**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice when experiencing a change in condition for 2 of 4 sampled residents (R7 and R8). R7 had a change in condition on 6/22/24. R7 has diabetes mellitus type 2. The facility has not completed daily diabetic foot checks, assessed, nor measured R7's diabetic wound, described the wound bed or continuously monitored R7's wound. In addition, R7's provider was not updated. R7 was sent to the hospital on 6/27/24 for osteomyelitis of the right second toe. Subsequently, R7's right second toe was amputated on 6/28/24. R7 developed a new diabetic wound that worsened and became infected with MRSA (Methicillin-Resistant Staphylococcus Aureus), Corynebacterium Striatum, Pseudomonas aeruginosa, and Enterococcus Faecalis; MRSA and Corynebacterium Striatum are life-threatening Multidrug-Resistant Organisms (MDRO). Staff failed to measure and assess R7's wound weekly, failed to contact a Physician/NP (Nurse Practitioner) timely, failed to complete wound treatments and failed to implement aggressive preventative measures to prevent R7's wound from deteriorating/worsening. These failures created a finding of immediate jeopardy that began on 6/22/24. NHA A (Nursing Home Administrator) was notifed of the immediate jeopardy on 10/10/24 at 12:35 PM. The immediate jeopardy was removed on 10/10/24 and continues at a severity/scope level of G (actual harm/isolated) as evidenced by the following: R8 received a burn on his foot from Tea Tree Oil after a nurse completed the treatment incorrectly placing undiluted Tea Tree Oil directly on R8's foot. The facility did not complete weekly assessment per standards of practice. R8's wound became infected requiring antibiotics. As evidenced by: The facility policy, Standard Diabetes Mellitus Protocol, undated, indicates, in part, as follows: Problem: Patient has potential for fluctuating blood sugar and/or complications of diabetes mellitus. Goal: Patient will: 1) remain compliant with diet 2) blood sugars to be within parameters as determined by the physician orders 3) exhibit no hypo/hyperglycemia episodes. Complete daily foot checks; Update physician and responsible party as needed, check blood sugars/labs as ordered. The facility policy, Pressure Injury Prevention and Managing Skin Integrity, reviewed 8/10/23, indicates, in part, as follows: Weekly Wound Rounds: a. Upon identification of abnormal skin findings, a licensed nurse will complete a skin assessment. Individual with abnormal skin concern(s) will be added to weekly wound rounds. b. Registered Nurse (RN) or designee will: i. Conduct weekly skin evaluation, ii. Update the PCP (Primary Care Provider) with any decline in wound appearance, or as necessary. iii. Update the care plan with interventions as applicable. Administrative Review a. Interdisciplinary Team (IDT) reviews Pressure Ulcer/Abnormal Skin Findings through Quality Assurance Committee. R7 was admitted to the facility on [DATE] with diagnoses including, but not limited to, diabetes mellitus type 2, neuropathy, BKA (below the knee amputation) to LLE (left lower extremity) on 12/16/22, toe amputation to right foot (7/28/21), peripheral arterial disease, phantom limb pain, history of MRSA (Methicillin-Resistant Staphylococcus Aureus) (unclear source), and Chronic Kidney Disease Stage 3b. R7's admission Minimum Data Set (MDS) dated [DATE] indicates R7 is cognitively intact with a Brief Interview for Mental Status (BIMS) of 15. R1's MDS indicates he is at risk for skin impairment and was admitted with no skin impairment. R7's Certified Nursing Assistant (CNA) Kardex, dated 10/8/24, documents the following: Skin Integrity Monitor/document/report PRN (as needed) any changes in skin status: appearance, color, wound healing, s/sx (signs/symptoms) of infection, wound size (length x width x depth), stage. R7's Progress Notes: On 6/10/2 at 10:25 PM, LPN O (Licensed Practical Nurse) documents, in part, the following: Rt (right) leg/foot noted with redness and weeping to the top of R foot cleansed with NS and wrapped with kerlix. On 6/11/24 9:45 PM, LPN O documents the following: Resident in w/c (wheelchair) started on PO (oral)/ABT (antibiotic)/Cellulitis/Rt Foot (right) with CDI (clean, dry, intact) T97.6 no adverse reaction noted. On 6/11/24, R7 was started on Cedfinir oral capsule 300 mg Give 1 capsule 2x/d for cellulitis for 10 days for right foot cellulitis. Note, Cefdinir is an antibiotic used to treat bacterial infections. On 6/12/24 at 11:59 PM, LPN O documents the following: Resident A/O x4 (Alert and Oriented) remains on PO/ABT/Tx/Cellulitis Leg with CDI dressing. T98.9 no adverse reaction noted. On 6/15/24 at 1:37 PM, LPN O documents the following: Resident up in w/c A/O/4 remains on PO/ABT/Cellulitis Rt Foot Red and dry no wheeping [SIC] noted Tx applied per MD (Medical Doctor) order tolerated well T-97.9 On 6/15/24 at 8:53 PM, LPN O documents the following: Resident remains on PO/ABT/Rt Leg infection no adverse reaction noted T98.7 Tx done per MD order tolerated it well. T97.9 On 6/16/24 at 11:49 AM, Resident remains on PO/ABT/TX no adverse reaction noted T97.6 Rt Foot Tx done tolerated it well to Rt Foot. On 6/17/24 at 10:11 PM, LPN O documents the following: Resident remains on PO/ABT/Tx/Lft [SIC] Leg Cellulitis no adverse reaction noted T97.6 Rt Foot Tx applied after Shower Foot very Red and Moist tolerated Tx well. R7 has an order for Mupirocin oint (ointment) 2% (Used to treat bacterial skin infections or staph) apply followed by ABD (dressing) and wrap with kerlix. The facility did not complete a total of ten (10) treatments on the following dates: 6/10/24, 6/12/24, 6/17/24, 6/19-6/22/24, 6/24-6/26/24; note there are no measurements or indication why the facility is using this. On 6/17/24, R7's Weekly skin check is blank. On 6/22/24 at 5:22 AM, LPN O documents as follows: Tx done per MD order to Rt Foot and Buttock both draining very much with foul order [SIC] and large amount of [NAME] drainage advised to keep leg elevated and take a break from sitting up in the W/C (wheel chair) resident is very non-compliant was also told that on PM shift as well but didn't listen. T97.8 It is important to note, there is no update to the provider, no measurement, or wound assessment. On 10/9/24 at 11:45 AM, Surveyor called LPN O (Licensed Practical Nurse). LPN O did not return Surveyor's call. On 6/24/24 at 1:30 PM, NP Q (Nurse Practitioner) documents the following: Chief Complaint: seen for follow up diffuse rash x 3 days R7 was seen resting in bed. He is seen for diffuse rash to upper torso, arms, legs, groin. He has increased edema to bilateral thighs as well as redness to bilateral groin. He was treated with Diflucan as well as nystatin cream with little improvement for intertrigo (a rash that appears between the folds of skin). He does have a diagnosis of T2DM (Diabetes Mellitus Type 2), but unable to see blood glucose monitoring. Will add Bumex (a diuretic to decrease fluid), will update A1C (blood glucose monitoring over 3 months), update labs, will add prednisone, continue Benadryl. Facility staff made aware of plan of care. Continue wound care with [NAME] [SIC], encourage to shower three times weekly if possible, patient agrees with POC (Plan of Care). Skin - no masses, no rashes, no lesion on exposed skin, PVD (peripheral vascular disease) skin change to RLE (right lower extremity) . Of note, NP Q is no longer employed with clinic and instructed the facility to not contact her. On 10/9/24 at 1:35 PM, Surveyor contacted NP Q (Nurse Practitioner). NP Q did not return Surveyor's call. On 6/24/24, R7's Weekly skin check is blank. On 6/24/24 at 10:21 PM, LPN O documents, in part, the following: Skin Evaluation: Skin warm & dry, skin color WNL (within normal limits), mucous membranes moist, turgor normal. Resident has current skin issues. Skin tissue: Open lesion (other than ulcers, rashes and cuts). Skin issue location .Infection of the foot. Skin issue location: Rt Foot Wound bed: Granulation. Wound exudate: Purulent. Per wound condition: Maceration. Dressing saturation: Heavy (75%). Wound odor: Yes. Tissue: Cool. Note: .Cellulitis to Rt Foot Note: Provider not updated, no indication of what the wound looks like or being updated on the odor or drainage. On 6/25/24 at 10:30 PM, LPN O document the following: Resident in recliner with leg elevated on a pillow with CDI (Clean, dry and intact) dressing to Rt Foot. On 6/27/24 at 4:47 AM, Physician/Med Dir R (Physician/Medical Director) conducted a visit at the facility. Physician/Med Dir R documents the following: Reason: Physician Monthly Follow-up Visit Type: SNF (Skilled Nursing Facility) Monthly Compliance Subjective: Patient seen today for multiple chronic conditions. Laying in bed no fever, chills, nausea, vomit, chest pain or chest tightness. Has a diffuse rash for which he was started on prednisone. It has been pruritic (itchy skin) but it seems to be improving as well. He does have some flaky skin and thus was started on Aquaphor as well. Care discussed with nursing staff. Physical Exam - General-no acute distress, comfortable Extremities-left below the knee amputation, right lower extremity dressing Phantom limb syndrome Type 2 diabetes mellitus with foot ulcer. Continue with current plan of care, monitor blood sugars, avoid hypoglycemia. Followed by wound care as well. It is important to note, this MD (Medical Doctor) note is for monthly compliance. The note indicates, right lower extremity dressing and Type 2 diabetes mellitus with foot ulcer. MD/Med Dir R's note does not indicate if Physician/Med Dir assessed or looked at R7's wound, or if he was aware that there was purulent drainage or an odor. On 6/27/24 at 6:53 AM, Physician S, a traveling wound physician, documented the first assessment and measurements for R7's wound. Non-Pressure wound of the Right, second toe Full Thickness Etiology (quality): Undetermined/Unknown Further Etiology Detail unclear of how wound developed per patient Duration: >1 day Objective: Healing/Maintain Healing Wound Size (L x W x D): 1.3 x 1.3 x 0.1 cm (centimeter) Surface Area: 1.69 cm2 Exudate: Moderate Sero-sanguinous Granulation Tissue: 60% Other viable tissues: 40% (Bone, Cartilage) Additional Wound Detail: bone/joint exposed in appearing toe fracture with surrounding cellulitis, unclear etiology of wound and onset and whether surrounding cellulitis is indicative of superficial vs deep (bone) involvement. Expanded Evaluation Performed: .Patient requiring an increase in the level of care, recommend sending patient to ED (emergency department) given toe wound with bone exposed with surrounding cellulitis, unknown duration of wound given cellulitis and bone exposure reccomend ED (emergency department) eval for abx (antibiotics) and possible amp (amputation). On 6/27/24, R7 was immediately sent to the ED following Physician S's assessment. R7's second (2nd) toe on his right foot was amputated on 6/28/24. On 6/27/24 at 8:14 AM. The facility notified the clinic (name) regarding resident bone/joint exposed in appearing toe fracture with surrounding cellulitis, unclear etiology of wound and onset and whether surrounding cellulitis is indicative of superficial vs deep (bone) involvement. Resident sent to Hospital ED. R7's hospital report documents the following: Chief complaint exposed bone, R (right) foot exposed bone - cefepime and vanco (intravenous antibiotics) given in ER - (ended up with [NAME] syndrome from vanco) - No s/sx (sign/symptoms) systemic infection. HX MRSA (Methicillin-Resistant Staphylococcus Aureus) and CKD (Chronic Kidney Disease) stg (stage) 3. R7 was hospitalized 6/27 - 7/2/24. (5 days) R7's Hospital Report documents the following: admission Dx (Diagnosis): Injury of toe on right foot, initial encounter. Reason for Hospitalization: Development of new ulcer with exposed bone wound of second toe on right foot. Significant Findings: Osteomyelitis of the second right toe Patient Course & Care: .R7 was sent for admission due to wound of his second right toe which looked infected. He was admitted and started on IV (intravenous) antibiotics and podiatry was consulted. Decision was made to do the toe amputation which was done. Infectious diseases was consulted and made long-term antibiotic recommendations. He was able to discharge back to his SNF (Skilled Nursing Facility) and receive his IV antibiotics they are to follow-up with podiatry and infectious diseases. PRINCIPAL/FINAL DIAGNOSES: Osteomyelitis right second toe On 8/1/24, R7 was seen by Infectious Disease. The report documents the following: Reason for follow up right foot secondary to osteomyelitis. Surgical cx (culture) distal portion of amp (amputation) 6/28/24 - MRSA (Methicillin-Resistant Staphylococcus Aureus); Pseudomonas aeruginosa, Corynebacterium Striatum. It is important to note, MRSA and Corynebacterium Striatum are both life-threatening Multidrug-Resistant Organisms (MDROs). Surgical cx (culture) proximal amp/bone 6/28/24: E. Faecalis (Enterococcus Faecalis); Corynebacterium Striatum Visit Diagnosis: Acute osteomyelitis of Right Foot On 10/7/24 at 11:45 AM, Surveyor spoke with R7. Surveyor asked R7 regarding the right second toe that was amputated. Surveyor asked R7 how the wound occurred. R7 stated he is unsure how the wound occurred; however, he may have stubbed or bumped it on something. Surveyor asked R7, is there anything that staff did to cause the wound. R7 stated, No. On 10/9/24 at approximately 12:00 PM Surveyor spoke with DON B (Director of Nursing). Surveyor asked DON B, do you expect medication to be administered per physician orders. DON B stated, Yes. Surveyor shared R7's order for Muprocin ointment: Muprocin oint (ointment) 2% (Used to treat bacterial skin infections or staph) apply followed by ABD and wrap with kerlix. Surveyor asked DON B, do you expect R7's Muprocin (an antibiotic)/treatment to be completed per physician orders. DON B stated, Yes. Surveyor shared with DON B that R7's Muprocin/treatment was not completed on the following dates: 6/10, 6/12, 6/17, 6/19-6/22 and 6/24-6/26. Surveyor asked DON B, should R7 have received Muprocin/treatment per physician orders. DON B stated, Yes. Surveyor asked DON B, did the facility identify that Cefdinir/treatment was not completed per physician orders. DON B stated, no. Surveyor shared LPN O's progress note on 6/22/24 that documents R7's toe was Draining very much with foul odor and Large amount of green drainage. Surveyor asked DON B if he sees documentation that the provider was notified. DON B reviewed R7's medical record for documentation. DON B stated, he does not see documentation that R7's provider was notified on this date (6/22/24) or any day prior to R7 being sent to the ED (emergency department). Surveyor asked DON B, should LPN O have notified the provider regarding Draining very much with foul odor and Large amount of green drainage. DON B stated, Yes. Surveyor asked DON B, how often should diabetic foot checks be done. DON B stated, Daily. Surveyor asked DON B, why is it important that this is completed daily. DON B stated, so we can catch things early so they don't become problematic later on. DON B added, We don't want a delay in care for our residents. Surveyor asked DON B, do you expect daily diabetic foot checks to be completed for diabetic residents. DON B stated, I would, yes. Surveyor stated, R7's weekly skin assessments are not completed on 6/17/24 and 6/24/24. Surveyor asked DON B, should staff have completed R7's weekly skin assessments on 6/17/24 and 6/24/24. DON B stated, Yes. Surveyor asked DON B, are any staff WCC (Wound Care Certified) staff. DON B stated, No, nobody has the credentials. Surveyor asked DON B, do you expect staff to assess and measure wounds. DON B stated, yes. DON B stated, A description of some sort should happen. DON B stated, he normally leaves wound measurements up to the wound care physician. Surveyor asked DON B, how often should wounds be measured. DON B stated, Weekly. On 10/9/24 at approximately 1:00 PM, Surveyor observed R7's amputation site is healed. On 10/9/24 at 4:05 PM, Surveyor spoke with PA P (Physician Assistant). Surveyor shared with PA P that the facility is not completing daily diabetic foot checks for R7. Surveyor asked PA P, would you expect the facility to be completing daily diabetic foot checks. PA P stated, Yes. Surveyor shared LPN O's (Licensed Practical Nurse) progress note from 6/22/24 documenting R7's toe wound as Draining very much with foul odor and Large amount of green drainage. Surveyor asked PA P, would you expect to be notified. PA P stated, Yes, absolutely in a situation like that. Surveyor asked PA P, how soon would you expect to be notified. PA P stated, Immediately upon finding this and Don't delay, even 1 hour. PA P checked the clinic records and stated on 6/22/24 there is no note that a provider was updated by the facility. PA P added, on 6/24/24 there was a follow up for a rash and no indication of the toe. Surveyor asked PA P, do you expect the facility to administer medications and treatments per provider orders. PA P stated, Yes, absolutely. The facility's failure to complete daily diabetic foot checks, assess, measure, and describe wound beds weekly, continuously monitor R7's wound, and notify R7's provider when the wound has deteriorated resulted in R7 being sent hospital on 6/27/24 for osteomyelitis of the right second toe. Subsequently, R7's right second toe was amputated on 6/28/24. This created a finding of immediate jeopardy which was removed on 10/10/24 when the facility completed the following: 1. Skin sweep of entire facility completed 10/10/2024 2. Sweep of all active treatment orders completed for accuracy done 10/10/2024. 3. All residents with DM have daily foot checks added to TAR. done 10/10/2024 4. Education will be mandatory for all nurses and CNA prior to next working shift including: DM foot care with completing daily diabetic foot checks; skin change observation expectations are that CNA report all skin changes immediately to the nurse; provider notification and change of conditions expectations are that nurses will report all diabetic foot ulcers, redness, purulence, drainage to physician; weekly wound assessments with measurements;and treatments completed as ordered. Starting 10/10/24 pm shift thru all staff completion. Monitoring, Audits, QAPI, and Facility Assessment 1. DON or designee will ensure DM foot checks done daily X 14, weekly x 4 and monthly x 2 bringing results to QAPI. 2. DON or designee will ensure weekly skin checks are completed daily x 14, weekly X 4 and monthly X 2 bringing results to QAPI. 3. DON or designee will ensure weekly skin documentation completed during wound rounds; weekly X 6 and monthly x 2 bringing results to QAPI. 4. DON or designee will audit wound care treatments two residents weekly X 6, monthly x 2 bringing results to QAPI. 5. Clinical Nurse Consultant will audit process of PCC documentation / 24 hour board follow up weekly x 6 and monthly X 2 to ensure changes of condition have needed follow up completed. Example 2 R8 was admitted to the facility 7/23/24 with diagnoses including, but not limited to, as follows: diabetes mellitus type 2, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, non-pressure chronic ulcer of the left foot, cellulitis of left lower limb, muscle weakness, lack of coordination, cramp and spasm. R8's Quarterly Minimum Data Set (MDS) dated [DATE] indicates R8 is cognitively intact with a Brief Interview for Mental Status (BIMS) of 15. R1's MDS indicates he does not have current venous or arterial ulcers. On 3/5/24 Physician/Med Dir R (Physician/Medical Director) ordered the following treatment: 3 drops of Tea Tree oil per ounce of water to soak left great toe three times a week. Every evening shift every Tue, Thu, Sat for fungal treatment of Left great toe. (It is important to note, Physician/Med Dir R (Physician/Medical Director) ordered the Tea Tree oil to be diluted and not applied directly to or under the the toenail.) On 4/4/24 R8's Weekly Skin Check indicates no areas of concern. On 4/24/24 R8's Weekly Skin Check indicates No skin issues. On 4/20 or 4/28/24, per interview with DON B (Director of Nursing) R8 reported to DON B (Director of Nursing) the second digit on his left foot was burning. DON B stated, he assessed the area and did not see anything. DON B stated, he thought this burning pain may be from neuropathy. DON B stated, R8's skin was intact with no redness. DON B did not document this encounter. DON B stated, this occurred when he was working the floor on a PM shift and completed R8's Tea Tree oil treatment. On 5/1/24, R8's Weekly Skin Check indicates the previous ADON (Assistant Director of Nursing; no longer employed at the facility) circled R8's feet and initiated; no additional information is provided. No areas of concern are documented on the Skin Check or Progress Notes. On 5/6/24 at 4:42 PM, updated by ADON (previous) on open area to Left foot/toe 2.0 cm x 0.4 cm x 0.3 cm. Great toe and next 2nd toe S/S (signs/symptoms) of infection, minimal drainage, redness and increased pain to area. New orders received: Culture wound prior to start of ABX (antibiotic) Start on Cefdinir 300 mg PO (by mouth) BID x 10 days Tx (Treatment): Cleanse Left foot with wound cleanser and apply non-adhesive dressing Daily x 10 days. Monitor S/S infection daily. On 5/6/24 at 5:52 PM, a Registered Nurse documented the following: Cx (culture) to Left toe obtained and sent to (hospital name) by Assistant Director of Nursing (prior), Tx (treatment) completed post cx (culture) by RN. Resident toes on left foot very sensitive. ABD applied to top of Telfa for protection. Physician S, a wound physician, completed the following wound assessments. 5/9/24 (Initial assessment) Exam - Peripheral Vascular: Examination of left lower extremities. Mild edema, foot warm, wound present. See Focused Wound Exam below. Examination of right lower extremities: Mild edema, foot warm Pedal pulses left .Dorsalis Pedis Monophasic Signal Detected by Portable Doppler Pedal pulses right .Dorsalis Pedis Monophasic Signal Detected by Portable Doppler Focused Wound Exam: Chief complaint: Patient present with a wound on his left foot. Focused Wound Exam: Burn Wound of The Left Foot Full Thickness Etiology: Burn Duration: > (greater than) 7 days Objective: Healing/Maintain Healing Wound Size: 1.5 x 0.5 x Not measurable cm (centimeters) Depth is unmeasurable due to presence of nonviable tissue and necrosis. Surface Area: 0.75 cm2 Exudate: Light Sero-sanguinous Thick adherent devitalized necrotic tissue: 30% Granulation Tissue: 70% 5/16/24 .Focused Wound Exam: Burn Wound of The Left Foot Full Thickness Etiology: Burn Duration: > (greater than) 14 days Objective: Healing/Maintain Healing Wound Size: 1.5 x 0.5 x 0.1 cm (centimeters) Surface Area: 0.75 cm2 Exudate: Light Sero-sanguineous Thick adherent devitalized necrotic tissue: 30% Granulation Tissue: 70% Wound Progress: Not at goal 5/23/24 .Peripheral Vascular Focused Wound Exam: Burn Wound of The Left Foot Full Thickness Etiology: Burn Duration: > (greater than) 21 days Objective: Healing/Maintain Healing Wound Size: 1.3 x 0.5 x 0.1 cm (centimeters) Surface Area: 0.65 cm2 Exudate: Light Sero-sanguineous Granulation Tissue: 100% Expanded Evaluation Performed: .The patient's advancing peripheral arterial disease/gangrene significantly increases their susceptibility to complications and poor prognosis. Patient with L (left) SFA (Superficial femoral artery) occlusion with distal region to popiteal. PT (Physical Therapy and DP (Doctor of Podiatry) referral to vascular surgery for revascularize discussion with angio with PTA (angiogram with percutaneous transluminal angioplasty is a procedure that combines an angiogram with an interventional procedure to open a blocked or narrowed artery. PTA is a minimally invasive procedure that involves inserting a catheter with a balloon into an artery to widen it and improve blood flow.) vs operative planing for possible distal bypass target given delayed wound healing from his injury. Wound Progress: Improved evidence by decreased surface area 5/30/24 .Focused Wound Exam: Burn Wound of The Left Foot Full Thickness Etiology: Burn Duration: > (greater than) 28 days Objective: Healing/Maintain Healing Wound Size: 1.4 x 0.7 x 0.1 cm (centimeters) Surface Area: 0.98 cm2 Exudate: Light Sero-sanguineous Granulation Tissue: 100% Wound progress: Not at goal 6/6/24 .Focused Wound Exam: Burn Wound of The Left Foot Full Thickness Etiology: Burn Duration: > (greater than) 35 days Objective: Healing/Maintain Healing Wound Size: 1.2 x 0.6 x 0.1 cm (centimeters) Surface Area: 0.72 cm2 Exudate: Light Sero-sanguineous Granulation Tissue: 100% Wound Progress: Improved evidence by decreased surface area 6/13/24 .Focused Wound Exam: Burn Wound of The Left Foot Full Thickness Etiology: Burn Duration: > (greater than) 42 days Objective: Healing/Maintain Healing Wound Size: 1.0 x 0.7 x 0.1 cm (centimeters) Surface Area: 0.70 cm2 Exudate: Light Sero-sanguineous Granulation Tissue: 100% Wound progress: Improved evidence by decreased surface area Dressing Treatment Plan: Primary Dressing(s): Silver sulfadiazine apply once [NAME] for 23 days. Secondary dressing(s): Telfa apply once daily for 23 days. Gauze roll (kerlix) 2.25 (inch) apply once daily for 23 days. 6/27/24 .Focused Wound Exam: Burn Wound of The Left Foot Full Thickness (*Note, the facility went 14 days in between wound assessments and measurements. The wound worsened and is now 50% slough. The facility did not notify Physician S that R8's wound worsened. Physician S assessed R8 for a routine wound care visit and noted R8's change in condition.) Etiology: Burn Duration: > (greater than) 56 days Objective: Healing/Maintain Healing Wound Size: 1.5 x 1.5 x 0.1 cm (centimeters) Surface Area: 2.25 cm2 Exudate: Light Sero-sanguineous Slough: 50% Granulation Tissue: 50% Wound progress: Not a goal Dressing Treatment Plan: Primary Dressing(s): Santyl apply once daily for 30 days; Alginate calcium with silver apply once daily for 30 days: silver will not inactivate santyl Secondary Dressing: Gauze island with bdr (border) apply once daily for 30 days Reason for no sharp debridement: Debridement not indicated secondary to severe peripheral arterial disease 7/4/23 .Focused Wound Exam: Burn Wound of The Left Foot Full Thickness Etiology: Burn Duration: > (greater than) 63 days Objective: Healing/Maintain Healing Wound Size: 1.7 x 1.5 x 0.1 cm (centimeters) Surface Area: 2.55 cm2 Exudate: Light Sero-sanguineous Slough: 30% Granulation Tissue: 70% Wound progress: Not a goal Dressing Treatment Plan: Santyl apply once daily for 23 days; Alginate calcium with silver apply once daily for 23 days: silver will not inactivate santyl Secondary Dressing: Gauze island with bdr (border) apply once daily for 23 days Reason for no sharp Debridement: Debridement not indicated secondary to severe peripheral arterial disease Investigations: Recommended And/Or Reviewed: X-ray recommended on left D2 (digit 2/2nd toe) R/O (rule out) OM (osteomyelitis) on 7/4/24. On 7/4/24 Physician S wrote the following new order: Doxycycline 100 mg (milligrams) BID (two times a day)x 14 days stop 7/18/24. pre-medicate prior to dressing changes given patient's pain with change and following to minimize patient refusal of care due to pain. *7/11/24 .Focused Wound Exam: Burn Wound of The Left Foot Full Thickness Etiology: Burn Duration: > (greater than) 70 days Objective: Healing/Maintain Healing Wound Size: 1.7 x 1.5 x 0.1 cm (centimeters) Surface Area: 2.55 cm2 Exudate: Light Sero-sanguineous Slough: 30% Granulation Tissue: 70% Wound progress: Not a goal Expanded Evaluation Performed: .The patient's advancing peripheral arterial disease/gangrene significantly increases their susceptibility to complications and poor prognosis, patient with PAD (peripheral arterial disease), have previously recommended vasc (vascular) studies and PVS (an ultrasound for Peripheral Vascular Disease) given nonhealing wound in setting of PAD (Peripheral Arterial Disease). MRI (Magnetic Resonance Imaging) ordered for definitive eval of possible underlying OM (osteomyelitis), patient will require sedation to perform as prior attempt unsuccessful. On 7/11/24, Physician S documented the following Progress Note: Patient with erythema surrounding wound site despite ongoing Doxycycline therapy, patient scheduled to see pcp (primary care physician) for clearance or MRI however given this erythema despite abx (antibiotic) patient would likely require hosp (hospital) admission for broadspec (broadspectrum) abx (antibiotic) and expidited workup for OM and intervention (revasc if possible) +1 amp. R8 was hospitalized from 7/11-7/23/24. On 7/18/24, Physician S's documented the following Progress Note: The patient's visit has been rescheduled, patient remains in hospital s/p (status post) LE (left extremity) stent placement. IV abx (antibiotics) R8's hospitalization documents the following: Chief Complaint: Toe necrosis/cellulitis Patient with worsening necrosis of his foot and some spreading cellulitis appearance. He had been on Doxycycline and followed closely by wound care in the outpatient setting. he has since been put on Cefepime and vancomycin under the direction of the infectious disease team. With evaluation by local podiatry they did not feel like they could definitely amputate the involved toe without knowing more about his vasculature. Apparently there is inability to get CT angiogram for a number of days locally. He is being brought up to facilitate the workup here with vascular evaluation and CT angiogram imaging. At the time of my evaluation he describes just the discomfort in his left second digit as noted. No new areas of discomfort. Feels like the erythema in his leg is improving. Physical Exam: Extremities: Some degraded tissue on the left second digit with some other surrounding erythema, the erythema up his foot to his is receding. Circulation: Radial, pedal pulses are intact and symmetrical Assessment and Plan Infected diabetic left foot ulcer Possible Left 2nd toe OM (osteomyelitis) Cellulitis Culture from 7/11/24 growing pseudomonas/MRSA (Methicillin-Resistant Staphylococcus Aureus) ID (Infectious Disease) consulted, appreciate recs - vanco (vancomycin), cefepime, metronidazole (intravenous antibiotics), continue on discharge, ordered per ID. He will need a 6 week course of IV (intravenous) antibiotic therapy, day 0 of therapy is 7/12/24. Surveillance labs while on IV antibiotic therapy to include weekly CBC (Complete Blood Count) with differential, creatinine, ALT (Alanine aminotransferase), and vancomycin trough (tests level of vancomycin in the bloodstream), and every other week CRP (C-Reactive Protein). Podiatry consulted, recs appreciated - underwent soft debridement, patient unable to [NAME][TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistive devices to prevent accidents for 1 of 1 supplemental residents (R180) reviewed for elopement, 2 of 2 residents (R17 and R23) reviewed for motorized wheelchair charging, and 1 of 3 sampled residents (R24) and 1 of 1 supplemental residents (R180) reviewed for falls. R180 was a high risk for elopement. The facility failed to ensure R180 had adequate supervision to prevent elopement. In addition, the facility did not ensure R180 had an elopement device on his person when the resident returned from a hospitalization. R180 eloped and traveled over ½ mile from the facility. R180 was at risk for falls and had numerous falls with fractures while at the facility. The facility failed to complete comprehensive, contemporaneous evaluations of each fall, identify root cause of the falls, and implement robust care plan interventions to prevent further falls or prevent injury from falls. The facility's failure to provide adequate supervision for a resident known to wander with a history of elopement, failure to check Wander Guard and door alarms per manufacturer's recommendations, failure to reapply Wander Guard device after R180 returned from an appointment, and failure to ensure interventions were in place to prevent falls with injury created a finding of immediate jeopardy (IJ) that began on 02/07/22. On 10/27/22 at 12:00 PM, NHA A (Nursing Home Administer) and DON B (Director of Nursing) were notified of the IJ. The immediate jeopardy was removed on 10/27/22 and continues at a scope and severity of D (isolated/no actual harm) as the facility continues to implement their removal plan. R17's and R10's motorized wheelchairs were observed charging in their rooms and not in a contained area behind firesafe doors. R24 did not have a call light within reach. Evidenced by: The facility's Elopement Prevention policy, reviewed 7/22/22, includes, in part, Policy: interventions for wandering prone individuals will be individualized to maximize their independence, safety, and well-being. Procedure: at the time of admission, gather data regarding history of wandering or elopement. A licensed nurse will complete the elopement risk evaluation upon admission, quarterly and change of condition. An interim plan of care for minimizing the risk of elopement will be initiated upon high-risk determination. The interdisciplinary team will initiate a plan of care for an individual determined high risk for elopement. Interventions to decrease risk of wandering such as devices and monitoring will be initiated . and documented in the individual's plan of care. Revisions of the Elopement Risk Evaluation will be completed quarterly and or upon an individual's significant change in condition, as needed, determined by the interdisciplinary team. the plan of care for minimizing elopement risk will be reviewed each time the elopement risk evaluation is completed. Employees will be educated to elopement prevention. The facility's policy, entitled Standard Wander Protocol, undated, includes: . problem has a history of wandering and/or displays risk of elopement . goal: to ensure safety of the individual who wanders or is at risk for wandering. RN/LPN: initiate wander guard . check wonder guard placement every shift . check wander guard functionality daily . document wandering incidents, including actions taken . replace wander guard per manufacturer's guidelines . review need for wander guard placement and removal quarterly . All: provide diversional activity is as appropriate, respond to alarms, redirect from unsafe situations, maintain a calm approach to the individual, approach from the front, walk in step with individual first before redirecting when attempting to elope, involve individual and/or responsible party in care plan process. Wander Guard, manufacturer's recommendations, include: . test your departure alarm system regularly. Test monitors weekly on each shift with all surrounding power devices turned on. Test signaling devices daily as detailed in the signaling device instructions and your Wander Guard user manual. Record results on the resident's med chart. Failure to regularly test your Wander Guard departure alert system could result in an unauthorized departure and cause injury or death to a resident. Wander Guard's departure alert system is designed to assist staff, not replace them. Because the Wander Guard system is so effective when used properly, staff may become complacent, thinking the system will not fail. Anything electronic can fail. The responsibility for maintaining the security of wanderers remains with a conscientious, alert staff. Test your Wander Guard system regularly . Troubleshooting: The alarm doesn't always sound when it should . Is there a metal object, such as a table or cabinet within 5 inches of the top, front or sides of the door monitor? . Is a nearby electromagnetic device such as computer . interfering with the system? . Are signaling devices worn by the monitored resident working? . Facility policy, entitled Falls, reviewed 6/24/22, includes, in part: a licensed nurse will determine the individual's risk for falls and individualized care needs . if the individual is at risk for falls then create a falls care plan. An individual falls care plan will be created as indicated. Administrative review: upon review of the fall incident report the interdisciplinary team (IDT) using root cause analysis will gather information to investigate and gather relevant information. IDT reviews fall event through quality assurance committee. Example 1: R180 admitted to the facility 2/2/2022 with diagnoses including schizoaffective, dementia without behavioral disturbance, anxiety disorder, and repeated falls. R180 was assessed as a high risk to wander. R180's Minimum Data Set (MDS), dated [DATE], indicated R180's cognition is severely impaired with a BIMS (Brief Interview for Mental Status) score of 3 out of 15. R180 required one person limited physical assist with walking, bed mobility, dressing, transfers, and toileting. R180 is incapacitated. R180's Wandering Risk Assessment, dated 2/2/22, indicates in part the following: R180 has a diagnoses of dementia . is independently mobile . paces, wanders, tries to get out doors, . perceives the need to be doing something other than what he is doing . does not exhibit sign of sundowners . does not have a history of elopement . family/responsible party has voiced concerns that would indicate resident may have wandering tendencies or try to leave . Resident has diagnosis of dementia. Resident is also a smoker. Was observed walking to door. Very forgetful, but easily redirected. Wander Guard was placed on ankle to alert staff. Score: 16 Category: High Risk R180's fall risk assessment, dated 2/2/22, indicates R180 is at risk for falls, with the following risk factors: intermittent confusion, 3 or more falls in last 3 months, incontinent, jerking, or unstable making turns, balance problems when walking, balance problems while standing, decreased muscular coordination, requires use of assistive devices (walker), takes 3 to 4 medications currently and has 1 to 2 predisposing diseases . R180's Care Plan includes, in part, the following: The resident is an elopement risk/wanderer related to History of attempts to leave facility unattended, Wander Guard in place Date Initiated: 2/14/22 The resident will not leave facility unattended through the review date. Date Initiated: 2/14/22 Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: (blank) . Date Initiated: 2/14/22 Family brought in vending machine money for resident to use instead of going to gas station Date Initiated: 3/4/22 Red Stop Sign Velcro exit signs posted by frequently attempted doors Date Initiated: 3/4/22 Signs in room to call for assist Date Initiated: 3/4/22 WANDER ALERT: Wander Guard Date Initiated: 2/14/22 R180's Care Plan, includes: R180 is at risk for falls related to deconditioning/weakness post hospitalization . need for assist with mobility, impulsivity, anxiety/depression, and Schizophrenia with psychotropic medication, . abnormal labs, balance concerns, history of falls . Interventions: 2/3/22 Bed mobility - one assist . Transfer - one assist with wheeled walker . Encourage R180 to use bell to call for assistance . 2/14/22 distract R180 from wandering by offering pleasant diversions, structured activities, food, conversation, television, books. Resident prefers: (blank) . Wander Guard applied. 2/25/22 R180 is to wear gripper socks 3/4/22 bedroom door alarm added. Family brought in vending machine money for resident to use instead of going to the gas station. Family provided scratch off tickets for use as needed. Signs in room to call for assist. 8/5/22 R180 to have a low-profile bed, mats next to bed, Dycem to chair 8/22/22 R180 is not to be left alone in dining room. R180 is to get up first in the morning unless he is sleeping, check often to see if he is awake. R180's Physician Orders, include: Start date: 2/3/22 End date: 7/28/22 check placement and function of Wander Guard every shift. Start date: 2/15/22 End date: 7/28/22 15-minute checks R180's Medical Record included the following: R180's Nurse's Note, dated 2/5/22 at 9:08 PM, includes Resident voiced wanting to go outside for a cigarette. Resident was easily re-directed. Medical Doctor (MD) was notified and request for nicotine patch was ordered for 21 mg 24-hour patch. Resident was given a shower. No skin breakdown. Resident's sister coming tomorrow morning to cut resident's hair. Will continue to monitor for smoking sensation and elopement. R180's Nurse's Note, dated 2/7/22 at 12:44 AM, includes Writer and CNA (Certified Nursing Assistant) were providing cares in room on short hall. Writer walked out of room to hear door alarm going off. Writer and CNA immediately began checking doors. While going to door by kitchen writer saw resident heading across parking lot. Writer opened door and directed resident back inside building. Resident offered no resistance but appeared a little shaky. When asked where he was planning on going resident stated he was headed to get coffee. Writer assisted resident back to his room and educated on risks of elopement to which resident stated Yes, I could freeze to death out there Resident was walking at fast pace and shuffling feet with walker not touching ground. Educated on need to use call light and wait for assistance as well for safety. decaf coffee made and given. Call placed with messages left for DON (Director of Nursing), NHA A (Administrator), and R180's first contact. Placed on 15-minute checks at this time. On 2/7/22 there was a high of 27 degrees and a low of 18 degrees in this area. R180's Nurse Note, dated 2/14/22 at 12:09 PM, includes: R180 has Wander Guard intact, and family is bringing in scratch off tickets as needed to keep his mind off going to gas station. R180's Nurse Note, dated 2/14/22 at 4:02 PM includes Nurse alerted by dietary that resident exited the building. Dietary aide seen the resident walk out the door. Resident's Wander Guard was in place but did not alert the alarm. The resident was found just outside exit door next to dietary. When the resident was asked where he was going the resident stated, I was trying to go to my mom's house. Resident was easily redirected back to his room. Family and DON notified of elopement. Implementing 15-minute checks and Wander Guard system check every shift. Will continue to monitor. On 2/14/22 there was a high of 27 degrees and a low of 12 degrees in this area. R180's Medical Record contained the following: Nurse's Note (NN) Fall report: 147 Witnessed Date: 2/24/22 Time: 8:05pm Location: Outside Injury: none Outcome: Root Cause: none Interventions in place at time of fall, noted in Report Notification: Yes Assessment: [NAME]: New Interventions: Yellow neon sign was placed on exit door near room to STOP do not exit Notes/Concerns: Med Tech Picked resident up off ground outside, R180's Fall Report, dated 2/24/22 at 8:05 PM, includes location - outside . Yellow neon sign was placed on exit door near room to stop and do not exit . Medication Technician picked resident up off of the ground outside. On 2/24/22 there was a high of 25 degrees and low of 10 degrees in this area. Fall report: 148 Unwitnessed Date: 2/25/22 Time: 6:15AM Location: Dining room Injury: none Outcome: Root Cause: not using walker regular socks on Interventions in place at time of fall, noted in Report Notification: Yes Assessment: [NAME]: Yes New Interventions: have gripper socks/or shoes on when ambulating Notes/Concerns: R180's NN 2/25/2022 06:51 AM Phone call to POA (Power of Attorney) to inform of resident's unwitnessed fall in the dining room. Spoke with POA who said, That's why I'm so relieved that he is going to stay longer than his therapy anticipated so he can be watched. R180's NN 2/25/2022 06:51 AM Resident up this am and walking down long hallway with walker looking for bathroom as his was clogged with cups and straws. Was assisted to bathroom in activity room. Writer getting report and was then called to dining room to resident on floor. He was not able to state why he fell. [NAME] was left in hallway and resident was only in regular socks. neuro checks, body check, and VS stable R180's Nurse's Note, dated 2/27/2022 at 3:15 AM Resident was not in his room. Staff had been doing rounds on other residents. Staff immediately went looking for him. Resident was found sitting in the employee break room eating a bag of potato chips he had purchased from the vending machine. Resident has his wallet and several dollars on the break room table. Resident was asked if he would like something to drink. Resident stated he wanted a Pepsi. Staff offered resident a 6oz can of cola from the kitchen, so he did not have to spend his money. Resident also had a pack of cookies to eat. Resident assisted to find his new room where he sat on the bed to watch TV. R180's Comprehensive Care Plan was updated with bedroom door alarm Date Initiated: 3/4/2022 NN dated 3/1/2022 8:03 AM Upon start of shift R180 displays erratic behavior with cognitive decline from baseline. Pt VS with tachycardia and hypotension increasing R180 fall risk status. R180 observed wearing pants upside down, walking in the hall with a commode as a walker, R180 able to answer question only to name, unaware of place, time, and situation. R180 shows flat affect and slight agitation with interaction, R180 room displays manic behavior with magazines, candy, and clothes everywhere and items placed in the toilet. R180 suspected to be psychiatric episode, this facility unable to safely attend to R180 to ensure fall and elopement risks. ER NOTE 3/1/22: your CT scan showed a T11 endplate fracture (small fx of thoracic spine . Follow up with Personal Care Provider in one week . (It is important to note the facility did not report this injury of unknown origin to the state agency or conduct a thorough investigation regarding this injury.) NN 3/1/2022 9:22 PM Wander guard replaced to left arm would not allow this nurse to place it on his ankle. Nurse Practitioner Note, 3/9/22: Patient seen ambulating in facility with his TLSO brace on .denies pain . no elopement attempts . Neurosurgery Note, 3/16/22 - wear brace at all times when you are not lying flat in bed . Do not lift anything greater than 5 lbs. restrict bending twisting or turning of the mid back and lower back . return to Neurosurgery in one month NN 3/21/2022 10:44 AM: Resident has an MRI April 6th @ 11:30 (hospital name). Pick up between 11:00 AM and 11:15 AM. (social worker name) will take to appointment. Fall report: 155 unwitnessed Date: 3/22/22 Time: 7:00pm Location: Hallway Injury: Right Knee Outcome: Bruising on Right Knee (front) Root Cause: Interventions in place at time of fall, noted in Report Notification: Yes Assessment: Yes [NAME]: New Interventions: Notes/Concerns: 6/22/22 resident is impulsive and has no safety awareness. Staff will be present with him, and they turn their head for one second and he attempts to get up on his own. Will continue to monitor res. To keep from having major injuries. (It is important to note 3 months after the fall the IDT team met and discussed this fall.) NN 3/22/2022 7:47PM: Resident was heard by Med Tech but not physically seen as he was pushing his w/c and went down in hallway landing on his knees. Some bruising noted to right knee. Neuro checks initiated. Dr. and family notified. Resident with dx. of schizophrenia stated he was just going too fast, stated everything was just going too fast, offered lorazepam which he took, and a snack sat in dining room for a while. Assisted to bed. Fall report: 157 Date: 3/25/22 Time: 2:00pm Location: Resident bedroom, By bed unwitnessed Injury: None Outcome: Root Cause: Interventions in place at time of fall, noted in Report Notification: Yes Assessment: [NAME]: New Interventions: Notes/Concerns: Fall report: 158 Unwitnessed Date: 3/26/22 Time: 2:00pm Location: resident's bedroom by Bathroom door Injury: Hit back of head Outcome: ER, Root Cause: Interventions in place at time of fall, noted in Report Notification: Yes Assessment: Yes [NAME]: New Interventions: Notes/Concerns: resident has had increase in tremor like movements, poor color with grayish hue. Constant reminders to call for assist. NN 3/25/2022 10:51 PM: At 2:00 PM R180 spilled his pop while attempting to pick it up slid down on floor next to his bed. No apparent injuries. Dr. and family notified. Neuro checks started. NN 3/31/2022 2:17 PM: R180 had unwitnessed fall during lunch, R180 was eating in dining room, staff unsure how as dining room is closed related to covid precautions. This RN was on break when another staff member alerted that R180 is on floor in dining room. R180's vitals obtained at the time and are within normal limits. No visible injury, R180 states a lot of pain all over. Non emergent paramedics called with no availability, 911 called and transported R180 to Hospital Emergency Department for evaluation. POA called without answer, message left to call hospice service for update. NN 3/31/2022 6:41PM: Resident returned from ER visit following a fall, No new orders. No apparent injuries. Had CT scan of head which was negative. NN 4/2/2022 12:37PM: Late Entry: Resident very weak this am, having a hard time standing and focusing. [NAME] skin tone. Stating he does not feel great. This writer was one on one with resident totally dependent on feeding. Was unable to hold cup d/t tremors. Oak medical was updated and will be in to evaluate. Spoke with POA [NAME] who stated just to monitor. Will speak to NP when she arrives. Will continue to monitor. 4/2/2022 17:03 Nurse's Note Late Entry: Note Text: Nurse completed AIMS assessment on resident related to increased uncontrollable body movements. Resident needs assistance with feeding due to uncontrollably shaking of the arms. Increase in shuffling gait. Increase in need of assistance with cares. POA and MD updated on change in condition. Neuro Note, 4/6/22: new acute fractures noted on MRI at T2, T5, and T11. (It is important to note the facility did not thoroughly investigate the new injuries of unknown origin and did not report them to the state agency.) NN 4/7/2022 8:49PM: This writer received call from R180's Nurse Practitioner (NP) from neuro. NP stated scan on 4/6/2022 revealed T2, T5, and T11 fracture. Not certain if this is old or new. Wanted R180 to come in tomorrow 4/8/22 to Ortho at 3:00 PM to receive new brace from neck to waist. Social Worker who usually transfers resident was unable. R180's family member will transport. Discussed with NP that resident has no complaints of pain and no facial grimacing noted. NP understands that R180 will probably not wear brace. Left message for POA to return call back. 2nd contact was updated on plan. NN 4/8/2022 5:01AM: Resident was walking down the hallway looking lost early this AM. Resident smelled strongly of bowel movement. Staff assisted resident into his bathroom to clean him up. He was incontinent of an extremely large bowel movement (BM) with formed stool balls (approx. 5 balls of BM that were approx. 3-4 in diameter) mixed with thick liquid stool. Perhaps this is what caused resident's nausea and emesis earlier. NN 4/8/2022 12:23PM: Sent to emergency room for change of condition, 2 falls, loose stools, leaning heavily to the right. Report called to emergency room nurse, family aware and will meet him there. Fall report: 162 Unwitnessed Date: 4/8/22 Time: 3:30pm Location: Bathroom Injury: Outcome: Root Cause: Interventions in place at time of fall, noted in Report Notification: Assessment: [NAME]: New Interventions: Notes/Concerns: med change lithium dose cut in half, possible change of plane Fall report: 163 Unwitnessed Date: 4/8/22 Time: 7:47pm Location: resident bedroom floor next to tv stand Injury: none Outcome: Root Cause: Interventions in place at time of fall, noted in Report Notification: Yes Assessment: Yes [NAME]: New Interventions: Notes/Concerns: Resident restless all morning, color pale NN 4/8/2022 8:03PM: Resident had a fall in his rm., had been more restless with multiple self-transfers after redirection. More tremors noted. Incontinent of loose stool 3 times this morning. Dr. notified along with POA. NN 4/9/2022 2:32 AM: Phone call to Mercy Hospital to get update on resident. Resident was admitted to 4th floor ortho RM [ROOM NUMBER] with DX of colitis (with MRI inflamed colon) and being treated with IV ABX. Resident also noted to have metabolic encephalopathy. Resident is reportedly on a video monitor in his room because he keeps getting up unassisted to walk around. This writer informed nurse on phone of resident passing of 5 huge round balls of hard formed stool (about the size of tennis ball or baseball) on the NOC shift 4/7/22 at approx. 0300. NN 4/9/2022 2:32 AM: Phone call to Hospital to get update on resident. R180 was admitted to 4th floor ortho RM [ROOM NUMBER] with diagnosis of colitis (with MRI inflamed colon) and being treated with IV antibiotics. Resident also noted to have metabolic encephalopathy. NN 4/13/2022 readmitted from Hosp . Catheter placed for retention . Fall report: 165 Date: 4/13/22 Time: 6:30pm Location: Dining Room Injury: redness to area on shin Outcome: Root Cause: Interventions in place at time of fall, noted in Report: had back brace on Notification: Assessment: [NAME]: New Interventions: Notes/Concerns: Resident restless reminded frequently to call for assist does not. Makes sudden moves. Hx of frequent falls. Fall report:166 witnessed Date:4/14/22 Time: 7:08pm Location: dining room Injury: none Outcome: Root Cause: Interventions in place at time of fall, noted in Report Notification: Yes Assessment: Yes [NAME]: New Interventions: Notes/Concerns: (noted that resident was 1:1, broda chair, back brace) Fall report: 167 Witnessed Date: 4/14/22 Time: 11:00pm Location: Nursing Station Injury: none Outcome: Root Cause: Interventions in place at time of fall, noted in Report Notification: Yes Assessment: [NAME]: New Interventions: Notes/Concerns: 1:1 d/t constantly trying to get up to walk when his legs are too weak to support him, and his balance is way off. Res. Being 1:1 due to earlier fall on PM at supper in DR. has made several attempts to stand up from broda chair while 1:1 at nurses' station. Went to get out of broda to stand up and went off the left side of footrest. NN 4/14/2022 11:17 PM: This nurse was getting this resident a drink while getting ice witnessed resident attempt to stand and went down on buttocks. No apparent injuries did not hit head. Resident very restless redirected freq. has decreased cognition and will reattempt to self-transfers at times just mins. later. NN 4/15/2022 12:55 AM: Fax out to clinic to inform of resident's witnessed fall while trying to stand up from his broda chair this night shift. Resident's legs are weak, and his balance continues to be very off so that whenever he attempts to stand unassisted, his legs give out and he drops straight to the floor. Resident also had a fall around supper time on the PM shift when he tried standing up from his chair. That fall was also reported as being witnessed. Resident currently on neuro checks from the same type of fall that he had yesterday 4/13/22 on the PM shift. R180 was wearing his back brace for all the falls. Fall report: 169 Witnessed Date:4/18/22 Time: 7:02pm Location: dining room self-transferring Injury: none Outcome: Root Cause: none Interventions in place at time of fall, noted in Report Notification: Assessment: [NAME]: New Interventions: Notes/Concerns: instructed multiple times to call for assist attempted to stand again in front of nurse right after instruction. Difficult to redirect. R180's MDS, with ARD 4/20/22, indicates R180's cognition is severely impaired with a BIMS score of 3 out of 15. NN 4/23/2022 3:53 AM: Resident seems to be much more alert and brighter with better balance. He woke up around 1am and was out in hallway looking for staff in his wheelchair. Resident was not wearing his brace. Resident easily redirected back to his room, assisted to toilet and then back to his bed. Resident refused to wear his back brace in bed. Resident sat up and ate two McDonalds hamburgers and drank a 4oz root beer then went back to sleep. NN 4/26/2022 6:32 PM: Resident ambulating independently fell, hit his head as witnessed by another resident. Did not move . called 911 for transport to Emergency Room, transported at 6:30 PM, POA notified. NN 4/29/2022 12:20 MDS: Weekly Medicare review for April: 4/19: PT: Max assist for mobility, significant fall risk. Have not been able to progress ambulation. Standing tolerance of 20 seconds. OT: max assist for all cares. Very confused. No carryover to directions. ST: brace appears to contribute to swallow issues. Nsg-assisted with mobility/personal cares. 2 falls with leg weakness, refusing brace use at times. Fall report:173 Unwitnessed 5/1/22 8:49 AM checking for ants in dining room Date: 5/1/22 Time: 8:49am Location: dining room Injury: none Outcome: Root Cause: Interventions in place at time of fall, noted in Report Notification: Yes Assessment: [NAME]: New Interventions: Notes/Concerns: 5/2/22 - res has had multiple falls throughout stay. All previous interventions have been in place and remain in place. Resident has memory issues and can't recall discussions from 2 min. ago. Will continue with interventions. will continue with frequent checks. NN 5/1/22 9:03 AM: Writer found Resident lying on right side in the dining room, near his table, approximately 6-8 feet from his wheelchair. On assessment, he was alert and oriented as per usual x1. When asked what he was doing on the floor, he responded, I'm checking for ants! and began to laugh. He was not wearing his brace at the time of the fall but was applied after the fall. He had no complaints of pain and moved all extremities well. CMS intact x4. No external rotation or shortening noted hips. Resident lifted to wheelchair after assessment with mechanical lift. VSS. NN 5/1/2022 12:30PM: . Was approached by CNA to assess the resident due to him leaning to the right in his wheelchair. On assessment, I found him leaning 45 degrees in his wheelchair. Alert and Oriented x1 as per usual. Resident denies pain at this time. BP= 169/103; P=112; r=20 SpO2=94% RA and T=97.7. Writer decided to send Resident to Emergency Department 911. 1240 Call place to on call Oak Medical. No one was available to speak to and to receive order. 1245 Call to Rock County 911 Center. 1250 While talking to 911 dispatcher, writer heard a sound behind me, and I turned around and found that resident had fallen out of his wheelchair onto the floor hitting his head on the med cart. 1257 Janesville Paramedics here to assess and transport resident Fall report: 5/1/22 1:18 PM - change of condition, leaning to the right, fall at nurses stations. RN turned back and resident fell. - sent to ER. NN 5/1/2022 8:35 PM: Resident returned to facility from emergency room following a fall on a.m. shift. No injuries were sustained, or evidence of any injuries found in ED. NN 5/2/2022 10:04 AM: Pt had another unwitnessed fall this morning in dining room after breakfast. R180 stated standing to obtain chocolate milk. R180 multiple times daily reminded to ask for help with transfers, staff unable keep R180 within sight constantly although attempted. NP at facility during incident, assessment shows R180 cognitive baseline decreased with unwitnessed fall, resident stated might have hit head. No visible injury assessed R180 sent to emergency room via paramedics per NP orders. Call placed to POA, and message left to return call to hospice services. Fall report: 174 Date:5/2/22 Time: 1:18pm Location: nurses station Injury: hit head on med cart Outcome: ER Root Cause: Interventions in place at time of fall, noted in Report Notification: POA Not notified Assessment: [NAME]: yes New Interventions: Notes/Concerns: No follow up in report 5/2/22 elopement risk score 15 NN 5/5/2022 7:18 PM Resident removed indwelling foley catheter. Resident had foley catheter in ER on [DATE] for urinary retention. Resident voided a total of 600 ml this p.m. shift. Resident showed no residual urine on bladder scan. MD notified. Order placed for bladder scan x3 days for residual urine monitoring. Resident has a urologist referral order placed. Will continue to monitor. NN 5/13/2022 4:49 AM: Resident was apparently seen by Neurosurgery on 5/12/22. After Visit summary scanned . Appointment for 5/24 was voided out. No new orders. Resident to be encouraged to wear brace at all times when not laying flat in his bed. NN 5/14/2022 3:45 PM: Nurse received a phone call at the nurses station from the lobby. The dietary aide on the call stated that a resident was in the lobby who needed assistance. Nurse went to the lobby with a wheelchair to assist the resident. The resident was in the lobby sitting in a lobby chair. Nurse transported resident to resident's room via wheelchair. Resident stated to a CNA on p.m. shift that he just returned from the library. CNA reported resident's statement to the nurse. Nurse asked resident if he had just gotten back from the library. Resident did not have a wander guard on his body. Nurse began to look for wheelchair and it was not located. Nurse placed a wander guard on R180's L ankle. When placed nurse noticed an open pack of cigarettes and a lighter tucked in his sock. Nurse could also smell cigarette smoke in the resident's room. Nurse then removed cigarettes and lighter from resident's possession. Nurse then asked the resident where the lighter and cigarettes had come from. Resident stated that he had gotten them from the gas station that he had went to today. Resident stated that his wheelchair was near the gas station. Staff located the wheelchair near a local gas station (location given in town 0.7 miles from facility). The wheelchair was returned to facility by a staff member. The wheelchair did not have the resident's Wander Guard. Nurse placed a [TRUNCATED]