Vernon Manor

Inspectors wroteBased 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

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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; [...]

Inspectors wroteBased 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]; [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]