse does a check with the pharmacy person, signs off that the medications were received, and makes sure that the medication matches the order. On [DATE] at 10:13 AM, Surveyor interviewed ADON E (Assistant Director of Nursing). Surveyor asked ADON E to review R65's levothyroxine order. Surveyor asked ADON E if the order was signed off by 2 nurses? ADON E stated that RN L signed and that she signed it. Surveyor reported that RN L stated that she did not check the order, she just signed that she received the order. Surveyor asked ADON E what the process was for new orders? ADON E stated that the order is given to the nurse, the nurse then documents it in the computer, the order is then passed off to the HUC who then enters the order into the computer, places it in the cart for the nurses to check, the nurse checks the order in the MAR and then they either sign or initial it. Surveyor asked ADON E if she checked R65's levothyroxine order in the MAR? ADON E stated yes. Surveyor asked ADON E what the MAR order said? ADON E stated that she could not remember. Surveyor asked ADON E to review the medication orders that Surveyor found without 2 signatures. Surveyor asked ADON E if the orders have 2 signatures on them; ADON E stated no. Surveyor asked ADON E if they should have 2 signatures on them indicating that 2 nurses checked the orders; ADON E stated yes. Surveyor asked ADON E when receiving medications from the pharmacy, does the receiving nurse check the pills against the orders? ADON E stated that they should be. It is important to note that R65's telephone order slip does not have the signatures of 2 nurses that have checked the order, only the signature that RN L received the order and a signature of ADON E (Assistant Director of Nursing). There is no evidence that the order was reviewed by nursing staff as having been entered into the EHR correctly. Nurse's notes state the following: [DATE] 2:16 PM: Note: Resident has increased weakness and confusion today, Resident refused lunch, encouraged fluids if he wasn't going to eat . [DATE] 2:27 PM: Fax sent to: NP I to address tomorrow rounds. Regarding: PT (Physical Therapy) request for ST (Speech Therapy) d/t (due to) garbled speech/swallowing. [DATE] 3:17 AM: Incident type: fall with injury, skin tear to right foot 2nd toe . [DATE] 9:39 AM: .NP I spoke with resident .Results: new orders received and noted [DATE] decrease propranolol to 10mg (milligrams) x 1 week then 10mg daily x 1 week, then d/c (discontinue). Monitor BP (Blood Pressure) and pulse BID (twice a day) x 4 weeks. CBC (Complete blood count) with diff (differential), electrolytes, creatinine, BUN (Blood Urea Nitrogen), BNP (B-type Natriuretic Peptide (provides information about how your heart is working and is used to diagnosis Congestive Heart Failure)), TSH . [DATE] 10:43 AM: Incident type: observed on floor. Resident was heard hollering help me! by staff. Found on floor next to bed sitting on legs .Physician notification: Physician notified NP I . [DATE] 12:03 PM: Spoke with: Nurse Practitioner Regarding: lab results Result: new orders received and noted .20mg Lasix today. Of note, Lasix is a diuretic typically given for increased fluid as seen in congestive heart failure (CHF). CHF is a concern with increased doses of thyroid hormone, R65 received ten times the prescribed dose of thyroid hormone. R65's TSH level on [DATE] was 0.69 uU/ml, which is a drop of 7.52 uU/ml in 33 days. Of note, this is a rapid and significant decrease in TSH level and should warrant review of the levothyroxine dose. This did not occur and R65 remained on ten times the dose of levothyroxine. [DATE] 6:54 PM: Held propranolol HCI 10mg tablet Reason: per orders from NP I, d/t (due to) low pulse (45). Spoke with NP I Regarding: xray results Result: new orders received and noted [DATE] Augmentin (antibiotic) 875 mg po bid x 7 days for pneumonia . [DATE] 10:09 PM: resident is lethargic, confused, but follows directions accurately. Resident denies difficulty breathing/SOB (shortness of breath). O2 (oxygen) sat (saturation) above 90% on RA (Room Air) Oxygen applied in bed .Pulse at bedtime was 55 . Of note, confusion and lethargy are seen with elevated levels of thyroid hormone which can be a result of too much thyroid hormone replacement such as levothyroxine. [DATE] 6:44 AM: Incident type: fall without injury .Description of Events: Resident was yelling out, without call light on. Resident was sitting on floor with feet in front of him .Mental State: confused . [DATE] 1:44 PM: Weekly Summary: AM shift Mental status: intermittent confusion .Health Events: .Has had 3 falls recently and increased confusion . [DATE] 6:39 AM: Infection: .Mental status abnormal: still experiencing increased confusion, restless at night, sleepy during the day . Of note resident has had several falls over a period of days and is restless and confused, all of which can be a result of too much thyroid hormone replacement such as levothyroxine. [DATE] 5:32 PM: .Mental status abnormal: confused, verbally nonsensical . [DATE] 12:48 AM: Behavior: Other: Resident is yelling out throughout the night .Duration: > 2 hr (hour) this shift . [DATE] 2:33 PM: Incident type: fall with injury .Description of events: Writer called to patient room at 0115 PM-resident found lying on floor. Resident hit head on floor - left side of face/head directly on floor - a moderate-large amount of blood noted to be coming from an area on his head/face .Nursing immediately called 911 as patient has redness/swelling already noted to entirety of left side of face/skull .Patient explanation of event: Patient was unable to explain the event as his speech was garbled and nonsensical . R65's Emergency Services note dated [DATE] states in part: .Encounter Diagnosis 1. Accidental Fall .2. Closed Head Injury .3. Facial laceration .4. AKI (acute kidney injury) 5. Dehydration 6. Hyperkalemia 7. r/o (rule out) Pulmonary infiltrate. Medical Decision Making/ Plan/ Summary: On arrival, he is a bit sleepy but is arousable, very slow to answer questions .Mild respiratory distress and loud upper airway noises .89% on room air .Lungs are somewhat coarse bilaterally .Potassium 6.1, Creatinine bumped to 1.9 up from 1.1 2 weeks ago. BUN 54 .BNP 2460 up from 1926 .TSH 0.1, free T4 2.2, slightly elevated. Chest x-ray shows small left effusion with atelectasis or consolidation .Patient does seem to have lost 2 kilos (kilograms) .Physical Exam .Pulmonary: Effort: Respiratory distress present .Comments: Loud upper airway respirations .Neurological: Comments: Significant global weakness . R65's General Medicine Progress Note dated [DATE] states in part: .Assessment & Plan Active Hospital Problems: *Thyrotoxicosis *Acute congestive heart failure *Acute kidney injury * Hyperkalemia .history of mixed Alzheimer's and vascular dementia, type 2 diabetes, immune thrombocytopenia .who has had a decline over the past 2 months with multiple medication changes, initially started on a low dose of levothyroxine, found to have received erroneously elevated doses of levothyroxine since early June. With subsequent decline, with renal failure, hypoxia. Medication error discovered on pharmacy review on [DATE] . R65's Death Summary dated [DATE] states in part, .Principal Diagnosis: Thyrotoxicosis (a medical emergency resulting in too much thyroid hormone. If gone undetected this can result in multiple organ failure and death. R65's thyrotoxicosis was caused due to receiving 10 times the dose of levothyroxine a thyroid hormone). Hospital Course: Patient was admitted for hyperkalemia (elevated potassium) and renal failure with hypoxic respiratory failure (too little oxygen in blood) in setting of chronic restrictive lung disease. He was treated for his hypercalcemia (elevated calcium in blood) with two rounds of insulin, calcium, kayexalate, IV (intravenous) fluid resuscitation, and scheduled Lasix (a diuretic). He was started on Ceftriaxone (antibiotic) in setting of hypoxic respiratory failure, not responsive to above treatments. Patient was also admitted with elevated T4 levels and suppressed TSH levels, found to have been erroneously receiving levothyroxine 125 mcg (instead of 12.5mcg) while at the Nursing home. Patient was therefore thought to be in multisystem organ failure secondary to exacerbation of multiple co-morbidities secondary to thyrotoxicosis. Patient did not have pain or suffering and continued to have decline during the final 24 hours of life .Cause of Death: Contributing causes: Multisystem organ failure secondary to suspected thyrotoxicosis . The facility was made aware of the medication error by the hospital's Pharmacist, and subsequently submitted a self-report to the State Agency (SA). The self-report indicated that the facility educated the nurses and the HUC on double checking orders and the 5 Rights of Medication Administration. However, current noncompliance was observed during survey. On [DATE] at 11:26 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what steps she took after finding out that R65 had received the wrong dose of levothyroxine? DON B stated she provided education to all the nurses verbally and via a packet with a test and the nurses were to return the test portion. Surveyor asked DON B what new process they put in place? DON B stated that when a nurse gets an order, they take it to the HUC and then it goes on the cart for 1st and 2nd check. Surveyor asked DON B how she ensures that all the nurses receive the education? DON B stated that they completed the education if they completed the test. Surveyor reviewed the completed education list with DON B and pointed out that not all the nurses had completed the test. Surveyor asked DON B if the education should have been completed prior to the nurses working their next shift? DON B stated yes. Surveyor asked DON B when they implemented the 2-check system? DON B stated that it was not a new process, they just streamlined it. Surveyor asked DON B what the facility's process was when medications are received from the pharmacy? DON B stated that the nurse that receives them, goes through the sheet to make sure that whatever medication is listed for the resident is the correct medication and quantity. Surveyor asked DON B if the nurses are checking the received medication with the physician's order? DON B stated no, they are just stating that they received the medication. Surveyor asked DON B if she would expect the nurse to ensure that the correct medication was delivered; DON B stated no. On [DATE], Surveyor reviewed the facility's education documentation and saw that there were 10 nurses that had not completed the education, 5 of the 10 nurses had worked in the last 2 weeks. Of note, the facility continues with current noncompliance. On [DATE], Surveyor reviewed physician's orders for R9, R24, and R5. Surveyor found 5 orders for these 3 residents that did not have current RN signatures validating orders per facility policy and procedure. The orders are as follows: 1. R9 - [DATE]: Dakin's 0.125% moistened 2x2 gauze with dry dressing over top to wound to rt. (right) foot . 2. R24 - [DATE]: Ativan 0.5mg - give 0.5mg every 8 hours PRN (as needed) for anxiety. 3. R52 - [DATE]: Cipro 250mg bid x 3 days for UTI (Urinary Tract Infection). 4. R52 - D/c Cipro, start Levaquin 750 mg PO q (every) HS (bedtime) x 5 days. 5. R52 - Hold Olanzapine 5mg PO daily at bedtime until the 21st. The facility's failure to ensure staff transcribe and administer the correct dose of medications created a finding of immediate jeopardy. The immediate jeopardy was removed on [DATE] when the facility completed the following: 1. DON/NHA provided education to licensed nursing staff on the 5 Rights of medication administration. 2. Nursing staff will be required to complete a post-test on 5 rights of medication administration after completion of the training. 3. The DON or Designee will complete daily audits of medication administration to ensure accuracy of delivery for 2 weeks. 4. The DON or Designee will begin medication administration competency audits on all licensed nurses and medication aides (if you have them). 5. The DON or Designee provided education to all licensed nurses and HUCs on transcription of physician orders, verifying orders, signing off medications, dangerous medications, understanding adverse drug events, and medication administration: avoiding common errors. 6. Nursing staff will be required to complete a post-test and return demonstration to ensure competency for education provided in #5. 7. The DON or Designee initiated audits for all new medication orders for to ensure correct transcription and medication dose is being administered. 8. The DON/NHA or designee will provide education on two nurses will verify transcription of physician orders including handwritten orders and ensure competency by completion of posttest with return demonstration. 9. The DON or Designee initiated audits for all new medication orders to ensure the orders have been verified by 2 nurses. 10. The DON/Designee has provided education to licensed nursing staff on reviewing medications as a potential root cause for falls and change of condition. 11. Nursing Administration team (DON/ADON/UM) will review and validate transcription of all orders daily in clinical meeting Monday through Friday to ensure accuracy of transcription. On weekends a designee will review and validate transcription of all orders to ensure accuracy of transcription. 12. The facility will conduct a weekly QAPI meeting to monitor compliance with the above plan for any further recommendations and/or resolution. The deficient practice continues at a scope/severity level of D (potential for more than minimal harm/isolated) as evidenced by: Example 2: R265 had an order for hydromorphone 2mg (milligrams) daily in the morning. Facility staff were only administering 1mg daily in the morning for a total of 5 doses. R265 continued to experience pain. R265 was admitted to the facility on [DATE] with diagnoses that include closed displaced fracture of surgical neck of the left humerus (shoulder) and a closed fracture of olecranon process of left ulna (pointy bone of the elbow). R265 was admitted to the facility with an order for hydromorphone 2mg every AM and 1 mg every 6 hours as needed for pain. The facility's narcotic sign-out sheet states in part: . Medication Name & Strength Hydromorphone 2mg Tabs Directions: Give ,d+[DATE] tablet by mouth every 6 hours as needed for pain . Facility staff administered the following incorrect doses: [DATE] 7:30 AM 1 tablet given. 10:27 AM: Current pain level: 4 [DATE] 8:00 AM 1 tablet given. 2:40 PM: Current pain level: 6 [DATE] 8:00 AM 1 tablet given. 10:35 AM: Current pain level: 5 [DATE] 7:30 AM 1 tablet given. 9:48 AM: Current pain level: 6 [DATE] 8:00 AM 1 tablet given. 1:48 PM: Current pain level: 6 R265's MAR (Medication Administration Record) shows that the facility's staff signed out R265 received 2mg of hydromorphone on [DATE], [DATE], [DATE], [DATE], and [DATE]. The facility's form titled Medication Event Form states in part: .Date/ time error detected: [DATE] .Date and time of error/s: ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], AM dose. Medication: hydromorphone. Correct dosage: 2mg. Dose given: 1mg. Frequency: daily. Frequency given: daily. # times given this way: 5 . On [DATE] at 7:58 AM, Surveyor interviewed RN L. Surveyor asked RN L if when administering the hydromorphone to R265, did she notice that a majority of her scheduled doses she was only getting 1 tablet (1 mg)? RN L stated yes, and that she was thinking that they ran out of the 2mg. Surveyor asked RN L if when she noticed that R265 was only getting 1 tablet, did she write that up as a medication error? RN L stated no. Surveyor asked RN L for the times that R265 received the 1mg dose instead of the 2mg dose, would that be considered a medication error? RN L stated yes. On [DATE] at 8:12 AM, Surveyor interviewed LPN N (Licensed Practical Nurse). Surveyor asked LPN N if she noticed that she had administered the wrong dose of hydromorphone to R265? LPN N stated that it was really confusing the way it was written, because she had 2 separate orders and the pharmacy only sent the ,d+[DATE] dose. R265 had an order for 2mg of hydromorphone in the AM scheduled and 1mg every 6 hours as needed for pain. The facility inadvertently administered 1mg instead of 2 mgs over the course of 5 days. The facility failed to ensure they were completing the 5 rights of medication administration which includes ensuring the the right dose is administered.

Based on interview and record review, the facility failed to ensure that residents advance directive was signed by resident or resident representative for 4 of 17 residents (R32, R54, R56, and R1) reviewed for code status of total sample of 24. The code status preference form for R32, R54, R56, and R1 is not signed by the resident or legal representative. Findings include The facility commonly uses a Provider Orders for Scope of Treatment (POST) form to distinguish resident code status. Under section E, the form states, Signature of Patient/Agent/Guardian (either patient/agent/guardian must sign or health care professional must initial). Additionally, the form states, Reviewing POST: The POST should be reviewed periodically and if: .The patient is transferred from one care setting or care level to another . The facility's advance directive policy states the following: *Upon admission, identify if the resident has an advance directive and if not, determine if the resident wishes to formulate an advance directive. A resident has the option to execute an advance directive but will not be required to do so . *Examples of advance directives include a living will, a directive to the attending physician a durable power of attorney for health care, a pre-existing medical order for do not resuscitate (DNR), DNR bracelet, POST, or other document directing the resident's health care wishes. *The facility will provide information on advance directives. Staff will identify the primary decision-maker and review the directives with them. Example 1 R32 is her own person and has a POST form that states she wishes to be a DNR. The form was signed by a physician on 4/13/22, but was observed on 8/15/23 by Surveyor to be blank with no signature from the resident, a representative, or noted in any way by the facility. On 8/15/23 at 9:40 AM, R32 stated to Surveyor that she had not signed anything at the facility for her code status but she did want to sign it as soon as possible so her family did not have to worry about it. R32 stated she desires to be a DNR. Example 2 R54 was admitted to the facility on [DATE] and has an activated Power of Attorney (POA). R54's medical record contains a POST form that states he wishes to be a DNR. The form was signed by a physician on 5/27/22, but was observed on 8/10/23 by Surveyor to be blank with no signature from the resident, a representative, or noted in any way by the facility. On 8/14/23 at 3:40 PM, Surveyor interviewed POA D (Power of Attorney) who stated that she wanted the POST signed and it should be done as soon as possible. POA D stated she had not been asked to sign the form before this time. POA D indicated R54 is a DNR. Example 3 R56 is his own person and has a POST form that states he wishes to be a DNR. The form was signed by a physician on 4/4/23, but was observed on 8/15/23 by Surveyor to be blank with no signature from the resident, a representative, or noted in any way by the facility. R56 stated he wishes to be a DNR. On 8/14/23 at 9:41 AM, Surveyor interviewed SW C (Social Worker) regarding the unsigned POST documents. SW C stated that she sometimes assists with advance directives when residents are admitted . SW C stated the facility will go through advance directives with residents and stated the POST forms should be signed by either the resident or their representative/POA/guardian. 36192 Example 4 R1 was admitted to the facility on [DATE]. R1's Minimum Data Set (MDS), dated [DATE], indicates R1 has a Brief Interview of Mental Status (BIMS) of an 8 out of 15, which indicates that R1 is cognitively impaired. R1's POST form indicates DNR. This form is blank where it states E. Signature of patient/agent/guardian (either patient/agent/guardian must sign or physician or nurse practitioner must initial) The box is unmarked on the form where it states the signing physician or NP has initaled this box to verify that the patient/agent/guardian consent to these orders but was unwilling or unable to sign in the space above. The form only has one signature which is R1's physician with a signature date of 8/5/20. On 8/15/23 at 11:05 AM, Surveyor reviewed R1's POST with RN E (Registered Nurse). RN E indicated that R1's POST only had a physician signature on it. Surveyor asked RN E if there should be a patient/guardian signature, RN E indicated not that she was aware of. Surveyor asked if a Resident elected their code status to be DNR, should that form be signed, RN E replied yes. RN E was unable to find a form signed by R1 or R1's representative related to R1 being a DNR.

Based on observation, interview and record review the facility did not provide privacy during personal care for 1 out of 17 residents (R214). R214's room door was left open, and the privacy curtain was not pulled during wound care to R214's coccyx. This is Evidenced by: The facility policy entitled, Resident Care, dated 10/2017, states, in part: . POLICY: It is [NAME] Manor's policy to provide resident care that promotes quality of care and quality of life. Procedure: . - . For most adults, washing is a personal and private activity and so it can be hard to adjust to this change. Always remember, it is important to be sensitive and tactful and to respect their dignity. - Personal cares can be difficult for care givers and is a common source of anxiety for many residents . - . residents may find it embarrassing to be undressed in the presence of other people. Keep them covered as much as possible during cares . R214 was admitted to the facility on [DATE] and has diagnoses that include Severe Protein-calorie malnutrition (a type of undernutrition that can lead to muscle loss, fat loss, and your body not working as it usually would) and Dementia. R214's Minimum Data Set (MDS) Admission Assessment, dated 7/23/23, shows R214 has a Brief Interview of Mental Status (BIMS) score of 00 indicating R214 is severely cognitively impaired. R214's Care Plan states, in part: . Problem: Potential for Impairment of Skin Integrity. Related To: Urine incontinent. Disease Process. Manifested By: Open Area to Buttock . Interventions: Nurses- Treat as Ordered . R214's Physicians Orders, dated 8/3/23, states, in part: . 7/17/23 Wound Care: Cleanse open areas to buttocks and dry area well. Apply Tegaderm+ pad to cover open area daily PM and PRN (As Needed). First Date: 7/17/2023 (until resolved). On 8/14/23 at 3:41 PM, Surveyor observed RN H (Registered/Wound Nurse) assess R214's bottom where open area had been but is now healed. RN H left R214's room door open and left privacy curtain open while RN H pulled R214's bottoms down exposing R214's bottom. On 8/14/23 at 3:54 PM, Surveyor asked RN H if R214's door should have been closed or privacy curtain been pulled to provide privacy while exposing R214's bottom and RN H indicated yes it should have been closed. On 8/14/23 at 1:40 PM, Surveyor asked DON B (Director of Nursing) if she would expect privacy to be provided during wound care to R214's bottom by having room door closed or privacy curtain pulled. DON B indicated yes. Surveyor informed DON B of observation with RN H leaving R214's room door open and privacy curtain not pulled while exposing R214's bottom for wound care.

Based on interview and record review, the facility did not have evidence that all alleged violations are thoroughly investigated for 1 of 10 residents reviewed for abuse (R56). R56 alleged that money had been stolen from him and the facility did conduct a thorough investigation that includes interviews of other residents and monitoring of R56 as he made threats because of the alleged theft. Findings include: The facility's Resident Abuse policy states the following: *Misappropriation of resident property is defined as: The deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of resident's belongings or money without resident's consent. *The investigation will include interviewing alleged victim(s) and witnesses. Interviewing other residents to determine if they have been abused .other protection steps to consider: 15-minute checks, assess for the appropriateness of a room change, evaluate medical condition, psychological evaluation, behavior intervention changes. R56 is his own person and has a Brief Interview for Mental Status (BIMS) score of 15 from his most recent Minimum Data Set (MDS), dated [DATE], indicating R56 is cognitively intact. R56 has his own car at the facility, can drive, and frequently leaves the facility grounds. On 6/24/23, R56 reported to facility staff that $700 had been stolen from his room. The facility assisted R56 with searching for any missing money, the police were called, and other staff were interviewed. In the investigation report, multiple staff state they witnessed R56 showing money to different people, including them, on 6/23/23. Additionally, a staff member's statement details how R56 became upset about the missing money and stated multiple times that he was going to run his car into the building. According to this statement, NHA A (Nursing Home Administrator) was present. The investigation did not include interviews of any other residents. On 8/15/23 at 2:24 PM, Surveyor interviewed NHA A who stated that the facility did not interview any other residents to see if they were missing any money or other items. NHA A stated that on 6/24/23, R56 yelled at her that he was going to run his car into the building and then went out to his car. NHA A also stated that she didn't think the facility did anything to monitor R56 when he stated he was going to run his car into the building, but maybe SW C (Social Worker) was more aware. On 8/15/23 at 3:11 PM, Surveyor interviewed SW C who stated that R56 is not the kind to make threats. SW C also stated that the facility did not do any additional monitoring or care planning considering R56's threat to run his car into the building. The facility became aware of an allegation - from a resident - of potential misappropriation and did not investigate further to ensure if other residents were not affected and did put measures into place to protect R56 and/or other residents when R56 made a threat to run his car into the building.

Based on observation, interview, and record review, the facility did not ensure a resident with a catheter receives appropriate treatment and services to prevent urinary tract infections for 1 of 2 residents (R43) reviewed for catheter care. Staff did not perform appropriate hand hygiene while providing catheter care. There was no barrier placed under supplies on the bedside table during the catheter care. Staff placed dirty wash cloths directly on bedside table and did not disinfect bedside table after use. This is evidenced by: The facility policy, entitled Incontinent/Perineal Care, dated 5/7/21, states, in part: . Policy: .It is the policy of [NAME] Manor that perineal care will be provided to residents requiring assistance with bathing . Procedure: . The perineal area also is a primary portal of entry for bacteria into the urinary tract, potentially causing infection. Therefore, it is important that this area be kept as clean as possible. Incontinent care will be completed as follows: . -Wash hands or use alcohol-based hand rub. -Apply gloves. -Apply soap or perineal spray to cloth or use pre-packaged wipes. -Starting at the front of the perineal area, wash the meatus and labial areas using friction and with a circular motion, work outward to the surrounding perineum . -Dirty linens should be placed in plastic bag until removed from room. -Change gloves with hand hygiene before applying clean gloves. -Rinse the area with warm water and pat dry . Remove gloves and wash hands. - .Clean resident's unit, by disinfecting side table or other surfaces as needed, provide clean linen as needed, and return items to the appropriate place. -Dispose of all soiled equipment and supplies . The facility policy, entitled Hand Hygiene, dated 1/13/23, states, in part: . Policy: It is the policy of [NAME] Manor that all staff will follow the hand washing guidelines of the CDC (Centers for Disease Control) and those outlined in the Infection Control for Long Term Care resource manual. Hand washing is the single most important means of preventing infection. Procedure: . Hand hygiene with soap and water: -Hands should be washed with soap and water when they are visibly soiled or contaminated with blood, body fluids, or other proteinaceous materials . The facility policy, entitled Foley Catheter Care, dated 6/29/23, states, in part: . Procedure: The catheter-meatal junction is a significant portal of entry for bacteria into the urinary tract, and potentially caused urinary tract infections. Therefore, it is important that the perineum, catheter-meatal junction, and tubing be kept clean . -Wash your hands or use alcohol-based hand sanitizer. -Apply gloves. -Wet wash cloth with warm water. Apply soap or perineal cleanser to the cloth. -Starting at the catheter-meatal junction, clean the tubing, labia, and meatus, using friction and a circular motion working outward to the surrounding perineum . - .If gloves become grossly contaminated . gloves should be changed before continuing. Wash hands or use alcohol-based hand sanitizer in between changing gloves. -Rinse area with clean, warm water and pat dry. -Remove gloves and wash hands or use alcohol-based hand sanitizer . R43 was admitted to the facility on [DATE], and has diagnoses that include Retention of urine, Neuromuscular dysfunction of bladder, and Benign prostatic hyperplasia with lower urinary tract symptoms. R43's Minimum Data Set (MDS) Quarterly Assessment, dated 5/17/23, shows R43 has a Brief Interview of Mental Status (BIMS) score of 11 indicating R43 has a moderate cognitive impairment. R43's Care Plan, dated 5/21/2023, states, in part: . Problem: Potential for Infection: UTI (Urinary Tract Infection) Related To: Moisture, body habitus, Indwelling catheters, fluid restriction, urology procedures. Approach: . Nurse Aide- Maintain enhanced barrier precautions. Use good hand washing techniques before and after cares. Keep area clean and dry. Help resident to wash hands. Wash and dry thoroughly in skin folds. Perform good catheter care . On 8/15/23 at 10:15 AM, Surveyor observed CNA G (Certified Nursing Assistant) perform catheter care to R43. Surveyor entered R43's room and observed grey wash basin containing washcloths and a bottle of equate body wash on bed side table with no barrier under supplies. CNA G and CNA F had gowns and gloves on. CNA G grabbed a wet washcloth and applied soap to it, performed catheter care with washcloth, then set the used washcloth directly on bedside table with no barrier under it. CNA G then grabbed another washcloth from grey basin and applied soap to it, continued catheter care, and set that washcloth on the bedside table with no barrier under the washcloth. CNA G then grabbed another wet washcloth from basin and rinsed catheter/perineal area and placed that washcloth on the bedside table with no barrier under it. CNA G did not remove gloves and perform hand hygiene and apply new gloves after washing (contaminated area) and rinsing (clean area). CNA G patted perineal area dry with same gloves on from beginning of procedure. CNA G gathered supplies when care completed. Neither CNA, CNA G nor CNA F disinfected the bedside table after supplies were removed.

Based on observation, interview and record review, the facility did not ensure that a resident who entered the facility without a pressure injury (PI) did not develop a PI and did not have deterioration of an existing pressure injury for 1 of 5 residents (R8) observed for Pressure Injury (PI)/skin prevention of 15 total sampled residents reviewed for PI's and PI prevention. R8 was admitted to the facility without a PI to her right foot and was identified to be at risk for PI development. R8 developed an avoidable, unstageable PI to her right foot while in the facility. She also had a deterioration of her PI to her left heel, which was present on admission. The facility failed to do weekly assessments and diabetic skin assessments per their policy. The facility failed to notify the MD (Medical Doctor) when a surgical dressing was removed and it was reapplied too tight, causing a PI to right foot. The facility failed to ensure that dressings were in place. The facility failed to have a process in place to ensure that podiatry visit notes were printed, reviewed and followed up on if needed. This is evidenced by the following: The facility's Wound Documentation policy and procedure, with a review date of 8/29/14, includes, in part: Procedure: Documentation: Daily Documentation: Evaluation of ulcer if no dressing is present; if dressing present, evaluation of dressing (clean, intact, drainage, leaking); possible complications (redness, swelling, increase drainage, pain); pain control (is it adequately controlled?): Weekly Documentation: Document cause and location .; Stage of wounds .; Documents size of wound .; Document presence of tunneling, undermining or sinus tract; Document exudate .; Document pain .; Document odor .;Document tissue types .; Document surround tissue characteristics .; Document any signs of infection .; Document interventions or healing .; Current treatment plan; and Document education given to resident and family. The facility's Infection Control/Wound Care policy and procedure, with a written date of 02/2011 and reviewed dates of 6/2013, 1/22/14, 4/11/2014, and 10/16/2014, includes in part: .For (facility) purposes - all wounds will be cared for using clean technique. Sterile technique will only be used when specifically ordered by the physician. All wound care will be provided as prescribed by MD. Wounds will be assessed and monitored weekly by a Wing Nurse and or Wound Care Certified Nurse. The facility's Diabetic Skin and Foot Care policy and procedure, without a date, includes in part: It is policy of (facility) to properly identify and assess residents whose clinical conditions increase the risk for impaired skin integrity and implement measures. Procedure: Identify residents at risk for skin breakdown. Skin assessments performed weekly . R8 was admitted to the facility on [DATE], with re-admitted s of 6/22/17 and 8/18/17. Her [DIAGNOSES REDACTED]. R8 is cognitively intact and her own decision maker. R8's admission Braden score, which is a skin risk assessment, dated 6/14/17, was 16 which indicate R8 is at low risk for pressure sore development. R8's Wound Assessment and Skin Progress Notes include, in part, the following entries: 6/14/17 at 11:35 PM: General Skin Condition: Pale, dry, warm .Foot Problem/Care: Has Ulcer to right great toe. Comments: .States her left heel is sore, slightly soft, no discoloration noted to skin at heel. 6/19/17 at 10:00 AM: Follow-up assessment: Venous/Arterial ulcer: Right great toe. Note: Large amount of thick pale green exudate, foul odor. Wet adherent white colored eschar. Call placed to Dr. (name) requesting they see her today after [MEDICAL TREATMENT]. Resident in agreement. Please note: Resident was admitted to hospital, from 6/20/17 to 6/22/17, for low blood sugars. 6/22/17 at 3:12 PM: General skin condition: Warm and dry .Foot problem/care: Has 1+ foot problem .res (Resident) has a black unstageable area on her left heel, 1.7 cm x 1 cm (Centimeter), dressing applied per order, res has 2 areas on her right great toe, lateral being 3 cm x 2.5 cm, has one on the underside of right great toe, this is 1 cm by 0.6cm, has orders for Dakin's for both right and left foot. 6/27/17 at 7:28 AM: Assessment Type: Follow-up assessment: Area 1: Venous/Arterial ulcer: from admission right great toe medial aspect. Area: length (cm): 3.1; width (cm): 2.1; depth: unknown; Description: Area has dried to dark stable eschar. Edges are intact. Periwound is somewhat macerated related to the Dakin's solution tx (treatment) per podiatry .Will request that tx be changed to [MEDICATION NAME] and that an x-ray is performed to rule out osteo[DIAGNOSES REDACTED]. Area 2: Pressure injury on admit: Unstageable - wound bed covered by slough and/or eschar left heel. Area: length (cm): 1.4; width (cm): 1; depth: unknown; Description: Darkened circular area (measurements above). Periwound is blanched and very boggy to touch .Will update MD and suggest a tx change. Heels are floated while in bed and in recliner. A bed cradle is also in place . Physician Orders: 6/27/17: Discontinue Dakin's to foot wounds. Start iodine BID (two times daily) to right hallux and left heel. Care plan updated 6/27/17: Nurse Aide - bed cradle; Nurse - Treat as ordered, Bandage as appropriate, Monitor for signs and symptoms of infection. Podiatrist C Progress Note, from 7/06/17 visit, indicated in part: Subjective: R8 .presents to clinic today for recheck of right great toe .No dressings on either wound today as she comes from the nursing home. She has [MEDICATION NAME] on, which are quite tight, and dried blood on the heel of the left. Objective: Posterior heel eschar is about 5 times the size it was today. It measures 1 cm in diameter .Plan: Iodine applied to both wounds and a light dressing on the hallux (to right toe) and [MEDICATION NAME] pad on the heel. I do not think she should use the [MEDICATION NAME] due to her [MEDICAL CONDITION] .Recommend not to get her feet wet .Recommend continued offloading of the posterior left heel wound. No shoe to the left foot . Podiatrist C progress note from 7/20/17 visit indicated, in part: Subjective: R8 .presents to clinic today for a recheck of her right hallux wound .Objective: R8 has increased [DIAGNOSES REDACTED] and [MEDICAL CONDITION] to the proximal right hallux .A thicker sanguineous drainage noted. This was cultured. Wound looks about the same except the plantar toe fat pad appears more dry and there is increased warmth and [DIAGNOSES REDACTED] .Posterior left heel has a dry eschar, it measures 1.7 x1.4cm .Plan: .Based on the wound (right toe), this is the worst it has looked as far as tissue loss .I am recommending amputation of her toe. She is very adamant that she will not have her toe amputated .Iodine painted to both wounds. [MEDICATION NAME] placed to the left heel. Will discontinue iodine on the right hallux. Start Dakin's solution. Orders given to nursing home. Continue offloading left heel at all times .Start [MEDICATION NAME] 500 . Physician order [REDACTED]. Cover with 2x2 and secure with Coban. 2. Iodine left heel daily and [MEDICATION NAME] feel foam. 3. Discontinue [MEDICATION NAME], elevate feet when sitting x 2 pillows. 4. Offload heels on pillows in bed and chair. Put pillow under bed sheet to secure while sleeping. Recheck 2-3 weeks. Wound Assessment and Skin Progress Notes: 7/11/17 at 1:10PM: Assessment Type: Follow-up assessment: Venous/arterial ulcer: Area 1: right great toe; area: length (cm): 3; width (cm): 2; depth: unknown; Description: Dry stable eschar noted to medial aspect of great toe .Area 2: Unstageable - wound bed covered by slough and/or eschar left heel; Area: length (cm): 1.5; width (cm): 1; depth: unknown; Description: Area of dark eschar is circular, edge of eschar is becoming macerated. Periwound measures 2.7 x 3 cm denuded and pink .[MEDICATION NAME] left off and [MEDICATION NAME] applied . (Of importance, there were no wound assessments between the ones dated 6/27/17 and 7/11/17, which is two weeks apart.) 7/19/17 at 11:33AM: Assessment type: Follow-up assessment: Venous/arterial ulcer: right great toe; Area: length (cm): 3; width (cm): 2; depth: unknown; Description: Wound presents with dry eschar. The anterior portion of the eschar is slightly lifted small amount of opaque purulent drainage was expressed .Area 2: .left heel; Area: length (cm): 1.5; width (cm): 1; depth: unknown; Description: Small circular stable eschar . Physician Orders: 7/20/17: 1. Start [MEDICATION NAME] 500 MG (Milligrams) BID x 10 days. 2. Recheck 7-10-days with x-rays. 3. Discontinue iodine right hallux. Start Dakin's 0.25% moist 2x2 to wound and secure with Coban, iodine and [MEDICATION NAME] left heel. 7/21/17: Change [MEDICATION NAME] 500 MG to daily at HS (bedtime). Continue with 10 day supply. Wound Assessment and Skin Progress Note: 7/28/17, at 6:20AM, Late entry for 7/27/17, Assessment type: Follow-up assessment: Area 1: Venous/arterial ulcer: right great toe: Description: Toe is nearly 75% black adherent eschar. There is a small amount of purulent and sanguineous drainage with dressing change. Edges are slightly lifted and moist .Area 2: Pressure injury on admit: Unstageable - Wound bed covered by slough and/or eschar left heel; Area: length (cm): 2; width (cm): 1.2; depth: unknown; Description: Continues to be a circular area of dark soft eschar .wound is boggy to touch . (Of note, R8 decided ,on 7/31/17, to have right great toe amputated. 8/1/17 Podiatrist C's office called and set up amputation for 8/3/17. R8 had right great toe amputation, on 8/3/17, with surgical dressing in place that was to be left on until next visit. Antibiotics were initiated for toe infection as well. Physician Orders: 8/3/17: [MEDICATION NAME] 100 MG PO BID x 1 week for foot infection/MRSA ([MEDICAL CONDITION] Resistant Staph Aureus). Ertapenem 500 MG IV (intravenously) daily x 6 days starting 8/4/17 for foot infection/MRSA. NS (Normal saline) flush every shift before and after IV medications x 1 week. 8/7/17: 1. D/C (discontinue) iodine right hallux; keep dressing dry, clean, and intact. Podiatrist C Progress Note, from 8/10/17 visit, indicated, in part: Subjective: R8 .presents to the clinic today for a recheck 1 week status [REDACTED].Objective: Patient's skin at the surgical site is well approximated without signs of infections or dehiscence. Discoloration and [MEDICAL CONDITION] within normal limits status [REDACTED]. No pressure [MEDICAL CONDITION] to the right foot heel. On the left the patient continues with a dry eschar posterior left heel. Today it measures 1.5x1.4cm . Plan: .New dry, sterile dressing placed. Keep clean, dry, and intact. In regard to the left heel, painted with iodine and [MEDICATION NAME] placed. She is given instructions for wound care at the nursing home. She is dispensed an offloading bunny boot. She is dispensed a heel protector for the left side with instructions for use to wear at all times. (It is important to note that this is not addressed in R8's care plan) . Patient has finished her [MEDICATION NAME] and Ertapenem. (It is important to note that she was started on these antibiotics [MEDICAL CONDITION] which was in the amputated toe) . Wound Assessment and Skin Progress Note: 8/10/17 at 6:24AM: Resident unwrapped her foot dressing during the night. Dressing was rewrapped and Tylenol given for pain. (Please note: Podiatrist C was not notified that this happened - this dressing was a surgical dressing that was supposed to be left in place until next appointment.) Physician Order: 8/10/17: 1. Keep surgical dressing dry, clean, and intact. 2. Left heel, paint with iodine daily and cover with [MEDICATION NAME] heel, secure with sock! 3. Wear heel cushion left all times. 4. F/U (follow-up) in 1 week. Wound Assessment and Skin Progress Note: 8/12/17 at 2:45AM: .Resident unwrapped foot dressing. Dressing was rewrapped. (Please note: Podiatrist C was not notified of this - this dressing was a surgical dressing that was supposed to be left in place until next appointment.) Resident was admitted to hospital, from 8/16/17 to 8/18/17, for low blood sugars. While at the hospital, Podiatrist C was contacted, on 8/17/17, by RN (Registered Nurse) from hospital in regards to wound care for R8's left foot heal pressure ulcer and right greater toe amputation. Instructed for resident's left heel ulcer to use iodine and [MEDICATION NAME] daily. There is a heel protector boot that is to be worn on her left foot at all times. Dressing on right foot should be left alone as long as it is C/D/I (clean/dry/intact). Podiatrist will look at it on Tuesday unless it should get soiled or saturated. Physician Order: 8/21/17: Fax sent to Dr. (name) (who is primary MD, not podiatrist, who usually follows R8 for any foot issues): can we please have treatment orders for [MEDICATION NAME] and leave OTA to left heel? Dr. (name) replied yes. Order: Paint left heel with [MEDICATION NAME] and leave left heel open to air. Wound Assessment and Skin Progress Note: 8/21/17 at 2:21PM: Area 2: Venous/arterial ulcer: left heel; Assessment type: follow-up assessment; Area: length (cm): 1; width (cm): 1; depth: unknown; Description: small circular stable eschar, no signs of infection, no drainage, no odor; Wound type: eschar/sloughing; Tissue type: Necrotic/eschar; Wound tissue: dk (dark) brown; Drainage: none present; Surrounding tissue: pallor; healing progress: improving; Description: becoming smaller. (Of importance, please note, there are no wound assessments for the left heel between the ones dated 7/27/17 and 8/21/17, which is 23 days apart.) Podiatrist C Progress Note, from 8/22/17 visit, indicated, in part: Subjective: R8 .presents to clinic today for a recheck of her right foot .She did well at her post-op (Post-Operative) visit without any problems. She was hospitalized last weekend for low blood sugar. I did receive a call from the nurse at that time and she was instructed not to remove the post-operative dressing .instructions were given for [MEDICATION NAME] and iodine to the left heel as well as her bunny boot. She presents to the clinic today with a different dressing on her right foot. She does not have a dressing on her left heel, no evidence of iodine, and she does not have her bunny boot. She has post-op shoes bilaterally .Objective: Patient has a Kling dressing to her right foot that has no padding and appears tight. Upon removal of the dressing, patient has new pressure wounds from that dressing being too tight with ridges on the top of her foot and associated necrotic areas at the dorsum of her foot. She has a large hemorrhagic blister along the lateral plantar foot encompassing from the 5th metatarsal head region to the base of the 5th metatarsal. It is sanguineous filled, partial-thickness .The distal incision is well approximated without signs of infection or dehiscence, but she does have some slough along the dorsal portion on the incision due to friction .She continues with a posterior left heel pressure wound/eschar measuring 1.7x1.5 .No surrounding [DIAGNOSES REDACTED] or signs of infection and no dressing .Plan: .Unfortunately, she has new [MEDICAL CONDITION] from the dressing being too tight .The bulla is drained and her surgical site is cleansed and debrided .It is re-dressed and well-padded, dressed appropriately not tightly. Instructions given to leave the dressing clean, dry, and intact. Nursing home is not to remove. Also orders given for daily dressing to the left heel with iodine, [MEDICATION NAME], and she is to wear bunny boot at all times, not post-op shoe . (Please note, R8 was evaluated by Podiatrist C on 8/22/17 (see note above) where she was found to have new pressure areas to right foot. A surgical dressing was applied to right foot which was supposed to be left in place until next appointment. On 8/27/17, there were 2 occasions where the resident removed the dressing and staff rewrapped this without notifying the Podiatrist about this.) Physician Order: 8/22/17: 1. Do not remove right foot dressing. Do not get wet. 2. Paint iodine to left heel daily, cover with [MEDICATION NAME]. 3. Must wear bunny boot left all times. 4. Recheck 1 week, call with questions. Wound Assessment and Skin Progress Note: 8/28/17 at 10:46AM: Area 2: Venous/arterial ulcer: left heel; Assessment type: Follow-up assessment; Area: length (cm): 1; width (cm): 1; depth: unknown due to eschar; Description: Small circular stable eschar, no signs of infection, no drainage, no odor; Wound type: eschar/sloughing; Tissue type: necrotic/eschar; Wound tissue: dk (dark) brown; Drainage: none present; Surrounding tissue: pallor; Healing process: no change; Description: no change. Podiatrist C Progress Note, from 8/29/17, visit indicated, in part: Subjective: R8 .At her last visit, she had necrosis at the dorsal foot and a new hemorrhagic bulla due to a tight dressing .The dressing has been left intact on the right. She presents with bilateral post-op shoes. She does not have her bunny boot on her left side and no dressing on the left .Objective: .Distal incision at the hallux amputation site is well approximated without signs of infection or dehiscence. Dorsal midfoot with increased necrotic tissue due to pressure. Bulla at the lateral foot resolved .At the head, she has 1 small dark necrotic area .Posterior left heel eschar not changed .similar size to last week .Assessment: 4. Pressure ulcer dorsum of right foot, unstageable .Plan: .Wounds are cleansed thoroughly. Iodine and [MEDICATION NAME] performed left heel. Recommend bunny boot at all times. Spoke with the nursing home to that effect. On the right, non-adherent [MEDICATION NAME] dressings followed by well-padded dressing with mild compression performed to the right. That should be kept clean, dry, and intact . Care plan updated 9/3/17, Nurse Aide - heel manager as allows. Podiatrist C Progress Note, from 9/12/17 visit, indicated, in part: Subjective: R8 presents to clinic today for recheck of left heel wound and right foot wound status [REDACTED].Dressing has not been not been changed to the right foot. On the left they have been performing daily iodine and [MEDICATION NAME]. Objective: Dermatologic: Patient continues with an eschar at the posterior left heel. It measures 2.1x2.0 cm. There is increased periwound [DIAGNOSES REDACTED] today .Question pressure [DIAGNOSES REDACTED] versus infection. On the right, has healing of her surgical incision distally .She has skin slough at the periwound area .Mild [DIAGNOSES REDACTED] of her right 2nd toe noted today which is new .Plan: The left heel is cleansed and dressed. X-rays performed today, negative for osteo[DIAGNOSES REDACTED]. Patient is placed on [MEDICATION NAME] 100 mg b.i.d. (two times per day) for 10 days .Will have the nursing home perform daily dressing changes (to right foot). Podiatrist C Progress Note, from 9/19/17 visit, indicated, in part: Subjective: R8 .presents to the clinic today for recheck of left heel wound and right foot wound. They are doing Dakin dressings daily to her left heel per the notes .She is on oral [MEDICATION NAME]. She does have extended spectrum beta lactamase producers as well as [MEDICAL CONDITION] resistant Staph aureus. She states that they have not been changing her right foot wound daily. (It is important to note that the nursing home was to start daily dressing changes on 9/12/17). She presents in post-op shoes with dressings intact. (It is important to note that R8 should have bunny boot to left foot) .Objective: .continues with eschar on the posterior left heel. Today it measures 2.1x1.9 cm .On the right, she has continued healing of her surgical wound distally .She has further skin slough of dark areas dorsal .does have some [DIAGNOSES REDACTED] at the 2nd toe and upon inspection of the 2nd toenail on the right is loose and avulsed .Plan: .At this time, using the Dakin's for prevention of infection, left heel, have not initiated IV antibiotics for the E coli (Escherichia coli). She is on [MEDICATION NAME] and will likely keep her on that for some time .Right foot wounds debrided to tolerance to remove all devitalized tissue. Cleansed thoroughly, dressed with iodine, Xeroform, and a light dry sterile dressing. The right 2nd toenail is removed without anesthesia. Wound is cleansed and dressed . (Please note, after Podiatry visit on 9/12/17, R8 was started on antibiotic for left heel infection. Dressing changes to right foot were initiated.) Physician Orders: 9/12/17: 1. Start [MEDICATION NAME] 100 MG BID x 10 days. 2. Continue iodine and [MEDICATION NAME] left heel. 3. Start daily dressings right foot, wash [MEDICATION NAME], rinse saline, paint iodine lateral foot and dark area, cover [MEDICATION NAME] 4x4, secure loosely with gauze roll and ACE (ace wrap). 4. F/U one week Podiatrist C. 5. Lotion to both legs daily. 9/14/17: D/C iodine left heel. Apply Dakin's 0.25% to 2x2 and then place on left heel and cover with dry dressing BID. Wound Assessment and Skin Progress Note: 9/15/27 at 4:44PM: Area 2: left heel; PI; Unstageable - wound bed covered by slough and/or eschar. Clarification of type of wound is unstageable from 8/21/17 documentation; Assessment type: Follow-up assessment; Area: length (cm): 3; width (cm): 3; depth: unknown due to eschar; Description: Small circular stable eschar, no signs of infection, no drainage, no odor; Wound type: Eschar/sloughing; Tissue type: necrotic/eschar; Wound tissue: dk brown; Drainage: none present; surrounding tissue: pallor; healing progress: no change; description: no change. Initial Assessment 9/15/17: Area 3: Right great toe area, area is related to surgical procedure for toe amputation with non- removable dressing changed by Podiatrist C in the clinic podiatry; Wound type: Eschar/sloughing; tissue type: Necrotic/eschar; Wound tissue: black; Drainage: clean and dry, none present; Surrounding tissue: reddened; Area: length (cm): 7; width (cm): 3.5; depth: undetermined due to the eschar; (Note: resident seen in clinic on Wednesday by Podiatrist C, no signs of infection no drainage) Area 4: R (Right) foot dorsum Pressure injury: unstageable - wound bed covered by slough and/or eschar; Onset/Discovery date: at Podiatry appointment on 9/12/17. (Important to note that this was actually identified by Podiatrist C on R8's 8/22/17 visit not 9/12/17); Wound type: Eschar/sloughing; Tissue type: Necrotic/eschar; Drainage: none present, clean and dry; surrounding tissue: reddened; Area: length (cm): 8; width (cm): 1.5; (Note: area is dry and clean, no signs of infection, no drainage, dressing change per order.) (Of importance, please note, there are no wound assessments for the left heel between the ones dated 8/28/17 and 9/15/17, which is 18 days apart.) Braden assessment 9/15/17 was 16, which continues to indicate low risk for pressure sore development. Physician order [REDACTED]. 2. Recheck 2 weeks. R8's most recent quarterly MDS (Minimum Data Set), with an Assessment reference date of 9/20/17; Section G0110: bed mobility requires extensive assistance with one person physical assist; Transfer requires extensive assistance with one person physical assist. Section M0150: R8 is at risk for PI development. Section M0210: R8 has a PI. Section M0300: F. R8 has 1 unstageable PI due to coverage of the wound bed with slough and / or eschar. Section M0610: A. Pressure ulcer length 8cm (centimeter); B. Pressure ulcer width 1.5 cm; and pressure ulcer depth 0cm. Section M0700: R8's most severe tissue type for any pressure ulcer is eschar. Wound Assessment and Skin Progress Note: 9/21/17 at 2:37PM: Area 2: Left heel PI: Unstageable - wound bed covered by slough/eschar, clarification of type of wound is unstageable from 8/21/17 documentation; Assessment type: Follow-up assessment; Area: length (cm): 2.5; width (cm): 2; depth: unknown due to eschar; Description: small circular eschar, no signs of infection, no drainage, no odor; Wound type: eschar/sloughing; Tissue type: necrotic/eschar; Wound tissue: dk brown; drainage: none present; Surrounding tissue: pallor; healing progress: improving; description: becoming smaller; Area 3: Right great toe area, area is related to surgical procedure for toe amputation with non- removable dressing changed by Podiatrist C in the clinic podiatry; Wound type: eschar/sloughing; Wound tissue: black; drainage: clean and dry, none present; Surrounding tissue: reddened; Area: length (cm): 4.5; width (cm): 3.5; depth: undetermined due to eschar; (Note: follow up with podiatrist, no signs of infection no drainage, area is smaller eschar is stable) Area 4: Right foot dorsum PI: Unstageable - wound bed covered by slough and/or eschar; Onset/discover date: at podiatry appointment on 9/12/17; wound type: eschar/sloughing; tissue type: necrotic/eschar; drainage: none present, clean and dry; surrounding tissue: reddened; healing process: improving; description: becoming smaller; Area: length (cm): 7; width (cm): 1; (Note: area is dry and clean, no signs of infection, no drainage, dressing change per order.) Physician Order: 9/22/17: D/C ACE wrap to right foot. Wound Assessment and Skin Progress Note: 9/27/17 at 3:10PM: Area 2: Left heel PI: Unstageable - Wound bed covered by slough and/or eschar, clarification of type of wound is unstageable from 8/21/17 documentation; Assessment type: follow-up assessment; Area: length (cm): 2; width (cm): 1.5; depth: unknown due to eschar; Description: small circular stable eschar, no signs of infection, no drainage, no odor .Area 3: Right great toe area, area is related to surgical procedure for toe amputation with non- removable dressing changed by Podiatrist C in the clinic podiatry; Wound type: Eschar/sloughing; Tissue type: necrotic/eschar; Wound tissue: black; Drainage: clean and dry, none present; Surrounding tissue: reddened; Area: length (cm): 4.5; width (cm): 3.5; depth: undetermined due to eschar .Area 4: Right foot dorsum PI: unstageable - wound bed covered by slough and/or eschar; Area: length (cm): 7; width (cm): 1; .Assessment Type: Initial assessment 9/27/17 Venous/arterial: venous; Area 5: Right 2nd toe; Onset/Discovery Date: 9/27/17 noted after admission; wound type: venous; Tissue type: Necrotic/eschar small area on the tip of toe that has eschar, tip of toe is reddened; Wound tissue: reddened; Drainage: none present, clean and dry; Surrounding tissue: reddened; Healing progress: N/A (new area); Area: length (cm): .2; width (cm): .2 eschar area; (Note: 2nd right toe, no signs of infection, pedal pulse faint, denies pain.) Podiatrist C Progress Note, from 10/3/17 visit, indicated, in part: Subjective: .R8 .presents to clinic today for recheck of left heel ulcer and pressure wound status right great toe amputation .Objective: .continue with an eschar on the posterior left heel. Today I measure 2.5x2.0 .on the right she has healing of her distal amputation site .sutures removed. She continues with an eschar at the dorsal 1st metatarsal region . Physician Order: 10/3/17: 1. Recheck 2 weeks. 2. Continue current dressings, no change. Wound Assessment and Skin Progress Note: 10/6/17 at 1:27PM: Area 2: Left heel PI Area: length (cm): 2; width (cm): 1.5; depth: unknown due to eschar .Area 3: Right great toe area, area is related to surgical procedure foe toe amputation with non-removable dressing changed by Podiatrist C in the clinic podiatry .Area: length (cm): 4; width (cm): 3; depth: undetermined due to eschar .Area 4: Right foot dorsum PI: Unstageable - wound bed covered by slough and/or eschar; .Area: length (cm): 1.3; width (cm): 1 .Area 5: Right 2nd toe venous; .Tissue type: Necrotic/eschar small area on tip of toe that has eschar, tip of toe is reddened; .Area: length (cm): .3; width (cm): .3 eschar area . Care plan updated 10/14/17: Nurse Aide - float heels, put foot pedals on when going out, watch placement of leg. (Of note, bunny boots were not in this comprehensive care plan as recommended from Podiatrist C. It is on the MAR but not as a sign off for the nurses to ensure it was done.) Wound Assessment and Skin Progress Note: 10/15/17 at 8:11AM: Area 2: Left heel PI Area: length (cm): 2; width (cm): 1; depth: unknown due to eschar Area 3: Right great toe area is related to surgical procedure Area: length (cm): 3.5; width (cm): 3; depth: undetermined due to eschar Area 4: Right foot dorsum PI: unstageable - wound bed covered by slough and/or eschar; .Area: length (cm): 1; width (cm): 1 (Please note there is a 2nd assessment for Area 4: Right foot dorsum; .Area: length (cm) 6; width (cm): 1 .); Area 5: Right 2nd toe venous Area: length (cm) .3; width (cm): .3 eschar area .) (Of importance, please note, there are no wound assessments for the left heel between 10/6/17 and 10/15/17, which is 9 days apart, but one full week was without an assessment as 10/6/17 was a Friday and 10/15/17 was a Sunday.) On 10/16/17, at 2:40 PM, Surveyor observed dressing change to R8's left heel by LPN D (Licensed Practical Nurse). Dark brown/black eschar area noted. No measurements done. LPN D reports are is firm to touch. Area cleansed. New dressing of Dakin's to 2x2 applied to left heel and then wrapped with gauze. Right foot dressing change was not done at this time. Podiatrist C Progress Note, from 10/17/17 visit indicated, in part: Subjective: .seen in clinic for recheck of bilateral foot wounds .Objective: .continues with eschar posterior left heel .on the right she continues with eschars dorsal right foot and dorsal proximal incision on the right foot and lateral foot .Small eschar now over the dorsal 2nd toe due to pressure, but stable .Plan: .wounds are debrided full thickness .recommend iodine and ABD or multiple gauze to pad the left heel with a light dressing. Place non-adherent dressing such as [MEDICATION NAME] or Xeroform followed by a well-padded dressing, not too tight to with her post-op shoe. She is not to get her feet wet . (It is important to note that the more recent Progress Notes from Podiatrist C were not found within R8's chart. There was a review of your visit document in the chart for 9/19/17. The Progress Note had to be obtained after asking for it. There was no documentation for the 10/3/17 visit from Podiatrist C in the chart. It had to be asked for.) Physician Orders: 10/17/17 at 1:35 PM: D/C Dakin's to left heel. Paint with [MEDICATION NAME] daily and cover for protection. May shower if right foot is covered with bag. 10/17/17 at 3:16 PM, noted at 3:55PM: 1. Continue dressings; add iodine and gauze to right 2nd toe. Recheck 1 week. On 10/18/17, at 7:10 AM, Surveyor observed dressing change to R8's right foot by LPN E. No measurements were done. Black eschar areas noted to right foot. Right great toe amputation site is healed. Has black eschar area below this amputation site. Another black eschar noted slightly below this area. Three black eschar areas observed to the dorsum of right foot or below the 5th digit - one larger one and two smaller ones. On 10/18/17, at 10:35 AM, Surveyor spoke to NHA A (Nursing Home Administrator) about R8's dressing changes that were done to surgical dressing. NHA A stated that on 8/10/17 and 8/12/17 surgical dressing was taken off by resident. A new dressing was re applied by RN G on 8/10/17 and RN F on 8/12/17. NHA A was asked if Podiatrist C was notified of this, since it is surgical dressing which she wanted left in place until she saw the resident at next visit. (TRUNCATED)

Based on observation, record review and interview, the facility did not ensure that each resident received adequate supervision and assistance to prevent accidents. Facility staff did not supervise Resident #3 to prevent falls. This is evidenced by: Resident #3 has a history of blindness, dementia with behaviors, anxiety, falls and weakness. Resident #3's Brief Interview for Mental Status (BIMS) was 3, indicating severe cognitive impairment. On 09/27/16 at 7:30 a.m., Surveyor observed Certified Nursing Assistant (CNA) I perform pericares for Resident #3. After performing these cares, CNA I transported Resident #3 into the sun room. No staff were present in the sun room from 7:45 a.m. until 8:00 a.m., when a breakfast cart was delivered to the 300 wing, and placed adjacent to the sun room. Surveyor reviewed Resident #3's clinical record. The nurses' notes and incident reports indicated that Resident #3 experienced the following falls: 07/06/16 at 5:45 a.m.: Resident #3 fell out of bed without injury while attempting to get to the bathroom. Resident #3 had an alarming floor mat in place at the time, which alerted the staff to check on the resident. The bed was in the lowest position. Resident #3 was found in the bathroom. The physician and family were updated. Interventions included monitoring neurological signs and assisting the resident to the bathroom every morning at 5:00 a.m., which was added to the resident's plan of care. 08/02/16: 12:45 p.m.: Resident #3 fell while attempting to self transfer while waiting for lunch in the sun room. No injuries were noted. Resident #3's family and physician were updated. Interventions included: Attempt not to leave in the sun room unsupervised (sic). This was added to the care plan on 08/02/16. 08/02/16: 7:13 p.m. (2nd fall on 08/02/16). Residen #3 was last seen sitting in her wheelchair by the supper table in the sun room. Resident #3 was found lying on the floor next to her wheelchair. A tab alarm was in place; however, the string to the tab alarm had become disconnected since the facility staff's last contact. Interventions included a new string attached to the tab alarm. Resident #3 was not supervised in the sun room. Resident #3's family and physician were updated. 08/13/16: 9:45 a.m. Resident #3 was sitting outside of the sun room in her wheelchair. CNA I witnessed the resident slide out of her wheelchair and onto the floor. No apparent injuries. Resident #3's family and physician were updated. Interventions included adding dycem (a non-slip material) to the resident's wheelchair cushion. 09/02/16: 6:45 p.m., while sitting in the sun room in her wheelchair, Resident #3 fell out of the wheelchair, landing on her face. Resident #3 was last toileted at 3:00 p.m. A tab alarm and grippy socks were in place at the time of the fall. CNA K stated: (Resident #3) was very restless and combative, setting her alarm off every 15-20 minutes. They were short of people to help assist with meals so CNA K was asked to leave the 300 wing and assist in the activity room (another room where meals were served). After assisting in the activity room for 15-20 minutes CNA D came and asked CNA K to come back to the sun room because (Resident #3) and another resident kept setting their alarms off and also there was many call lights on. CNA K stated that Resident #3 was still very restless, and leaning forward. CNA K offered to assist Resident #3 to lay down, but Resident #3 refused. CNA K pushed Resident #3's wheelchair up to the table and put a pillow on the table for comfort, then CNA K and CNA D left the sun room to assist other residents. CNA K stated that Resident #3 was observed every 2-5 minutes as they walked by the sun room. However; at the time of the fall, no staff was present in the sun room. CNA D heard the tab alarm sounding when she was returning to the wing. CNA D alerted Licensed Practical Nurse (LPN) J. CNA D stated that the resident was on the floor on her left side, with her face touching the floor. The resident was bleeding from facial injuries. LPN J stated, I heard an alarm sounding. It was coming from the 300 wing. (CNA D) was walking down the hallway towards it. I went back to what I was doing then heard (CNA D) yell 'She's on the floor.' Prior to the evening meal, (Resident #3) restless, setting (sic) her alarm off Resident had blood coming from her mouth, dripping from her nose and her left eye was purpled (sic) and abraised. She had a deep lip laceration and a cut on her left eye. LPN J contacted EMS, the physician and Resident #3's family. Resident #3's daughter, who was the POA-HC (Power of Attorney for Healthcare), met the ambulance at the hospital. Surveyor reviewed a document entitled Vernon Memorial Healthcare Discharge Instructions. Under the title Radiology Note, there was a finding of a fracture to the left paramedian anterior arch of C1. There was also a finding of left nasal bone fracture. Treatment included a cervical collar (which the resident's family refused due to causing the resident to become more agitated) and as needed pain medication. The notes stated that the family wished comfort measures only. Resident #3 was returned to the facility at 8:05 p.m. On 09/27/16, at 3:00 p.m., Surveyor interviewed the Director of Nursing (DON). Surveyor asked how the staff interpreted the intervention, Attempt not to leave Resident #3 alone in the sun room. The DON stated that staff were to be present in the sun room with Resident #3 unless they were busy with other duties. The DON agreed that this intervention left Resident #3 alone in the sun room without staff supervision.

Based on observation, interview and medical record review, the facility failed to ensure that the resident environment remains as free from accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 4 (Residents #5, 11, 25, 17) of 15 residents reviewed who have had falls. 1. Resident #5 has had several falls involving independent use of a Merry Walker. The physician ordered Physical Therapy/Occupational Therapy (PT/OT) evaluations. Despite PT's evaluation recommendations that the Merry Walker was not safe and that stand by assistance and in-line of sight supervision was needed to keep her safe, the Interdisciplinary Team decided to continue using the Merry Walker, without the level of supervision recommended by PT, because it offered Resident #5 maximum mobility. Surveyor review showed that Resident #5 had sustained eight falls in the last year, two being significant, with the majority of these falls occurring between 8 and 10 a.m. The facility had not done a trend analysis and had not, at a minimum, considered providing stand-by assistance during this time period. The failure to provide adequate supervision to prevent accidents created an Immediate Jeopardy situation. The Immediate Jeopardy began on 02/14/13. The facility was notified of the Immediate Jeopardy on 06/06/13. The facility removed the Immediate Jeopardy on 06/06/13. The deficient practice continues at a scope/severity level of D (potential for harm that is not immediate jeopardy/isolated) as evidenced by the following: 2. Resident #25 had falls with no apparent injuries on 09/22/12, 09/26/12, 03/31/13, 04/11/13, 04/14/13 and 04/22/13. Several incident reports lacked new interventions, indicating the actions taken were "continue to observe." 3. Resident #11 fell on [DATE] at 1:35 a.m. while leaning over the side of the recliner to get a glass of water. Resident #11 was assessed after the fall and it was determined she had no injury. On same date Resident #11 complained of pain and an x-ray was obtained. The x-ray revealed a bilateral fracture of the right and left sided pelvis. No new interventions were put into place following the fall. 4. Resident #17 who is identified by facility as at high risk for falls and requires an alarmed seatbelt in her wheelchair in order to prevent falls was observed on 06/05/13 without her alarmed seatbelt attached. Resident #17 also experienced a fall on 03/10/13 and no new interventions were put into place following the fall in order to prevent future falls. This is evidenced by: 1. Resident #5 [DIAGNOSES REDACTED]. Resident #5's most recent Brief Interview for Mental Status (BIMS) score was two (severely impaired) per Minimum Data Set with assessment reference date of 03/18/13. Resident #5's Fall assessment dated [DATE] = 10 (high risk for falling). Resident #5 also wears a wanderguard bracelet. Resident #5's Guidelines for Daily Care (CNA care sheet) read in part: Restraints: Merry Walker - "independent" was handwritten next to it; Wanderer: Wanderguard. Resident #5's Interdisciplinary Care Plan (2nd copy received on 06/05/13 at 8:55 a.m. from RN G showing all handwritten updates) Fall care plan read: 02/21/12 Problem: Trauma-falls 07/07/12 hx (history) of falls. 02/21/12 Related to: with increased confusion and unsteady gait, disease progression. 02/21/12 Manifested by: fall (or near fall) in past 180 days. 02/21/12 Approach: Nurses - observe, record and report all unsafe conditions and situations, monitor neuro status, encourage to ask for assistance, assess change in level of consciousness, instruct on safety, administer meds as ordered. 02/21/12 Nurses Aids - Encourage to ask for assistance, call light in reach, glasses on AM off HS. 02/21/12 Goal: No Injury. Goal Time: 02/21/1203/06/12, 07/13/12, 02/22/13 review. Evaluation: Continue to POC (handwritten with no other entry). The facility began using a Merry Walker as a means to prevent falls and to allow for maximum independent mobility on 6/6/12. The "Use of Merriwalker-restraint daily care plan" showed all Problem, Approach and Goal dates of 07/13/12, with Goal Time dates of 07/13/12 and 03/04/13, nothing under Evaluation section. Medical record review indicates that Resident #5 has fallen 8 times since she began using the Merry Walker. On 06/05/13 from 11:11 a.m. to 12:40 p.m., Surveyor met with RN G and SW H to discuss the falls that Resident #5 has sustained while in the Merry Walker. Surveyor , RN G and SW H reviewed each Incident Report, discussing what happened, injury or no injury, witnessed or not, interventions put into place and care plan updates. RN G and SW H provided information and documentation through review of hard chart, electronic chart, overflow chart, care plans (most recent copy of 06/05/13 showing updates), etc. The following information was gathered: ~06/06/12 Nurses Notes read in part: "Trying merry walker with resident. Resident did well with merry walker this shift. Team Leader reports that resident attempted to crawl underneath merry walker and did scoot on her bottom to attempt to exit merry walker." ~06/07/12 Nurses Notes read in part: "Assessment for Use - Merry Walker; Benefits/Purpose: Enable better sitting balance and positioning, prevent sliding/scooting out of chair, comfort/security; Alternatives: 1:1 family/volunteer, safe footwear, medication, behavior intervention, safety instruction/use of assistive devices, device appropriate safety. Plan: Device appropriate; Teaching done: safety equipment use; Comments: (Resident #5) has had changes in her behaviors for which med (medication) changes have been made. She is a fall risk and in perpetual motion. Team felt the merry walker would be the most appropriate device to allow her continuing access to her own body and enhance the safety of self and others." ~Fall #1: 06/08/12 at 3:30 p.m.: Incident Report read in part: "Fall without injury - in her merry walker and entered other resident's room, found down, exited merry walker on her own as seen by residents of room 219." Provider Communication report read in part: "Found on floor. No injury." This report also included vital signs; no other information regarding incident. Surveyor asked RN G if an intervention was put into place. RN G stated, "None that I can see; don't see anything in the nurses notes; she was already on 30 minute observations and two-hour toileting and walk to dine." Surveyor asked RN G and SW H if they could see where the care plan was updated with any new interventions, and they stated they could not. ~06/11/12 Physician's Telephone Order read: "May use merry walker if needed for safety." Surveyor asked RN G if an initial OT/PT assessment was completed prior to Resident #5 using the Merry Walker. RN G stated, "None that I see." ~Fall #2: 06/26/12 at 2:30 p.m.: Incident Report read in part: "Fall without injury - resident was in merry walker and had turned around and was facing the seat. Fall was witnessed and resident had a slow fall and did not hit her head per witnesses." Employee Incident Summary read in part: "Location: by mechanical equipment door and laundry door." Incident type: Fall, Witnessed. Is the resident on scheduled observation? No." Provider Communication Form read in part: "(Resident #5) had a fall today. No injuries she did not hit her head." Surveyor asked if there were interventions put into place. RN G stated, "Nothing for the follow up in assessment and no new orders." SW H confirmed she saw no updates to the care plan. ~Fall #3: 07/07/12 at 9:15 a.m.: Incident Report read in part: "Controlled fall, resident transferring into merrywalker from 200 wing bathroom." Employee Incident Summary read in part: Controlled Fall, Witnessed. "I was trying to put her back into her mary (sic) walker after toileting her after breakfast. We started into the walker and didn't step into the walker and just turn (sic) and sat down missing the chair. I had a hold of her at this point I helped her down to the floor." New intervention was use two to transfer and the care plan was updated. ~Fall #4: 08/03/12 at 8:30 a.m.: Incident Report read in part: "Fall without injury in sunroom. Turned around in merry walker and was facing the seat. Appears resident was attempting to sit down, but was facing the wrong way. Resident was sitting on her bottom on the floor. Employee Incident Summary read in part: Controlled Fall, Found. Is the resident on scheduled observation? nothing was circled. "When I turned from the med cart found resident sitting backwards so she was facing the sit (sic) and sitting on strap." Provider Communication Form read in part: "(Resident #5) had a fall this morning. It appears she attempted to sit down, but was facing the seat. She landed on her bottom. No injury noted." RN G stated the intervention was 15 minute observations per the observation sheets; RN G stated she did not see any updates to the care plan. Surveyor asked if there may have been a temporary care plan. RN G stated, "Not that I see." ~Fall #5: 08/06/12 at 8:45 a.m.: Incident Report read in part: "Fall without injury. Res (resident) found in Room 208 A side of room near window-Res is laying on her back beneath the Merry Walker-The belt that goes btw (between) res legs was still fastened and res right leg was up on the belt-res confused per usual and unable to answer what happened to cause fall. Resident currently on 15 min (minute) obs (observations) will cont (continue) this." The Employee Incident Summary read in part: "Location of incident: (2 other resident names) room. Fall was circled, Found was circled. Is resident on scheduled observation? Yes was circled. Time they were last checked: 7:45." 08/06/12 Physician telephone order read: "PT/OT eval re: positioning/safety in Merry Walker." 08/08/12 PT evaluation was completed. The Merry Walker Assessment read in part: "Recommendations: Discussed with (RN G) and (OT, RD). Pt (patient) does not meet criteria for safe use of Merry Walker at this time. Further advise to discuss risk and benefits with POA (power of attorney). Needs SBA >supervision for safety." The following items were checked yes: "wanders, agitation/attempts to climb out, steers with difficulty around other residents, history of falls from Merry Walker, perceptual deficits - hallucinations, motor deficits - mild weakness, meds affecting ambulation - psychotropics, cognitive level <4.4; sitting balance-good, standing balance-good, coordination-fair, problem solving/motor planning-poor, functional extremity use-good." PT Plan of Care read in part: "Pt (patient) amb (ambulates) throughout facility reqs (requires) SBA to supervision for safety awareness; negotiating obstacles; and verbal cues for direction." Following Surveyor 's review of the above document, RN G stated, "That's when we have our ID (interdisciplinary) Team meeting." 08/09/12 Social Service Note read in part: "The interdisciplinary team (IDT) met to discuss the safety of (Resident #5) in merrywalker verses (sic) wheel chair. After much discussion, it was felt that the merrywalker is the safest and most appropriate for (Resident #5) to use. It will continue to allow her to ambulate and it promotes more independence with ambulation than a wheel chair with an alarm. It does enhance her quality of life. Writer called and spoke to (Resident #5's daughter) to involve her in the interdisciplinary decision. Educated (Resident #5's daughter) on risks of equipment and she stated that she felt that the merrywalker was the safest for (Resident #5) and stated that she knew that there is the likelihood that (Resident #5) will fall again and she is comfortable with her decision with the IDT. She understands that (Resident #5) does have times when she is not in the merrywalker such as meal times and when staff are walking her. Staff are having her eat in the dining room for breakfast and the activity room for other meals as a preventative measure to help promote safety and fall prevention." 08/09/12 Nurses Note read in part: "Assessment for use: Merry Walker; Benefits/Purpose: Prevent sliding/scooting out of chair, Comfort/security; Alternatives: attempted PT/OT eval, 1:1 family/volunteer, Medication, Behavior intervention, Restorative program-strengtheng (sic), Continence program, shoes/non-skid socks worn to bed, resident/family education: Daughter (name) updated to continued use of Merry Walker and is fine with use for res safety and cont (continued) ability to ambulate d/t (due to) use of Merry Walker. Plan: Device appropriate per team decision (inter-department). Comments: Res is not safe in either standard w/c (wheelchair) or Merry Walker-However decision made by interdepartmental team to continue using Merry Walker d/t it allows res to cont to be ambulatory throughout facility and not restrict movement as standard w/c would-res cont to be on 2 hour toileting schedule and removed from Merry Walker for all meals-res also cont on FMP (functional maintenance program) for ambulation with staff-daughter (name) is agreeable to cont to keep res in Merry Walker at this time and understands risks." (Emphasis added.) RN G stated the intervention was to have Resident #5 eat in the dining room or activity room to increase supervision, versus eating in the 200 hall dining room. SW G confirmed the care plan was not updated with new intervention. ~08/16/12 Activity Progress Note read in part: "Quarterly Review: (Resident #5) continues to move about indep (independently) in a merry walker. She is in motion a good share of the day wandering up and down halls without purpose or direction. She has no attention span and is easily redirected... She has no sense of where she is or what she is doing and requires a great deal of patience and direction." ~11/19/12 Activity Progress Note read in part: "She lacks direction, purpose or any sense of safety..." ~Fall #6: 02/14/13 at 8:10 a.m.: Incident Report read in part: "Fall with injury observed on floor. Res wheel of Merry Walker potentially got caught in EZ stand and Merry Walker tipped over. Res found down in 200 hallway-Merry Walker tipped over and laying on it's (sic) front res legs are still in Merry Walker-bruise/bump starting to form to right forehead-res appears comfortable and no visible pain sx (symptoms) noted-(Resident daughter) did return call and states that she is fine with sending res to ER." Employee Incident Summary read in part: "Location of incident: In the middle of the hallway on 200 wing. Fall, Found. Is the resident on scheduled observation? No. I found the resident on the floor with her marywalker (sic) tiped (sic) over with her. The walker wheel apeared (sic) to be caught in the ez-stand. The resident was on her side and was wearing the posis (sic) she was also holding her head." 02/14/13 Physician's Telephone Order read: "Send to ER for evaluation." 02/14/13 at 1:12 p.m. Nurses Note states Resident #5 returned from ER with no new orders, head CT was negative, x-rays of neck were negative and resident was up in Merry Walker. 02/14/13 A Physician's Telephone Order read: "PT/OT to eval + tx (and treat) as indicated for safety, tx (treatment), balance." 02/14/13 PT Merry Walker Assessment read in part: "Recommendations: Recommend pt have SBA>supervision for safe use of Merry Walker." The following items were checked yes: "wanders, agitation/attempts to climb out, steers around other residents inconsistencies, history of falls, perceptual deficits - hallucinations, meds affecting ambulation - psychotropics, cognitive level <4.4; sitting balance-good, standing balance-good, coordination-fair+, problem solving/motor planning-poor, functional extremity use-good." RN G stated there are nurse ' s notes that state her daughter wants her to remain in the Merry Walker. RN G and SW H confirmed no new interventions were added to the care plan. Nurse ' s note at 1:14 p.m. PT/OT order-(daughter) states that she "loves that she is in the Merry Walker states that it gives her mom a chance (sic) to cont to be ambulatory and safe-(daughter) states that she feels that her mother should remain in Merry Walker-she states that she has not had a fall for so long, accidents happen, as long as she's ok, I'm ok. " 02/15/13 Nurses Note read in part:" Resident is up and about in her merry walker this afternoon, when asked about pain resident rubbed her right forehead where she hit it yesterday during fall." ~02/20/13 Activity Progress Note: Quarterly Progress Note: Read in part: "(Resident #5) is up and about walking ad lib around the building in her merry walker most of ea (each) day. She recently had an accident with it, but it continues to be her best option for maintaining mobility and independence. She is easily redirected when she wanders into other res rooms or a tight spot." ~03/03/13 Nurses Note read in part: "Assessment for use-Merry Walker. Benefits: Enable ambulation and movement throughout the facility independently. Alternatives: Attempted PT/OT eval, 1:1 family/volunteer, lower bed/chair, safe footwear, medication, behavior intervention, safety instruction/use of assistive devices, continence program, shoes/non-skid socks worn to bed, resident/family education: Have spoken with daughter (name) numerous times regarding Merry Walker and (daughter) continues to agree that Merry Walker appropriate. Plan: Device appropriate." ~05/10/13 Activity Progress Note read in part: "This week she has been in almost constant motion knocking into tables, walls & doorways." ~05/22/13 Activity Progress Note read in part: "Quarterly Review: (Resident #5) is up moving about most of each day in her merrywalker... Due to her dementia she is unaware of where she is, what she is doing, or who is around her so she does cause (sic) disturb others unintentionally fairly frequently... Usually she is unaware of and indifferent to what is going on around her." ~Fall #7: 05/27/13 at 10:00 a.m.: Incident Report read in part: "Fall with injury, resident tipped over Merry Walker. Activity at the time: standing in the Merry Walker. Witnessed fall by team leader (team leader's initials) - appears res has gotten merry walker stuck in door way and tipped over backwards-res does have a large hematoma to back of head with bleeding-pressure dressing applied and sent to ER for evaluation. Change in level of consciousness res slightly more lethargic than normal." Employee Incident Summary read in part: "Location of Incident: 200 wing hall; Incident type: Fall, Witnessed; Is resident on scheduled observations? No. Merry Walker was sideway in doorway of room 209, resident fell backward from that spot. Resident landed completely on her back/head. We ran down to her & she was still conscious, did have a large hematoma & bleeding from back of the head." 05/27/13 Physician Telephone Order read in part: "Send res to ER for eval." 05/27/13 CT results read in part: "There is a scalp hematoma to the right posterior region. No skull fracture is seen." 05/27/13 1:33 p.m. Nurses Note read in part: "Res returned from ER-no new orders at this time-CT negative-daughter (name) updated-decision made per interdisciplinary team to continue to have res in merry walker to maintain mobility status and ambulatory status-daughter (name) agrees with continuing to have res is (sic) Merry Walker as it 'gives her freedom to move around' (name) updated to the risks of continuing to use Merry Walker and is fine with this decision-res is up ambulating throughout hallways in Merry Walker at this time." 05/27/13 3:44 p.m. Nurses Note read in part: "Hematoma to right back of head, res also found with large swollen firm area on right butt cheek with a 5 cm by 8 cm bruise. No c/o (complaint of) pain but did c/o pain in her brain later to med nurse and was given Tylenol... Actions: Continue to observe. Comment: Daughter (name) would like her to cont. (continue) to use the merry walker, feels this is the safest and least restrictive option place for her even after she had the incident today." 05/28/13 6:29 a.m. Nurses Note read in part: "...edema swelling noted on right buttock, with deep bruising scrape on back of head." 05/28/13 10:16 a.m. Nurses Note read in part: "This am resident self propelling self in merri walker up/down hallways per usual. Noted to be leaning to L (left), unsure whether she is having difficulty bearing weight on R buttock/hip. Was pleasant, participated in neurochecks with pleasant confusion per usual. Later noted by staff not to want to open eyes, appears sleepy. Resident was laid down on bed mid morning which is unusual, feel asleep but awakens easily. Grimaces with pain with turning, rubbing R hip..." 05/28/13 10:26 a.m. Nurses Note read in part: "...Has approx (approximate) 8 cm x 8 cm purple bruise on R buttock. Skin beneath firm. Resident states "ow" and rubs hip buttock when turning. Does not sit well on R buttock." 05/28/13 Physician's Telephone Order read in part: "R (with circle around meaning right) pelvis/hip x-ray. Repeat CT scan, O (with line through it meaning without/no) contrast for A in LOC." 05/28/13 CT results read in part: "There is a large right posterior scalp hematoma similar to yesterday's exam. There is no evidence of underlying intracranial hemorrhage, mass or infarct.... No skull fracture. 05/28/13 right hip x-ray results read in part: "No fracture or dislocation is demonstrated." 05/28/13 1:30 p.m. Nurses Note read in part: "Alert, arrived back from ER after having a head CT and hip and pelvic x-rays. Placed in her Merry Walker after she began crawling out of her bed. Ambulating up and down the halls per usual." 05/28/13 6:58 p.m. Nurses Note read in part: "... seems to want to go in the other direction with her walker at times rather than facing forward, will face to the side and try to propel forward. Writer only noted resident doing this a time or two, but did mention it to resident's daughter, (name) when she was here visiting this afternoon." 05/29/13 9:10 a.m. Nurses Note read in part: "res is up in Merry Walker throughout hallways as usual-does appear more lethargic today-attempted to lay res down in bed and she got right back up and in Merry Walker-pale-cont with large hematoma to back of head from previous fall and large hematoma to right buttock from fall also-will update Dr. (name) to res status today." 05/29/13 5:11 p.m. Nurses Note read in part: "Resident sitting on chair portion of Merry-Walker in the sunroom, wasn't too long before resident was back-up, self-propelling Merry-Walker in the halls this afternoon. Resident denies any pain anywhere, including to the hematoma located on the back right-side portion of her head, nor to the back of right-leg where bruise is located-when asked specifically about it. Both injuries occurred from recent fall... Resident is pale and tired looking in appearance..." 05/29/13 5:20 p.m. Nurses Note read in part: "Bruise/hematoma right back-side of head, mid-line length 5.5 cm x width 6.5 cm. Raised and circular in appearance, dark-pink bruising in center and throughout, with dark-purple bruising surrounding." 05/29/13 5:26 p.m. Nurses Note read in part: "Resident is pale this afternoon, looks tired in appearance..." 05/30/13 Physician's Telephone Order: "PT/OT eval. Tramadol 25 mg q (every) 6 (degree sign meaning hours) PRN (as needed) - pain." 06/01/13 PT Merry Walker Assessment read in part: "Recommendations: Pt requires SBA or close supervision for safe use of Merry Walker. Multifactoral risk for recurrent falls." The following items were checked yes: "wanders, agitation/attempts to climb out, history of falls, perceptual deficits, meds affecting ambulation, cognitive level <4.4; sitting balance-good, standing balance-good, coordination-fair, problem solving/motor planning-poor, distal sensation-good-appears intact, functional extremity use-good." Tinetti (performance oriented mobility assessment) score = 6/28; meaning High risk for falls (anything less than or equal to 18 is high). Therapy Care Plan: SBA to close supervision if Merry Walker is utilized..." RN G and SW H confirmed no new interventions were added to the care plan following 05/27/13 fall. ~Fall #8: 06/01/13 at 9:30 a.m.: Incident Report read in part: "fall without injury observed on floor, dining room, slid from chair, found down. Shoes off, had R shoe off and shoe was found some distance away. Had both socks on. Belt that runs between legs and fastens to merriwalker (sic) was unclasped, allowing resident to slid (sic) out merriwalker (sic) onto floor. CNA (name) stated belt was fastened when toileting cares given approx 2 hours prior. Provider Communication For Routine/Non-Immediate Concerns read in part: "Had fall this am, appears to have slid out of merriwalker (sic). Found in semi sitting position. PERRLA (pupils equal round reactive to light and accommodation) otherwise O (with a line through meaning not) cooperative (c with line over meaning with) neuro checks (check mark). Has bruising on coccyx, gluteal fold and R buttocks but I believe this is from a bad fall on 5/27 in which she sustained severe hematoma on back of head, bruising on R buttock. She head CT scan on 5/27 & again on 5/28, pelvic & R hip xray on 5/28 - all negative. She bears weight today w/out obvious pain." (Note: On 6/10/13 at 12:43 p.m, a nurse ' s note read, " Skin Problems: Has abrasion/bruise present in past 7 days. Location: Back of head-right side. Length: 4 cm Width: 4 cm. Location: Right side of neck. Length: 6 cm Width 3 cm. This bruise is barely visible at this time-light yellow in color. Location: Right hip. Length: 22 cm Width: 8 cm Bruise varies in colors-peppered in places-light purple to yellow-old resolving bruise-Res has no pain to area with palpation. Location: Low back. Length: 6 cm Width: 3 cm This bruise also light yellow-small light purple peppered bruising to center-Res denies pain with palpation. " ) RN G stated the intervention following the fall on 5/27/13 was 30 minute observations, but she had been on that since June 2012 when started in the Merry Walker. She further stated staff were informed to make sure the seat belt was fastened. The care plan was updated on 06/03/13 (2 days after the fall) to "30 min obs - check for strap placement btwn legs." At the end of the meeting with RN G and SW H, Surveyor asked if there was anything else, any additional information. They stated there was not. Surveyor stated if there was any additional information they thought would be helpful to please share it. On 06/06/13 at 8:35 a.m., Surveyor talked to Resident #5's daughter via telephone call. Surveyor asked the daughter if she was aware of the number and times of Resident #5's falls involving the Merry Walker; 8 falls with 6 of them being between the hours of 8:10 a.m. and 10:00 a.m. She stated she is notified of every fall but would have guessed 6 or 7. Surveyor asked the daughter if she was aware of PT's recommendations. She stated she knew she went to PT. Surveyor explained PT's recommendations regarding SBA, increased supervision to keep Resident #5 safe. Surveyor asked if she was against the SBA, increased supervision. She stated, "No, but if they can't provide supervision then what, does the Merry Walker go away?" Surveyor explained the facility has to ensure that Resident #5 receives adequate supervision to prevent accidents. The daughter stated she understood, and that Surveyor made it very clear in the meeting on 06/05/13, that it was not the Surveyor's intention to take away Resident #5's Merry Walker. On 06/06/13 at 8:30 a.m., Surveyor met with PT I. Surveyor informed PT I of the number of falls Resident #5 has had involving the Merry Walker. PT I stated she was not aware there were that many. PT I stated she was very concerned for Resident #5 and confirmed her recommendations have been SBA or close supervision. PT I stated close supervision means within arm's length. PT I stated line of sight supervision is not enough to keep Resident #5 safe. PT I further stated, "I stand by my recommendations." On 06/10/13 at 10:43 a.m., Surveyor met with PT I regarding the definition of "line-in sight". PT I stated, "Stand by assistance within reach for balance and line-in sight, it's both, not one or the other, they have to go hand in hand." On 06/06/13 at 3:29 p.m., when Surveyor questioned DON and NHA on providing the increased supervision per PT recommendations, DON stated, "Can't anticipate one time." On 06/04/13 at 8:55 a.m., Surveyor observed Certified Nursing Assistants (CNAs) J and K transfer Resident #5 to the toilet. Surveyor noted a large bruise on Resident #5's right back thigh and hip area. Resident #5 stated something, and CNA J stated she knew it hurt. Upon further questioning, Surveyor observed a large hematoma to the right back side of the head, a bruise on the right side of the neck and a large bruise to the right coccyx, buttock, hip, back thigh area. Staff reported this was from a recent fall out of the Merry Walker. On 06/04/13 at 3:30 p.m., Surveyor observed Resident #5 in the 300 hallway standing up in the Merry Walker touching items on the housekeeper's cart which was in the doorway of another resident's room. A staff member walked by, looked at Resident #5 and continued down the hallway. Resident #5 then began walking in the Merry Walker with her hands on the side bar, facing the side of the Merry Walker and walking with it sideways down the hall independently. There was no staff supervision of the resident. On 06/06/13 at 3:15 p.m., DON informed Surveyor there had been no policy and procedure on the use of a Merry Walker. The facility, however, had developed a policy and procedure titled, "Use of a Merry Walker" on 06/04/13, which read in part: Purpose: To maintain safety and mobility for residents who are physically unstable without the use of this adaptive device. Policy: It is the policy of Vernon Manor to maintain the highest practical level of function for all residents. This may be done through the use of a piece of equipment called a merry walker, which is a PVC framed ambulation device that provides stability for residents with poor balance. Procedure: -A merry walker may be considered for use with a resident that has documented poor balance or is at risk of falling. -Before initiating use, the resident should be evaluated by therapy to assess their appropriateness for this piece of equipment. -Upon implementation, the resident should be monitored closely as there is an adjustment period of familiarization. This adjustment period may be different for each individual. -The continued appropriateness and use of this equipment should be made periodically decided by the interdisciplinary team. Family and resident involvement will always be considered. On 06/10/13, Surveyor received a copy of Facility policy and procedure titled, "Accident/Incident" with a written date of 03/26/07, Updated date of 05/17/11 and another updated date of May 2013. It read in part: "Policy: It is the policy of Vernon Manor that we will attempt to keep all residents safe and free of injury. We will do our best to keep the environment free of accident hazards, and provide adequate supervision and assistive devices to prevent accidents and injuries. For the purpose of this facility, an accident or incident is an unexpected, unintended event that can cause a resident bodily injury. It does not include adverse outcomes of treatment or care such as drug side effects of reactions. Procedure: All residents that reside at Vernon Manor will have a thorough assessment before a restraint is considered or used. There will be interdisciplinary input and routine follow up to make sure the continued use of restraint is appropriate. In the event that an accident/incident does occur, the following measures will be taken to investigate its cause and determine a plan to prevent reoccurrence. -Implement any immediate changes necessary to prevent a similar accident. -Revise the care plan and communicate any changes in the care plan to direct care staff. Failure to provide the supervision that Resident #5 required to prevent falls and to prevent the potential for serious injury created a finding of immediate jeopardy. According to " For Elderly, Even Short Falls Can Be Deadly: Ad

UNCORRECTED AT VERIFICATION VISIT (Previous Survey Event ID: 7L1011) Based on interview, record review and policy review the facility did not ensure the resident ' s environment remained as free of accident hazards as possible for one of five residents. Resident #7 had a fall on 07/16/13 and again on 07/19/13. The root-cause of each fall was not assessed and no new fall prevention interventions were put into place after each fall. This is evidenced by: The facility policy for Accident/Incidents was reviewed by Surveyor on 08/19/13 at 03:30 p.m. The policy written on 03/26/07 and last updated in May 2013 reads, in part, "In the event an accident/incident does occur, the following measures will be taken to investigate its cause and determine a plan to prevent reoccurrence. -Assess the resident for injury and provide for the resident's immediate safety. -Implement any immediate changes necessary to prevent a similar accident. -The accident will be reviewed by the interdisciplinary team during each AM report Monday through Friday, with any additional measure needed to insure safety being identified and implemented then." Surveyor reviewed the facility policy titled, "Use of ? and ? hour observation," which was written in February 2006 and last reviewed in June 2013. The policy reads, in part: -Policy: Vernon Manor staff will implement the use of ? hr. (hour) and ? hr. observation as a means of observing residents in need of closer monitoring -Procedure: The interdisciplinary team will decide which time frame is appropriate if possible; however, if an event occurs after normal business hours, the nurse in charge will make a decision she feels is appropriate until it can be discussed by the team. Situations necessitating the use of ? hour observation are as follows: ~Behavior which is deemed abnormal, unsafe or threatening for a specific resident, such as: Inappropriate self-exit from w/c (wheelchair) or bed. Removal of a monitoring device or alarm. Behavior deemed dangerous to the resident or other residents. Initiation of any/all physical restraints. Reduction of discontinuation of restraints or monitoring devices or alarms. Change in dose of anti-anxiety, hypnotic, anti-psychotic medications. Attempted unauthorized exit or exploration outside the building. -This monitoring will continue for 72 hours, after which time it will be reevaluated and reduced, discontinued or moved to a more term form of monitoring as behavior monitoring if indicated." The policy does not indicate ? and ? hour observations should be used as a fall prevention measure after a fall has occurred. On 08/20/13, Surveyor reviewed Resident's #7 medical record. A Fall Assessment: Predisposition For Falling form was completed by the facility on 07/11/13. Resident #7 scored 14 points, which a score of ten or above indicates Resident #7 presented a high risk for falling. Surveyor also reviewed Resident #7's "PT (Physical Therapy)-Therapist Progress and Discharge Summary" report, which was dated 07/12/13. The form reads, in part, "Impact on Burden of Care/Daily Life: Pt reqs 24/7 supervision/assist. Precautions: Fall risk secondary to impaired cognition with poor judgment; lack of safety awareness and standing balance impairment; HOH." On 08/19/13, Surveyor reviewed Resident #7's Incident Report from 07/16/13. Resident #7 had a fall on 07/16/13 at 09:30 p.m., in which she was walking throughout the facility, lost her balance and fell in the clean linen room. The Incident Report reads in part, under "Description of Events: resident has her socks and shoes on, she is known to lose her balance. Resident had been in the nurses station 5 minutes earlier in her w/c (wheelchair) her w/c was found in the nurses station with the alarm reset, it had sounded earlier. MEDICAL CONDITIONS: chronic recurrent illness dementia. Actions/Investigation/Teaching: continue to observe, placed on ? hour obs when resident is awake." The nurses notes attached to the Incident Report, dated 07/17/13 at 10:10 p.m. read, in part, "ACTIONS: continue to observe. TEACHING DONE: Use call light for assistance when she needs to get up, ask staff for assistance. Resident stated understanding to this, but has dementia-short-term memory is impaired." Resident #7's Falls Follow Up form states, in part, "Intervention put in place at time of fall: Was on obs (observation) 30 minutes-increased obs to 15 minutes. IDT follow up to intervention: (was left blank)." Surveyor noted this form was initialed by the IDT. No date was indicated on the form as to when these initials were added. Resident #7 had an un-witnessed fall on 07/19/13 at 07:00 p.m. The Incident Report reads, in part, "ACTIVITY AT THE TIME: sitting in her wheelchair-sleeping and fell out or transferring to another chair. POSSIBLE CAUSE: fell asleep and slid from chair/transferred without staff assist. OTHER: Resident had told aide she fell asleep and slid out of her chair. Resident also told nurse she was trying to get into the other chair a high back chair in sunroom-without assistance from staff. COMMENT: ...She was last checked on at 1845 (06:45 p.m.) and was not asleep at time. Actions/Investigation/Teaching: pain assessed placed on observations (specify) placed on observation (specify) 15 minutes obs for safety." Surveyor reviewed Resident #7's Falls Follow Up from the 07/19/13 fall. The sections of "Intervention put in place at time of fall" and "IDT follow up to intervention" were both blank. There were no staff initials or signatures at the bottom of the form. Surveyor interviewed the DON on 08/20/13 at approximately 08:35 a.m. regarding Resident #7's falls. During the above interview with the DON, Surveyor asked about the Falls Follow Up form for Resident #7's fall on 07/19/13. The DON stated the IDT "failed to send the sheet around for signatures." Surveyor asked if the DON remembered discussing Resident #7's fall from 07/19/13, to which the DON stated she didn't remember discussing it and she thought she was on vacation from July 15th through July 19th. The DON stated the Falls Follow Up form is discussed the next business day in the morning IDT meeting. During the interview the NHA stated the facility is "slowly weaning away from (observations)." He also stated "They are great, but we only have so many staff hours" in order to complete the observations. The NHA stated he remembers the IDT discussed "more" about Resident #11's fall and indicated he would check on additional information for Surveyor . At approximately 10:50 a.m., the NHA provided Surveyor with a sheet of paper with 28 different, potential interventions other than 15 or 30-minute observations after a fall. The NHA stated the facility has discontinued the use of observations as of 08/19/13 and are moving forward with the other interventions, which were listed on this form. The NHA also stated, "This (form) is a work in progress" and the IDT has been discussing the other interventions on this form during the last couple of months.

Based on the comprehensive assessment of a resident, the facility must ensure a resident having pressure sore receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. Based on observations, interviews and record reviews the facility did not ensure preventative pressure ulcer care for 1 of 4 resident s reviewed with pressure ulcers. Resident #9 has an un-stageable pressure ulcer on her right heel; the facility did not ensure pressure was off loaded from Resident #1's heels while she was in her wheelchair; nor was a pressure reduction cushion in resident 's wheelchair. This is evidenced by: The Minimum Data Set ((MDS) dated [DATE] section on skin identifies Resident #9 has 1 unhealed pressure ulcer, marked as an un-stageable pressure ulcer with suspected deep tissue injury. It also identifies Resident #9 is at high risk to develop pressure ulcers. The skin and ulcer treatments identified are: pressure reducing device for chair and bed, turning/repositioning program, nutrition or hydration intervention, pressure ulcer care and application of dressings to feet. The most recent Braden Scale for pressure ulcer risk assessment was completed on 05/30/13 with a score of 16, meaning Resident #9 is at risk for pressure ulcers. The nursing care plan has the problem Potential for Impairment of skin integrity, dated 04/06/13, nonstageable pressure area to right heel. The approaches include in part: 04/06/13- float heels with repositioning, use pressure relieving device in bed, 04/09/13-dry gauze to right heel to protect blister, rest Q mattress, minimize pressure on bony prominences. The Certified Nursing Assistant care plan has in part: Dressing-total care, Bed Mobility- Reposition every 2 hours, Transfer-Needs assist 2, mechanical lift, Supportive- Heel elevate in bed to float heels, Paralysis-right side, Communication-non-verbal at times. The nurse ' s notes on skin documentation were reviewed from 07/12/13 to present and includes in part: 07/15/13 - " Unstageable - wound bed covered by slough and/or eschar ...Area 1: (215) Right heel ...Healing progress: no change, length 2.5 cm x width 3 cm ... " 07/22/13- " Unstageable-wound bed covered by slough and/or eschar ...length 3 cm x width 2.5 cm ... " 07/29/13- " Unstageable- suspected deep tissue injury in evolution. Area 1- Right heel ...length 3 cm x width 2 cm ... " 08/05/13- " Unstageable ...Area Right heel ...length 2 cm x width 2.5 cm ... " 08/14/13- " Unstageable- wound bed covered by slough and/or eschar. Area 1-(215) Right heel ...Healing progress- no change. Length 2.1 cm x 1.4 cm width ... " Surveyor made the following observations of Resident #9: 08/19/13 at 12:45 p.m. Resident #9 was sitting in her wheelchair in her room with her tray table in front of her. Resident #9 was wearing pink slipper socks, with her right heel resting directly on the metal bar at the base of the tray table. The wheelchair was observed to have no cushion in place. 08/19/13 at 3:20 p.m. CNA FF and CNA HH assisted Resident#9 with personal cares. Resident #9 was positioned on her left side; a reddened area was noted by her coccyx. CNA FF touched the area; the color went from red to white, then back to red. CNA FF indicated the red area may be from the incontinent product. Resident #9 was transferred using a Hoyer lift into the wheelchair, which did not have a cushion in the seat. Resident #9 ' s feet were placed directly on the metal footrests of the wheelchair. Resident #9 was wearing only the pink slipper socks on her feet. The right heel was directly on the footrest. Resident #9 was then brought to the dining area on the 300 hall to have some juice and left in this position. On 08/20/13 at 7:50 a.m. CNA II and CNA GG assisted Resident #9 into the wheelchair using the Hoyer lift. Again there was not a cushion in the wheelchair. The footrests were put in place by CNA II and then Resident #9 ' s feet were placed directly on the metal footrests, wearing only the pink slipper socks. Resident #9 was taken to the dining area and left in this position. On 08/20/13 a t 8:05 a.m. Surveyor went to get Licensed Practical Nurse (LPN) V to share the observation of the right heel. Surveyor asked if the location of the heel ulcer was in contact with the metal foot rest. LPN V said, " Yes, I see what you are saying, she should have heel protectors on when she is in the wheelchair, I will have someone get them. " On 08/20/13 at 8:30 a.m. Surveyor interviewed CNA II to ask if Resident #9 had a cushion for her wheelchair. CNA II stated, " No she has not had one she could recall. " Surveyor asked how long CNA II had worked at the facility. CNA II indicated about 3 years. Surveyor interviewed Registered Nurse (RN) JJ on 08/20/13 at 9:55 a.m. RN JJ completed the MDS for Resident #9. Surveyor asked why the MDS states Resident #9 is at high risk for pressure ulcers and has a cushion in her wheelchair, yet no cushion was observed. RN JJ stated, " I know she has one, I have the staff looking for it. " Surveyor asked who updates the care plan to include information on pressure relief. RN JJ indicated any nurse could update the care plan and at the quarterly review RN JJ reviews it. Surveyor asked if Resident #9s heels are considered to be at high risk for additional breakdown. RN JJ stated, " Yes. " Surveyor asked if the care plan had any information about the cushion for the wheelchair or for pressure relief for Resident #9 ' s heels when she is up in the wheelchair. RN JJ reviewed the care plan and stated, " No, this information is not on the CNA care plan or nursing care plan. I guess we need to be more specific on the care plan. " Surveyor asked if there has been any pressure relief for Resident #9's heels when up in the wheelchair. RN JJ stated, " I did not think about that, just when she was in bed. " On 08/20/13 at 11:25 a.m. Surveyor interviewed the Nursing Home Administrator (NHA) and the Director of Nursing (DON) about the concerns for Resident #9.

Based on observation, staff interview and record review, the facility did not ensure 2(Resident #8, Resident #9) of 4 residents reviewed for pressure ulcer risk in a total sample of 15 residents and 1 of 2 wound care observations received the necessary treatment and services to prevent pressure ulcers from developing. Resident #8 had a history of [REDACTED]. Resident #8 currently has a Stage 3 pressure ulcer on her left anterior inner ankle which was first assessed on [DATE] according to the nurse's notes dated [DATE] at 10:46 a.m.. Resident #9 was readmitted to the facility on [DATE] noted to have no pressure ulcers; on [DATE] a right heel blister was noted. The facility did not document assessments, measurements, staging until [DATE] and no new interventions were implemented. Resident #8 received care of her pressure ulcer from a nurse who did not wash her hands after cleansing the wound, and before applying a clean dressing. This is evidenced by: The facility's policy and procedure for the treatment and prevention of skin breakdown read in part: B. Identification of causal factors and clinical conditions which indicate high risk for pressure ulcer and skin breakdown.... Potential Risk Conditions....decreased mobility or bedfast...cognitive loss, circulatory disease ([MEDICAL CONDITIONS], Chronic stasis)...end stage/terminal illness. III. Pressure Ulcer Treatment... 2. Implement care plan with appropriate interventions. 3. Initiation of a weekly wound documentation progress in ECS with the onset of skin condition, which will include: type of wound, location date, stage, length, width and depth; wound base description, wound edge description and if present: drainage, odor, undermining, tunneling, and/or pain. The weekly wound documentation progress sheet should only have one wound per form... 4. When a pressure ulcer is present, daily monitoring (with accompanying documentation, when a complication or change is identified)... Resident # 8 had been admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #8 had a history of [REDACTED]. Resident #8 currently has a Stage 3 pressure ulcer on her left anterior inner ankle which was first assessed on [DATE]. According to the nurse's notes dated [DATE] at 10:46 a.m. which read: "Pressure Ulcer: Full thickness of skin lost, exposing the SubQ tissues-presents as a deep crate (Pressure stage 3) Location: left anterior inner ankle Length: .7 cm WIDTH: .7 cm Depth: 0.2 cm Surface Area (LxW): 0.3 -0.6 cm sq Tissue Type: slough Wound Tissue: yellow/edges pink Drainage: none present Surrounding Tissue: intact. No documentation noted before this date to show skin assessments to left anterior inner ankle. Nurse's notes dated: [DATE] at 01:40 a.m. read in part as follows: "PRN Med Given: [MEDICATION NAME] HCL 5 mg (milligram) tablet given for pain level before med 7 ankle." No documentation of an assessment of the ankle was provided with a date prior to [DATE]. The [DATE] CAA's (Care Area Assessment) indicated resident #8 requires assistance with bed mobility with evaluation showing bed mobility has decreased. The CAA also indicates Resident #8 is "prone to skin breakdown or the development of pressure areas. The pressure area to coccyx has healed but she now has a stage 3 over a bony prominence of her left medial foot, although actual measurements are not great, it is a stage 3 in light of the exact area it inhabits." Resident #8's Plan of Care dated [DATE] read in part as follows: Problem: Impairment of Skin Integrity Related to: Internal factors, weight loss, sensory perception, immobility Manifested by: Pinpoint open area on coccyx. With a undated hand written note that read: Pressure ulcer-stage III to left inner ankle Approach: Nurses: ~ Assess skin condition daily and note any changes, ~Treat as ordered. With an undated hand written note added that read: Treat per wound nurse to ankle ~Monitor use of skin protective devices ~Bandage as appropriate ~Keep clean and dry ~Instruct on the importance of good skin care ~Use lift sheet when moving resident in bed ~Keep linen clean, dry, and wrinkle free ~Change wet linen ~Lotion extremities with cares ~Lotion/massage as needed ~Assist with hygiene and general skin care ~Reposition every two hours ~Minimize pressure on bony prominence's ~Keep skin clean and dry The care plan did not address approaches or what to do if Resident #8 refuses repositioning or how to minimize pressure on bony prominences. On [DATE] the facility completed a PUSH (Pressure Ulcer Scale for Healing, created by the National Pressure Ulcer Advisory Panel) Score of Resident #8's left ankle pressure ulcer. This initial PUSH score was 14. On [DATE] the facility completed a second PUSH score of resident #8's left ankle pressure ulcer, documenting a score of 5, indicating that the pressure ulcer was healing. On [DATE] the facility completed a third PUSH score of Resident #8's left ankle pressure ulcer documenting a score of 5 indicating the pressure ulcer was not healing or worsening after numerous interventions had been implemented. On [DATE] the facility completed a fourth PUSH score of Resident #8's left ankle pressure ulcer, documenting a score of 7 which indicated the pressure ulcer was worsening and showed the length of the area had increased from .50 cm to .80cm , the width of the area had increased from .50 cm to 1.00 cm and the area had increased from .20 cm to .63 cm. On [DATE] at 10:10 a.m. Surveyor interviewed LPN (Licensed Practical Nurse) E regarding Resident #8's left ankle pressure ulcer. LPN E verified she consistently works on the 400 hallway with Resident #8 but RN (Registered Nurse) A measures the wounds on this hallway weekly and documents her findings. LPN E also stated, "I do treatments on the wounds and will measure them occasionally if RN A is off on Tuesdays." LPN E attempted to retrieve documentation from ECS (Electronic Computer System) related to the pressure ulcer date of origin but was unable to obtain. On [DATE] at 11:05 a.m. Surveyor interviewed RN A regarding Resident #8's left ankle pressure ulcer. Surveyor asked RN A to clarify if Resident #8's pressure ulcer on her left ankle was first noted on [DATE] by her. RN A verified she was the one who first assessed it on [DATE] after one of the CNA's brought it to her attention during the residents bath that morning. Surveyor discussed with RN A that according to the documentation the pressure ulcer was first noted on [DATE] at a stage 3 and asked if the area been reported at any time before that. RN A responded, "No I was so surprised when I saw it and thought how could this happen?" Surveyor reviewed Resident #3's skin integrity plan of care with RN A referring to the approach "Nurse--assess skin condition daily and note changes." RN A responded, "The med nurses will look at the residents skin and the CNA's look at the residents skin daily during their bath and will report changes to the med nurses and the RN's." Surveyor asked if their were interventions in place before the pressure ulcer was noted. RN A responded, "She always had heelbos on but they would get twisted off and get up around her ankles. Staff would also turn her every two hours." Surveyor asked RN A about Resident #8's mattress. RN A responded, "She is on a pressure relieving mattress that she has been on since admission but will refuse to be repositioned at times and likes to lay on her right side." Surveyor asked if air mattresses were ever implemented related to pressure relieving. RN A responded, "We do not use air mattresses here, only if a resident is on a hospice program for example and hospice provides the air mattress." Surveyor asked RN A if other staff are aware of Resident #8's preference to lay on her right side and refusal at times to be repositioned. RN A responded, "Yes, staff is aware of the resident's preference to lay on her right side and because she is contracted she will lay with her left ankle on top of her right ankle." RN A demonstrated this by holding her wrists together at the bony prominence. RN A went on to say,"Staff on the night shift had told me they don't turn Resident #8 if she refuses and I informed them she needs to be repositioned at least every two hours." Surveyor asked when this conversation took place with the night shift staff. RN A responded, "It was after the pressure area had developed." Surveyor asked RN A why she assessed the pressure area as a stage 3 initially. RN A responded, "Because of the location on a bony prominence and how Resident #8 always wanted to lay." Surveyor asked RN A if there was any other information she would like to share related to our conversation. RN A responded, "I want to add we measure the area every Tuesday, we have consulted therapy, we have kept the MD up to date, we have consulted the PA (Physician Assistant) and we have involved a certified wound nurse from AMT." RN A also added, "the area is not as painful as it was when it first developed. Since we have found the area we have added lots of interventions with the biggest one being repositioning and a protein drink." On [DATE] Surveyor asked the DON what Standard of Practice for relieving pressure. The DON responded, "AHCPR." The AHCPR used by the facility state the following: Resources: According to: Summary of the Agency for Health Care Policy and Research (AHCPRClinical Practice Guideline Copyright 1995 - 2010 Tissue Load Management: The goal of load management is to create an environment that enhances soft tissue viability and promotes healing of the pressure ulcer (s). The vigilant use of proper positioning and support surfaces are important. Avoid positioning patients on a pressure ulcer. Do not use donut-type-devices. Use devices like pillows or foam to keep the heels off the bed, keep knees and ankles from touching Maintain the head of the bed at the lowest degree medically necessary. No evidence to show that any one support surface consistently performs better than another. A patient should avoid sitting if he/she has an ulcer on a sitting surface. Move a sitting patient at least once an hour. Resident #9 was readmitted to the facility on [DATE] with current [DIAGNOSES REDACTED]. On [DATE] at 10:10 a.m. Surveyor observed License Practical Nurse (LPN) V provided Resident #9's dressing change to the right heel. The right heel was off loaded with a cushion in bed. The right heel has a large black eschar with dry edges. LPN V cleansed and applied a clean dressing to the right heel. Surveyor reviewed Resident #9's medical record. Resident #9 was readmitted on [DATE] to the facility from the hospital following an [MEDICATION NAME] hemorrhage. The nurses notes date [DATE] general skin condition read in part: ...has a 1 X 0.5 centimeter (cm) bruise to outer aspect of right foot, possibly from a brace she wears at night and while in bed to prevent contractures, will have night shift check brace to make sure it is not causing a pressure area,... PRESSURE ULCERS ON ADMIT: no pressure ulcers on admit...SKIN TREATMENT: receives turning/repositioning program. Continue to observe repositioned. Nurses' note date [DATE] at 10:36 a.m. reads in part: ...Also updated him to intact blister to right heel, asked that we have an order for [REDACTED].new orders received and noted [DATE] for dry dressing and for speech therapy. Surveyor did not find skin assessment, measurement, staging documentation or interventions for Resident #9's right heel ulcer until [DATE]. Nurses' note on [DATE] at 1:21 p.m. reads in part: FOOT PROBLEM/CARE: Has 1 plus foot problem - e.g.. (example) corn, callous, bunion, hammer toe, overlapping toe, pain, structural problem. Has intact black blister on heel of right foot. Measures 3.5 cm long and 5.5 cm wide. Heel is padded with 4 X 5 gauze and wrapped in kling. Floated on pillows. Resident on every 2 hour repositioning schedule. The next skin assessment documented is 13 days later on [DATE] at 11:09 a.m. reads in part: blister that has resolved to black, firm eschar, right heel, length 5 cm, width 3.5 cm, closed, black, firm eschar,...has pressure relieving device for bed. Has heel elevator under bilateral extremities. Nurses' note on [DATE] at 1:22 p.m. skin problems: has hard, black intact blister on right heel. Measures 3.5 cm X 4 cm. Heel remains floated on heel protector, resident remains on repositioning schedule. Foot wrapped in gauze and cling for protection. Nurses' note on [DATE] at 10:14 a.m. reads in part: blister has intact blister to right heel, black with skin over intact. Hardened. Length 4.5 cm, Width 3.5 cm... The next skin assessment documented is 16 days later on [DATE] at 8:37 a.m. reads in part: Has had eschar intact blister to right heel. Length 4 cm, width 3 cm, depth not measurable... Surveyor reviewed Resident #9's care plans that were requested on [DATE] from the Director of Nursing (DON). The care plan problem titled: Potential for impairment of skin integrity reads in part: Approach, [DATE] Nurses --- Develop and monitor turning schedule, two hour repositioning schedule, [DATE] Nurse Aide --- Reposition every two hours, [DATE] Nurse Aide --- Minimize pressure on bony prominences. The care plan did not address when to monitor or assess skin. No new interventions to off load heels after the pressure ulcer was discovered. The facility's policy addressing hand washing, dated [DATE] states, in part, "The use of gloves does not replace hand washing." Surveyor observed Registered Nurse (RN) A provide wound care for the pressure ulcer on Resident #8's left inner ankle on [DATE] beginning at 7:35 a.m. RN A had gloves on when Surveyor entered the room. RN A sprayed wound cleanser on gauze 4 - by - 4s and cleansed the pressure ulcer. She then used gauze to dry the area. RN A removed her gloves, but did not wash or sanitize her hands. She went to the treatment cart, opened a package of gloves and put them on without washing her hands. She brought a tube of a cream containing silver as ordered to the bedside, and applied some to the sore, using a cotton-tipped swab. RN A then applied a border gauze to the pressure ulcer. She removed her gloves but did not wash or sanitize her hands. RN A pulled down Resident #8's [MEDICATION NAME], put on her gripper sock, pulled down her pants leg, moved the garbage can, then washed her hands for the first time since the observation began. Surveyor confirmed with RN A that she did not wash her hands each time she removed her gloves, including after cleansing the pressure ulcer. She stated, "No, you're right. Could I have used hand gel? I didn't think - you're right." The observation was discussed with the facility's Infection Preventionist, RN B on [DATE] at 1:10 p.m. RN B stated that she was already aware of the above observation.

Based on interview, medical record review, policy review and observation the facility did not ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 1 residents with falls resulting in a fracture (Resident #4). Resident #4 had a known history of removing his tab clip alarm and a history of falls. The facility had implemented an alarmed self release Velcro seat belt 10/07/10 which did prevent falls. However, the alarmed seat belt stopped working 03/14/11 and the facility resumed the tab clip alarm while he was in the Broda chair, despite knowing that this was an ineffective approach because he could remove the tab clip alarm. The facility also continued to use the tab clip alarm for Resident #4 while he was in bed despite knowing he would remove the alarm from his clothing and it would then not alarm. The facility did not put other interventions in place to prevent falls. Subsequently, Resident #4 fell on [DATE] and on 04/16/11. The fall on 04/16/11 resulted in a fracture of his left lateral epicondyle (arm). The facility did not follow its policy to investigate the cause and implement immediate changes to prevent a similar accident. Following the left arm fracture no new interventions were put in place, the alarmed seat belt was still not working and a tab clip alarm continued to be in use. The facility's use of a measure that had already been proven to be ineffective in preventing falls for Resident #4 created a situation of immediate jeopardy which began on 04/11/11. The Nursing Home Administrator (NHA) and Director of Nursing (DON) were informed of the immediate jeopardy on 04/21/11 at 2:30 p.m. by Regional Field Operations Director (RFOD)/Surveyor by phone in the presence of Surveyors , and . The facility had removed the immediate jeopardy on 04/20/11. The deficient practice continues at a scope/severity level E (potential for harm that is not immediate jeopardy/pattern) due to the following examples related to wandering and falls: Based on observations, medical record review, interviews and policy review the facility did not ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents for 14 of 20 residents with WanderGuard devices: Residents #1, #4, #20, #25, #27, #28, #29, #30, #31, #32, #33, #34, #35 and #36 and 2 of sampled residents related to falls: Resident #12 and 1. Resident #4 eloped from the building on 12/17/10 without staff knowledge and was found outside by a visitor. After that event, the facility applied a WanderGuard bracelet to his Broda chair. On 01/24/11 Resident #4 again exited the building without staff knowledge. He was again found outside by a visitor. Resident #4's WanderGuard bracelet did not sound the alarm when he exited or re-entered the building. The facility did not determine the cause of why the alarm did not sound. The facility used WanderGuard transmitters that were good for 90 days. The facility did not have a system in place for tracking the 90 day expiration dates. Three of 20 residents with WanderGuard bracelets in use were found to have transmitters in use beyond the 90 day expiration period, Residents #31, #32 and #33. Two additional residents, #34 and #35, did not have clearly identified expiration dates of their 90 day transmitters. As of 04/20/11, 9 of 20 residents with WanderGuard devices were identified as having the transmitter placed on the metal of their wheel chair or walker which is against manufacturer's directions. Resident #1, #4, #20, #25, #27, #28, #29, #30 and #31. The manufacturer directs the WanderGuard transmitters are not to be applied to the metal of a wheelchair or walker. The facility policy directed the transmitter could be applied to the wheelchair and walkers. Resident #12 was lowered to the floor during a transfer with 2 assists on 04/02/11. The nurse told the Certified Nursing Assistants (CNAs) that the resident should thereafter be transferred with an EZ stand lift. Four hours later, CNAs on the night shift again transferred Resident #12 without the EZ stand, and again had to lower her to the floor. Resident #1's last Functional Maintenance Plan (FMP) from physical therapy reads that he requires the Hoyer lift with 3-4 staff persons. On 3/24/11, 2 staff persons were transferring Resident #1. One CNA slipped as the other CNA began to raise the lift before the last loop was secured. Resident #1 received no injury. A re-evaluation by physical therapy on 4/25/11 recommends that the Hoyer and 3 persons continue to be needed for Resident #1's safe transfer. This is evidenced by: 1. The facility policy titled "Vernon Manor Accident/Incident Policy" effective date of 03/26/07 read in part as follows: "3. In the event that an accident does occur, the following measures will be taken to investigate its cause and determine a plan to prevent reoccurrence. c. Document the accident and the investigation in the resident record. d. Implement any immediate changes necessary to prevent a similar accident. e. Revise the care plan and communicate any changes in the care plan to direct care staff." Resident #4 has [DIAGNOSES REDACTED]. Resident #4 has a legal guardian and was protectively placed at the facility. Resident #4's most recent Minimum Data Set (MDS) assessment dated [DATE] identified he had ~ difficulty making himself understood, ~ very poor memory recall, ~ fluctuating periods of inattention, ~ disorganized thinking, ~ altered level of consciousness and ~ psychomotor retardation. The 03/08/11 MDS also identified Resident #4 required extensive assistance of one person physical assistance with transfers. The Certified Nursing Assistant (CNA) care plan identified he transferred with one or two assistance with the gait belt or using the Hoyer (mechanical lift) as needed. Resident #4's most recent Care Area Assessment (CAAs) for falls completed with the 03/08/11 MDS identified Resident #4 has impulsivity and poor safety awareness. The CAAs also read, "Resident has poor judgment and safety awareness. He has poor balance and needs staff assist with transfers and toileting. Resident is not anticipated to improve with functioning. He is dependent on the Broda chair for mobility. Resident does ambulate with staff assist and a walker. He has an alarming seatbelt on the Broda chair, to remind him to ask for assist with transfers. Resident is at risk for falls due to the daily use of antidepressant medication. He will continue to be at risk for falls due to medication use and poor balance." During a personal care observation on 04/19/11 beginning at 9:55 a.m. Surveyor observed the Certified Nursing Assistant (CNA) apply the Velcro seat belt to Resident #4 after he was seated in his Broda chair. Surveyor asked the CNA if Resident #4 was able to remove the seat belt himself. CNA W told Surveyor the seat belt is not alarmed, the alarm box quit working for the alarmed seat belt. They were told to use the clip alarm in the chair. He can remove the seat belt. CNA W said they were supposed to order a new alarm box for the seat belt a couple of weeks ago. During a meeting at 5:10 p.m. on 4/19/11, Surveyor informed the DON and NHA what CNA W had told Surveyor , that Resident #4's seat belt alarm was broken. The CNA said they were using the Velcro seat belt but the alarm box was broken and did not work. Surveyor asked if a new seat belt alarm had been ordered and the DON stated she did not know his alarm was broken, so one had not been ordered. A. Fall on 2/27/11 Review of Resident #4's medical record by Surveyor beginning on the afternoon of 04/18/11 identified Resident #4 sustained a fall without injury on 02/27/11 at 11:00 p.m. He was found on the floor in his room by the entry way by his bathroom. The incident note identified Resident #4 said he was going to bed. The note read, "His alarms did not sound." The note did not identify details as to why the alarms did not sound. The incident note was written by Registered Nurse (RN) Z. An interview was conducted on 04/20/11 beginning at 8:35 a.m. with RN Z by Surveyor regarding Resident #4's fall on 02/27/11. Surveyor asked RN Z where Resident #4 had been just prior to the fall as the note did not identify this. RN Z stated he had been in bed. Surveyor asked why his alarm did not sound. RN Z told Surveyor , "He took off the tab alarm, I didn't write that though. We checked it before we put it back on." Surveyor asked RN Z how she knew Resident #4 had removed the alarm versus a CNA forgot to attach it. RN Z said there is no way of knowing for sure. The CNA's on nights are instructed to check alarms, rounds start right away at 10:00 p.m. The main reason for the 10:00 p.m. rounds is to be sure alarms are on, mats are in place and beds are low. Surveyor asked RN Z when Resident #4 had last been checked on prior to the fall. RN Z stated she had asked the CNA's and they both said Resident #4's alarm was on him when they did the 10 o'clock rounds, he would have been checked around 10:15-10:20 p.m. RN Z said he is up and down a lot, they are in there with him often. Surveyor asked RN Z if she had reported this fall to the Director of Nursing (DON) or the Nursing Home Administrator (NHA) and she said "Not at that time, when they do morning report they go over incidents. If it is a serious injury I would notify them." During the above interview, Surveyor asked RN Z, since she knew Resident #4 had a history of [REDACTED]. RN Z said "No, I don't see that I did, normally I'd put him on 1/2 hour observations. I don't see that I did. I didn't write it." Surveyor requested that RN Z look and see if there were any 1/2 hour observation sheets for the time following this fall. None were provided. A phone interview was conducted on 04/20/11 at approximately 5:30 p.m. with CNA Y, one of the night CNA's that were identified as working on Resident #4's hall the night of the 02/27/11 fall. CNA Y also told Surveyor Resident #4 would take his clip alarm off and his seat belt alarm had not been working but he had been in bed when this fall occurred. On 04/20/11 Surveyor reviewed a form called "Employee Incident Summary" that was related to Resident #4's fall of 02/27/11. This form identified CNA BB was the one who found Resident #4 on the floor at 11:00 p.m. on 02/27/11. CNA BB completed the section that read "Description of Incident or Injury:" "Hollering out. Found on floor by his doorway." The form asked "Do you have a potential explanation of how the injury occurred?" CNA BB wrote "Walking from his w/c (wheelchair) to the doorway." CNA BB's statement did not identify whether the alarm was on or not, or if it were sounding. B. Fall on 4/9/11 Resident #4's medical record identified Resident #4 fell on [DATE] at 9:44 p.m. while in the bathroom with CNA C. The incident note written by RN B identified as CNA C was assisting him from the toilet to his chair he pushed his wheelchair back despite the brakes being locked on the chair, Resident #4 sat on the edge of the chair and then slid to the floor as CNA C was unable to lift him further into the chair before he slid to the floor. This incident showed an example of Resident #4's impulsivity, poor judgment in regard to his safety and why two staff assisting with his transfer would be safer for Resident #4 and staff. The care plan was not revised after this fall regarding how many staff were needed to safely transfer Resident #4. C. Fall on 4/11/11 Further review of Resident #4's medical record by Surveyor identified Resident #4 was found on the floor of his room on 04/11/11 at 9:44 p.m. The incident note written by RN B read: "Observed on floor CNA was walking by resident's room and noted resident sitting on floor beside bed. Broda chair and room chair were near bed." The note identified Resident #4 had no apparent injuries. The note identified his gripper socks were off and lying on his bed, they had been on when he was assisted to bed. "Activity At The Time: transferring appeared to have been getting out of bed to either get in broda chair or room chair that was near bed." "Actions: continue to observe motion alarm applied resident had tab alarm on when put into bed, tab alarm was still attached to bed with string attached to alarm, appears resident took alarm off." On 04/19/11 at 5:05 p.m. at the meeting with the DON and NHA Surveyor referred to the incident note written by RN B on 04/12/11 regarding Resident #4's fall on 04/11/11 at 9:44 p.m. Surveyor asked if applying a motion alarm was a new intervention for Resident #4. The DON said no, the motion alarm is the same as a tab alarm, it sounds if he is in motion and then pulls the alarm. The DON stated a clip/tab/motion alarm are the same and the words are used interchangeably here. No new motion alarm was started, he is up and then down again. Surveyor asked once they knew Resident #4 could remove the clip alarm was he put on 15 minute checks or any different measures. The DON stated she did not know. An employee incident summary statement written by CNA CC on 04/11/11 after the fall read in part under "Description of Incident or Injury: He often takes his grippy socks off because he does not like wearing them and hits the aides when they try to put them on again. His alarm he takes off frequently during the day and night." On 04/20/11 beginning at 11:50 a.m. an interview was conducted with RN B by Surveyor regarding Resident #4's fall on 04/11/11. Surveyor asked RN B when Resident #4 had last been toileted prior to the fall. RN B said around 7:30-8:00 p.m. when the girls had put him to bed. Surveyor asked RN B if she added a motion alarm or if the motion alarm she referred to in her note is the same thing as a clip tab alarm. RN B confirmed it is the same as a clip tab alarm. RN B told Surveyor "(Resident #4) had a tab alarm, it was not unusual for him to take it off, we put it back on, he had taken the tab alarm off prior to his fall. The clip that goes to his clothing was still on the bed." Surveyor asked RN B how she knew he had removed the alarm versus the CNA forgetting to put it on. RN B said she had asked the CNA's that put him to bed and they said they had put it on. RN B again said "It's not uncommon for (Resident #4) to take that alarm off." Surveyor asked RN B since she knew Resident #4 would remove the alarm did she implement any different measures. RN B told Surveyor they got him up in his chair after the fall. Other than that no new interventions were put in place. On 04/20/11 at 5:50 p.m. an interview was conducted by phone by Surveyor with CNA E regarding the fall of 04/11/11. Surveyor asked CNA E if she knew if the alarm was sounding when that fall occurred. She stated she did not know, she did not find him. Surveyor asked CNA E if she knew that Resident #4 would take his clip alarm off and she stated "Yes." Surveyor asked CNA E if she was aware that the seat belt alarm was not working and she said "Yes." During an interview conducted by Surveyor on 04/21/11 at 10:05 a.m. with RN T Surveyor asked when it was reported to RN T the seat belt alarm was not working. RN T said awhile ago, that is why we put the tab alarm on in the wheelchair. RN T was asked what she did when she was told the seat belt alarm was not working. RN T said she had Maintenance G look at it. RN T said the seat belt was not fixable. Maintenance G said we would need a new one. RN T was asked if she had told the DON Resident #4's seat belt alarm was not working. RN T said "I can't remember to be honest. I remember talking to (Maintenance G) about it." RN T told Surveyor "Usually (the DON) orders the alarms and mats." Surveyor asked RN T if she was aware Resident #4 would take his clip tab alarm off. RN T said "Yes, it's probably the most ineffective alarm we have." RN T was then asked by Surveyor if they had tried any other type of alarm. RN T said if the seat belt alarm was not able to be used, they were to use the tab alarm. Surveyor asked RN T when the alarmed seat belt had been broken. RN T stated she thought about a month ago. During the above interview Surveyor asked RN T if they had tried the alarming floor mat for Resident #4. RN T said, "I don't think so." Surveyor asked if Resident #4 was put on any 15 minute checks. RN T said she thought he was. Surveyor and RN T looked at Resident #4's care plan and 15 or 30 minute checks were not identified. RN T stated she would check and get back to Surveyor . On 04/21/11 at 10:15 a.m. RN T provided Surveyor with a form titled "OBS (observation) LIST Updated 04/13/11. This list identified residents who were on close observations which could include 15 or 30 minute checks. Resident #4 was not on the list. On 04/21/11 at 10:30 a.m. Surveyor conducted an interview with Maintenance G and asked if he had any way of knowing when it was reported to maintenance that Resident #4's alarmed seat belt was not working. Maintenance G said I should have it in my book. Maintenance G retrieved a note book and found an entry dated 03/14/11 that read "(Resident #4) seat belt alarm will not sound." This entry was written by CNA W. By this entry an entry written by Maintenance G read, "We have none, we need new seat belt." Maintenance G told Surveyor the seat belt alarm has a cord like a phone line, the wires were stripped, it wasn't the box it was the wire coming from the alarm itself, it was not fixable. Surveyor asked once he had determined the seat belt was not fixable what did he do about it. Maintenance G said he told his supervisor and he said he thought he told RN T. Maintenance G said he had no further involvement with the alarm. D. Fall on 4/16/11 Review of Resident #4's medical record by Surveyor identified Resident #4 sustained a fall on 04/16/11 at 9:15 p.m. A nurses' note dated 04/16/11 with a time of 10:00 p.m. written by RN R read, "Fall with injury observed on floor other: (please specify) res (resident) found with left arm twisted behind his back with his hand behind his right shoulder. DATE OF INCIDENT: 04/16/11 TIME OF INCIDENT: 21:15 (9:15 P.M.) WING: 200 Wing LOCATION: resident's room. OTHER LOCATION: N/A POST INCIDENT ASSESSMENT: internal or external rotation of extremity noted (specify) left arm deformity of bone or joint noted (specify) of right (it was the left) elbow No change in level of consciousness MENTAL STATE: normal for resident, confused VITALS: BP: (blood pressure) 158/90 P: (pulse) 98 R: (respirations) 20 T: (temp) 98.2 POTENTIAL CONTRIBUTING FACTORS restless per usual. ACTIVITY AT THE TIME: transferring into bed ENVIRONMENTAL FACTORS: dry floor no clutter lights off call light within reach BED IN LOWEST POSITION: YES, ACTIONS: transferred to emergency room STAFF INVOLVED: none WITNESSES: none EQUIPMENT INVOLVED: wheelchair/bed NEURO (neurological) CHECKS: did not get done RESIDENT ASSISTED WITH: Gait belt 3 or more person assist to get into bed MEDICAL CONDITIONS: chronic recurrent illness mental retardation POSSIBLE CAUSE: transferred without staff assist RESIDENT SPECIFIC CARE PLAN IN PLACE: appropriate safety precautions/device in place? yes toileting program not applicable rehab (rehabilitation)/restorative program no behavior program yes PHYSICIAN NOTIFICATION: Physician notified Dr. (last name of doctor) orders received to sent to ER (emergency room ) for evaluation and treatment FAMILY NOTIFICATION: notification attempted message left for (guardian's name) and (name) awaiting return call COMMENT: Attempted to stabilize left arm until Tri State arrived, appears to be either fractured or dislocated." An additional nurse ' s note dated 04/17/11 with times of 12:20 a.m. and 12:22 a.m. identified Resident #4 returned to facility on 04/16/11 at 11:20 p.m. with a splint and sling in place to left arm. Resident has fracture of left lateral epicondyle. On the morning of 04/20/11 Surveyor requested the investigation or any additional information related to Resident #4's fall of 04/16/11. A copy of an incident report was provided to Surveyor by the DON on 04/20/11 at 11:15 a.m. The incident report contained the same information as written in the incident nurses' note. Neither contained information identifying if the alarm was sounding to alert staff of his self transfer. An Employee Incident Summary was attached to the incident report. A statement written by CNA Y, the CNA who found Resident #4 on the floor at the time of the 04/16/11 fall read: "Description of Incident or Injury: Heard (Resident #4) call out and so I went to check. Found right of bed on floor between bed & (and) wall. (CNA X) was in hallway and I asked her to stay with (Resident #4) and went to call (RN R). CNA Y's statement did not identify if his clip tab alarm was sounding. On 04/20/11 beginning at 12:32 p.m. an interview was conducted by Surveyor with RN V regarding Resident #4's fall on 04/16/11. RN V told Surveyor she (RN V) was doing medications on the 200 hallway. RN R was the charge nurse that night. RN V was asked if she had heard an alarm sound at the time of Resident #4's fall. RN V stated she didn't hear an alarm. RN V was asked if the CNA's had heard his alarm, RN V said she did not know. RN V told Surveyor to speak with RN R. RN V went to Resident #4's room right away and RN R came to his room right away also. RN R took over and RN V left the room and resumed doing medications. On 04/20/11 beginning at 2:15 p.m. an interview was conducted with RN R by Surveyor regarding Resident #4's fall on 04/16/11. Surveyor asked RN R where Resident #4 had been just prior to the fall. RN R stated Resident #4 had been up in his Broda chair. RN R said he does not like to wait. RN R was asked who had found Resident #4 on the floor that evening. RN R identified CNA Y. Surveyor asked RN R if the alarm sounded when Resident #4 fell on [DATE]. RN R said she remembered asking CNA X and CNA X had told RN R the alarm was on Resident #4 when that had gotten him up but at the time he fell RN R didn't think it was sounding. Surveyor asked RN R why the alarm was not sounding. RN R said "He would take it off." RN R was asked where in the room was he found? RN R said on far side of bed on floor, he gets out of the chair and gets into bed on his knees. RN R said Resident #4 was on his left side with his left arm behind him and bent up under him. RN R said he was trying to pull himself up with his right arm. Surveyor asked RN R what type of alarm was in use at the time of the fall. RN R said he had a clip type alarm and he would pull the clasp off. RN R was asked at what time Resident #4 had last been seen just prior to fall. She stated she was not sure. RN R was asked if she had been aware that Resident #4's seat belt alarm was not working at the time of the fall and the clip alarm was being used. RN R said she did not know that. On weekends there is one charge nurse and she (RN R) usually doesn't work the 200 wing. During the above interview, RN R was asked if she had questioned the CNAs if the alarm was sounding when Resident #4 was found on the floor 04/16/11. RN R told Surveyor the CNAs are to fill out a report. RN R said when she did her report she didn't see the CNAs, it was at the end of the shift. RN R said she sent a form down to wing 200 with Licensed Practical Nurse (LPN) OO for the CNAs to complete. On 04/20/11 at 2:55 p.m. Surveyor interviewed CNA X regarding Resident #4's fall on 04/16/11. CNA X was asked if she had found Resident #4 at the time of his fall. CNA X said she had not. CNA X was asked if she had heard an alarm around the time of Resident #4's fall. CNA X stated she had not heard an alarm. CNA X said she was working on the 200 hall in another room. When she came out in the hall, CNA Y told CNA X that RN R needed help in Resident #4's room. CNA X told Surveyor Resident #4 had laid down after supper and had slept for awhile. CNA X said she got him up in his chair around 7:30-8:00 p.m. and she had put his clip alarm on his shirt. Surveyor asked CNA X about the seat belt alarm and CNA X told Surveyor the seat belt alarm was not working so they were using the clip alarm in the chair. CNA X assisted in getting Resident #4 off the floor with CNA Y and RN R. CNA X told Surveyor Resident #4 gets in and out of bed all the time, we put his alarm on and he takes it off, he usually doesn't sleep. Surveyor asked CNA X if she had heard that Resident #4's alarmed seat belt was not working. CNA X said "Yeah, I knew it wasn't working, we still put in on him, that's why we use the tab alarm on the wheelchair." CNA X was asked if she had told any nurse it was not working. CNA X said No, I assumed they knew, because they gave us the tab alarm to use if the other alarm is not working. Surveyor asked CNA X if she knew how long the alarmed seat belt had not been working, CNA X said no, she had just started working on the 200 hall about two weeks ago. CNA X did say the alarmed seat belt was not working when she started on the 200 wing about two weeks ago. On 04/20/11 beginning at 5:40 p.m. a phone interview was conducted by Surveyor with CNA Y regarding Resident #4's fall of 04/16/11. CNA Y told Surveyor she had came in early, at 8:00 p.m. that night to help the p.m. shift. CNA Y normally worked the 10:00 p.m.-6:00 a.m. shift. CNA Y told Surveyor she had been in the 200 hall and heard "Help, help." She went in Resident #4's room and saw him on the floor between the wall and his bed. His arm was behind him. CNA Y told Resident #4 to lay still and she went for help. CNA Y stated she saw CNA X in the hall and told her to go in by Resident #4 and CNA Y called RN R. CNA Y told RN V and both RN R and RN V came to Resident #4's room. Surveyor asked CNA Y if the alarm was sounding when she went in Resident #4's room when she heard him say help, help. CNA Y told Surveyor "He transferred himself from his Broda chair to bed, the clip alarm was off." CNA Y was asked about the alarmed seat belt, CNA Y said "It was not working, I have to be honest." CNA Y was asked if she knew how long the alarmed seat belt had not been working, CNA Y said "At least a month." "I told them the seat belt alarm was not working." Surveyor asked CNA Y who she had told and CNA Y said the nurses. CNA Y stated CNA C had tried to fix the alarm as it was beeping and the next night there was nothing. CNA Y stated they were told since the seat belt alarm didn't work to use the clip alarm. CNA said, "He was smart enough to take that off." On 04/21/11 beginning at 3:15 p.m. an interview was conducted by Surveyor with CNA E regarding Resident #4's fall on 04/16/11. CNA E told Surveyor the clip tab alarm was on his chair when he was found on the floor. CNA E said she had not put him to bed and CNA E had asked CNA X and CNA X had said she had not put him to bed. CNA E told Surveyor she thought Resident #4 had gotten in bed by himself, then fell from the bed. On 04/21/11 beginning at 11:35 a.m. Surveyor interviewed CNA PP and asked CNA PP, when the alarmed seat belt was working did it prevent falls for Resident #4. CNA PP told Surveyor it did alert them and did prevent Resident #4 from falling. Surveyor asked CNA PP how she transfers Resident #4. CNA PP said she used two staff because he is not steady and has behaviors. At 11:40 a.m. Surveyor interviewed CNA W and asked her if the alarmed seat belt, when it was working properly prevented falls for Resident #4. CNA W said yes, we could get to him quicker, he could take the tab alarm off. Surveyor asked CNA W how she transfers Resident #4. CNA W said she typically used two staff, especially now with the broken arm. CNA W said, "I use two staff because he can go ape wire over nothing, he is not patient." Another interview was conducted with CNA QQ at 11:50 a.m. by Surveyor . CNA QQ was asked if the alarmed seat belt prevented falls for Resident #4 when it was working and said it did, better than the clip alarm. CNA QQ also told Surveyor she used two staff for transfers with Resident #4. On 04/20/11 at 4:20 p.m. during the information sharing meeting with the NHA and DON Surveyor informed them of the numerous statements from staff that identified Resident #4 frequently removed the clip tab alarm. Surveyor asked since it was a well known fact and given his seat belt alarm was broken why was he not reassessed and further interventions put in place to help keep him safe. The DON stated "I would agree with you on that." According to the federal hearing decision, Bethel Center vs. CMS, " ...an alarm must function properly in order to be an adequate assistance device. An alarm which fails to sound when a resident attempts an inappropriate activity is worse than useless because the staff may have been lulled into a false sense of security by assuming that the alarm would work as advertised. " The failure to replace the non-functioning seat belt alarm and implement alternative or additional interventions from the clip tab alarm created a situation of immediate jeopardy. The facility was put on notice of the immediate jeopardy on 04/21/11. The immediate jeopardy was removed on 04/20/11 when they applied a different working seat belt alarm and provided Resident #4 with a low, wider bed. 2. Resident #4 was given a WanderGuard bracelet on 12/17/10 after being found outside under the awning. He was wearing a long-sleeved flannel shirt, sweat pants, shoes, socks, and a baseball cap. Temperature was 3 degrees Fahrenheit. Review of Resident #4's medical record by Surveyor on 04/19/11 identified a nurses' note written 01/24/11 at 8:49 p.m. The computer identified the note was written by RN H but through interview with RN H on 04/19/11 RN H said she had heard about the incident but she did not work p.m. shift at that time. RN H said she probably had not logged off the computer. It was determined the note was written by RN B. An interview with RN B on 04/19/11 beginning at 1:22 p.m. confirmed RN B had charted the incident of Resident #4's elopement on 01/24/11. The nurses' note of 01/24/11 at 8:49 p.m. noted the following: Elopement: Resident was found outside in main parking lot of VM (Vernon Manor) by visitor at 6:15 p.m. on 1/24/11. Resident had on long sleeved shirt, sweat pants, socks and shoes and baseball cap on head. Did not have on any winter outer clothing. Was sitting in own wheeled chair. According to this note, Resident #4 had no apparent injury, moves all extremities CMS (circulation, movement, sensation) checks of hands WNL (within normal limits) except hands very cold and L (left) ear very cold. no c/o (complaint of) pain No change in level of consciousness MENTAL STATE: normal for resident, confused VITALS: BP: 122/78 P: 74 R: 20 T: 96 Oxygen saturation: 94% RA (room air). Temperature in the mid teens. The note indicates that the doctor ordered resident to ER (emergency room ) for evaluation of possible hypothermia. The note indicates that staff tested the WanderGuard for working condition. Found to be working and was moved from lower part of chair to upper handle. On 04/19/11 beginning at 1:22 p.m. Surveyor interviewed RN B regarding Resident #4's elopement on 01/24/11. RN B was asked about further details of the event. RN B was asked if it had been snowing or raining at the time Resident #4 was found outside. RN B said there was no precipitation coming down, there was snow on the ground. RN B stated Resident #4 was outside the front door when she went outside. RN B and two CNA's went out and got him. Surveyor asked RN B if she had found out how far away from the building he had gotten, if she had asked how far he had gotten. RN B said "No, I didn't." Surveyor asked RN B if the WanderGuard alarm sounded when he went outside. RN B said "I don't know, I can't answer that.