Every finding on record at Bayou Chateau Nursing Center

Based on interviews and record review, the facility failed to ensure direct care staff consulted with the Physician or Nurse Practitioner for 1 (Resident #2) of 3 (Resident #1, Resident #2 and Resident #3) sampled residents reviewed. The facility failed to notify the Physician or Nurse Practitioner when Resident #2 refused medications for the months of May, June, and July 2026.Findings:Review of the Clinical Record for Resident #2 revealed Resident #2 was admitted to the facility on [DATE] with diagnoses, which included Paranoid Schizophrenia, Bipolar Disorder, Current Episode Mixed, Severe with Psychotic Features.Review of July 2026 Physician Orders revealed in part. (1) Trileptal 300mg 1 tablet by mouth twice a day with a start date of 04/29/2026. (2) Zyprexa 15mg 1 tablet by mouth at bedtime with a start date of 04/29/2026. On 07/20/2026 at 1:58 p.m., review of the Quarterly MDS with an Assessment Reference Date of 05/13/2026 for Resident #2 revealed she had a BIMS (Brief Interview for Mental Status) of 15, which indicated the resident was cognitively intact. Review also revealed Resident #2 was receiving antipsychotics on a routine basis only.In an interview on 07/21/2026 at 4:04 p.m., with S3 NP revealed she was not aware of Resident #2 refusing her medications of Trileptal and Zyprexa for the months of May, June, and July 2026. She stated she should have been notified of Resident #2 refusing her medications but was not.Review of Resident #2's May EMAR (electronic medication administration record) revealed Resident #2 refused Trileptal 300mg for the entire month of May. EMAR also revealed Resident #2 refused Zyprexa 15mg for the dates of July 2,3, 5-11, 13-19, 21-28, and 30.Review of Resident #2's June EMAR revealed Resident #2 refused Trileptal 300mg for the entire month of June. EMAR also revealed Resident #2 refused Zyprexa 15mg for the dates of July 1-4, 6,7, 9-11, 13,14, and 16-30.Review of Resident #2's July EMAR revealed Resident #2 refused Trileptal 300mg for dates of July 1-4, July 5-8, and July 10-21, 2026. EMAR also revealed Resident #2 refused Zyprexa 15mg for the dates of July 1-4, July 6,7, 10-11, 14-17, and 19.In an interview on 07/21/2026 at 4:10 p.m., S2 DON stated, if a resident refuses a medication more than once, they are to notify the MD/NP. In an interview on 07/21/2026 at 4:47 p.m., S4 LPN stated, if a resident refuses a medication more than once, nurses are to notify the MD/NP by the end of the day and not wait until multiple doses had been refused by the resident. When the 1st dose is refused, I call the NP to make them aware by the end of my shift.In an interview on 07/21/2026 at 5:07 p.m., S2 DON confirmed Res #2 had been refusing her medications for the months of May, June, and July and the nurses did not notify the MD/NP but should have.

Based on interviews, and record reviews, the facility failed to maintain accurate medical records in accordance with accepted professional standards and practices. The facility failed to ensure documentation on the EMAR Electronic Medication Administration Record was accurate for Resident #2. The facility had a census of 75. Findings:Review of the undated facility's policy titled Medication Administration Policy and Procedure revealed in part.Procedure: (35) Each dose of medication administered shall be properly recorded in the resident's medical record. On 07/20/2026 at 1:58 p.m., review of the Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 05/13/2026 for Resident #2 revealed she had a BIMS (Brief Interview for Mental Status) of 15, which indicated the resident was cognitively intact. Review also revealed Resident #2 was receiving antipsychotics on a routine basis only.Review of Resident #2's May 2026 EMAR revealed Resident #2 did not receive her medication of Paliperidone Palmitate ER Intramuscular Suspension Prefilled Syringe 234mg/1.5ml one time a day monthly on the 28th.Review of Resident #2's June E[DATE] revealed Resident #2 did not receive her medication of Paliperidone Palmitate ER Intramuscular Suspension Prefilled Syringe 234mg/1.5ml one time a day monthly on the 28th.On 07/21/2026 at 4:04 p.m., review of nurses' progress notes for 05/28/2026 at 2:24 p.m. revealed the Paliperidone Palmitate ER Intramuscular Suspension 234mg was not administered with the reason of awaiting arrival from pharmacy okay to admin upon arrival by [NAME] Lee, LPN. Review of review of nurses' progress notes for 06/28/2026 at 11:47 a.m. revealed the Paliperidone Palmitate ER Intramuscular Suspension 234mg was not administered with the reason of waiting on Rx by [NAME] Laprarie, LPN. In an interview on 07/21/2026 at 4:47 p.m., S4 LPN stated she had ordered Resident #2's medication (Paliperidone Palmitate ER Intramuscular Suspension 234mg) from the pharmacy and that S6 ADON must administer it to Resident #2. S4 LPN stated Resident #2 will not allow anyone else to administer her injections but S6 ADON. S4 LPN stated she was off for a couple days after ordering the medication, so when she returned, she asked S6 ADON did she got Resident 2's medication and gave it to her. She stated S6 ADON told her she had given Resident #2 her injection. Observation of the medication room with S4 LPN revealed Resident #2's injection was not available, therefore S4 LPN stated, she must have given it. S4 LPN stated they must wait and order the medication when it is almost due to be administered, so in a couple days they will order the July dose. In an interview on 07/21/2026 at 5:00 p.m., S5 Pharmacist revealed the Paliperidone Palmitate ER Intramuscular Suspension 234mg had been ordered and delivered on 05/29/2026 and 06/29/2026. In an interview on 07/21/2026 at 5:07 p.m., S2 DON stated, any medication that is given to a resident should be documented. S2 DON stated S6 ADON is the only nurse who can administer Resident #2's injections because she will not allow anyone else to give it to her. S2 DON stated S6 ADON probably gave Resident #2 her monthly injections for May and June 2026 and did not document it but should have. In an interview on 07/21/2026 at 6:02 p.m., S2 DON confirmed the medical record for Resident #2 was not accurate but should have been.

Based on observation, record review, and interview the facility failed to follow infection control practices to prevent the development and transmission of infection. The facility failed to implement Enhanced Barrier Precautions for 1 (Resident #1) of 3 (#1, #2, #3) sampled residents.Findings:Review on 01/06/2026 of the facility's policy and procedure dated 04/15/2025, and titled Enhanced Barrier Precautions read in part. It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multi-resistant organisms. Policy Explanation and Compliance Guidelines: 1. Prompt recognition of need: a. All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions. 2. Initiation of Enhanced Barrier Precautions: b. Enhanced barrier precautions will be implemented for residents with any of the following: i. indwelling medical devices (feeding tubes) even if the resident is not known to be infected or colonized with a MDRO. 4. High-contact resident care activities include: g. Device use: feeding tubes.Review of Resident #1's clinical record revealed an admit date of 09/04/2025, with diagnoses which included Anoxic Brain Damage, Dysphagia following Cerebral Infarction, Gastrostomy, Moderate Protein-Calorie Malnutrition, Personal History of Sudden Cardiac Arrest and Aphasia following other Cerebrovascular Disease.Review of Resident #1's Quarterly MDS with an ARD of 12/10/2025 revealed the BIMS was not assessed due to Resident #1 rarely/never being understood, which indicated the resident had severe cognitive impairment. Resident #1 had a feeding tube and was dependent for oral hygiene; total hygiene; showering/ bathing; upper and lower body dressing; putting on and taking off footwear; personal hygiene and rolling left to right.Review of Resident #1's Care Plan revealed in part. I have the potential for alteration in health maintenance related to my diagnosis: PEG tube feedings. Interventions included. administer medications as ordered and provide a clean/safe environment.Observation of Resident #1's room door on 01/06/2026 at 9:20 a.m. revealed an enhanced barrier precaution sign.Observation of medication administration on 01/06/2026 at 1:35 p.m. with S3 LPN revealed S3 LPN did not don a gown when administering Resident #1's medications and tube feeding through her PEG tube.Interview with S3 LPN on 01/06/2026 at 1:49 p.m. revealed Resident #1 was on Enhanced Barrier Precautions due to her having a PEG Tube. S3 LPN confirmed she did not wear a gown while administering Resident #1's medications and tube feeding.Interview with S1 DON and S2 ADON revealed a gown should be worn for direct contact with a resident on enhanced barrier precautions. S2 ADON confirmed a gown should have been worn during the administration of Resident #1's medications and feeding through her PEG tube but was not.

Based on observation and interview the facility failed to ensure drugs and biologicals were labeled and stored appropriately based on current acceptable professional principles. The Facility failed to ensure: 1. Expired medications were not available for administration to residents for 1 (med cart A) of 3 (med cart A, med cart B, and med cart C) medication carts observed. 2. Medications and wound care products were labeled with the date it was opened for 1 (med cart B) of 3 (med cart A, med cart B, and med cart C) medication carts observed. 3. Medications were stored in a locked compartment and not available to unauthorized staff to access for 1 (med cart B) of 3 (med cart A, med cart B, and med cart C) medication carts observed.This deficient practice had the potential to affect any of the 52 residents who resided in the facility.Findings: Review of the facility's policy titled Labeling of Medications and Biologicals with a revised date of 07/21/2021 revealed, in part. Labels for multi-use vials must include:a) The date the vial was initially opened or accessed;b) All opened or accessed vials should be discarded within 28 days unless the manufacturer specifies a different date for that opened vial. Review of the facility's policy titled Medication Storage with a revised date of 05/14/2025 revealed, in part . a) All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. b) Only authorized personnel will have access to the keys to locked compartments. #1Observation on 09/16/2025 at 08:55 a.m. of Med Cart A accompanied by S8 LPN revealed a vial of insulin with an open date of 07/25/2025 and a discard date of 08/21/2025. S8 LPN confirmed insulin vial should have been discarded after 08/21/2025 and was not. Interview on 09/16/2025 at 9:56 a.m. with S2 DON confirmed insulin vial was opened on 07/25/2025 and should have been discarded after 08/21/2025 and was not. #2Observation on 09/17/2025 at 11:00 a.m. of Med Cart B revealed multiple open items that were undated, including: (1) bottle of 100ml Normal Saline, (1) tube of Calmosepetine cream, (1) bottle of Gentian Violet, and (1) tube of Silver Antimicrobial Wound Gel. S5 LPN confirmed items in Med Cart B should have been dated upon opening and were not. Interview on 09/16/2025 at 11:33 a.m. with S2 DON confirmed items in Med Cart B should have been dated upon opening and were not. #3Observation on 09/17/2025 at 11:00 a.m. revealed the keys to Med Cart B hanging on a hook attached to the outside of the cart, making them accessible to unauthorized personnel. Interview with S5 LPN confirmed that staff hang Med Cart B's keys on the hook located on the outside of the cart. Interview on 09/17/2025 at 11:33 a.m. with S2 DON confirmed that keys to Med Cart B should not have been left unattended or accessible on the outside of the cart.

Based on observation, record review, and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections by: 1. Failed to ensure staff sanitized hands between residents, while providing assistance during mealtime. This deficient practice had the potential to affect 12 residents that are fed by staff in the facility, and; 2.Failed to ensure Enhanced Barrier Precautions were followed for Resident #5 and Resident #33. This deficient practice had the potential to affect all 12 residents that are on EBP. The total sample size was 20. 1. Review of the facility's undated policy titled Dining Room/Meal Time Procedure read in part.Purpose: To ensure residents are provided meals in a timely, organized manner that preserves dignity, promotes adequate nutritional intake while ensuring safety. 3. General Procedure. A. All employee serving meals will wear hair protections and exercise appropriate infection control measures. An observation on 09/15/2025 at 11:22 a.m., while in the dining room, S3 CNA was observed sitting at a table assisting 2 residents with lunch service. S3 CNA was observed going back and forth feeding the 2 residents without sanitizing her hands between residents. An interview on 09/15/2025 at 12:00 p.m., S3 CNA confirmed that she did not sanitize her hands between feeding more than one resident at a time during lunch service. 2. Review of facility policy titled, Enhanced Barrier Precautions, revised 04/15/2025, revealed in part. Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high-contact resident care activities. 2b. Enhanced Barrier Precautions will be implemented for residents with any of the following: wounds (e.g., chronic wounds such as pressure ulcers, etc.) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, hemodialysis catheters, PICC lines, midline catheters). Resident #33 Review of Resident #33's electronic medical record (EMR) revealed a facility admission date of 06/06/2012, with diagnoses that included in part, Pressure Ulcer of Right Buttock, Stage 2, Extended Spectrum Beta Lactamase (ESBL) Resistance, Retention of Urine, and Resistance to Multiple Antimicrobial Drugs. Special Instructions: Transmission-Based Precautions: Enhanced Precautions (Indwelling urinary catheter). Review of Resident #33's Annual MDS with an ARD of 09/03/2025 revealed the resident had a BIMS score of 15, indicating intact cognition. Review of Resident #33's care plan initiated on 02/27/2025, revealed Resident #33 had an indwelling urinary catheter and a stage 2 pressure area to right buttock with interventions that included in part. Enhanced Barrier Precautions per protocol. On 09/16/2025 at 09:40 a.m. observation of EBP signage on Resident #33's door read . Stop Enhanced Barrier Precautions Everyone Must: Clean their hands, including before entering and leaving the room. Providers and staff must also: Wear gloves and a gown for the following High-Contact Resident Care Activities Dressing Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing Briefs, or assisting with toileting, Device care or use: Central Line, Urinary Catheter, Feeding tube, Tracheostomy. Wound Care: any skin opening requiring a dressing. On 09/16/2025 at 9:50 a.m., observation revealed S5LPN entered Resident #33's room, performed direct patient care, including wound care to Resident #33's right buttock stage 2 pressure ulcer and right leg skin tear, and flushed Resident #33's urinary catheter. S5LPN did not apply a gown prior to or during the course of the direct patient care. In an interview on 09/16/2025 at 09:58 a.m. S5LPN revealed she was aware Resident #33 required Enhanced Barrier Precautions (EBP). S5LPN confirmed she did not wear a disposable gown while performing direct patient care for Resident #33, and should have. In an interview on 09/16/2025 at 10:20 a.m., the above findings were discussed with S2DON. S2DON confirmed the nurse should have applied a disposable gown prior to performing wound and catheter care for a resident on enhanced barrier precautions, and did not. Findings: Review of Resident #5's medical record revealed an admission date of 04/06/2025 with an admitting diagnosis of Hypertensive Chronic Kidney Disease with Stage 5 CKD or End Stage Renal Disease, Kidney Transplant Failure, Type 1 Diabetes Mellitus, Anemia in Chronic Kidney Disease, and Dependence on Renal Dialysis. Review of Resident #5's Quarterly MDS (Minimum Data Set) dated 07/16/2025 revealed in part. Resident#5 required substantial/maximal assistance with personal hygiene and Resident #5 had a BIMS (Brief Interview Mental Status) score of 5 indicating cognition was severely impaired. Review of Resident #5's Care Plan on 09/16/2025 at 1:34 p.m. initiated on 04/25/2025 with revision date of 04/25/2025 revealed in part, Focus: I have the potential for alteration in health maintenance related to my diagnosis: End Stage Renal Disease (ESRD) on hemodialysis status post renal transplant in 2012 .Intervention/tasks: Enhanced barrier precautions as per protocol when providing care related to implanted dialysis access, PEG tube. On 09/16/2025 at 8:32 a.m., an interview with S7 CNA revealed she had just performed a bath, oral care, and peri care on Resident #5. When surveyor asked S7 CNA what personal protective equipment she wore while performing the care to Resident #5, she stated, just gloves. She stated she did not wear a gown. When asked what the Enhanced Barrier Precaution sign meant, she stated, It means precautions, wear gloves and gown if necessary. On 09/17/2025 at 11:54 a.m. an interview was conducted with S2 DON who confirmed S7 CNA should have worn a gown and gloves while providing Resident #5's bath and did not.

Based on observation, interview, and record review, the facility failed to ensure the resident's right to formulate an advanced directive was properly reflected in the resident's medical record for 1 (Resident #30) of 1 resident reviewed for advanced directives. The facility failed to ensure all medical records regarding advanced directive/code status consistently reflected Resident #30's wishes to be a DNR (Do Not Resuscitate).Review of the facility undated policy titled Advanced Directives read in part. Advanced directives will be respected in accordance with state law and facility policy. 4. Information about whether or not the resident has executed an advanced directive shall be displayed prominently in the medical record. Review of Resident #30's electronic medical record (EMR) revealed an initial admission date of 08/09/2024 with diagnoses that included in part, Hypertensive Heart Disease without Heart Failure, Major Depressive Disorder, Essential (Primary) Hypertension, Type 2 Diabetes Mellitus without Complications, and Unspecified Dementia, Mild, with Anxiety.Review of Resident #30's Significant Change MDS with ARD of 06/11/2025 revealed in part. Resident #30 had a BIMS score of 09, indicating moderate cognitive impairment. Resident #30 received hospice care.Review of Resident #30's current care plan read in part. Focus: Advanced Directive: I have an Advanced Directive. Interventions included in part. I am not to receive cardio-pulmonary resuscitation. A do not resuscitate (DNR) request was completed by me/my responsible party/representative, communicated and submitted to my physician, and communicated to staff. A STOP sign has been placed in my visual cue in my room.Review of Resident #30's September 2025 active orders in the electronic medical record revealed in part. 06/09/2025- Admit to All Saints Hospice with terminal diagnosis of Alzheimer Disease. Resident #30 did not have any active orders reflecting advanced directive/code status information.In an interview on 09/16/2025 at 12:29 p.m. S8LPN revealed Resident #30's code status information can be found in multiple places such as on QCARD above the resident bed, the binder spine on the resident hard chart, special instruction tab in EMR, physician orders, and if the resident had a documented advanced directive such as a LAPOST (Louisiana Physician Orders for Scope of Treatment), it would be located in hard chart behind the face sheet. S8LPN revealed a picture of a red stop sign present on QCARD above the resident's bed and on the spine of the hard chart, indicated DNR status. A picture of a green go sign present on QCARD above the resident bed and on spine of hard chart, indicated Full Code status. On 09/16/2025 12:35 p.m., observation of QCARD above Resident #30's bed revealed a red Stop sign, indicating Resident #30 code status was DNR. In an interview on 09/16/2025 at 12:45 p.m., S2DON revealed if a resident did not have an advanced directive on file, the resident was presumed full code. After review of Resident #30's EMR with S2DON during interview, S2DON stated Resident #30 did not have advanced directive/code status documentation present in active orders or the code status section of EMR; therefore, Resident #30 was presumed a full code. Further into the interview, S2DON learned from another facility staff member, Resident #30 did have an advanced directive, and the information was documented in profile tab of EMR. Review of this section of Resident #30's EMR with S2DON revealed Resident #30 was documented as a full code status. S2DON stated, Resident #30 was a full code.On 09/16/2025 at 12:50 p.m., review of Resident #30's hard chart with S2DON revealed Resident #30 had a green go sign on spine of hard chart. S2DON stated the green Go sign indicated Resident #30 was a full code. Further review of Resident #30's facility hard paper chart with S2DON revealed Resident #30 had two LAPOST documents signed and dated. One LAPOST document signed and dated 08/09/2024, reflecting Resident #30's code status was full code, and the most up-to-date LAPOST signed and dated 06/09/2025, reflecting Resident #30's code status was DNR. S2DON confirmed Resident #30 was not a full code, Resident #30's code status was DNR. S2DON confirmed there was conflicting advanced directive/code status information within Resident #30's medical record, and should not have been.

Based on record review and interview, the facility failed to ensure residents identified with Mental Disorder and/or Intellectual Disability had an accurately completed PASARR (Pre-admission Screening and Resident Review) Level I and/or Level II for 1(#8) of 1 resident reviewed for PASARR screening. Findings: Review of the facility's undated policy titled, Resident Assessment-Coordination with PASARR Program read in part .8. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a Level II resident review. Review of Resident #8's medical record revealed an admit date on 08/23/2005 with the following diagnoses: Vascular Dementia with Agitation, Major Depression Disorder with Severe with Psychotic Symptoms, Generalized Anxiety Disorder, and Schizoaffective Disorder (12/10/2018). Review of Resident #8's medical record revealed a Level 1 pre-screening was provided for Resident #8 prior to admission on [DATE], which indicated diagnoses of Major Depressive Disorder and Generalized Anxiety Disorder. No Level II screening was completed at time of or since admission. Review of Resident #8's electronic record revealed a diagnosis of Schizoaffective Disorder with a start date of 12/10/2018. An interview on 09/16/2025 at 10:47 a.m., S4 SSD revealed that Resident #8 had not had a Level II screening completed since admit in 08/17/2005. S4 SSD stated that Resident #8 had a new diagnosis of Schizoaffective Disorder on 12/10/2018 and the facility failed to submit a new level 2 screening at that time, but should have. An Interview on 09/16/2025 at 10:54 a.m., S2 DON confirmed that Resident #8 had a pre admission Level 1 screening on admit and the facility failed to provide a Level II screening after Resident #8 was diagnosed with Schizoaffective Disorder in 2018, but should had.

Based on observation and interview the facility failed to dispose of garbage and refuse properly. This deficient practice had to the potential to affect all 52 residents who resided in the facility according to the Resident Census and Conditions of Residents Form dated 09/15/2025.Findings: Review of the facility policy titled (Facility Name) Disposal of Garbage and Refuse on 09/15/2025 at 1:30 p.m. revealed in part.the facility shall properly dispose of kitchen garbage, and other garbage. Policy Explanation and Compliance Guidelines: (7) Surrounding area shall be kept clean so that accumulation of debris and insect/rodent attractions are minimized. Observation of the facility dumpster area on 09/15/2025 at 8:57 a.m. accompanied by S6 Dietary Manager revealed there were 3 shopping carts, a broken chair, and 3 open trash cans with trash and debris not contained. Interview with S6 Dietary Manager at that time confirmed the findings and stated the items should be thrown away.

Based on observation, record review and interview, the facility failed to ensure 1 (Resident #2) of 4 ( Resident #1, Resident #2, Resident #3, and Resident #4) sampled residents received the necessary treatment and services to prevent and promote the healing of pressure ulcers by failing to perform hand hygiene during treatment of a pressure ulcer.Findings:Review of the facility's undated policy titled Clean Dressing Change read in part.Policy: 3. Each wound will be treated individually. 7. Perform hand hygiene and put on clean gloves. 9. Loosen the tape and remove the existing dressing. 10. Remove gloves, pulling inside out over the dressing if able. Discard. 11. Perform hand hygiene and put on clean gloves. 12. Cleanse wound as ordered. 14. Perform hand hygiene and put on clean gloves. 16. Secure dressing. Review of Resident #4 's medical record revealed an admit date of 05/15/2025 with diagnoses that included: Adult Failure to Thrive, Long Term use of Antibiotics, Anxiety Disorder, Functional Quadriplegic, Encephalopathy, Methicillin Resistant Staphylococcus Aureus Infection, Contracture of the right and left shoulder, Contracture of the right and left upper arm, Contracture of right and left hand, and Cognitive Communications Deficit. Review of Resident #2's admission Minimum Data Set (MDS) with an ARD of 05/26/2025 revealed a Brief Interview for Mental Status (BIMS) score of 00 , indicating severely impaired cognition. Resident #2 was totally dependent on staff and required physical assistance for all activities of daily living.Review of Resident #2's 06/2025 Physicians Orders read in part.06/25/2025 -Clean Right Hip wound with wound cleanser of choice, pat dry, apply vashe or Dakin's solution on dampened gauze, apply barrier of choice to periwound and apply dry dressing daily.Observation of Resident #2's wound care on 08/06/2025 at 11:00 a.m. with S2 Treatment Nurse revealed during wound care to the right hip wound, S2 Treatment Nurse did not remove gloves and perform hand hygiene after removing old dressing, before or after cleaning the wound, or before applying a new dressing. Interview on 08/06/2025 at 11:10 a.m. with S2 Treatment Nurse confirmed she did not remove gloves and perform hand hygiene after removing dressing, after cleaning wound or prior to applying a new dressing, but should have. Interview on 08/06/2025 at 1:34 p.m. with S1 DON confirmed S2 Treatment Nurse had a skills checkoff on hand hygiene in 03/2025 with no issues and should have changed gloves and provided hand hygiene during wound care.

Based on observation and interview the facility failed to post nurse staffing information on a daily basis that included the resident census, and total number and actual hours worked by RNs, LPNs and CNA staff directly responsible for resident care per shift. The facility census was 47. Findings: Observation on 08/05/2024 at 6:03 a.m. revealed a form for daily nursing hours dated 08/01/2024- 08/12/2024 was posted on a bulletin board near the nurse's station. Daily staffing hours were not posted for 08/02/2024, 08/03/2024, 08/04/2024, and 08/05/2024. Interview with S3 RN revealed she was unsure who was responsible for completing and posting the daily nursing hours over the weekend, but that they should be posted daily. Observation on 08/05/2024 at 7:45 a.m. revealed the form for daily nursing hours dated 08/01/2024- 08/12/2024 was not updated and posted to include the required information. Interview on 08/05/2024 at 12:35 p.m. with S1 DON revealed she was responsible for updating and posting the facility's daily nursing hours. S1 DON confirmed no one had updated or posted the daily nursing hours for 08/02/2024- 08/05/2024.

Based on observation, interview, and record review, the facility failed to ensure a resident received services in the facility with reasonable accommodation of needs for 1 (#15) of 2 (#15 and #41) sampled residents reviewed for call bell placement. The facility failed to ensure Resident #15 had a call bell in reach in order to call for assistance. Findings: A review of Facility's undated policy dated 11/27/2023 titled Call Lights: Accessibility and Timely Response, read in part . 6. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room. Review of Resident #15's medical record revealed an admitted [DATE], with diagnoses that included Microcephaly, Cognitive Communication Deficit, and Muscle Wasting and Atrophy. Review of Resident #15's Minimum Data Set (MDS) with an ARD of 07/26/2024, revealed Resident #15 had moderately impaired decision. The MDS revealed Resident #15 required staff assistance for oral hygiene, toileting, bathing, dressing and transferring. Interview on 08/05/2024 at 7:52 a.m. with S4 LPN revealed Resident #15 was able to use the call light if she needs. Observation on 08/05/2024 at 7:52 a.m., 9:17 a.m., 12:09 p.m., and 1:31 p.m. revealed Resident #15 lying in bed with the call light on the floor next to the left hand side of the bed. Interview on 08/06/2024 at 8:45 a.m. with S5 LPN/MDS, revealed Resident #15 was able to use a call bell if she needs assistance.

Based on observation, record review and interview, the facility failed to ensure ADLs (activities of daily living) were performed for 1 (#40) of 2 (#34 & #40) residents reviewed for ADLs. The facility failed to ensure Resident #40 received nail care. Findings: Review of the medical record for Resident #40 revealed an admitted [DATE] with diagnoses that included in part .Type 2 Diabetes Mellitus, Chronic Kidney Disease, Heart Failure, and Major Depressive Disorder. Review of Resident #40's Quarterly MDS with an ARD of 05/29/2024 revealed a BIMS score of 12, which indicated moderate cognitive impairment. Review of the MDS revealed Resident #40 required supervision or touching assistance with personal hygiene. Review of Resident #40's current care plan revealed Resident #40 requires assistance for all ADLs related to general weakness and impaired cognition. Interventions included give verbal cues to help prompt, break up tasks into smaller steps. Resident requires supervision/cues for personal hygiene. An observation on 08/05/2024 at 7:15 a.m. revealed Resident #40 was noted to have multiple long fingernails to both hands. Interview with Resident #40 at that time revealed he would like his nails cut. Resident #40 stated he did not refuse to have them cut. An observation and interview on 08/06/2024 at 3:23 p.m. with S2 LPN revealed Resident #40 had long nails on both hands. S2 LPN stated Resident #40 had some nails that definitely need cutting. S2 LPN reported the treatment nurse cut the nails of the diabetic residents and nurses can, if needed. Resident #40 was asked if he wanted his nails cut and he said, Yes.

Based on observation, interview, and record review the facility failed to meet the nutritional needs of residents in accordance with established national guidelines. The facility failed to follow the menu to ensure nutritional adequacy for 3 (#15, #19, and #22) of 3 (#15, #19 and #22) residents on a pureed diet. Findings: Record review of the menu for the 08/05/2024 lunch meal for residents on a pureed diet revealed in part: Sliced Ham - #10 scoop Red Beans and Rice - #8 scoop Seasoned Greens - #10 scoop Cornbread - #10 scoop Fruit Crisp - #8 scoop Observations on 08/05/2024 at 10:30 a.m. of the food serving line in the kitchen, revealed S7 Dietary Assistant preparing trays on the serving line for residents #15, #19 and #22 that were on pureed diets. As the trays were prepared, they were then given to the CNAs to serve the residents. Observations revealed that seasoned greens, cornbread and fruit crisp were not being served and were not on the serving line. Interview on 08/05/2024 at 10:40 a.m. with S6 Dietary Manager, confirmed that the menu called for seasoned greens, cornbread and fruit crisp which were not served on the serving line.

Based on observation, interview and record review, the facility failed to ensure that food was properly stored, prepared, distributed and served in accordance with professional standards for food service safety. The facility failed to ensure: 1. Food was properly labeled and stored; and 2. Cooked food was maintained at or above 135 degrees Fahrenheit on the serving line. Findings: 1. Observation of the kitchen on 08/05/2024 at 6:05 a.m. with S6 Dietary Manager revealed the following: A block of cheese was partially wrapped and open to air in the walk-in cooler. The cheese closest to the opening was darker in color. A tube of ground meat was defrosting on the bottom shelf of the walk-in cooler. The tube of ground meat was partially in a shallow pan on the wire rack of the cooler shelf. The tube of ground meat was dripping blood tinged liquid onto the wire shelf and floor. A bag of frozen fish with approximately 10-12 pieces was in a Ziploc bag that did not have an expiration or use by date. An interview with S6 Dietary Manager at the time, reported that the block of cheese should have been sealed and not left open to air, the ground meat should have been defrosting over the pan, and the frozen fish should have had a use by date. Observations of the dry storage area on 08/05/2024 at approximately 6:20 a.m. with S6 Dietary Manager revealed the following: A 46 ounce canned Steen's syrup and a 20 ounce canned Pineapple sauce on the shelf that had approximately a 1/2 inch dent along the top seal. A large bag of open Fettuccini noodles stored on a shelf. An interview with S6 Dietary Manager at the time, reported that the canned Steen's syrup and Pineapple sauce should have been pulled from the shelf and the Fettuccini noodles should have been placed in a sealed bag. 2. Observation on 08/05/2024 at 6:40 a.m. revealed breakfast trays were being prepared and served. The pureed sausage was on the steam table in a non-heated area. S6 Dietary Manager took the temperature of the pureed sausage upon request, and revealed a temperature of 125 degrees. An interview with S6 Dietary Manager at that time reported that the sausage was not at the required holding temperature.

Based on observation, interview and record review the facility failed to ensure that a resident's person-centered plan of care for the use of bright tape to her bathroom door frame was followed for 1 (#2) of 3 (#1, #2, and #3) sampled residents. The facility had a total census of 50. Findings: Review of Resident #2's clinical record revealed an admitted [DATE] with diagnoses which included in part . Unspecified Dementia, Aphasia, Dizziness and Giddiness, Drusen (degenerative) of Macula Left Eye and Other Specified Anxiety Disorders. Review of Resident #2's Admission MDS with an ARD of 04/24/2024 revealed a BIMS score of 7 (indicating severely impaired cognition), and required supervision or touching assistance with transfers and toilet use. Resident #2 had no impairment of ROM to her upper or lower extremities. Review of Resident #2's care plan with a review date of 08/02/2024 revealed she had a fall in her room while attempting to ambulate to the bathroom on 06/03/2024, with interventions that included-will add bright tape to door frame. Observation on 06/06/2024 at 1:35 p.m. revealed Resident #2 sitting in the day room on the memory care unit. Observation of Resident #2's room at this time revealed no bright tape to her bathroom door frame. Interview with S1 DON on 06/06/2024 at 1:55 p.m. revealed she was aware of Resident #2 not having bright tape to her bathroom door frame as indicated in her person- centered plan of care. S1 DON stated she had ordered the bright red tape, but it had not arrived. S1 DON confirmed no other fall prevention measures had been implemented for Resident #2.

Based on observation, interview, and record review, the facility failed to ensure that residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene. The facility failed to provide oral care and nail care to dependent residents for 2 (Resident #1 and Resident #2) of 3 (Resident #1, Resident #2, and Resident #3) residents sampled for ADL's. Findings: Review of the Facility's policy/procedure titled Activities of Daily Living (ADLs) read in part: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. 1. Bathing, dressing, grooming and oral care. Policy Explanation and Compliance Guidelines: 3. A residence who is unable to carry out ADL will receive necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of the Facility's policy/procedure titled Oral Care read in part: It is the practice of this facility to provide oral care to residents in order to prevent and control plaque-associated oral diseases. 3. Use tongue depressor and penlight to assess the integrity of the resident's mouth (lips, teeth, mucosa, gums, palate and tongue). Review of the Facility's policy/procedure titled Nail Care read in part: The purpose of this procedure is to provide guidelines for the provision of care to resident's nails for good grooming and health. 3. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. 4. Routine nail care, to include trimming and filing, will be provided on a regular schedule. Nail care will be provided between schedule occasions as the need arises. 6. a. Nails should be kept smooth to avoid skin injury. #1 Review of Resident #1's EHR (Electronic Health Record) revealed an admitted [DATE], diagnosis included Alzheimer's disease, Major Depressive Disorder, and Benign Prostatic Hyperplasia. Review of Resident #1's 02/2024 physician orders revealed he was admitted to Hospice care on 02/15/2024 for Alzheimer's and was NPO. Review of Resident #1's Care Plan with a target date of 03/06/2024 revealed Resident #1 required extensive to total assistance of 1-2 staff members for all areas of ADLs. Review of Resident #1's Quarterly MDS with an ARD of 11/22/2023 revealed no BIMS score (resident is rarely or never understood). Resident #1's functional status revealed he required extensive assistance one-two person physical assistance with all ADLS. Review of the physician progress notes on 02/24/2024 by S3 NP revealed an on-site visit of Resident #1. The notes read in part: CC: thrush. Resident noted with a thick white coat to his tongue. Dx. - Candidiasis (Thrush) with Nystatin oral 100,000 IU -swab 5 ml. to oral cavity qid x 10 days. Review of Resident #1's detailed care by CNAs revealed: 02/15/2024- oral care at 8:50 p.m. 02/16/2024- no documentation of oral care or bath. 02/17/2024- oral care at 5:05 p.m. 02/17/2024- no documentation of a bath. 02/18/2024- oral care at 3:11 p.m. and 9:04 p.m. 02/18/2024- no documentation of a bath 02/19/2024- no documentation of oral care. 02/19/2024- bed bath at 6:08 p.m. 02/20/2024- oral care at 2:00 p.m. and 8:14 p.m. 02/20/2024- bed bath at 8:14 p.m. Observation on 02/19/2024 at 11:00 a.m. revealed Resident #1 was positioned in bed on his back with his mouth open, tongue shifted to right side near his bottom lip, tongue with thick white coating, lips dry and cracking with strings of skin peeling from his bottom lip. Observation on 02/19/2024 at 2:45 p.m. revealed Resident #1 positioned on his right side with his bottom lip folded inside of his mouth. The top lip and corner of mouth was noted to be dry with white substance noted. Observation on 02/20/2024 at 8:25 a.m. revealed Resident #1 positioned in bed on his left side, tongue still with a thick white coating slightly protruding out of the right side of mouth, and lips dry and cracking with strings of skin peeling from his bottom lip. Observation on 02/20/2024 at 10:20 a.m. of Resident #1 accompanied by S2 ADON was positioned in bed on his back, still with dry cracked lips and a thick white coating on his tongue. S2 ADON stated Resident #1's mouth looks better than it did whenever he returned from the hospital (02/15/2024). S2 ADON stated his lips were not dry because his face was not dry and the white crust on his tongue would not come off and maybe the resident did have thrush. S2 ADON stated she was not certain about the resident's tongue so she would have S3 NP exam Resident #1. Observation on 02/20/2024 at 10:30 a.m. of Resident #1 accompanied by S3 NP revealed Resident #1 still with dry cracked lips and a thick white coating on his tongue. S3 NP performed oral care on Resident after examination of his lips and mouth. S3 NP performed oral care on Resident #1 using a moist oral swab to scrub and clean the tongue and gums, lemon glycerin swab and applied lip ointment (pomegranate). There was a foul odor coming from Resident #1's mouth as S3 NP performed oral care. S3 NP confirmed that Resident #1 Candidiasis (thrush), and lips were dry, and cracking. S3 NP confirmed that Resident # 1was in need of oral care. S3 NP stated she would order Nystatin qid for 10 days. #2 Review of Resident #2's EHR revealed an admitted [DATE], diagnosis included Anorexia, Essential (primary) HTN, Osteoarthritis bilateral knee, and Hemiplegia Subarachnoid hemorrhage. Review of Resident #2's Care Plan with a target date of 04/24/2024 revealed the resident required extensive to total assist with dressing, toileting, and personal hygiene. Review of Resident #2's Quarterly MDS with an ARD of 01/10/2024 revealed a BIMS of 3 (severely impaired cognition). Resident #2 required substantial/maximal assistance with oral care, upper/lower body dressing, and personal hygiene Observation on 02/19/2024 at 9:30 a.m. revealed Resident #2 in wheelchair in the dining area, fingernails on right hand untrimmed with dark substance underneath the nailbeds. Resident #2's left hand was contracted, fingernails cleaned but untrimmed. Interview with Resident #2 at the time of the observation, revealed she raised her right hand up, looking at her fingernails. When ask the resident if her fingernails were dirty and needed to be clean and cut, she looked at her nails and stated yes they are dirty and are long. Observation on 02/19/2024 at 11:00 a.m. revealed Resident #2 sitting in the dining room eating lunch. Resident #2's fingernails on right hand were still untrimmed with dark substance underneath the nailbeds and fingernails on left hand untrimmed. Observation on 02/19/2024 at 12:15 p.m. revealed Resident #2 in her wheelchair near the dining room entrance. Resident #2's fingernails on right hand still untrimmed with dark substance underneath the nailbeds and fingernails on left hand untrimmed. Observation of Resident #2 on 02/19/2024 at 2:10 p.m. in her wheelchair propelling self near the dining room. Resident #2's fingernails on right hand still untrimmed with dark substance underneath the nailbeds and fingernails on left hand untrimmed. Observation of Resident #2 on 02/20/2024 at 8:15 a.m. in her wheelchair near dining room entrance. Resident #2's fingernails on right hand still untrimmed with dark substance underneath the nailbeds and fingernails on left hand untrimmed. Interview on 02/20/2024 with S1 DON after inspection of Resident #2's fingernails, confirmed Resident #2's fingernails needed to be cleaned, filed and trimmed.

Based on observation, record review, and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety by failing to: 1) ensure cooking equipment was cleaned after each use, 2) ensure food preparation equipment was cleaned after each use, 3) ensure spices and seasonings containers were placed on the shelf in a sanitary condition, and 4) ensure spices and seasonings stored on the shelf were not expired and were labeled and dated properly. This deficient practice had the potential to affect the 48 residents that received meals prepared in the facility's kitchen. Findings: Review of the facility's Policy and Procedure title Cleaning Instructions Cleaning Ranges read in part: Policy: The cook on each shift is responsible for keeping the range as clean as possible during the preparation of the meal. The range will be cleaned after each use. Spills and food particles will be wiped up as they occur. Review of the facility's Policy and Procedure title Cleaning Instructions Cleaning Toaster read in part: Policy: Toaster will be cleaned after each use. Review of the facility's Policy and Procedure title Cleaning Instructions Cleaning Food Preparation Appliances read in part: Policy: Small appliances and food appliances (such as mixers, and food processors) will be cleaned and sanitized after each use. Review of the facility's Policy and Procedure title Cleaning Dishes Manual dishwashing read in part: Policy: Dishes and cookware will be washed and sanitized after each meal to assure that all dishes are cleaned and sanitary. Review of the facility's Policy and Procedure title Care of the storeroom read in part: Procedure 6. Foods with expiration dates are used prior to the date on the package. Canned and dry foods without expiration dates are used within six months of delivery. Observation of the kitchen on [DATE] at 10:00 a.m. revealed: 2-large side by side ovens with large amount of black substance covering the entire bottom panel, removable wired rack with large amount of caked-on gel-like dark brown drippings. Convection oven- blower located on the back panel with a buildup of thick layers of grayish substance with flexible extended coils covered with dust particles. Rice cooker stored on the counter top with a filmy white substance around the rim, dried white substance inside. Food processor with long strand of black hair, covered with greasy film- S2 Dietary Manager not certain when it was last cleaned and was last used this morning. Toaster- large amount of black crumbs on the crumb plate. Microwave inside top surface with covered with large amount of brown, yellowish and orange color substance, and bottom panel with spattered yellow and brown substance. Mixer/bread kneading was covered with a plastic bag was noted to have a large amount dried white substance inside of the blade. ,d+[DATE] cup cupcakes baking pan stacked on top of one another with large brown clumpy cake-like substance, greasy film (dark brown on the bottom surface). ,d+[DATE] cupcakes baking pan stacked on top of one another with large amount of dark brown greasy pasty gel-like substance around the bottom and inside of the pans. 6 large pot lids located on the floor between the wall and stationary storage/sink area- dusty, greasy film. 2 large deep serving pans with dried brown/black thick greasy film around the bottom rim and inner surface. 2 small deep serving pans with dried white substance in the bottom of the pan and one with greasy film in the inner surface and outer. 12 quart size pot with dried white substance in the inside. Medium stainless steel colander with dried green substance on the side and in holes in the center. Large stainless steel colander with white flaky substance in the holes. Stationary floor mounted stainless steel table with sink insertion was noted to have an 8 pack hamburger buns opened and not secured with a wrapper, fastener or tied closed with 6 buns remaining with a used by date of [DATE]. The following seasonings and spices were located on a shelf above a floor mounted stationary stainless steel table were noted to have yellow labels with the following dates and use by date: 2 - 16 ounces ground all spice- [DATE] use by [DATE] 25 ounces cream of tartar- [DATE]- use by [DATE] 14 ounces ground cumin - [DATE]- use by [DATE] 14 ounces bay leaves- [DATE]- use by [DATE] The following seasonings and spices were located on a shelf above a floor mounted stationary stainless steel table were noted with illegible yellow label (unable to read the date) faded with no use by readable date, was on the shelf opened and available for use: 14 ounces ground cumin 2 ounces ground black pepper 24 ounces rotisserie chicken seasoning 24 ounces ground thyme 12 ounces ground oregano 12 ounces ground thyme 2- 12 ounces ground sage 28 ounces lemon pepper seasoning. There was a total of 33 plastic containers of spices and seasonings on the shelf which were all opened with greasy film, caked substance, drippings on the outside of the bottles and or tops. Refrigerator in dry storage area was noted to have 4 bags of expired hot dogs - 1- [DATE], 2 - [DATE], and 1-[DATE]. During the observation some of the following items were on the counter top below the above seasonings and spices, were opened/dated in black with yellow labels: 28 ounces jiff peanut butter, 16 ounces iodized salt, 16 ounces seafood/crab boil, 8 pound plastic container of [NAME] Chachere's creole seasoning, 6.5 pound plastic container of granulated garlic, 128 ounces browning season sauce, and 128 ounces of parsley flakes were opened and dated. Interview on [DATE] at 12:10 p.m. with S2 Dietary Manager confirmed all of the above findings at the time of the observation. S2 Dietary Manager stated the food purchasing company provides the facility with yellow labels which includes the date of delivery. S2 Dietary Manager stated a label is placed on each item and no date is placed on the item(s) once it is opened. S2 Dietary Manager stated the yellow stickers that the yellow label provided by the purchaser with the date of delivery is the date that is used as the date of opening the item(s). S2 Dietary Manager stated the items are used until the expired date according to the stamped date on the item. S2 Dietary Manager stated she had no explanation as of why there were outdated, faded unreadable, and/or no legible use by date containers of spices and seasonings opened and available on the shelf for use. S2 Dietary Manager confirmed that she also had no explanation as of why some of the items had yellow labels but were still marked in black with a date. S2 Dietary Manager confirmed the date marked in black was the date the item(s) was opened. S2 Dietary Manager confirmed that all of the food preparation equipment, cookware, and seasonings/spices were all in unsanitary condition. S2 Dietary Manager confirmed that all seasoning and spices should be checked by dietary staff for use by date before being used for food preparation. Interview on [DATE] at 1:30 p.m. with S1Administrator revealed the dietary department uses yellow labels provided by the food purchasing company. S1 Administrator stated the yellow sticker implies the receiving date not necessarily the opening date. S1 Administrator stated the facility had no system in place as it relates to opening (dated) of food items such as seasoning, spices and other food favoring items. S1 Administrator stated the facility uses the manufacturer use by date as a guide for usage. When surveyor asked about items which were dated in black, S1 Administrator stated she was not certain about that and was unable to answer that question. S1 Administrator stated she would have to refer back to S2 Dietary Manager. S1 Administrator invited to surveyor to accompany her to the Dietary Department. S2 Dietary Manager confirmed that some of the food items were improperly labeled as evidenced by presenting the ones identified by the surveyor (during kitchen tour) for inspection by S1 Administrator. S1 Administrator confirmed that the using of the yellow labels by the food purchasing company was not effective and something else would have to be devised through the Facility's Quality Assurance Program.

Based on observation, record review and interview, the facility failed to ensure 1 of 1 sampled residents (Resident #39), reviewed for pressure ulcers, and at risk for pressure sore development, received the necessary treatment and services to prevent and promote the healing of pressure ulcers. The total sample was 31 residents. The Facility failed to: 1. Timely identify/assess a new pressure ulcer to Resident #39's right heel and an open excoriation to right buttocks; 2. Implement treatment timely for newly identified unstageable PU to Resident #39's left heel, stage 2 to left great toe, and stage 2 to the top of left foot; 3. Follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 4. Follow policy and procedures for wound treatment/assessment; 5. Implement infection control practices during treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] 6. Follow care plan interventions for pressure ulcers. Findings: Review of the facility's policy and procedure titled Documentation of Wound Treatments revealed in part . wound assessments are documented upon admission, weekly, and as needed if the resident or wound deteriorates. The following elements are documented as part of a complete wound assessment: type of wound, stage of wound, measurements and description of the wound characteristics. Review of Resident #39's Face Sheet revealed she was admitted to the facility on [DATE]. Resident #39's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #39's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 9 (indicating moderate cognitive impairment). The MDS revealed Resident #39 required extensive 2+person physical assistance for bed mobility and dressing, totally dependent upon staff for transfers, toilet use and hygiene, and had ROM impairment to lower extremities both sides. The MDS revealed Resident #39 had one Unstageable Pressure Ulcer and two Stage 2 Pressure Ulcers. Review of Resident #39's care plan with a start date of 06/02/2022 revealed the resident was at high risk for the development of Pressure Ulcers related to immobility and incontinence. The care plan goal was for the resident to remain free of skin breakdown through the next quarter. One of the interventions included in the care plan was to float the resident's heels off the bed. Review of a revised care plan with a start date of 07/08/2022 revealed the resident returned from a hospitalization with an Unstageable Pressure Ulcer to her left heel, a Stage 2 Pressure Ulcer to the dorsal side of her left great toe and a Stage 2 Pressure Ulcer to the top of her left foot. New interventions included provide treatments to areas as ordered until resolved, adjust treatment per protocol, monitor for signs and symptoms of infection and notify the Physician as indicated. Review of Resident #39's medical record revealed a Transfer Form dated 07/01/2022, that revealed Resident #39 was sent to the hospital, and that Resident #39's skin was intact. Resident #39's medical record revealed she was hospitalized from 07/02/2022 - 07/08/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Discharge Summary from the hospital dated 07/08/2022 revealed there was no documentation Resident #39 had any Pressure Ulcers. There was no documentation in the medical records from the hospital stay that Resident #39 received any treatments to any Pressure Ulcers during her hospital stay from 07/01/2022 - 07/08/2022. Review of a Nurses' Note for Resident #39 dated 07/08/2022 at 5:33 p.m., documented by S3 LPN read that Resident #39 returned from the hospital. The Nurses' Note revealed a skin assessment was documented as follows: Right foot bruise 4 X 5, R top foot 1st and 2nd toe abrasion, 4th toe and 2nd joint at 1 X 5.5 Dorsal Left foot 3.7 X 2 to great toe joint, 2.8 X 2.8, left heel necrotic 6.5 X 4, left foot bruising 3 joint dorsal 5th toe. Review of Resident #39's medical record revealed 3 Wound Assessment Reports were documented by S12 DON on 07/08/2022, and read as follows: 1. Left Heel - The assessment revealed the wound was an Unstageable pressure ulcer due to slough/eschar. There was no drainage; however, the surrounding skin was red and indurated. The area measured 6.5 cm in length, 4.0 cm in width and 0.1 cm in depth. S13 FNP was notified. Under the Treatments section of the form was documented Pending treatment orders. 2. Left Great Toe - Stage 2 to the Dorsal left great toe, proximal phalangeal/metatarsal, that measured 2.8 cm in length, 2.8 cm in width and 0 cm in depth. S13 FNP was notified, and under the Treatments section of the form was documented Pending treatment orders. 3. Top of Left Foot - Stage 2 to the top of left foot, mid-foot area which measured 3.7 cm in length, 2.0 cm in width and 0 cm in depth. S13 FNP was notified, and under the Treatments section of the form was documented Pending treatment orders. Review of the Wound Assessment Report and the Nurses' Notes revealed there were no other documented assessments or measurements per policy, of Resident #39's wounds until 07/22/2022. Review of Resident #39's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Monitor bruising under right foot until healed, and then discontinue. Clean necrotic tissue to left heel with Normal Saline, pat dry, paint with [MEDICATION(S)], apply border dressing to protect area every 3 days until healed, and then discontinue. 2. Clean abrasions times 2 to top of left foot with Normal Saline, pat dry, paint with [MEDICATION(S)], apply border dressing to protect area every 3 days until healed, and then discontinue. Further review of Resident #39's 08/2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #39's EMAR dated 07/2022 revealed the treatment orders on 07/10/2022 to the left heel and top of left foot were not started until 07/11/2022. There was no documentation on the EMAR, or in the Nurses Notes that any treatment was provided to the necrotic area to Resident #39's left heel, or the two Stage 2 pressure ulcers to the top of the left foot until 07/11/2022. Further review of Resident #39's EMARs dated 07/2022 and 08/2022 revealed the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #39's ETAR revealed moisture barrier was not documented as being applied every shift as ordered on 07/23/2022 or 07/24/2022. Review of Resident #39's Progress Notes from the Podiatrist dated 07/26/2022 at 10:45 a.m. revealed the resident had severe vascular disease with multiple Unstageable pressure ulcers of the left foot. The right foot is free of open [CONDITION(S)]. There is an Unstageable dry gangrenous pressure ulcer on the posterior heel with well adhered dry eschar. There is no drainage, malodor or signs of acute infection. The Assessment/plan- PVD with Gangrene - continue offloading of heels while in bed and continue treatment orders with [MEDICATION(S)]. Review of Resident #39's weekly Head to Toe Skin Assessments revealed the last documented assessment was dated 08/09/2022 by S2 ADON, and revealed no new skin issues at that time - existing issues only. Observation on 08/15/2022 10:05 a.m. revealed Resident #39 was lying in bed with a bandage noted to the left heel. The bandage was dated 08/10/2022. Resident #39's left and right heels were resting on pillows in her bed and not floated. There were two Stage 2 Pressure Ulcers to the top of the Resident #39's left foot that were not covered with a dressing. Observation on 08/15/2022 at 12:00 p.m. revealed Resident #39 was eating lunch in her room. Resident #39's heels were noted to be resting on pillows in her bed and not floated. There was no dressing on the top of the Resident's left foot, exposing the two Stage 2 Pressure Ulcers. During an interview with Resident #39 at that time, surveyor asked if she had any issues with her heels being floated, and she stated she did not mind if her heels were floated. Observation with S3 LPN on 08/15/2022 at 3:00 p.m. revealed the following: Resident #39 was lying in bed with both her heels resting on pillows in her bed and not floated. S3 LPN went in the room to perform treatments to Resident #39's pressure ulcers. At that time, S3 LPN confirmed there was a bandage to Resident #39's left heel dated 08/10/2022 with initials on the bandage as well. S3 LPN stated those were her initials from when she last changed the bandage on 08/10/2022. Interview with S3 LPN revealed she stated the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . S3 LPN picked up Resident #39's left heel off the pillow it had been resting on, removed the bandage dated 08/10/2022 and placed her heel, uncovered, back on the pillow without providing a protective barrier for the pillow. The area to the left heel covered the entire heel and was necrotic. S3 LPN cleaned Resident #39's left heel with Normal Saline and placed her heel back on the same pillow while she retrieved the [MEDICATION(S)]. S3 LPN picked up Resident #39's heel, wiped it with [MEDICATION(S)] and placed her heel back on the pillow while she retrieved a bandage. S3 LPN then picked up Resident #39's heel from the pillow, applied the bandage and placed her heel back on the pillow. Resident #39 grimaced as the treatment was being completed. Resident #39 stated she was ready for it to be over as it was painful to have staff move her foot and leg. Interview with S3 LPN on 08/15/2022 upon completion of Resident #39's treatment revealed Resident #39 did not have any open areas to her right heel or her buttocks. Resident #39's heels were both resting on pillows at that time. Observation on 08/16/2022 at 8:30 a.m. revealed Resident #39 was awake in her bed. Resident #39's left heel remained covered with a bandage dated 08/15/2022; however, her heel was resting on the mattress of her bed and not floated. Resident #39's right heel was also resting on a pillow and not floated. Telephone interview with S4 LPN on 08/16/2022 at 8:50 a.m. revealed she worked the day shift on 08/13/2022 with Resident #39. S4 LPN stated she did not change the bandage to Resident #39's left heel on 08/13/2022, because she got sidetracked and forgot to change the bandage. S4 LPN stated she did treatment to the pressure ulcers on top of the Resident's left foot on 08/13/2022 but not her heel. S4 LPN stated she was not aware of any pressure ulcers to Resident #39's right heel, or any open areas to Resident #39's buttocks. Interview with S3 LPN on 08/16/2022 at 9:00 a.m. revealed she assessed Resident #39 upon return from the hospital on 07/08/2022. S3 LPN stated she did not remember why the treatments to Resident #39's pressure ulcers did not start until 07/11/2022. Observation with S15 CNA and S16 CNA on 08/16/2022 at 9:20 a.m. revealed they were entering Resident #39's room to provide incontinent care. Both of Resident #39's heels were noted to be resting on pillows in her bed, and not floated. S15 CNA and S16 CNA were observed removing Resident #39's brief and rolling her to her left side. Observation revealed no moisture barrier had been applied to Resident #39's buttocks. There was a round Duoderm dressing to her right buttocks approximately 3 inches in diameter. S15 CNA and S16 CNA stated they were not aware of any area to Resident #39's buttocks. While Resident #39 remained on her left side, her right heel was visualized. There were 2 dark areas to her right heel. The center of one of the areas was pink and the top layer of skin was missing from that pink area. They were approximately 1/2 inch each in diameter. S15 CNA and S16 CNA stated they had not provided care for Resident #39 in a few days, and were not aware of the areas to her right heel. S15 CNA informed S3 LPN of the right heel and buttock areas at that time. Observation on 08/16/2022 at 9:30 a.m. with S3 LPN revealed S3 LPN was shown the area to Resident #39's right buttocks with the Duoderm dressing. S3 LPN stated she was not aware Resident #39 had a dressing to her buttocks. S3 LPN instructed S15 CNA to remove the dressing. S15 CNA removed the dressing from Resident #39's buttocks and there was an open area of excoriation that was approximately 1/2 inch in length. The top layer of skin was gone. S3 LPN stated the area was a scratch. S3 LPN was shown the areas to Resident #39's right heel. S3 LPN stated those were old areas that healed. S15 CNA and S16 CNA placed a new brief on the resident and did not apply any moisture barrier to Resident #39's buttocks. Interview with S2 ADON on 08/16/2022 at 9:40 a.m. revealed she was not aware of any new areas of skin breakdown to Resident #39's buttocks, or right heel. The surveyor informed S2 ADON of those areas at that time, and S2 ADON stated she would assess these areas. S2 ADON confirmed the orders for treatment to Resident #39's pressure ulcers to the left heel and top of left foot were dated 07/10/2022. However, S2 ADON stated she thought this was a mistake and that the orders were obtained on 07/08/2022. Therefore, the next treatment would be dated 07/11/2022. S2 ADON was informed and confirmed there was no documentation that wound treatment was performed to Resident #39's left heel and top of left foot on 07/08/2022. S2 ADON was informed by the surveyor that S4 LPN reported she did not do the treatment to Resident #39's left heel on 08/13/2022, and there were no weekly measurements of Resident #39's wounds to the left heel and top of the left foot from 07/08/2022 - 07/22/2022. S2 ADON stated there were measurements in the Nurses' Notes; however, review of the Nurses' Notes revealed there were no weekly wound measurements in the Nurses' Notes after 07/08/2022 until 07/22/2022. Observation on 08/16/2022 at 10:57 a.m. revealed Resident #39 was lying in bed with her left heel resting on the bed, and her right heel resting on a pillow. Neither of her heels were floated. Review of a Nurses' Note for Resident #39 by S2 ADON dated 08/16/2022 at 2:02 p.m. revealed Resident #39's right heel noted to have reddened area. Area is blanching at this time and Resident #39 stated it was tender. Area of concern is approximately 2.5 cm of red circumference. Resident #39 stated she did not like to wear heel protectors due to the way they feel on her feet. Resident #39's right buttocks had an area of excoriation and some redness. All areas were blancheable. NP was contacted at that time with new orders noted. Review of Resident #39's orders by the NP on 08/16/2022 revealed monitor red area to right heel every day until healed and then discontinue (ok to float heels if resident allows); and apply moisture barrier to buttocks every shift until healed. Observation and interview with S2 ADON on 08/16/2022 at 4:20 p.m. confirmed Resident #39's right heel had 2 dark brown areas each approximately 1/2 inch. One of the areas had a pink center. When S2 ADON pressed the pink center, it did blanch. S2 ADON confirmed the area around the pink center was darkened. The surveyor pointed out to the S2 ADON that the top layer of skin was missing from the pink area to the right heel, and S2 ADON stated it was because Resident #39's skin was flaky and dry. S2 ADON then removed Resident #39's brief and the cotton padding beneath the brief's lining was stuck to the excoriated, open areas to Resident #39's right buttocks. S2 ADON peeled the padding from the brief away from the buttocks, and S2 ADON stated the area on the right buttocks was excoriated, and they received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . S2 ADON stated she thought moisture barrier was only ordered prn. S2 ADON revealed her last assessment of Resident #39's skin was on 08/09/2022, and there was no excoriation to her buttocks, or skin breakdown to her right heel. S2 ADON confirmed if the moisture barrier was applied as ordered, someone should have noted the open area and informed a nurse and the physician. S2 ADON stated she had no idea who applied the Duoderm to Resident #39's buttocks. Observation of Resident #39 on 08/17/2022 at 9:05 a.m. revealed the right and left heels were not floated. Resident #39's right heel was resting on a pillow, and left heel was resting on the mattress. Telephone interview with S13 FNP on 08/17/2022 at 11:10 a.m. revealed she could not remember the exact date the staff notified her of Resident #39's pressure ulcers to the left heel and top of left foot. S13 FNP stated Resident #39's treatments to the pressure ulcers should have started prior to 07/11/2022, and that she was not informed of any delay in treatment by the facility staff. S13 FNP confirmed S2 ADON notified her of red areas to Resident #39's right heel and excoriation to her buttocks on yesterday (08/16/2022). The surveyor informed S13 FNP that observation on 08/16/2022 at 9:20 a.m. revealed Resident #39's right heel was not only red, but dark areas with the top layer of skin missing. S13 FNP stated she would assess it on her next visit. S13 FNP stated Resident #39's heels should be floated at all times to prevent the worsening of the current pressure ulcers and in an effort to prevent any new skin breakdown. S13 FNP stated she knew the resident did not like to wear heel protectors, but her heels should be floated.

Based on record review and interview the Facility failed to ensure the orders for Advance Directives accurately reflected the preference; choice of the resident; or responsible party for 1 (Resident #46) of 2 (#42 and #46) sampled residents for advance directives. Findings: Review of the Facility's Advance Directives policy revealed in part . Information about whether or not the resident has executed an Advance Directive will be displayed in resident's medical record. Review of Resident #46's Face sheet revealed an admitted [DATE] and a re-admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident #46's Face Sheet revealed additional information of Advance Directives status Full Code. Review of Resident #46's LAPOST dated [DATE] revealed to attempt CPR with Full treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #46's Living Will dated [DATE] revealed to perform Cardiopulmonary Resuscitation. Review of Resident #46's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident #46's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #46's Annual MDS with an ARD of [DATE] revealed a BIMS score of 13 indicative of intact cognition. Review of Resident #46's Care Plan with target date of [DATE] revealed a goal to make her decisions for my end of life care known. Interventions with a start date of [DATE] revealed in part . to receive CPR, clinical chart updated and SSD to review/ initiate LAPOST/ Living Will with me and my family/ representative to determine my wishes regarding my end of life care in the event I have a terminal condition and the attending physician determines it to be irreversible or incurable, and death is imminent. Interview on [DATE] at 09:14 a.m. with S17 Ward Clerk revealed she was responsible for placing the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on [DATE] at 11:34 a.m. with S3 LPN revealed the green dot located on the outside of Resident #46's medical chart meant the resident is a Full Code and to do CPR. S3 LPN further revealed Resident #46's LAPOST and Living Will both stated resident had a Full Code status. S3 LPN verified the code status on Resident #46's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . S3 LPN further confirmed the DNR status noted on the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on [DATE] at 11:39 a.m. with S2 ADON confirmed Resident #46's LAPOST and Living Will stated to perform CPR. S2 ADON stated either she or the DON reviewed and manually signed all Physicians Orders monthly before putting on the charts. S2 ADON further confirmed her signature on Resident #46's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . S2 ADON confirmed the Advance Directives noted on the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on [DATE] at 11:45 a.m. with S7 SSD confirmed Resident #46's Advance Directives status noted on the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . S7 SSD stated it was an oversight with the printing of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observations, interviews and record reviews, the facility failed to provide the necessary care and services to ensure and maintain good hygiene and grooming for 2 Residents (#5, and #37) of 31 sampled Residents. Findings: Review of the Facility's P/P titled Nail Care read in part: The purpose of this procedure is to provide guidelines for the provision of care to a Resident's nails for good grooming and health. 1. Assessment of Resident nails will be conducted on admission and readmission to determine the Resident's nail condition, needs, and preferences for nail care, if possible. 3. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. 5. Residents without complicating disease processes may have their nails clipped and cleaned by appropriate nursing staff. Resident #5 Review of Resident #5's EHR revealed an admitted [DATE] with admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's Care Plan revealed Resident #5 had self-care deficits related to ADLs and required total assistance with all ADLs. The Care Plan further revealed that Resident #5 had difficulty expressing herself so staff must anticipate her needs and provide care accordingly. Review of Resident #5's MDS Quarterly Assessment with ARD of 05/18/2022 revealed a BIMS of 99 (severely impaired). Resident #5's functional status revealed she required maximum assistance for transferring, shower/bathing, toileting and dressing. Observation on 08/15/2022 at 10:12 a.m. and 2:50 p.m. revealed Resident #5 lying in bed, her nails were noted to be untrimmed with dark black substance underneath her nails. Interview on 08/15/2022 at 3:00 p.m., S8 RN/IP confirmed after observation of Resident #5's nails, they were dirty and needed to be cleaned and trimmed. She further stated the CNAs are responsible for non-diabetic Resident(s) nail care and Resident #5's nails should have been cleaned and trimmed at the time of her bath by the CNAs. Resident #37 Review of Resident #37's EHR revealed an admitted [DATE] with admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan revealed Resident #37 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #37's MDS Annual Assessment with ARD of 07/27/2022 revealed a BIMS of 15 (cognition intact). Resident #37's functional status revealed he required maximum assistance with transferring, and all of his ADLs. Observation on 08/15/2022 at 10:35 a.m. and 3:10 p.m. of Resident #37 lying in bed revealed a salt and pepper beard with thick long unkempt hair, and a salt and pepper thick unkempt mustache. Interview with Resident #37 at the time of the observation revealed that he was unable to shave himself and he required total assistance from the staff to shave him. He stated he was unable to recall the last time that he was shaved and he needed and wanted to be shaved. Interview on 08/15/2022 at 3:15 p.m., S8 RN/IP confirmed after observation of Resident #37's beard and mustache confirmed that he needed to be shaved. She further stated that the CNAs should have shaved Resident #37 during bath time and didn't.

Based on observation, interview, and record review, the facility failed to ensure that a resident receive adequate supervision and assistance devices to prevent accidents for 1 of 3 residents who had falls in a sample of 7 (#2). There were 37 falls in the facility for June 2010 to September 2010 on the facility's Incident Log. According to the facility's Resident Census and Condition of residents dated 9/10/2010 there were 33 residents who required assistance of 1 or 2 persons for transfer and 21 who were dependent for transfer. Resident #2 fell ,while attempting to transfer himself to the geri chair, when he was left in the bathroom unsupervised and sustained a laceration to his forehead. The facility failed to: 1. Supervise a resident at risk for falls 2. Ensure the resident's broken toilet and wall were repaired to prevent fall hazards and injury. 3. Review and revise the resident's plan of care after a fall 4. Monitor to ensure staff were present on the locked unit at all times Findings: Observation on 9/9/2010 at 4:05 a.m. revealed there were no personnel on the locked unit. S3LPN who was assigned to the unit was sitting at the nurses station which was outside the unit. Interview at 4:06 a.m. with S10CNA, who was in the dining room, off of the locked unit, revealed that she was assigned to the locked unit, but was also assigned to 12 other residents who were on the same hall, but not behind the locked doors of the unit. She stated that she had to leave the unit when she cared for other residents off of the locked unit, leaving no one on the locked unit, without staff. Observation on 9/9/2010 at 4:20 a.m. of resident #2 revealed the resident' s room door was closed, he was sitting in a geri chair with a lap tray, was sliding down in the chair and his call bell was positioned on the bed, out of his reach. Further observation at the above date and time reflected he had no shoes on, his floor was wet, his feet were positioned in the water. Observation on 9/9/2010 at 6:12 a.m. revealed S10CNA was assisting the resident to the bathroom and she did not place shoes on the resident's feet before the transfer. Further observation in the bathroom at the above date and time revealed that there was a large hole in the sheetrock near the sink. Pieces of sheetrock and broken tile were on the floor and the baseboard was lying by the sink. A black wet substance was noted in the broken sheetrock. Observation of the toilet revealed that it was not properly secured to the wall or the floor and was turned partially sideways. Observation and interview on 9/9/2010 at 7:35 a.m. in the residents bathroom with the S6Assistant Administrator revealed the resident would wet his head, wet the wall and then fall into the wall and that was probably how the wall in the resident's bathroom wall got busted. The S6Assistant Administrator stated the resident had a history of [REDACTED]. Interview on 9/9/2010 at 6:12 a.m. with S10CNA revealed that she had come back from leave last Thursday, September 2, 2010 and the resident's bathroom wall was already busted at that time. Interview with #S2Maintenance Supervisor on 9/9/10 at 7:25 a.m. revealed that he was aware of the hole in the wall, broken tile laying on the floor and loose toilet, but just could not get around to fixing them. He stated that this resident had a history of [REDACTED]. Review of a Post Occurrence assessment dated [DATE] for the resident reflected that upon entering the room, it was observed that the resident had tipped over his gerichair and vomited on the floor. Resident helped back up into the chair. No bruises or skin tears at this time. Review of a Post Occurrence Report completed by the S3LPN for resident #2 dated 9/1/2010 reflected the resident' s left eyebrow was bleeding and there was a small laceration above his left eyebrow. The form further reflected the resident stated he was trying to go to the bathroom and slipped bumping his head on his chair. Review of the measures to prevent reoccurrence of the incident on the report reflected to encourage the resident to call for assistance. Phone interview on 9/9/2010 at 9:30 a.m. with S8CNA revealed she was making rounds on 9/1/2010 at 5 a.m. and had helped resident #2 to the bathroom. She stated she left him there, went to get clean linens for his bed, returned to the resident ' s room and began making his bed when the resident tried to get up by himself and fell hitting his chair. Further interview with S8CNA at the above date and time revealed that she was unaware that the resident should not have been left in the bathroom alone and had not been told since the incident the resident should not have been left alone. Review of a physician's orders [REDACTED]. Apply steri-strips daily to protect area until healed. Review of the Treatment MAR for September 2010 reflected the resident continued to receive treatments to his left brow. Interview on 9/10/2010 at 11:10 a.m. with the S4DON revealed the S3LPN on duty had called her at 5 a.m. on 9/1/2010 to inform her the resident had fallen in his bathroom but she had not been made aware the resident was not supervised when he fell . Review of an inservice dated 9/2/2010 reflected fall precautions were discussed but there was no outline to reflect what the staff were inserviced on or that the incident for resident #2 was addressed. Review of the quarterly MDS dated [DATE] revealed that the resident was coded as modified independence, for cognitive skills. He was also coded as requiring extensive assistance of one person for transfers, toileting, walking in room, eating, personal hygiene and dressing. He was coded being totally dependent for bathing. Review of the resident's care plan revealed the resident was at high risk for falls. His last documented fall on the care plan was dated 4/15/10. New approaches included to remind the resident to call for assistance dated 4/15/10 and discontinue the merriwalker secondary to his unsafe gait due to the progression of the disease process resulting in decline in his ability to ambulate dated 5/20/10. The care plan also identified that the resident "required assist with ADL's x 1 or 2 CNA's". Approaches included required extensive-total assistance of 1 or 2 CNA's with transfers, ambulation, dressing, toilet use, personal hygiene, locomotion, and bathing. The care plan also included an approach to get the resident up in a geri-chair with lap tray as tolerated, secondary to frequent falls, unsteady gait, frequency in falling asleep and inability to redirect. Continued review of the resident' s current plan of care dated with a problem onset dated 5/20/10 reflected that the resident's obsession with water was not addressed. The care plan only reflected that the resident enjoyed playing with water. There were no measures to redirect the resident when he began wetting things. The care plan also had no measures for the resident to have continuous supervision when toileting and no new approaches after he fell on [DATE] and sustained a laceration to his left eyebrow. Review of the resident's Fall Risk assessment dated [DATE] reflected he was high risk for falls. Review of information given to facility staff at an inservice dated 6/24/2010 reflected that contributing factors to resident's falls were cluttered floors, needing to go to bathroom and balance problems. The inservice further reflected that to create a safe ennviroment resident's call lights should have been in reach. The information reflected there should have been individual interventions to reduce the risk of falls and the care plan would be adjusted as needed. Interview on 9/09/2010 at 10:05 a.m. with S12CNA, who was assigned to the unit revealed the resident would try to get up by himself if left alone and would fall. Interview on 9/9/2010 at 8:05 a.m. with S3LPN revealed she was on duty 9/1/2010 when the resident fell . S3LPN further stated she had been aware that S8CNA had left the resident on the toilet when he fell on [DATE]. S3LPN stated the resident's door should have remained open, staff should have stayed in the unit and the resident could push his call bell for assistance if it was in his reach. Interview on 9/10/2010 at 11:10 a.m. with the S4DON revealed the resident should not have been left by himself in the restroom the morning of 9/1/2010 when he fell and should not have been left unsupervised in the unit at any time. S4DON confirmed when she gave an inservice on 9/2/2010, after the resident's fall on 9/1/2010, she was unaware the resident had been left by himself when the fall occurred. S4DON confirmed that there should be staff on the locked unit at all times and the unit should have not been left unattended. Review of the Policy and Procedure for the locked, secure unit reflected that at all times there should have been an employee on the secured unit, positioned where residents could be seen. Should that person need to leave the unit or enter behind a closed door, the employee should notify the nurse so that another employee could be stationed on the unit. Review of a notebook found at the nurses' station reflected that it was signed that staff were present on the unit on 9/9/2010 at 4 a.m. by the S3LPN. Observations on 9/9/2010 at 4:05 a.m. by the survey team revealed there was no staff present on the unit. Further review of the log revealed there was no monitoring to reflect staff was present on the unit for the dates of 9/1/2010 after 6:00 a.m., 9/2/2010, 9/3/2010, 9/4/2010 and 9/5/2010. Request for any more monitoring from S4DON at 12:00 p.m. on 9/10/2010 revealed none was provided by exit 9/10/2010 at 3:00 p.m.