Every finding on record at Louisburg Healthcare and Rehabilitation Center

The facility reported a census of 54 residents, one kitchen and one kitchenette. Based on observation, record review, and interview, the facility failed to prepare and serve food under sanitary conditions, to prevent the potential for food borne bacteria. This placed the residents at risk of food borne illnesses. Findings included:- During an initial tour of the kitchen on 08/24/25 at 09:23 AM, observation revealed the following areas of concern: 1. One black two-tiered cart utilized to hold milk, juice, clean cups, and other supplies at mealtimes had food debris on both tiers. 2. One three-tiered blue, plastic cart utilized to deliver food to residents at mealtimes had food debris on all tiers. 3. One two-tiered black, plastic cart utilized for holding desserts during mealtimes had several dried-on sticky areas. 4. The inside of a two-doored reach-in refrigerator had a dried-on red liquid on the bottom along with food debris. 5. The inside of a two-doored reach-in refrigerator contained three one-gallon containers of dressings with dried-on dressing around the top and sides of the containers. 6. One prep table had food debris on the bottom shelf. On 08/26/25 at 09:13 AM, Dietary Staff BB confirmed the areas of concern would need to be added to the kitchen's cleaning schedules. The facility did not provide a policy for the cleanliness of the kitchen.

The facility reported a census of 54 residents; the sample included 16 residents. Based on interviews, record reviews and observation, the facility failed to ensure a safe and sanitary environment in all areas of the facility including the laundry area. This deficient practice placed the residents at risk for contaminated laundry.Findings included:- During an observation on 08/25/2025 at 08:15 AM, the ceiling in clean linen processing room had paint flaking and missing in multiple areas above the resident's clean laundry. The clean linen folding counter was cluttered with items that were not resident clean laundry, that included a staff purse, a laptop, and a desk organizer with pens/pencils/scissors.During an observation on 08/25/25 at 08:30 AM, the dirty laundry washing area was cluttered and backed up with resident linen and clothes in bags that were stacked on the floor that blocked the staff hand-washing sink, the eye-wash station, and the washer laundry-soap refill. Multiple areas of the ceiling had paint chipped and missing, and the wall on the dryer side had multiple areas of chipped and missing paint. During an interview on 08/25/25 at 08:40 AM, Administrative Staff A stated that paint flaking and chipping in or around the clean laundry was not appropriate and presented an infection concern and acknowledged that the only items that should be on the clean laundry folding area was clean laundry.During an interview on 08/25/25 at 08:45 AM, Maintenance U stated that he had been unaware of the missing paint on the ceilings and walls in the laundry management areas and acknowledged that it should not have been that way. During an interview on 08/25/25 at 08:47 AM, Housekeeping V stated that one of the washers had been down for repairs and that laundry had been backed up while maintenance was awaiting parts. Housekeeping V further reported that she had been unaware that non-laundry items should not have been on the laundry folding counter.The facility policy Preventive Maintenance Program, dated 10/25/19, documented that the maintenance director would be responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner.

The facility reported a census of 54 residents; the sample included 16 residents. Based on interview, observation, and record review, the facility failed to inform Resident (R) 4, R8, R18, R43 and R49 and/or their representative regarding the risks related to psychotropic (alters mood or thoughts) medications. These practices had the potential to lead to uninformed decisions regarding treatment.Findings included:- Review of the Electronic Health Record (EHR) for R4 included diagnoses of altered mental status (a change in a person's level of consciousness, awareness, and cognitive function), metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), and anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R4’s Admit Minimum Data Set (MDS), dated [DATE], documented a Brief Interview of Mental Status (BIMS) score of 14, indicating intact cognition. The MDS documented that R4 used a walker for mobility; R4 required substantial to maximum assistance for bathing, toileting, and personal hygiene, partial to moderate assistance for eating and upper body dressing, set-up and clean-up assistance for oral hygiene, and was dependent on staff for lower body dressing and putting on shoes. R4’s MDS section for high-risk drug classes documented she used an antidepressant (a class of medications used to treat mood disorders). The Falls Care Area Assessment (CAA), dated 07/07/25, documented R4 had been taking an antidepressant. The Psychotropic Drug Use CAA, dated 07/07/25, documented R4 had been taking an antidepressant. R4's “Medicare-A MDS,” dated 08/06/25, documented a BIMS score of nine, which indicated moderate cognitive impairment. The MDS documented that R4 used a wheelchair or walker for mobility, required set-up and clean-up assistance for eating, and substantial to maximum assistance for all other care and activities of daily living (ADLs). The MDS further documented that R4 used antidepressant medication. R4's Care Plan, dated 05/28/25, documented R4 had been prescribed psychotropic medications and was at risk for complications. An intervention dated 07/15/25 included the administration of ordered medications and for staff to monitor for side effects and effectiveness every shift. R4’s EHR revealed a psychotropic consent signed and dated 05/04/25, listed psychotropic medication types with side effects, but lacked the names of individual medications and prescribed dosages.R4's EHR documented orders, dated 05/25/25, for Buspar (an antidepressant medication) 75 milligrams (mg) in the afternoon, and Cymbalta (an antidepressant medication), delayed release, 60 mg to be given in the afternoon. Observed on 08/26/25 at 09:48 AM, R4 was still in bed sleeping. During an interview on 08/25/25 at 01:00 PM, Administrative Staff A stated that the psychotropic consents had been completed as required by having the type of medication listed on the consent. Administrative Staff A further stated that the resident had been verbally educated about the individual medication, the medication dosage, and why they were prescribed it, but that was not documented. The facility policy for Use of Psychotropic Medications, dated 02/05/25, included: Prior to initiating or increasing a psychotropic medication, the resident and/or resident representative must be informed of the benefits, risks, and alternatives for the medication. The facility shall document that the resident and/or the resident representative was informed in advance of the risks and benefits of the proposed care. - Review of the Electronic Health Record (EHR) for R8 included diagnoses of borderline personality disorder (a disorder characterized by disturbed and unstable interpersonal relationships and self-image along with impulsive, reckless, and often self-destructive behavior), cerebral palsy (a progressive disorder of movement, muscle tone, or posture caused by injury or abnormal development in the immature brain, most often before birth), major depressive disorder (major mood disorder that causes persistent feelings of sadness), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), insomnia (inability to sleep). R8’s Admit Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of six, indicating severe cognitive impairment. The MDS documented that R8 used a wheelchair for mobility and required a mechanical lift; R8 required partial to moderate assistance for eating and oral hygiene and was dependent on staff for all other care and activities of daily living (ADL). R8’s MDS section for high-risk drug classes documented she used antipsychotics (a class of medications used to treat major mental conditions that cause a break from reality), antianxiety (a class of medications that calm and relax people), and an antidepressant. The Falls Care Area Assessment (CAA), dated 07/07/25, documented R8 had been taking antianxiety and antidepressant medication. The Psychotropic Drug Use CAA, dated 07/07/25, documented R8 had been taking antipsychotic, antianxiety, and antidepressant medication. R8's “Quarterly MDS,” dated 08/08/25, documented a BIMS of 10 which indicated moderate cognitive impairment. The MDS documented that R8 used a wheelchair for mobility and was dependent on staff for all cares and ADLs. The MDS further documented that R8 used antipsychotic, antianxiety, and antidepressant medication. R8's Care Plan, dated 05/22/25, documented R8 had been prescribed psychotropic medications and was at risk for complications, and R8 had a mood problem related to borderline personality disorder, major depression, and anxiety disorder. As an intervention, staff were to administer medications as prescribed and monitor R8 for side effects and effectiveness. R8's Care Plan, dated 06/17/25, documented R8 experienced trouble sleeping related to placement. Interventions included the administration of medications that promoted sleep for staff to obtain a sleep history and review her current medications that may have interfered with or promoted sleep. R8's Care Plan, dated 06/18/25, documented R8 had impaired thought processes at times and required assistance. Interventions included the administration of medications as ordered, and for staff to monitor and document side effects and effectiveness. R8’s EHR revealed a psychotropic consent signed and dated 05/17/25 that listed psychotropic medication types with side effects but lacked the names of individual medications and prescribed dosages. R8's EHR documented orders, dated 07/18/25, for olanzapine (an antipsychotic medication) 10 mg twice a day, lorazepam (an antianxiety medication) one mg four times a day, fluoxetine (an antidepressant medication) 40 mg in the morning, and temazepam (an insomnia medication) 15 mg at bedtime. Observed on 08/25/25 at 10:35 AM, R8 became anxious and defiant when this surveyor asked to witness facility staff flush her gastrostomy tube (G-tube: tube surgically placed through an artificial opening into the stomach). During an interview on 08/25/25 at 01:00 PM, Administrative Staff A stated that the psychotropic consents had been completed as required by having the type of medication listed on the consent. Administrative Staff A further stated that the resident had been verbally educated about the individual medication, the medication dosage, and why they were prescribed it, but that was not documented. The facility policy for Use of Psychotropic Medications, dated 02/05/25, included: Prior to initiating or increasing a psychotropic medication, the resident and/or resident representative must be informed of the benefits, risks, and alternatives for the medication. The facility shall document that the resident and/or the resident representative was informed in advance of the risks and benefits of the proposed care. - R18’s Electronic Medical Record (EMR) revealed diagnoses, which included schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought) and major depressive disorder (MDD-major mood disorder that causes persistent feelings of sadness). R18’s “Annual Minimum Data Set” (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. He received antipsychotic (medication used to treat psychosis, a major mental disorder characterized by a gross impairment in reality perception) and antidepressant (a medication used to treat symptoms of depression) medications during the assessment period. R18’s “Psychotropic Drug Use Care Area Assessment” (CAA), dated 12/03/24, documented the staff shall monitor the resident for adverse side effects of the medications. R18’s “Quarterly MDS,” dated 06/05/25, documented the resident had a BIMS score of 15. He received antipsychotic and antidepressant medication during the assessment period. R18’s Care Plan, revised 07/11/25, instructed staff to monitor the resident for side effects of his psychotropic medications. R18’s EMR, under “Orders,” included the following physician’s orders: Abilify (an antipsychotic medication), 30 milligrams (mg), by mouth (PO), every hour of sleep (QHS), for a diagnosis of paranoid schizophrenia, ordered 06/10/25. Zoloft (an antidepressant medication), 25 mg, PO, every morning (QAM), for a diagnosis of MDD, ordered 03/24/25. R18’s EMR under “Misc” lacked a thoroughly completed psychotropic consent form. On 08/25/25 at 01:00 PM, Administrative Staff A stated the facility’s psychotropic consent forms are signed by the resident and/or the resident representative. The consent forms only include the classification of the medication, but no other specifics. Administrative Staff A said the facility will verbally explain risks, benefits, dose and name of medication, but they do not document the conversation. The facility policy for Use of Psychotropic Medications, dated 02/05/25, included: Prior to initiating or increasing a psychotropic medication, the resident and/or resident representative must be informed of the benefits, risks, and alternatives for the medication. The facility shall document that the resident and/or the resident representative was informed in advance of the risks and benefits of the proposed care. - Review of the Electronic Health Record (EHR) for R43 included diagnoses of alcohol induced dementia (a progressive mental disorder characterized by failing memory and confusion), alcohol induced psychosis (any major mental disorder characterized by a gross impairment in reality perception), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). R43's Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. R43 had a mood score of 0, indicating no depression, and no behaviors were documented. The MDS section for high-risk drug classes documented she used an antidepressant (a class of medications used to treat mood disorders). The Psychotropic Drug Use Care Area Assessment, dated 01/04/25, documented R43 had been taking an antidepressant. R43's “Quarterly MDS” dated 08/012/25, documented a BIMS score of 15 and mood score of 0. The MDS documented that R43 used antidepressant medication and an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality). R43’s “Physicians’ Orders” noted an order for Seroquel (an antipsychotic medication) 25 milligrams (mg) at bedtime for depression; ordered on 07/18/25. R43 also took Sertraline (an antidepressant medication) 75mg for depression; ordered on 07/21/25. R43’s EHR revealed a psychotropic consent signed and dated 09/04/24. The psychotropic consent documented R43 took an antidepressant and an antipsychotic medication with side effects for the medication class, but lacked the names of individual medications and prescribed dosages and reason for taking the medications. The consent did not show that R43 was notified of the required information when the dosages were changed or when the Seroquel was discontinued and later restarted. On 08/26/25 at 10:16 AM, R43 laid in bed with the cover up over her head. During an interview on 08/25/25 at 01:00 PM, Administrative Staff A stated that the psychotropic consents had been completed as required by having the type of medication listed on the consent. Administrative Staff A further stated that the resident had been verbally educated about the individual medication, the medication dosage, and why they were prescribed it, but confirmed that it was not documented. The facility policy for Use of Psychotropic Medications, dated 02/05/25, included: Prior to initiating or increasing a psychotropic medication, the resident and/or resident representative must be informed of the benefits, risks, and alternatives for the medication. The facility shall document that the resident and/or the resident representative was informed in advance of the risks and benefits of the proposed care. - Review of the Electronic Health Record (EHR) for R49 included diagnoses of anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). R49’s Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. R43 had a mood score of 0, indicating no depression, and no behaviors were documented. The MDS documented R49 took an antidepressant (a class of medications used to treat mood disorders). The Psychotropic Drug Use Care Area Assessment, dated 07/07/25, documented R40 took an antidepressant medication. R49 Care Plan documented R49 was at risk for complications related to taking psychotropic medications; dated 06/05/25. R49 took Trazodone (antidepressant) for depression related to loss of independence and past traumas; dated 06/05/25. R49’s “Physicians’ Orders” noted an order for trazodone (an antidepressant) 100 milligrams (mg) at bedtime for depression; ordered on 03/03/25. R49’s EHR revealed a psychotropic consent signed and dated 07/21/25 that listed psychotropic medication types with side effects, but lacked the names of individual medications and prescribed dosages Observation on 08/26/25 at 10:30 AM, R49 had been sleeping and just got up into his wheelchair. R49 got irritated when asked about his antidepressant medication. He said he did not want to take an antidepressant, but that he was told it would help with his pain. He then stated it is not helping with his pain. During an interview on 08/25/25 at 01:00 PM, Administrative Staff A stated that the psychotropic consents had been completed as required by having the type of medication listed on the consent. Administrative Staff A further stated that the resident had been verbally educated about the individual medication, the medication dosage, and why they were prescribed it, but that was not documented. The facility policy for Use of Psychotropic Medications, dated 02/05/25, included: Prior to initiating or increasing a psychotropic medication, the resident and/or resident representative must be informed of the benefits, risks, and alternatives for the medication. The facility shall document that the resident and/or the resident representative was informed in advance of the risks and benefits of the proposed care.

The facility reported a census of 54 residents. The sample included 16 residents including one resident reviewed for dignity. Based on observation, interview, and record review, the facility failed to show respect and dignity to one Resident (R) 10 when staff left the window-blinds open during cares. This placed the resident at risk for impaired dignity and embarrassment. Findings included:- Review of R10's Electronic Medical Record (EMR) documented a diagnosis of dementia (a progressive mental disorder characterized by failing memory and confusion).R10's admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of nine, indicating moderately impaired cognition. She was frequently incontinent of bowel and bladder and was dependent on staff for toileting.The Care Area Assessments, dated 05/08/25, lacked analysis of findings.R10's Quarterly MDS, dated 08/08/25, documented that the resident had a BIMS score of three, indicating severe cognitive impairment. She was always incontinent of bowel and bladder and was dependent on staff for toileting.R10's Care Plan, revised 06/11/25, instructed staff that the resident was incontinent of bowel and bladder and wore incontinent products.On 08/25/25 at 08:59 AM, Administrative Nurse F and Certified Nurse Aide (CNA) N entered R10's room to perform peri-care. Staff removed the cover from the resident, unfastened her incontinent brief, and turned her toward the window. The window in the resident's room looked out onto the front parking lot with the window blinds raised approximately 12 inches. Staff GG requested Administrative Nurse F to close the blinds before continuing with the residents' cares.On 08/25/25 at 08:59 AM, Administrative Nurse F stated she should have closed the window blinds before the initiation of the cares.On 08/25/25 at 08:59, CNA N stated she had not thought to close the blinds before the cares were initiated.On 08/26/25 at 08:17 AM, Administrative Nurse E stated it was the expectation for the staff to close the window blinds before doing resident cares.The undated facility policy for Resident Rights included: Residents have the right to be treated with respect and dignity.

The facility reported a census of 54 residents; the sample included 16 residents. Based on observation, interview, and record review the facility failed to complete a thorough Minimum Data Set (MDS) for Resident (R)10, when staff did not complete the analysis of findings for the triggered Care Area Assessments (CAA). This placed the resident at risk for impaired care due to unidentified care needs. Findings included:- R10's Electronic Medical Record (EMR) documented a diagnosis of dementia (a progressive mental disorder characterized by failing memory and confusion).R10's admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of nine, indicating moderately impaired cognition. She was frequently incontinent of bowel and bladder and was dependent on staff for toileting. The Care Area Assessments, dated 05/08/25, lacked analysis of findings. R10's Care Plan, revised 06/11/25, instructed staff the resident was incontinent of bowel and bladder and wore incontinent products. On 08/26/25 at 08:17 AM, Administrative Nurse D stated it is the expectation for staff to thoroughly complete the MDS, including the triggered CAAs. The facility utilized the RAI manual for the accurate and thorough completion of the MDS, including the triggered CAAs.

The facility reported a census of 54 residents; the sample included 16 residents. Based on interviews, record reviews and observation, the facility staff failed to implement adequate Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) personal protective equipment (PPE- gowns, face shields and/or eyeglasses/goggles, and gloves) for Resident (R) 8 while accessing her gastrostomy tube (G-tube: tube surgically placed through an artificial opening into the stomach) for flushing. The facility failed to ensure a sanitary environment in the laundry area. This deficient practice placed the resident at risk infections related to lack of proper PPE usage and possible contaminated laundry.Findings included:- During an observation on 08/25/2025 at 08:15 AM, the ceiling in clean linen processing room had paint flaking and missing in multiple areas above the resident's clean laundry. The clean linen folding counter was cluttered with items that were not resident clean laundry, that included a staff purse, a laptop, and a desk organizer with pens/pencils/scissors.During an observation on 08/25/25 at 08:30 AM, the dirty laundry washing area was cluttered and backed up with resident linen and clothes in bags that were stacked on the floor that blocked the staff hand-washing sink, the eye-wash station, and the washer laundry-soap refill. Multiple areas of the ceiling had paint chipped and missing, and the wall on the dryer side had multiple areas of chipped and missing paint. During an observation on 08/25/25 at 10:42 AM, Licensed Nurse (LN) G and LN H accessed and flushed R8's G-tube with tap water. LN G and H performed proper hand hygiene before and after the procedure and donned gloves, but neither LN G nor LN H wore a gown as required.R8's electronic health record had an order dated 05/16/25, for EBP of gown and gloves due to a feeding tube for all cares.During an interview on 08/25/25 at 08:40 AM, Administrative Staff A stated that paint flaking and chipping in or around the clean laundry was not appropriate and presented an infection concern and acknowledged that the only items that should be on the clean laundry folding area was clean laundry.During an interview on 08/25/25 at 08:45 AM, Maintenance U stated that he had been unaware of the missing paint on the ceilings and walls in the laundry management areas and acknowledged that it should not have been that way. During an interview on 08/25/25 at 08:47 AM, Housekeeping V stated that one of the washers had been down for repairs and that laundry had been backed up while maintenance was awaiting parts. Housekeeping V further reported that she had been unaware that non-laundry items should not have been on the laundry folding counter.During an interview on 08/25/25 at 11:00 AM, LN H stated that the proper PPE to be worn while accessing a G-tube should have been gown and gloves, and acknowledged that she had only worn gloves while performing the G-tube flushing on R8.During an interview on 08/25/25 at 03:38 PM, Administrative Staff A stated that EBP PPE should have been used on residents that had chronic wounds, any open wounds being treated, had multiple drug-resistant organisms (MDRO-common bacteria that have developed resistance to multiple types of antibiotics), or had any implanted medical devices.During an interview on 08/25/25 at 03:52 PM, Administrative Nurse E stated EBP was utilized for residents who had chronic wounds, any implanted medical devices, or if they had an MDRO.The facility policy Preventive Maintenance Program, dated 10/25/19, documented that the maintenance director would be responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner.The facility policy Enhanced Barrier Precautions, dated 04/01/24, documented that an order for enhanced barrier precautions will be obtained for residents that had wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous ulcers) and/or implanted medical devices (e.g., central lines, urinary catheter devices, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with an MDRO.

The facility reported a census of 54 residents. Based on observation, interview, and record review, the facility failed to ensure the posted daily nurse staffing sheets included accurate and identifiable information to include the daily licensed and unlicensed staff actual worked hours.Findings included:- Observed on 08/24/25 at 08:15 AM, the facility's posted daily staffing sheet did not list the actual number of hours worked. Also posted were the daily staffing sheets for 08/23/25 and 08/22/25, which also lacked the actual hours worked.Observed on 08/26/25 at 11:09 AM, the actual hours worked were not posted on the daily staffing sheet for 08/26/25. Record review for the month of August 2025 revealed the following daily staffing sheets did not list the actual hours worked: 08/20, 08/19, 08/17, 08/16, 08/12, 08/11, 08/10, 08/05, 08/08, 08/07, 08/06, 08/05, 08/04, 08/03, 08/02, and 08/01.During an interview on 08/26/25 at 08:30 AM, Administrative Staff A stated that if the actual hours worked was the same as the total number of hours worked, she did not rewrite it on the daily staffing sheet.The facility policy Nursing Services and Sufficient Staff, dated 02/05/25, documented that it was facility policy to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The policy further documented that the facility was responsible for submitting timely and accurate staffing data through the CMS Payroll-Based Journal (PBJ) system.

The facility reported a census of 54 residents. Based on interview and record review, the facility failed to electronically submit complete and accurate staffing information to the Federal regulatory agency through Payroll-Based Journaling (PBJ) when the facility failed to accurately submit hourly staffing data for all weekend personnel. The facility failed to submit complete and accurate staffing information to the Federal regulatory agency through PBJ when the facility failed to accurately submit hourly staffing data for all weekend personnel.Findings included: - Review of the PBJ Staffing Data Report for Fiscal Year (FY) for Quarter 4 - 2024 (July 1 - September 30), FY Quarter 1-2025 (October 1 - December 31), and FY Quarter 2 - 2025 (January 1 - March 31) the facility failed to have sufficient staffing for the weekends.Review of the Nursing Schedule and Payroll Data Sheets for the weekends of the above months revealed the facility had sufficient weekend staff coverage.During an interview on 08/26/25 at 08:30 AM, Administrative Staff A stated that reported time had not been accurately recorded as it relates to how staff were scheduled to work, and that every staff member has a half-hour automatically deducted from the worked time by corporate for lunch. Administrative Staff A also stated that she ensures that staffing was sufficient for the questioned weekends.The facility policy Nursing Services and Sufficient Staff, dated 02/05/25, documented that it was facility policy to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The policy further documented that the facility was responsible for submitting timely and accurate staffing data through the CMS Payroll-Based Journal (PBJ) system.

The facility reported a census of 33 residents. Based on observation, record review, and interview, the facility failed to prepare and serve food under sanitary conditions, to the residents of the facility appropriately to prevent the potential for food borne bacteria. Findings included: - During an initial tour of the kitchen on 10/25/23 at 11:31 AM, the following areas of concerns identified: 1. The stationary can opener had a dried-on, sticky substance on the tip. 2. A half-gallon of sour cream in the reach-in refrigerator was undated. 3. Two reach-in refrigerators had food debris on the bottom. 4. There were two half-gallon jugs of apple juice stored directly on the floor of the dry storage room, without a barrier. 5. A three-gallon box of grape juice and a three-gallon box of cranberry juice for the juice machine stored directly on the kitchen floor, without a barrier. 6. Four pans stored on a shelf beneath one prep table had food debris in the lip of the pans. 7. Two food scales, used to weigh food, had a layer of a dust type substance. 8. The shelf over the range contained a build-up of a dusty food debris. 9. A shelf under a food prep table held cookie sheets which contained food debris. 10. The grate of the juice machine lacked the protective coating on multiple areas of the grate. 11. The inside of the microwave had dried-on food. On 10/30/23 at 01:01 PM, Administrative staff A stated the facility did not currently have a Certified Dietary Manger (CDM). They were actively looking to hire a CDM. Administrative staff A stated the above areas would be taken care of. The Cleaning and Sanitation of Dining and Food Services Areas, dated 2017, included: The nutrition and food services staff will maintain the cleanliness and sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule. The facility failed to prepare and serve food under sanitary conditions for the residents of the facility appropriately to prevent the potential for food borne bacterial.

The facility reported a census of 33 residents. Based on interview and record review, the facility failed to provide residents opportunities to change their declinations for the influenza/pneumococcal vaccine. Findings included: - Review of Resident (R) 23's electronic medical record Immunization task revealed consent refused for influenza pneumonia and COVID. A COVID declination was signed by the resident on 10/27/22. A declination for pneumococcal and influenza vaccine was signed by the resident on 11/04/21. Review of the Annual Minimum Data Set (MDS) dated [DATE], indicated the resident had a Brief Interview for Mental Status (BIMS) score of 08, that indicated moderately impaired cognition. Review of R 15's electronic medical record, under the Immunization tab contained undated entries which revealed the resident declined the pneumococcal vaccination once and the influenza vaccine three times. A pneumococcal vaccination declination was signed by the resident on 07/29/22. The resident signed an agreement for the influenza vaccination on 09/11/20. No signed influenza declinations were found for the influenza vaccine. Review of R13's electronic medical record, under the Immunization tab contained two undated entries that the resident declined the influenza immunization and one undated entry that the resident declined the pneumococcal vaccine. Further review of the electronic medical record revealed the resident signed the pneumococcal declination dated 11/04/21. The resident agreed to the influenza vaccine dated 11/04/21. The medical record lacked declinations for the influenza vaccine. Review of R3's electronic medical record, under the Immunization tab revealed an undated entry for pneumovax vaccine as refused. Further review of the medical record revealed the resident's responsible party verbally declined the pneumococcal vaccine dated 12/10/21. Interview, on 10/30/23 at 02:45 PM, with Administrative Nurse E, confirmed the above and stated she would conduct an audit of the charts. Administrative Nurse E stated the facility administered influenza and pneumococcal vaccines on 09/28/23. The last COVID clinic was 06/23/23. The facility's policy for Infection Prevention and Control Program dated 05/11/23, instructed staff to offer the influenza vaccine annually and the pneumococcal vaccine upon admission and offer residents the opportunity to refuse the immunization and document the education provided and details regarding whether the resident received the immunizations. The facility failed to provide residents opportunities to change their influenza and pneumococcal vaccination declination status as required.

The facility reported a census of 33 residents. Based on interview and record review, the facility failed to provide residents opportunities to change their declinations for the COVID vaccination. Findings included: - Review of Resident (R)23's electronic medical record, under the Immunization task tab, revealed an entry consent refused for the COVID vaccination with the entry undated. A COVID declination was signed by the resident on 10/27/22. Review of R15's electronic medical record, under the Immunization tab contained an undated entry which revealed the resident declined the COVID vaccination. Further review of the medical record revealed a signed Covid declination undated, and three signed declinations dated 06/02/21, 05/04/21, and 12/23/21. Review of R13's electronic medical record, under the Immunization tab contained an undated entry that the resident declined the COVID vaccine. Further review of the electronic medical record revealed the resident signed a COVID declination dated 12/17/21 and 10/10/22. Interview, on 10/30/23 at 02:45 PM, with Administrative Nurse E, confirmed the above and stated she would conduct an audit of the charts. The last COVID vaccine clinic was conducted on 06/23/23. Administrative Nurse E stated the local pharmacy had difficulty getting the newest booster. The facility policy Infection Prevention and Control Program dated 05/11/23, instructed staff to offer the COVID-19 vaccine when available so the residents could accept or refuse the vaccine and change their decisions based on current guidance. The facility failed to provide residents opportunities to change their COVID vaccination declination status as required.

The facility reported a census of 33 residents with 16 residents selected for review, which included two residents reviewed for range of motion. Based on observation, interview, and record review, the facility failed to provide consistent restorative services to one Resident (R)6 of the two residents reviewed for range of motion. Findings included: - Review of Resident (R)6's Physician Order Sheet, dated 10/01/23, revealed diagnoses included cerebral vascular accident (stroke-sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), left hemiplegia (paralysis of one side of the body muscular weakness of one half of the body), dysphagia (swallowing difficulty), diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), major depressive disorder (major mood disorder), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview of Mental Status (BIMS) score of 13, which indicated normal cognitive function. The resident required extensive assistance of two staff for bed mobility, transfer, and toileting and extensive assistance of one staff for dressing and personal hygiene. The resident had impairment in functional range of motion on one side in the upper and lower extremities. The ADL (Activity of Daily Living) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 07/21/23, assessed the resident required staff assistance for ADL cares and therapy services for increase in functional mobility. The Care Plan, revised 10/25/23, instructed staff that the resident received restorative care for active and passive range of motions to the left lower and upper left extremities. Staff instructed to encourage the resident to attend the morning group exercise program and utilize the home exercise program set up prior to admission. The recommendation from physical therapy included standing in the hallway with the use of a handrail, gait belt, and sling for left upper extremity, and assistance of one staff to shift weight daily as tolerated. Review of the Restorative Nursing Task, from 10/02/23 through 10/30/234 for passive, active assist range of motion to left lower extremities all planes for 10 repetitions in two sets, daily as tolerated, and may use the floor bike revealed staff provided restorative services seven times, with resident refusal twice. Review of the Restorative Nursing Task, from 10/02/23 through 10/30/23 for the morning group exercise with staff, revealed the resident attended this activity 10 times and refused twice. Review of the Restorative Nursing Task, from 10/18/23 through 10/30/23 for ambulation revealed staff provided the service three times. Observation, on 10/25/23 at 09:45 AM, revealed the resident seated in her wheelchair in her room. The resident had a foam protective boot on her left foot. The resident stated she had a stroke that paralyzed her left arm and leg. The resident stated she would like to overcome her disability and return home, and had received therapy, but no longer qualified for it, and staff were to do a restorative therapy. The resident stated she did not consistently receive restorative therapy as the staff had other duties. The resident displayed depressed affect. Observation, on 10/25/23 at 10:00 AM, revealed an exercise group in the common dining room, and the resident did not attend. Observation, on 10/26/23 at 08:55 AM, revealed Certified Nurse Aide (CNA) N and O provided morning care and transferred the resident from her bed to her wheelchair. Observation, on 10/26/23 at 09:30 AM, revealed Licensed Nurse (LN) G, administered the resident her morning dose of insulin prior to the resident eating her breakfast. Observation, on 10/26/23 at 10:00 AM, revealed the resident continued to eat her breakfast. The morning exercise group began at 10:00 AM. Interview, on 10/30/23 at 12:18 PM, with CNA Q, revealed she did provide restorative services to the resident as much as time allowed, but did get pulled from restorative services to provide resident care. Interview, on 10/30/23 at 01:21 PM with LN H, confirmed the restorative CNA got pulled from restorative therapy to provide resident care. Interview, on 10/30/23 at 02:45 PM, with Administrative Nurse D, revealed the facility had plans to train the direct care staff to provide restorative services, and confirmed during the past month, the restorative CNA got pulled from restorative services to provide resident care. The undated facility policy Restorative Nursing Program, instructed staff to provide maintenance and restorative services to residents. The facility failed to provide consistent restorative services to this resident to enhance her physical abilities and sense of wellbeing.

The facility reported a census of 33 residents, with 16 residents sampled, including six residents reviewed for accidents. Based on interview, record review, and observation, the facility failed to ensure appropriate interventions initiated for one Resident (R)12, and failed to utilize appropriate interventions to prevent a fall for R 139, which resulted in a non-injury fall when staff failed to utilize a gait belt while toileting the resident. Findings included: - Review of Resident (R)139's electronic medical record (EMR) revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Five-day Minimum Data Set (MDS), dated [DATE], documented the resident admitted to the facility on [DATE] from an acute care hospital. His Brief Interview for Mental Status (BIMS) score was six, which indicated severe cognitive impairment. He required extensive assistance of two staff for toileting and transfers and required limited assistance of two staff for ambulation. His balance was not steady, and he was only able to stabilize with staff assistance. He used a walker and a wheelchair. He had one non-injury fall since admission to the facility and had one fall in month prior to admission which resulted in a fracture. He had a recent orthopedic surgery which required skilled nursing care. The Discharge MDS, dated [DATE], documented the resident discharged to the hospital with his return anticipated. The falls care plan, dated 09/18/23, instructed staff the resident was at risk for falls. Staff were to utilize a gait belt while transferring and ambulating with the resident. Review of the resident's EMR revealed a fall assessment on 09/18/23, which placed the resident at a high risk for falls. Review of a Fall Report, dated 09/18/23, provided by the facility, included: At 05:37 PM, Certified Nurse Aide (CNA) M assisted the resident to the toilet in his bathroom. When CNA M assisted the resident up from the toilet, he lost his balance and fell to the floor. CNA M had not utilized a gait belt while toileting the resident. The resident did not receive an injury during the fall. On 10/30/23 at 02:12 PM, Administrative Nurse D stated the CNA had not used a gait belt at the time of the resident's fall. It was the expectation of the facility for staff to use gait belts while ambulating with residents. The facility policy for Accidents and Supervision, undated, included: Each resident shall receive adequate supervision and assistive devices to prevent accidents. The facility failed to utilize a gait belt while caring for this dependent resident which led to a non-injury fall. 28560 - Review of Resident (R)12's Physician Order Sheet, dated 10/01/23, revealed diagnoses included cerebral vascular disease (impaired blood flow to the brain), diabetes (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), and generalized anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The resident was occasionally incontinent of urine and required limited assistance of one person for transfer and toileting. The Falls Care Area Assessment (CAA), dated 06/19/23, assessed the resident required staff anticipation of the resident's care needs to prevent the resident from performing activities of daily living without staff assistance. Staff were to provide opportunities to participate in the resident's care to promote independence. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 06/19/23, instructed staff to provide incontinence cares as needed to minimize the risks of incontinence . The Quarterly MDS, dated [DATE] assessed the resident with a BIMS of 13. The resident required extensive assistance of two person for transfers and toileting use. The resident's balance was not steady. The resident was frequently incontinent of urine. The Care Plan, reviewed 10/17/23, instructed staff the resident had a toileting schedule to offer/encourage toileting when getting out of bed, before/after meals, and before bed. Times listed as 07:00 AM-09:00 AM, 11:00 AM-01:00 PM, 05:00 PM-07:00 PM, and 08:00 PM-10:00 PM. The resident had an overall decline and required extensive assistance with cares. An entry dated 06/28/23 instructed staff the resident used a urinal and to monitor for need to empty. Review of the Fall Investigations for falls that occurred on 07/15/23, 07/23/23, 07/27/23 and 08/10/23, all involved the resident toileting with the intervention for the fall on 08/10/23 to develop and follow a toileting plan. Observation, on 10/26/23 at 11:39 AM, revealed the resident positioned in his bed. The resident's bed was in a raised position (not in the lowest position) as the resident had the bed control in his hand. The resident responded appropriately to verbal cues. Certified Nurse Aide CNA N and O checked the resident's brief and found the brief to be dry (unsoiled). CNA N and O did not offer a toileting opportunity at that time and transferred the resident from his bed to the wheelchair with a full body mechanical lift. CNA N stated the resident did not use a urinal as he frequently spilled it in the past, and now staff checked and changed the resident due to his decline and admission to hospice. Interview, on 10/30/23 at 02:45 PM, with Administrative Nurse D, confirmed the resident was on a toileting plan after a fall in August 2023, when she determined the previous falls involved toileting. Administrative Nurse D stated she would expect staff to provide toileting opportunities to the resident before/after meals as an intervention for fall prevention. The facility policy Accidents and Supervision, revised 2017, instructed staff to implement specific interventions to reduce the resident's risk from hazards. The facility failed to offer this resident with multiple falls a toileting opportunity as care planned, to reduce the risk of falls.

The facility reported a census of 32 residents. Based on observation, interview, and record review, the facility failed to provide necessary housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior in resident areas that included the dining room, resident hallways, and resident rooms. This failure affected all the residents that resided in the facility. Findings included: - An environmental tour of the facility, on 07/10/23 at 04:00 PM, and an extended tour of the facility on 07/11/23 at 01:45 PM, with Maintenance staff U revealed the following areas of concern: The front lobby and 100 hall included 12 resident rooms, a shower room and a beauty shop closed off and in a remodel mode due to a major water break/flooding that previously occurred on that hallway and side of the facility. Construction/remodel was evident in various areas of the lobby and resident areas. The facility identified the water break of the sprinkler system occurred on December 22, 2022, over 6 months previously. The 200 hall had the following areas of concern: 1. The fire doors from the nurses' station area had large areas that lacked paint. 2. A resident room that lacked paint across the lower edge of the entrance door frame. 3. A resident room wall had two areas that lacked paint that measured approximately four inches in length and another that measured approximately 14 inches in length. The wall by the shower door had approximately 16 inches of scrapes that lacked paint. 4. A shared resident's bathroom had both doors that lacked paint on the door. The floor at the toilet base had a rusty brown color and lacked caulking around the base, which left a gap between the floor and the toilet. In addition, the floor had linoleum with dark brown permanent type discoloration. Furthermore, the sink had a dark brown, dull discoloration and a dark brown ring that surrounded the drainage pipe. 5. A shared resident's bathroom had dark brown rings between the toilet base and the floor. The toilet base lacked caulking. In addition, there were six holes in the wall tile and each hole measured approximately one/fourth inches diameter. Furthermore, the floor covering had open cracks near the door. 6. A resident's room had floor tile that pulled away from the floor. In addition, the bedroom wall lacked paint that measured approximately one-half inch diameter. 7. A resident's bedroom door had gouges that exposed the raw wood. The bedroom wall had missing paint areas along the wall where the resident's television was. 8. A resident's room had numerous large gouges in the wall that exposed the sheet rock underneath. The wall by the bathroom also had areas that lacked paint. The resident's shower was a private shower and lacked a shower head. The air conditioning unit lacked a cover. 9. A resident's bedroom door frame had large areas of missing paint. 10. A resident's bedroom door lacked numerous areas that lacked a protective finish. 11. A resident's bedroom wall had areas of mismatched paint. 12. A resident's entrance door lacked areas of a protective finish. In addition, there was an area that lacked a finish board on top of the panel that exposed the raw wood. Furthermore, the bathroom had worn linoleum that appeared to have a permanent brown discoloration to it. 13. A resident's room had a wooden panel along the wall. This panel had a hole that measured approximately one-half inch. 14. A resident's bedroom had numerous gouges in the walls that exposed sheet rock. 15. A resident's toilet had areas of missing caulking from the toilet base to the floor. 16. The entire length on both sides of the hall corridors at the height of the handrails lacked any type of finish. The lack of finish exposed areas of raw sheetrock. Maintenance staff U identified the area where wooden trim board had been dyed. 17. The entire length of the hall corridors where the ceilings met the walls were white and lighter in coloration. Unable to determine if this lighter color was a different color of paint, raw sheet rock exposure, or sheet rock compound. 18. The hall corridors had numerous areas of cracks in the walls. 19. The hall corridors above the resident doors had an area of white sheetrock compound and lacked paint. 20. A community shower room door had numerous areas of missing paint. 21. The housekeeping door had numerous areas of missing paint. 22. Two clean linen doors lacked paint. 23. The vent on the ceiling in the hall corridor had discolored stains around the vent. 24. The air vents on the ceiling in the hall corridor had a build-up layer of dust. 25. The carpet had numerous worn spots. There were over 93 carpet stains down the corridor and measured from approximately the size of a quarter to an approximate 3 feet diameter stains. 26. The corner of the wall in the resident hallway near the crash cart stored, lacked sheet rock compound and the metal corner strip exposed. 27. A shared resident room had a strong urine odor that lingered on both days of the complaint survey on 07/10/23 and 07/11/23. The dining room had numerous areas above the cove base that lacked paint as well as over 30 areas on the walls at approximately chair level height that lacked paint. Review of a design company, dated 11/04/2022 (before the sprinkler flood), revealed a plan, without bid/costs for demolition plan, design plan, interior elevation plan, wall finish plan, floor finish plan, furniture plan, interior detail, and interior finish notes. The facility was able to provide one proposal, dated 05/08/23, for Phase 11- all the other res.[resident] rooms, corridors, lobby and offices. The proposal was valid until 08/08/23. On 7/10/23 at 02:32 PM, Administrative staff B, reported the carpets in the resident hallway was dirty, and staff attempted to shampoo the carpets, but they were uncleanable. The facility was supposed to get a remodel, but it's a long waiting period. On 07/10/23 at 03:22 PM, Resident (R)1 reported he resided on the other hallway until his room flooded. He was aware of the dirty and stained hallway carpet but did not really pay attention to the hallway walls, because that's the way it always looked. On 7/10/23 at 3:33 PM, R2 reported the hallways were not clean. The hallway carpets were horribly and terrible and the hallways were filthy. Housekeeping staff may vacuum maybe three times a week, but those carpets are in dire need of work. Carpet can't be that expensive anymore. On 07/10/23 at 04:14 PM, Administrative staff A reported the facility had insurance issues. Our crew consists of one maintenance person and 1 transportation person that had been working on the 100 hall when they were able. The original plan was to repair/remodel the 100 hall, front area, then move to the 200 hall where residents resided. The longer it has drug on, the less she was aware of the time frames for starting/completing the remodel. Staff A worked in the facility since 2021, and the walls had not changed. The facility was unable to do major things or maintenance without corporate approval. The facility had not hired any outside contractors to help with the renovation. On 07/11/23 at 09:12 AM, Licensed Nurse (LN) G reported she worked at the facility for over a year and a half. The 100 resident hallway walls and the stained worn carpet have been the same way since she started. On 07/11/23 at 11:23 AM, a complainant (who wished to remain anonymous) reported by phone that the facility needed to be cleaned Badly. The complainant reported the environment was always dirty looking. On 07/11/23 at 02:00 PM, Maintenance staff U verified the above concerns. He started in February 2023 and reported he has been busy keeping up with the regular maintenance. The hallway carpet was in disrepair, worn and stained since he started working at the facility. He was told insurance has to come through before we can start remodeling. Remodels are on hold on the closed hall (100 hall, front lobby and rooms throughout the 100 hall) right now because of insurance issues. He was unable to purchase paints until corporation would approve it for the damaged 200 hall. The hallway walls have been in the same disrepair since he started and he was told to leave that alone. The facility's policy for Preventative Maintenance Program dated 10/25/19, revealed a preventative maintenance program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. The facility failed to provide necessary housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior in resident areas that included the dining room, resident hallways, and resident rooms. This failure affected all the residents that resided in the facility.

The facility reported a census of 32 residents. Based on observation, interview and record review, the facility failed to ensure the residents environment remained as free of accident hazards as possible related to a resident's transfer pole, sharp jagged edges on bedroom doors, hallway carpet pulled away from the threshold strip in occupied resident doorways, and bubbled tile near an ambulatory resident's dresser. Findings included: - An environmental tour on 07/10/23 at 04:00 PM with Maintenance Staff U, revealed the following areas of accident hazardous concerns: 1. Four occupied resident room entry ways had carpet which pulled away from the threshold, that created a possible trip accident hazard for those four residents. 2. Several resident bedroom entry doors had broken laminate across the lower section of the doors. The laminate had loose areas that had been pulled away from the broken laminate, that created sharp, jagged edges, creating possible accident hazards to residents' arms that used a wheelchair for mobility, and with broken, jagged edges that had the potential to create sharp accident hazards for any passing residents' legs. One of the laminate coverings had loosened vertically so that the laminate was extremely loose. 3. A resident's transfer pole that went from the ceiling to the floor broke thru the ceiling sheet rock. The transfer pole was currently being used by a resident. Maintenance staff U reported that when the transfer pole was positioned, staff failed to place the transfer pole on a ceiling stud to secure it and it went through the ceiling. This failure placed the resident at risk for an accident when transferring to/from his bed to wheelchair with the transfer pole being very loose and not steady when pulled on. 4. A resident's room had a floor tile near his built-in dresser that lay warped and bubbled. This resident was ambulatory and used an ambulatory device, which created a trip hazard for the resident. 5. A shared resident bathroom had several areas with part of the non-skid strip/strips worn away. 6. A resident's bedroom had two areas of worn anti-skid strips. There were missing areas on each of the set of strips. On 07/10/23 at 03:22 PM, Resident (R)1 reported he resided on the other hallway until his room flooded. He reported the ceiling had been a problem for a while and the part of the transfer pole went through the ceiling since staff moved the transfer pole into his current room. On 07/10/23 at 4:00 PM, Maintenance staff U reported he was aware of the broken door laminates, worn anti-skid strips, carpet pulled away from the threshold and bubbled floor tile. He was not made aware the transfer pole broke through into the sheetrock from the ceiling because no one told him about it and apparently no one looks up at the ceiling. The facility's policy for Preventative Maintenance Program dated 10/25/19, revealed a preventative maintenance program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. The facility failed to ensure all of the facility 32 residents environment remained as free of accident hazards as possible to prevent injury from; a loose transfer pole, multiple sharp jagged laminate edges on multiple resident bedroom doors, from the hallway carpet that pulled away from the threshold strips in occupied resident doorways, and a bubbled tile near an ambulatory resident's dresser.

The facility reported a census of 32 residents. Based on observation, interview and record review, the facility QA (Quality Assurance) program failed to develop and implement appropriate and effective action plans to timely correct infractions of the residents' multiple environment and accident hazards, for the residents of the facility. Findings included: - Interview, on 07/11/23 at 12:59 PM, Administrative staff A, revealed the Quality Assurance and Performance Improvement QAPI) committee met monthly to identify infractions and to develop performance improvement plans. However, the facility continued with multiple areas in the residents' environment in need of repair or housekeeping, since at least December 22, 2022, over 6 months, when one resident hallway experienced flood from broken water pipes. The facility also continued with multiple areas of accident hazards to the residents of the facility. Refer to F584, the facility failed to provide necessary housekeeping and timely maintenance services to maintain a sanitary, orderly, and comfortable interior in resident areas that included the dining room, resident hallways, and resident rooms, for the residents of the facility. Refer to F689, the facility failed to ensure the residents environment remained as free of accident hazards as possible regarding a resident's loose transfer pole, multiple sharp jagged laminate edges on residents' bedroom doors, the hallway carpet that pulled away from the threshold strip in occupied resident doorways, and a bubbled tile near an ambulatory resident's dresser. The facility did not provide a policy related to QA. The facility QA (Quality Assurance) program failed to develop and implement appropriate and effective action plans to timely correct infractions of the residents' multiple environment and accident hazards, for the residents of the facility.

The facility reported a census of 39 residents, with 15 residents sampled, including four residents reviewed for accidents. Based on interview, record review, and observation, the facility failed to ensure appropriate interventions were initiated for three Residents (R)135, R 7 and R 15, following falls. R135 with a history of falls without interventions experienced a fall with a [CONDITION(S)] (wound to the skin) requiring approximately 20 staples to close. In addition, the facility failed to ensure resident living areas remained free from environmental hazards in one resident room and failed to ensure one resident room door panel did not have exposed sharp edges. Findings included: - The Physician Order Sheet (POS), dated 07/21/21, documented Resident (R)135 had a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of three, indicating severely impaired cognition. She had no rejection of care and required supervision and assistance of one staff for walking in her room or hallway. Her balance was always steady, and she used no mobility devices. She had a fall within the month prior to admission, but no falls since admission. The Falls Care Area Assessment (CAA), dated 07/04/21, documented the resident was at high risk for falls and ambulated without an assistive device. She had poor safety awareness. The discharge MDS, dated [DATE], documented the staff assessment for cognition revealed severe impairment. She required extensive assistance with walking in her room and corridor. Review of the resident's Activities of Daily Living (ADL) Care Plan, dated 07/03/21, instructed staff the resident required supervision while walking. Review of the resident's Falls Care Plan, dated 07/03/21, instructed staff the resident was at risk for falls related to impaired mobility. Staff were to ensure the resident was wearing appropriate footwear while ambulating and to provide a safe environment. Review of the resident's electronic medical record (EMR), under the Assessments tab, revealed the following Fall Risk Assessments which placed the resident at a high risk for falls, dated: 06/28/21, 07/16/21, 07/21/21, 07/23/21, 07/26/21, 08/04/21, and 08/07/21. The Fall Report dated 07/26/21, revealed staff discovered the resident on the floor in the dining room. The resident had a hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from traumas) to her forehead and the side of her head, and a skin tear to her left forearm. No measurements were available. Staff sent the resident to the emergency room (ER) for evaluation, and she returned later that day to the facility. (The facility failed to investigate the resident's fall thoroughly and determine the root cause of the resident's fall, and failed to initiate an immediate, appropriate intervention following the resident's fall to prevent possible further falls.) A Fall Report dated 08/03/21, revealed the resident had an un-witnessed fall in her room. The resident had no injuries from the fall. (The facility failed to investigate the resident's fall thoroughly and determine the root cause of the resident's fall and initiate an immediate, appropriate intervention following the resident's fall to prevent possible further falls.) A Fall Report on 08/07/21, revealed the resident bent over to pick something up from the floor and fell forward and hit her head. The resident received a skin tear to her left elbow. No measurements were available. (The facility failed to investigate the resident's fall thoroughly and determine the root cause of the resident's fall and initiate an immediate intervention following the resident's fall to prevent possible further falls.) Another Fall Report on 08/07/21, revealed the resident experienced a second fall. Staff discovered the resident on the floor on her left side in the hallway. There was blood on the floor around the resident's head and the left side of her forehead was peeled back with her eyebrow hanging down over her left eye. Emergency Medical Service (EMS) transported the resident to the ER for evaluation. No measurements were available. (The facility failed to investigate resident's fall thoroughly and determine the root cause of the resident's fall and initiate an immediate intervention following the resident's fall, to prevent further falls.) The Hospital Report, dated 08/08/21, no time available, included: The scalp and upper forehead lacerations repaired with approximately 20 simple staples. A clean pressure dressing applied and hemostasis (stopping of active bleeding) obtained. The discharge plan instructed the facility staff to complete clean dressing changes daily, continue with her prior medications, and to recheck with the facility physician in one day. The resident returned to the facility. Wound measurements were not made available. The resident discharged from the facility on 08/21/21. On 01/04/22 at 03:21 PM, Licensed Nurse (LN) G stated when a resident had a fall, staff were to assess the resident for injury and send them to the ER if needed. The nurse working when a resident fell , was to initiate an immediate intervention following each fall. The resident had multiple falls and the Director of Nursing (DON) would usually initiate the fall interventions for that resident. On 01/04/22 at 02:45 PM, LN H stated the resident paced the halls often. The nurse on duty would initiate an intervention at the time of a fall. On 01/05/22 at 11:30 AM, Administrative Nurse E stated the resident had dementia and was anxious. When a resident fell , the nurse would assess the resident for injuries. Staff should implement a fall intervention. On 01/05/22 at 10:58 AM, Administrative Nurse D stated when a resident fell , the nurse should assess them. The resident would be monitored for any changes. A new intervention should be initiated immediately, based on the cause of the fall. The undated facility policy for Accidents and Supervision included: Interventions are based on the results of the evaluation and analysis of information about hazards and risks and are consistent with relevant standards. The facility failed to implement appropriate, immediate interventions to prevent this resident with a history of falls who experienced a fall with a [CONDITION(S)], requiring approximately 20 staples to close. - Review of resident R7 Physician Order Sheet, dated 12/30/21, revealed diagnoses included [CONDITION(S)] (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), dementia (progressive mental disorder characterized by failing memory, confusion) and abnormality of gait and mobility. - The Quarterly Minimum Data Set (MDS), dated [DATE], assessed the resident Brief Interview for Mental Status (BIMS) of 15, that indicated the resident had normal cognition. The resident required supervision for transfers and ambulated with a walker. The resident's balance was always steady and the resident had no impairment in functional range of motion in her upper or lower extremities. The Significant Change Minimum Data Set, (MDS) dated [DATE], assessed the resident had severe cognitive impairment, required extensive assistance of two persons for transfers, toileting and personal hygiene, and was dependent on one staff for mobility. The resident had impairment in balance and required staff assistance for stabilization. The resident had no impairment of functional range of motion in upper or lower extremities and required a walker or wheelchair for mobility. The resident had an indwelling urinary catheter (a device to drain urine from the bladder connected to a drainage bag.) The Falls Care Area Assessment, (CAA), dated 10/25/21, assessed the resident was at risk for falls due to impaired balance and decreased physical and functional abilities. The resident received skilled therapy services to increase her strength and endurance and improve her balance. The resident required extensive assistance of one to two staff for activity of daily living. The Care Plan revealed the following fall interventions: On 02/08/21- Ensure appropriate footwear when ambulating/mobilizing in the wheelchair. Alter/remove any potential causes of falls. On 02/03/21- Encourage the resident to use the call light for assistance/supervision while in the bathroom. On 04/29/21 -Nonskid strips on the floor in the bathroom for safety. On 03/08/21- Therapy for evaluation and treatment. On 12/23/21 -Unwitnessed fall of 12/23/21; order to discontinue the urinary catheter. On 11/18/21 -Unwitnessed fall on 11/18/21; Occupational therapy to evaluate the resident's wheelchair for appropriate size, and work on transfer safety. On 12/09/21 - Witnessed fall on 12/09/21; roommate educated not to ask the resident to hand her things and to use her call light to ask staff. Review of the facility Unwitnessed/Witnessed Fall Reports, revealed the following falls: Unwitnessed fall, on 08/07/21 at 10:00 AM, revealed the resident was found on her left side, on the floor, close to the bathroom door, in her room. Immediate intervention included an ice pack to her forehead and neurological checks. Staff observed no injuries post fall. The facility failed to thoroughly investigate the root cause of the resident's fall and failed to implement an appropriate intervention to prevent further falls. Unwitnessed fall, on 09/08/21 at 08:15Pm, revealed staff found the resident on the floor in her bathroom, leaning against the wall. The immediate action included neurological checks. Staff observed no injuries post fall. The facility failed to thoroughly investigate the root cause of the resident's fall and failed to implement an appropriate intervention to prevent further falls. Unwitnessed fall on 10/23/21 at 11:40 AM, revealed staff found the resident lying on the floor of her room with her head toward her roommate's legs pointing toward her bed. The resident's catheter tubing/urine collection bag remained attached to the resident's bed frame. Staff determined the resident tripped over the catheter tubing. Staff place a mattress on the floor beside her low bed. The resident sustained no injuries. (Administrative Nurse D stated the physician ordered removal of the catheter as the intervention). However, the resident's care plan documented the urinary catheter removed on 12/23/21 as a fall intervention. Unwitnessed fall, on 11/18/21 at 07:00 PM, revealed staff found the resident on the floor in a sitting position, and faced her bed with her wheelchair behind her. The resident stated she slipped on the floor. The intervention was to consult occupational therapy for an appropriate size wheelchair and transfer safety. Interview on 01/05/21 at 12:58 PM with Administrative Nurse D revealed the wheelchair was not sized appropriately for the resident at the time of the fall and the wheelchair was changed by therapy. Witnessed fall, on 12/09/21 at 05:30PM, revealed the resident was on the floor in a sitting position, in front of a small dresser next to her bed. The resident reported she tried to find her roommate a book. The resident's roommate told staff the resident walked without her walker and fell . The immediate intervention was to educate the roommate to not request the resident to retrieve things and call for staff instead. Interview on 01/05/21 at 12:58 PM, with Administrative nurse D revealed the resident attempted to give her roommate a book, so the intervention was staff reminded the roommate to call staff for assistance.) Unwitnessed fall, on 12/28/21 at 05:45 PM, revealed staff found the resident on the floor with her sheet and blanket. The facility failed to determine a root cause for the resident's fall. The immediate intervention was to place a fall mat next to the bed. Unwitnessed fall, on 12/28/21 at 09:00 PM, revealed , staff found the resident on the floor with her back to her bed. The resident did not have appropriate foot wear. The immediate intervention was staff to provide visual checks through the night and discontinue her [MEDICATION(S)] (an antidepressant medication discontinued on 12/29/21, the following day.) Interview on 01/05/21 at 12:58 PM with Administrative Nurse D revealed medications were reviewed, and [MEDICATION(S)] discontinued, however the resident remained on [MEDICATION(S)] 15 mg (milligrams) at night for major depressive disorder the physician ordered on 12/07/21._ Unwitnessed fall, on 12/30/21 at 12:15AM, revealed the roommate called staff as the resident was found in a sitting position on the floor, with the resident's on the linens on the floor, with her back against the bed. The resident told staff she was getting dressed. The Immediate intervention was for staff to increase visual checks, and get a hospice evaluation on 01/04/22, due to decline. Interview on 01/05/21 at 12:58 PM with Administrative Nurse D revealed increased visual checks were initiated but staff did not document the checks in the electronic record. Unwitnessed fall, on 01/03/21 at 02:45AM, staff found the resident on the fall mat by the bed. The immediate intervention was to assist the resident back to the bed, and bolsters (mattress with raised perimeter edges) added to the bed on 01/04/21 by hospice. Records evidence this was the third fall from the bed since 12/28/21. Observation, on 01/03/21 at 08:00 AM, revealed the resident asleep in her low bed, with fall mat in place beside the bed. The resident's room door closed. The resident lay curled in her bed with two blankets around her. Observation, on 01/03/21 at 10:00 AM, revealed the resident remained asleep in bed, the door to the room remained closed. Observation, on 01/03/21 at 12:00 PM, revealed CNA MM, awakened the resident to offer her assistance to get up out of bed for lunch, the resident declined and continued to lay curled up in her bed. CNA MM stated the resident had decline mentally and physically. CNA MM stated fall safety included the low bed and fall mat, and frequent checks on the resident. CNA MM stated the resident's roommate usually goes to the dining room for lunch and so the door is kept open. Interview, on 01/04/22 at 08:44AM, with consulting therapy staff GG, stated the resident had decrease cognition and pain in her hips, but did receive therapy for balance. Interview, on 01/04/22 at 03:37 PM, with CNA Q, revealed the resident did not usually get out of her bed on the second shift. CNA Q stated had not witnessed the resident falls, and stated fall interventions included a low bed with a fall mat beside the bed. Interview, on 01/04/22 at 03:26 PM with Licensed Nurse (LN) H, revealed the resident fell frequently after return from acute care in October 2021. LN H stated the resident had poor safety awareness. Interview, on 01/04/21 at 03:40 PM with LN,J stated the resident did walk with therapy, and she had observed the resident taking herself to the bathroom. Staff should keep the resident's bed in a low position with a fall mat in place. Interview, on 01/05/21 at 12:59 PM, with Administrative Nurse D, revealed the fall reviews should contain root cause analysis, (however, the facility failed to provide them to the surveyors at this time.) Administrative Nurse D stated the charge nurse should fill out the fall document should add interventions to the care plan. Administrative Nurse D stated administrative staff determined the root cause of the falls but did not provide them to the surveyors at that time. Administrative Nurse D confirmed not all new interventions were on the care plan, which would transfer to the KIOSK (electronic computer terminal for CNA use which contains the care plan and daily documentation by certified staff for cares provided) but the CNA did not rely on this for resident care. The facility policy Accident and Supervision, undated, instructed staff to ensure the resident environment remains as free of accident hazards as is possible. Staff instructed to identify, evaluate hazards and risks and implement and monitor interventions to reduce hazards and risks. The facility failed to provide fall interventions consistently for this resident's falls, which included two falls from her bed, to promote resident safety. - Observation, on 01/05/21 at 11:00 AM, with maintenance staff U, confirmed the following areas of concerns: A resident room contained chair railing near the head of his bed that contained an area of approximately 10 inches that splintered with an approximate five-inch sliver of wood sticking out and approximately a one-inch nail sticking out. A resident room hall door contained a buckled lower door panel in a triangle shape approximately two feet in length with sharp edges of the plastic exposed. The facility policy Accident and Supervision, undated, instructed staff to ensure the resident environment remains as free of accident hazards as is possible. Staff instructed to identify, evaluate hazards and risks and implement and monitor interventions to reduce hazards and risks. The facility failed to maintain the environment in a safe, homelike manner, to prevent possible resident injuries. - Review of Resident (R) 15's Physician Order Sheet, dated 05/14/2021 revealed diagnoses included unspecified dementia (progressive mental disorder characterized by failing memory, confusion), without behavioral disturbance, difficulty in walking, muscle weakness, spondylosis (a painful condition of the spine resulting from degeneration of the intervertebral disks), thoracic region (a part of the body between the neck and the abdomen), cervical region (a part of the body relating to the neck), [CONDITION(S)] ([CONDITION(S)] changes to one or may joints characterized by swelling and pain), need for assistance with personal care, diabetes type 2 (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), unspecified signs and symptoms involving cognitive (a mental action or process of acquiring knowledge and understanding through though, experience, and the senses), functions and awareness, [CONDITION(S)] (inability to sleep), and unspecified injury of the head. The Quarterly Minimum Data Set (MDS), dated [DATE], assessed the resident required extensive assist of three to transfer, toilet, for bed mobility, personal hygiene, transfers, dressing and locomotion on and off the unit. She had five falls since admission at the time of Quarterly Assessment. Her Brief Interview for Mental Status (BIMS) scored her at a one, that revealed severe cognitively impairment. The Falls Care Area Assessment (CAA), dated 05/20/21, assessed the resident with balance problems during transition and the resident required assistance of two for transfers, bed mobility and for standing from a sitting position. The CAA indicated that the resident had a history of falls prior to admission in the past two to six months. The Care Plan, dated 12/07/2021, instructed staff to assist with transfers, mobility, bed mobility, walking/ambulation, and toileting with an assist of one person. The resident identified as a fall risk related to impaired mobility, confusion and unaware of safety needs. The facility failed to implement fall interventions for unwitnessed falls when the resident was found down on the floor on 10/22/2021, 12/05/2021, 12/12/2021, 12/13/2021, and 01/01/2022. Review of the Fall Scene Investigation Report, dated 10/17/21 at 08:41 AM, documented the resident had a witnessed fall and she slid out of her wheelchair to the floor. After the fall on 10/17/2021 at 08:41 AM, an intervention instructed staff to allow the resident freedom to change position/planes independently while monitoring for safety. Review of the Fall Scene Investigation Report, dated 10/17/21 at 08:00 PM, documented resident was witnessed crawling on her hands and knees across her room and getting into the empty bed in her room. The report stated that the bed alarm was functioning, but the tone was so low that with normal noise on the unit it was not audible unless in the resident's room. The report lacked documentation of how the resident got to the floor to crawl prior to be witnessed crawling. After the fall on 10/17/2021 at 08:00 PM, an intervention instructed staff that the resident would intentionally crawl on her hands and knees in her room. A review of Nurses Notes in the electronic medical record (EMR), under the progress notes, indicated that the resident had been found sitting on her floor mat next to the bed on 10/22/21 at 05:53 PM by a direct care staff. In the note, when asked what happened, she stated I scooted. An Interdisciplinary team (IDT) note dated 10/25/21, located in the EMR under IDT note, indicated that the IDT team reviewed the fall that occurred on 10/22/21 and documented the incident as a change in plane by the resident. The IDT note was completed by Administrative Nurse D. A Review of Nurses Notes located in the progress notes of the EMR, indicated that the resident was found on the floor on 12/5/21, 12/12/21, 12/13/21, 1/1/22. A Fall scene investigation report was not completed for these dates and the Care Plan was not updated with an intervention. Details of being found on the floor on the above dates as follows. 1) On 12/5/21 (unwitnessed fall) in the EMR, progress notes dated 12/05/2021 at 07:43 PM, documented staff found the resident on the floor in the commons area. 2) On 12/12/21 (unwitnessed fall) in the EMR, progress notes dated 12/12/2021 at 04:03 PM, documented the resident had slid herself out of the wheelchair in the dining room while watching tv with several people were around. The report did not document if the people with her were residents or staff members, and a fall investigation report was not completed. 3) On 12/13/2021 (unwitnessed fall) in the EMR, progress notes, dated 12/13/2021 at 07:56 PM, documented that staff had found the resident on the floor in the resident's room. 4) On 1/1/2022 (unwitnessed fall) in the EMR, progress notes, dated 1/1/2022 at 02:54 PM documented staff found the resident on the floor in another resident's room. It also documented that the resident had just been pulled up in the chair. Interview with Administrative Nurse D, on 01/04/2021, at 10:00 AM, stated the wording of the progress note is incorrect because the resident slid out of the wheelchair. Administrative Nurse D stated she spoke to the nurse that completed the progress note and said the wording would be updated by the nurse. She stated that the resident is care planned to allow herself to slide out. Morse Fall Assessments, a method of assessing a patient's likelihood of falling, completed on the following dates place the resident at a high risk for falls based on a score range of 55-75 as a high risk for falls. Morse Fall Scoring range is High Risk for a score of 45 and higher The dates of the falls assessments completed on 9/27/21, 9/29/21, 9/30/21, 10/11/21, 10/17/21, 10/18/21, 10/22/21, 10/26/21, 11/2/21, 11/10/21 Observation on 12/29/2021 at 10:08 AM, revealed Certified Nurse Aide (CNA) N, transferred the resident from the toilet to her wheelchair. The resident wore shoes on both her feet and bore full weight on both feet. The resident held the handrail and followed staff instructions and turn slowly and pivoted to the wheelchair and sat down. Interview on 01/03/22 at 10:08 AM with CNA N, revealed the resident does not use the call light. She stated the resident started propelling with it attached to her clothing and pulled the cord from the wall attachment. Interview on 01/04/22 at 12:35 AM with CNA NN, revealed when a resident fell , the charge nurse on the hall was notified immediately. The CNA should obtain vitals (blood pressure, pulse, respiration, and temperature) and should check for skin tears. She stated that the nurses filled out paperwork. Interview on 01/04/22 at 12:05 PM with Licensed Practical Nurse (LPN) G, revealed the resident cannot communicate her needs and has had a few falls. She likes to propel herself in the wheelchair down the hall and has been found in another resident's room and is then redirected back down the hall towards her room. The facility policy Accidents and Supervision, undated, instructed staff to document interventions based on results of the evaluation and analysis of information about hazards and risks and to use specific interventions to try to reduce a resident's risks from hazards in the environment. The facility failed to implement fall interventions for unwitnessed falls when the resident was found down on the floor on 10/22/2021, 12/5/2021, 12/12/2021, 12/13/2021, and 01/01/2022, to ensure the resident was as safe as possible from further falls.

The facility reported a census of 39 residents. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions to prevent the spread of food borne illnesses to the residents of the facility. Findings included: - An environment tour of the facility on 01/04/22 at 11:36 AM, noted the following areas of concern: 1. The dish drying rack by the dishwasher had multiple areas of rust, making it unable to sanitize. 2. The covered trash can by the hand washing sink had dried food substances on the lid and the front of the trash can. 3. The juice machine grate had multiple rusty areas, making it unable to sanitize. 4. The inside of the toaster had a heavy build- up of crumbs. 5. The condiments container had crumbs and food debris in the bottom of all six compartments. 6. The shelf underneath the steam table where the pans and lids stored for the steam table, had a build- up of food debris. 7. Three skillets had the non-stick coating missing from the cookware. On 01/05/22 at 09:19 AM, dietary staff BB stated, the toaster and juice machine should be cleaned after each use. The trash can and condiment container should be wiped down weekly and as needed. The skillets need to be replaced. The facility policy for Cleaning and Sanitation of Dining and Food Service Areas, dated 2017, included: The nutrition and food services staff will maintain the cleanliness and sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule. The facility failed to store, prepare, and serve food under sanitary conditions to prevent the spread of food borne illnesses to the residents of the facility.

The facility had a census of 39 residents. Based on observation, record review, and interview, the facility failed to provide a sanitary environment for residents and staff in the kitchen. Findings included: - On 01/04/22 at 11:36 AM, observation revealed an accumulation of built-up grime, dirt and food debris on the floor of the kitchen including underneath the appliances, shelving, and around the perimeter of the kitchen floor. On 01/05/22 at 09:19 AM, Dietary staff BB stated, staff are to clean the kitchen floor at least twice daily. The staff are not getting the floor as clean as they should be. The facility policy for Cleaning and Sanitation of Dining and Food Service Areas, dated 2017, included: The nutrition and food services staff will maintain the cleanliness and sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule. The facility failed to provide a safe and sanitary environment for the residents and staff related to the dirt, debris on the kitchen floor, appliances, shelving and parameter of the floor.

The facility reported a census of 39 residents. Based on observation, record review, and interview the facility failed to maintain a comfortable room temperature for one resident's room. Findings included: - Interview, on 12/29/21 at 09:30 AM, with alert resident (R)13, revealed his heating unit malfunctioned for the past two days and he was cold and uncomfortable. The resident stated he had notified an unidentified staff member two days ago. He stated the heater ran for a while two days ago, then shut off. Observation, on 12/29/21 at 09:30AM, revealed a room temperature of 66 degrees Fahrenheit. The heating unit did not turn on when the power switch attempts to be activated. The resident positioned in his bed, wrapped in a thick blanket. Interview, on 12/29/21 at 09:45 AM, with Maintenance staff U, revealed staff did not notify him of the problem. Maintenance staff U determined the breaker on the plug needed reset. Maintenance staff U reset the breaker and the unit produced heat. The facility policy Safe and Homelike Environment, dated 10/25/19, instructed staff to strive to maintain comfortable and safe temperature levels. The policy instructed staff to keep the temperature in common resident areas between 71- and 81-degrees Fahrenheit. The facility failed to ensure this resident's room heating unit maintained a comfortable temperature as required.

The facility reported a census of 41 residents with 17 identified as elopement risks and three included in the sample. Based on observation, record review, and interview, the facility failed to provide adequate supervision to prevent one cognitively impaired Resident (R) 1, who had a history of exit seeking and falls in the facility, from leaving the facility through an exit door without staff knowledge at approximately 07:18 PM at night. The resident walked through the facility parking lot and up one block on a residential street. At approximately 07:25 PM (7 minutes later), Consultant Staff GG, who left the facility to go home, found R1 walking up the street towards a stop sign and stopped to redirect and assist the resident back into the facility. This deficient practice placed the resident in immediate jeopardy. Findings included: - R1's signed Physician Orders (PO), dated 05/16/21, documented the resident had diagnoses of dementia with behavioral disturbance (chronic disorder of the mental processes caused by brain disease or injury marked by memory disorders, personality changes and impaired reasoning) and [CONDITION(S)] (severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality). The Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident with a Brief Interview for Mental Status (BIMS) score of 3, which indicated severely impaired cognition. The resident had fluctuating inattention and disorganized thinking. The resident also experienced hallucinations (sensory experiences that appear real but are created by your mind) and delusions (fixed, false beliefs that conflict with reality). R1 was ambulatory and had no wandering behaviors during the seven-day lookback period. The Annual MDS, dated [DATE], documented the resident with a BIMS score of 3, which indicated severely impaired cognition, fluctuating inattention, disorganized thinking, hallucinations, and delusions. The resident was ambulatory and wandered daily. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 04/09/21, documented the resident displayed disorganized thinking, short attention span, impaired safety awareness, and impaired judgment. R1 rejected care from staff frequently and was an elopement risk. The Falls CAA, dated 04/09/21, documented the resident had a history of falls. The Care Plan, dated 12/17/19, revealed the resident was at risk for elopement and a high risk for wandering and elopement. The resident's care plan listed the following interventions: 1. In the event of an elopement, follow search and reporting protocols. 2. Keep the resident's routine consistent to alleviate confusion. 3. Provide picture/ID description of resident in the elopement book. 4. Redirect the resident with wandering around doors/exits. 5. Visualize resident whereabouts frequently. 6. Wanderguard (bracelet that sets off an alarm when a resident attempts to exit the building) is in place. Check for proper function daily and as needed. Change prior to expiration date of 06/24/21. Added to care plan on 12/03/20. 7. Engage the resident in active conversation as a form of redirection. Added to care plan on 12/30/20. A Wandering/Elopement Risk Scale, dated 12/13/20, documented the resident had a score of 12, which indicated a high risk of wandering. The resident wandered daily without purpose or intent. A Wandering/Elopement Risk Scale, dated 02/16/21, documented the resident had a score of 10, which indicated a risk of wandering. The resident wandered daily and her gait was unsteady at that time. Review of the facility's video footage, dated 5/14/21, with Administrative Staff A, revealed at approximately 07:04 PM, the resident was at the end of the 200 Hall by the exit door. She set off the alarm and proceeded to walk back up the hallway. She met and passed Licensed Nurse (LN) G in the hallway as the nurse was answering the exit door alarm. LN G was the only staff that responded to the door alarm. The resident continued up the hallway toward the front of the facility while the nurse went to shut off the alarm. The nurse proceeded up the hallway towards the front of the facility to turn off the front door alarm that the resident set off. At that time, a vendor showed up with a wheelchair delivery that was handled by LN G. No other staff were noted. R1 walked into the commons area and dining room. LN G went into the dining room and R1 walked back towards the 200 Hall to the exit door, opened the door, and walked out at approximately 07:18 PM. No other staff were in the hallway and nobody saw the resident exit the facility. A Behavior Note, dated 03/19/21 at 6:37 PM, revealed the resident walked in and out of resident rooms, bothered the residents by going plate to plate in the dining room, and kicked the glass in the dining room door looking for her house. A Multidisciplinary Care Conference Note, dated 04/19/21, documented the resident with cognition impairment and behaviors of pacing, exit seeking, crying, self-isolation, loss of appetite, angry outbursts, and resistive to care by staff. A Nurse's Note, dated 05/15/21 (late entry for the 05/14/21 incident) at 12:15 AM, revealed R1 fluctuated between agitation and being pleasant but confused most of this shift. The resident requested to leave and wanted help. She clutched her private area at one point and LN G asked her if she needed to go the restroom, she replied no but she took her to restroom anyway. The resident fluctuated between wanting to leave, confused, and agitation and hostility. After supper at approximately 07:05 PM, she set off the East hallway door alarm. LN G went to reset it and the resident passed her heading West toward the day hall. LN G was unable to get the alarm to reset, so she used an ink pen to reset the alarm as she had been shown by staff. Instead of the alarm turning off, the sound changed to a high pitch sound. LN G checked the door to see if it was locked and it was locked. After several attempts to get it to stop alarming and reset, LN G went looking for floor staff to have them try to fix the alarm. The other staff were assisting other residents in their rooms and not available. LN G stayed in the day hall area waiting for the other staff to become available. R1 was going back and forth from the day hall to front lobby area. LN G received several front door deliveries from a pharmacy and a vendor providing a wheelchair. Each time LN G had to redirect R1 away from the door so the alarm would not go off and she could not view the code. At approximately 07:20 PM, LN G saw Certified Nurse Aide (CNA) M go out the east door and at approximately 07:29 PM, Consultant Staff GG brought R1 in through the front door. Consultant Staff GG said that R1 was at the stop sign. LN G assessed R1 for injuries and none were found. The resident refused vital sign assessment. R1 wore appropriate garments for the weather and shoes. Review of Accuweather.com's weather history for May 14, 2021, revealed the weather was 67 degrees when the resident eloped from the facility. A Witness Statement, dated 05/14/21, CNA M documented she and CNA N were assisting two residents in the facility in their rooms. When they left the room, she heard a weird beeping noise that wasn't normal. LN G and CMA S were trying to fix the door alarm and they realized the door was unlocked. CNA M went outside to look because she had the feeling somebody escaped. Outside she saw R1 by the front door with Consultant Staff GG and they entered the facility. She reported to the other CNAs that R1 was outside. A Witness Statement, dated 05/14/21, CNA O documented she was coming back to work from her break and saw CNA M go outside the facility. CNA O followed her out and CNA M reported to her that R1 exited the facility. They found R1 had re-entered the facility with assistance from staff. A Witness Statement, dated 05/14/21, LN G documented at around 07:05 PM the resident went down the East hallway (200) to the door setting off alarms. R1 headed back up the hallway as she was heading down to shut off the alarm. When she got to the door, she put in the code and it would not stop, so she used an ink pen to reset it which was what staff have been doing at that time. The alarm started making a different high pitch sound that she couldn't turn off. LN G tried several things and also checked the door and it was locked. She went to find staff to help with the door, but the staff were unavailable and busy with residents. She was side-tracked by vendors at the front door and the next thing she knew, R1 was being brought back to the facility by Consultant Staff GG. A Witness Statement, dated 05/14/21, Consultant Staff GG documented she left the facility at 07:25 PM to drive home. One block from the facility, she saw R1 walking on the sidewalk with the Wanderguard on her ankle. Staff GG stopped and encouraged the resident to walk back to the facility with her. The resident was agreeable but seemed nervous. R1 stated to Staff GG that she was going to another town. They walked back to the facility and staff GG found nursing staff and reported what happened. Observation, on 05/18/2021 at 09:07 AM, revealed R1 ambulated independently without use of a mobility device to the front door and set off the door alarm. A Wanderguard bracelet was in place around the resident's right ankle. Certified Medication Aide (CMA) R immediately assisted and redirected the resident away from the door. The resident was pleasant, smiled, and cooperated with the staff. CMA R led R1 to a couch next to the nurse's station, sat down with her, and they visited pleasantly for a few minutes. Staff left and R1 sat on the couch by herself without any signs or symptoms of distress or agitation. Interview, on 05/18/21 at 02:00 PM, CMA S stated she was on her scheduled 30-minute break and left the building at 06:55 PM. She returned to the building at 07:10 PM. Her break ended at 07:20 PM and she returned to the floor. She went to assist visitors at the front door and saw Consultant Staff GG and R1 walking through. She helped assist R1 to the nurse's station. CMA S stated the resident wandered from door to door every single day several times a day. R1 was always setting off the door alarms. Interview, on 05/18/21 at 02:20 PM, with CNA M, revealed she had nothing to add regarding the elopement. She stated that she monitored and redirected R1 frequently due to the resident set the alarms off all the time in the facility. Interview, on 05/18/21 at 02:20 PM, with CNA O, revealed she had nothing to add regarding the elopement. She stated the resident wandered the facility and was capable of exiting on her own. Interview on 05/19/21 at 09:10 AM with LN G, verified the above witness statement. She stated nobody saw the resident leave the building, but she saw CNA M exit the 200 hall exit door and it was unlocked. All the staff were busy, staff should have supervised the resident. Interview on 05/19/21 at 09:45 AM with CNA N revealed the staff in the facility had to watch R1 all the time. On the night of the elopement, she and CNA M were helping put residents to bed. They were in the resident rooms with the doors closed, so they did not hear any alarms until they came out into the hallway. R1 was already out of the building when she came out of the resident's room. CNA N followed CNA M outside to go find R1. R1 was coming in the front door with Consultant Staff GG when they saw her. Interview on 05/18/21 at 01:38 PM with Administrative Nurse D revealed she was on-call the night of the elopement. LN G could not get the alarm to shut off and she went to find staff to help her. She didn't get help to shut off the alarm until after R1 exited the facility. She did not realize the resident left the building until Consultant Staff GG brought her back. There was nobody supervising the resident when she left the building. Staff should have supervised the resident. Interview, on 05/19/21 at 02:19 PM, with Consultant Staff GG, verified the witness statement. She stated she always parked in front of the building and came and went through the front door. She stated she was slowing down for the stop sign and just happened to look to the left and saw the resident walking on the sidewalk and was a few feet from reaching the stop sign. She stated before she left the building, at 07:25 PM, she heard noises like call lights, but couldn't verify if it had been a door alarm. The facility policy Elopements and Wandering Residents, dated 02/01/20, documented .This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care .6. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering .d. Adequate supervision will be provided to help prevent accidents or elopements . The facility failed to provide adequate supervision to prevent R1 from leaving the building through an exit door of the facility, without staff knowledge after displaying exit seeking behaviors of setting off exit alarms prior to the elopement. The resident eloped through an exit door on the 200 hall on 05/14/21, at approximately 07:18 PM, when the resident who the facility identified as an elopement risk, left the facility by opening an exit door in the hallway and leaving the building. Approximately seven minutes later, Consultant staff GG, who had left the building on her way home, found R1 walking up the street towards a stop sign and stopped to redirect and assist the resident back into the facility. No other staff had knowledge that the resident left the building or were searching for the resident at the time Consultant staff GG found the resident. This deficient practice placed the resident in immediate jeopardy. This deficiency was cited as past non-compliance as the facility completed the following as of 05/15/21 at 06:00 AM: 1. On 05/14/21, from 07:28 pm through 10:00 pm, staff placed R1 with 1:1 care. 2. The facility placed a secondary alarm system at the East 200 hallway door. 3. Facility staff checked all other door alarms and confirmed they were in working order. 4. On 05/15/21 at 06:00 AM, elopement policy education began.

The facility reported a census of 36 residents with three sampled and reviewed for accidents. Based on observation, record review, and interview, the facility failed to provide adequate supervision and assistive devices to prevent an accident for one of the three sampled residents, Resident (R)1. The facility staff failed to serve R1's coffee with a lid as care planned. R1 spilled the hot coffee and experienced large second degree [CONDITION(S)] to the bilateral inner thighs and private areas, which covered three percent of his body surface area (BSA). R1 required an ER (emergency room ) evaluation and follow-up treatment care at a burn unit. Findings included: - The Admission Record evidenced the facility admitted R1 on 08/20/2019. The primary care physician (PCP) listed diagnoses of [CONDITION(S)] [TBI - Brain dysfunction caused by an outside force, usually a violent blow to the head} and hemorrhage of brainstem with loss of consciousness of unspecified duration, when a teenager. The 12/21/20, Quarterly Minimum Data Set (MDS) assessment included a Brief Interview Status (BIMS) on 12/02/20, with a score of 14/15, indicating intact cognition. He was independent with mobility in a wheelchair and with transfers. He had no impairment with range of motion in his upper and lower extremities. The 08/20/19, Plan of Care included instructions for a regular liberalized diet, with thin liquids. The revised 07/13/20 care plan added instructions for R1's hot liquids should be in a lidded cup to prevent injury from spills. This care plan update followed a hot coffee spill to his mid legs on 07/11/20. At that time, the physician gave an order for [MEDICATION(S)] cream (antibiotic) and the areas healed well. The Activities of Daily Living care area assessment (CAA), dated 07/30/20, included the resident required assistance with activities of daily living. He had impaired cognition due to a head injury and required assistance with daily decision making. The Facility Self Investigation, included on 02/22/21 at approximately 06:00 PM, R1 requested an additional cup of coffee from Dietary Aide G and requested she leave the lid off so he could take a sip. When she handed him the cup, she reported he began to shake. She grabbed for the cup, but it spilled before she could retrieve the cup. The hot coffee spilled in his lap. Licensed Nurse (LN) C immediately transported the resident to his room by wheelchair and removed the wet clothing. LN D called the physician and received orders to apply cold compresses and monitor the area. The areas blistered around 7:30 PM. Staff notified ARNP (advanced registered nurse practitioner) E of the blistered areas, and she ordered [MEDICATION(S)] Cream applied and Tylenol 325 milligram (mg) three times a day for pain. The staff notified the resident's family. The hospital emergency room Evaluation dated 02/22/21 at 11:59 PM, indicated the resident had a three percent total body surface area, partial thickness burn, from boiling liquid to R1's bilateral medial thighs and private area. The summary stated the resident was a poor historian, had a history of a TBI with information provided by his family. The resident received treatment and returned to the facility with dressings, orders, and a follow-up appointment for the burn unit care. The Progress Notes, dated 02/23/21 at 02:14 AM, documented the resident returned with grey foam dressings, reinforced with kerlix, and a cloth wrap to the burn areas. The facility measurements included, 1.) left inner/medial thigh as 53.17 centimeters (cm) diameter, 2.) private area 4.23 cm by 1.23 cm diameter, 3.) and the right inner/medial thigh as 64 cm in diameter. On 03/01/21 at 11:30 AM, observation of licensed nurse (LN) F completing the resident's dressing change to the burn areas revealed some healing noted with some pink and with some darkened discolored areas. The resident tolerated the treatment well without signs of pain. LN F explained the areas were showing improvement since the incident and the treatments. On 03/01/21 at 09:50 AM, the resident could remember the coffee spill from the cup without a lid and pain but could not provide any details. On 03/01/21, at 12:20 PM, interview with the resident's family member revealed the resident required staff assistance for decisions as R1 had short term memory problems. She further explained that staff notified her on 02/22/21 at 08:10 PM of the coffee spill and burn. She went to the facility, saw the injury, and made the decision to take him to an emergency room for evaluation of the skin burn. She then decided to call the EMS (emergency medical service) for the transport. At 09:30 PM, paramedics took the resident to the emergency room . On 03/01/21 at 03:00 PM, interview with dietary aide (DA) G, revealed she was the staff that provided the resident with the special cup without the lid on it, the evening of the burn incident. DA G reported the resident wanted to take a sip of the hot coffee before she put the lid on it, so she handed it to him. The facility's Food Safety: Preventing [CONDITION(S)] policy, dated May 18, 2017 included, .Hot beverages will be served at 160 degrees Fahrenheit to 185 degrees Fahrenheit, the optimum temperature for patient satisfaction. Food will be held and plated at minimum of 135 degrees Fahrenheit, as per accepted food safety guidelines. The facility failed to follow R1's care plan and failed to serve his coffee with a lid. R1 spilled the coffee on to his lap and sustained second degree [CONDITION(S)] to his bilateral medial thighs and private area. He required emergency room care and follow-up with a burn unit. This deficiency will be cited as past non-compliance on 02/26/21 at 08:30 AM, after the facility completed the following actions: 1.) On 02/22/21, immediately following the burn incident/accident, the facility staff notified the medical director. 2.) On 02/23/21, the staff made the follow-up appointment for the resident with the hospital burn center unit. 3.) On 02/23/21, the staff updated the care plan for staff to continue the burn treatments as ordered and to adequately monitor for signs and symptoms of infection of the affected areas. 4.) On 02/23/21 upon return from the hospital the staff re-educated the resident the importance of keeping the lid on the hot coffee cup/mug at all times. 5.) On 02/23/21 at 09:30 AM the (interdisciplinary team (IDT) met and reviewed the incident. 6.) On 02/23/21 at 02:00 PM, the coffee machine serviceman for the coffee dispenser, entered and lowered the coffee dispenser temperature, from 160 degrees to 135 degrees. 7.) On 02/26/21 at 08:30 AM, all staff completed the re-education, on the importance of putting the lid on this resident's cup, prior to handing it to him to prevent any further coffee [CONDITION(S)]. 8.) Dietary staff would continue to monitor the food and liquid temperatures every meal, three times per day, seven days per week, to ensure continued safety to the residents.

The facility reported a census of 41 residents. The 6 sampled residents included 3 reviewed for skin issues. Based on interview and record review the facility failed to provide adequate skin assessments for foot care and failed to provide treatment as ordered for 1 (#01) of 3 sampled residents. The facility failed to identify and treat a wound, in a timely manner, on the distal tip of resident's right great toe, until the wound was black with [DIAGNOSES REDACTED] present around the wound bed (identified on 09/14/18 by the physician extender documented in history and physical notes). The resident's right great toe developed a necrotic ulcer at the end of the toe and tip of the nail bed (as documented by the physician in history and physical notes on 09/19/18). Furthermore, the facility failed to provide the treatment, to the resident's toe, as ordered by the physician, due to the inability to obtain the LidoDose ([MEDICATION NAME] - a substance which numbs the area it is applied to) gel from the pharmacy in a timely manner. Findings included: - The electronic medical record evidenced the facility admitted resident #01 on 8/27/18 and admitted the resident to the hospital on [DATE]. The physician included [MEDICAL CONDITION] (abnormal condition where the blood vessels narrow and decrease circulation) in the list of admitting diagnoses. The 9/6/18 admitting MDS (minimum data set) assessment identified the resident with a BIMS (brief interview for mental status) score of 12/15, indicating intact cognition. The resident was in need of extensive assistance with most activities of daily living. The resident required both scheduled and as needed pain medications. The CAA (care area assessment), dated 9/6/18 for cognition included, the resident showed signs of cognitive loss/dementia. The CAA for pressure ulcer included, the resident was at risk for PU (pressure ulcer) but did not have a PU. Will proceed to care plan for skin integrity. The 8/2/18 plan of care, lacked update to include any right toe skin integrity problems. Skin assessments, dated 9/10/18 and 9/17/18, both documented the staff applied [MEDICATION NAME] (protective skin barrier) to the resident's buttocks and scrotum. Neither of these skin assessments documented any skin integrity problems with the resident's right great toe, which the physician extender noted on 9/14/18 in history and physical notes. On 9/7/18, a progress note, by physician extender O, revealed he/she evaluated the resident and documented he/she noted the resident with bilateral feet pain. This progress note lacked an assessment of the resident's feet, at that time. Per interview with physician extender O, on 11/19/18 at 9:30 A.M., explained he/she did not think he/she saw the resident's toes on the 9/7/18 visit. He/she stated, he/she would have documented if he/she removed the resident's socks or bandage to see the resident's toes and he/she did not do that. On 9/14/18, a history and physical note, by physician extender O, documented the resident's right great toe distal tip black, no drainage, slight [DIAGNOSES REDACTED] (a superficial reddening of the skin, as result of an injury or irritation causing dilation of the blood capillaries), around the wound bed and no [MEDICAL CONDITION]. At that time, physician extender O included orders instructing the staff for a follow-up with a RLE (right lower extremity) US (ultrasound) related to: diminished pulses, possible arterial ulcer right great toe. Treatment to start [MEDICATION NAME] gel (a medication to numb the feelings of pain) mixed with TAO (triple antibiotic ointment)/1:1, apply around the wound perimeter. Per interview with physician extender O, on 11/19/18 at 9:30 A.M., he/she remembered seeing the distal tip of the resident's right toe and it being black. He/she had started the treatment, at that time, to the right great toe and ordered the arterial ultrasound. The physician, not the extender, saw the resident during a visit the next week. The medical record evidenced a physician's orders [REDACTED]. The treatment record, verified the LidoDose gel medication was not available from 9/14/18 to 9/27/18. According to this record the facility staff administered only the TAO from 09/15/18 thru 09/27/18, failing to administer just the TAO on 09/18, 09/26, and 09/27/18. The clinical record failed to evidence the facility notified the physician of their inability to provide the treatment, as ordered, when the LidoDose medication was unavailable from the pharmacy. On 9/19/18, a history and physical note, by physician P, revealed he/she evaluated the resident's right foot and documented, the right great toe at the nail bed, necrotic ulcer, no drainage, slight [DIAGNOSES REDACTED] around the wound bed and no [MEDICAL CONDITION]. Right minimal foot drop. Patient/resident has a history of [MEDICAL CONDITION] and was currently on [MEDICATION NAME] (a blood thinner; works by preventing blood platelets from sticking together to form clots that would restrict blood flow), will continue to monitor for any worsening, continue as ordered [MEDICATION NAME] gel with TAO, apply daily. (However, the facility pharmacy did not send the resident's ordered (9/14/18) combined medicated treatment, so the treatment was not being provided to the resident's toe ulcer, as ordered by the physician.) On 9/17/18 at 10:01 A.M., nurse's notes included, LidoDose Gel 3 % apply to right great toe topically one time a day for right toe ulcer. Mix with TAO 1:1 and apply thin layer around wound perimeter. Apply non-stick dressing and change daily. Waiting on pharmacy. (3 days after ordered by the physician). 09/18/18 at 10:51 A.M., nurse's notes included LidoDose Gel 3% apply to right toe ulcer mix with TAO 1:1 and apply thin layer around wound perimeter. Not available. 09/19/18 at 9:31 A.M., nurses notes included LidoDose Gel 3% apply to right toe ulcer mix with TAO 1:1 and apply thin layer around wound perimeter. Have ordered from pharmacy twice. On 9/18/18, the ultrasound report, of the resident's right lower extremity, faxed to the doctor. Conclusion: 1). [MEDICAL CONDITION] with calcifications (happens when calcium builds up in body tissue, blood vessels, or organs. This build-up can harden and disrupt your body's blood flow), with estimated less than 50% stenosis (the abnormal narrowing of a passage in the body). Hospital records, dated 9/19/18 at 11:21 A.M., included a picture of the resident's right great toe covered with necrotic black tissue, which included over the entire top of the right big toe to the nail bed. The 9/24/18 weekly skin assessment, lacked documentation of any new or increased skin concerns. Documentation revealed the great toe and third toe dressing is intact. There was not a description of the wounds on the great toe or the third toe (did not document which foot was affected). On 10/31/18 at 9:15 A.M., administrative staff A reported they planned to change pharmacy companies on 11/1/18 due to multiple discrepancies in ordering and receiving medications in a timely manner. On 10/31/18 at 9:40 A.M., administrative nursing staff B commented the facility did not document or track skin conditions other than pressure ulcers until after their QAPI (quality assurance and performance improvement) meeting in October/2018. Review of the facility's weekly pressure ulcer skin assessments, from 9/5/18 through 9/26/18, revealed the facility staff failed to include this resident's wound on the great toe. The facility failed to adequately assess the residents skin condition on an ongoing basis to identify concerns with the resident's feet in a timely manner, and failed to treat the resident's right foot great toe ulcer, with the physician ordered treatment and failed to notify the physician of the treatment's unavailability. The resident acquired a necrotic vascular ulcer that covered the entire top of the right big toe, up to the nail bed.

The facility reported a census of 43 residents. The sample size included 4 residents, including 3 reviewed for non-pressure wounds. Based on interview and record review, the facility failed to provide the necessary care and services to treat 1 (#1) of 3 residents reviewed with vascular/stasis ulcers. This resident's wounds worsened, as evidenced by an increase in drainage and odor to the wounds with a culture which revealed 3 separate bacterial species. Findings included: - The facility admitted resident #1 on 12/18/15, per the EMR (electronic medical record) with [DIAGNOSES REDACTED]. The resident's admission MDS (Minimum Data Set) , dated 12/24/15, revealed the resident with short and long term memory problems, but able to recall the season, location of room, and that he/she is in a nursing home. Severely impaired for cognitive skills for daily decision making. Inattention and disorganized thinking fluctuated. The resident required extensive assistance for bed mobility, transfer, locomotion on and off of the unit, dressing, and personal hygiene. The resident had 4 venous and arterial ulcers present at that time; and a [MEDICAL CONDITION]. The Pressure Ulcer CAA (Care Area Assessment), dated 12/24/15, documented the resident has numerous venous/diabetic ulcers on bilateral legs and feet. He/She was seen by the mobile wound care (an outside company that specialized in wound care) and had daily treatments and dressing changes done by the facility nursing staff. These ulcers were chronic stasis ulcers (lesion of the lower leg ) and have been reoccurring for months. The resident was hospitalized recently to try to heal them. He/She was non-compliant with keeping his/her legs elevated which added to the difficulty of healing them. The resident's care plan, dated 1/12/16, indicated the resident had actual skin breakdown, and directed staff to evaluate wound areas daily including the surrounding tissue and presence or absence of drainage/infection and/or new wound pain and report to the physician as indicated. Monitor skin for signs/symptoms of skin breakdown, i.e. redness, cracking, blistering, decreased sensation, and skin that does not blanche easily. Staff to provide wound treatment as ordered: Silver sulfadizine 1%, topical, to bilateral legs daily. Sodium hypochlorite 0.125% solution, topical, twice a day, apply to bilateral lower extremities for 30 minutes daily. The mobile wound care's last report, dated 12/14/15, evidenced the resident was in the hospital. The facility failed to provide any further reports after the resident returned to the facility on [DATE]. A wound care evaluation from a hospital, dated 12/14/15 (before the resident's return to the facility), revealed the resident's bilateral lower leg wounds, measured 20 x 20 cm (centimeters) with no measurable depth. The admission orders [REDACTED]. The Resident Data Set, dated 12/18/15, identified the resident with wrapped bilateral lower extremities, and chronic wound treatments. The assessment lacked any description or measurements of the actual wounds. The skilled nursing narrative note, dated 12/18/15 at 12:45 PM, documented the resident returned to the facility at approximately 9:45 AM, and identified that the dressings to the resident's bilateral lower extremities were intact. The note lacked any description or measurements of the actual wounds. The skilled nursing notes, dated 12/19/15 to 12/22/15, identified Other open wounds via a check mark. The notes all lacked any description or measurements of the actual wounds. The skin assessment, dated 12/21/15, identified the presence of skin concerns of chronic venous wounds to the bilateral lower extremities. The assessment of the resident's lower extremities included, 2+ [MEDICAL CONDITION], and a description of flaky/scaled, purple/red, darker/discolored lower extremities. The assessment lacked any description or measurements of the actual wounds. A physician's progress note, dated 12/29/15, documented a follow-up note related to the resident's chronic venous stasis ulcers on his/her bilateral lower extremities, which was recently treated at a hospital and the resident returned to the facility. Bilateral lower extremity dressing/ Ace wraps were in place, and discussed with nursing. The assessment/plan included to continue wound care by nursing, and administer diuretics (medication to promote the formation and excretion of urine). The wounds will not heal. This is maintenance management. A skin assessment, dated 1/4/16, identified the presence of skin concerns of chronic venous wounds to the bilateral lower extremities. The assessment of the resident ' s lower extremities included 2+ [MEDICAL CONDITION] and a description of flaky/scaled, purple/red lower extremities. The assessment lacked any description or measurements of the actual wounds. A physician's progress note, dated 1/5/16, documented bilateral lower extremity [MEDICAL CONDITION], and bilateral lower extremities with venous stasis changes with moderate serosanginous drainage (semi-thick reddish drainage). The assessment/plan included the resident completed antibiotics for an infection. He/She was not cooperative with elevation of his/her legs, and to continue compression and wound care with monitoring, which included the mobile wound care's assistance. Review of the clinical record lacked evidence of treatment of [REDACTED]. Furthermore, the clinical record lacked evidence the facility staff clarified this with the physician. A skin assessment, dated 1/11/16, identified the presence of skin concerns to the resident's bilateral lower extremities. The assessment of the resident ' s lower extremities included 2+ [MEDICAL CONDITION] and a description of flaky/scaled, purple/red lower extremities. The assessment lacked any description or measurements of the actual wounds. The nurse's note, dated 1/16/16 at 5:40 PM, documented the resident had not been feeling well and stayed in bed more often. His/her lower extremities weeped (drained) and was painful when the treatments were completed to his/her legs. Staff spoke with a nurse practitioner about the resident last Thursday (1/14/16). The physician was to evaluate the wound areas on the next Tuesday (1/19/16). The note lacked any description or measurements of the actual wounds. A skin assessment, dated 1/18/16, identified the presence of skin concerns to bilateral lower extremities. The assessment of the resident's lower extremities included 2+ [MEDICAL CONDITION] and a description of flaky/scaled, purple/red lower extremities. The assessment lacked any description or measurements of the actual wounds. An undated physician's progress note, documented bilateral lower extremity [MEDICAL CONDITION], and bilateral lower extremities with venous stasis changes/ discoloration, copious (abundant in supply or quantity) malodorous (smelling very unpleasant) drainage, and crusting (especially on the right foot), and a large open area on the resident's left shin with slough (dead tissue, usually cream or yellow in color). The assessment/plan included the chronic venous stasis wounds had been very difficult to treat at the facility. He/She was non-compliant with elevating his/her legs. A mobile wound care followed the resident's wounds, but the wounds started to worsen again. The plan included to check a culture of the wound, start [MEDICATION NAME] (an antibiotic), and refer the resident to a (different) hospital associated wound clinic. Review of the clinical record lacked evidence of treatment of [REDACTED]. Furthermore, the clinical record lacked evidence the facility staff clarified this with the physician. A telephone order, dated 1/19/16, included the plan from the previous physician's progress note, and directed staff to 1.) check a wound C&S (culture and sensitivity) of the resident's left shin. 2.) start [MEDICATION NAME] (an antibiotic) for wound infection. 3.) Please get appointment at a hospital associated wound clinic for bilateral chronic venous stasis wounds. A nurse's note, dated 1/22/16 at 2 PM, documented the facility obtained the wound culture of the resident's left shin, 2 days after the physician's orders [REDACTED].>A telephone order, dated 1/26/16 at 2:30 AM, directed staff to: 1.) Continue the current 10 day course of [MEDICATION NAME] for the infected wounds. 2.) Start [MEDICATION NAME] (a different antibiotic) for the infected wounds. 3.) Start [MEDICATION NAME] (a different antibiotic) for the infected wounds. The hospital associated wound clinic's Wound Care Report, dated 1/28/16 at 12:43 PM, revealed the resident's chief complaint included multiple lower extremities wounds. History of the present illness included the patient presented to the wound care center that day with a wound to his/her lower extremities. The patient had a culture on 1/22/16, which [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus a resistant bacterial infection), pseudomonas (a bacterial infection), group B strep (a bacterial infection), and [MEDICATION NAME] faecalis (a bacterial infection). The patient was on [MEDICATION NAME] at the time, was started on [MEDICATION NAME]([MEDICATION NAME]), and had a large amount of drainage to his/her wound. The patient had the wound for some time, but was non-compliant with elevating his/her legs, per paperwork from the facility. The December 2015, Treatment Record, revealed the application of Silver sulfadizine 1% topical to bilateral legs daily recorded completed daily from the 19th through the 31st, and Sodium hypochlorite solution topical twice a day, apply to bilateral lower extremities; both of these treatment were recorded as completed only daily on 6-2 shift from the 19th through the 31st. No documentation noted of a second treatment of [REDACTED]. The January 2016, Treatment Record, revealed the application of Sodium hypochlorite solution, topical, twice a day, completed every morning through 1/24/16. The 2-10 shift included 5 days without any initials, and 2 other days of an X or a / drawn through. The Treatment Record provided by the facility failed to document any completion of the Silver sulfadizine order. The hospital associated wound clinic's, Wound Care Procedure and Progress Note, dated 1/28/16, documented a wound to the right lower leg 24 x 17.5 x 0.4 cm, and to his/her left lower leg 4.1 x 16.3 x 0.4 cm. The physician debrided the wound due to abnormal wound base and the tissue removed was [MEDICATION NAME] subcutaneous with a curette (A surgical instrument shaped like a scoop or spoon, used to remove tissue or growths from a body cavity). The wounds to the resident ' s feet included, unmeasured to the right foot, and 6.4 x 9.4 wound to the left foot. The hospital associated wound clinic's nurse ' s notes, dated 1/28/16, included the same measurements with a depth of 0.4 to the left foot wound and large amount of yellow drainage with a strong odor to each of the four wounds. The physician admitted the resident to the hospital with [DIAGNOSES REDACTED]. On 2/16/16 at 4:11 PM, licensed consultant staff E reported the resident ' s paperwork (Intake) started on 1/28/16, timed at 10:46 AM. Upon intake, staff E, confirmed the resident arrived with saturated and dripping socks and dressings, bilaterally, with a foul odor. The resident ' s wounds left puddles on the floor of the clinic. Upon removal of the dressings, the resident had multiple lower leg/ foot wounds with thick slough and necrotic tissue. On 2/16/16 at 2:45 PM, direct care staff F reported the resident's sores got worse from his/her shins to his/her toes, with green drainage and chunks of skin would slide off in the shower. The nurses completed dressing changes every shift and mobile wound care came in once a week and wrote new orders. The resident's wounds would weep all of the way through the dressings in 5-6 hours. On 2/15/16 at 12:20 PM, administrative nursing staff C reported the resident had a lot of [MEDICAL CONDITION] (swelling) and the facility had difficulties caring for the wounds. Staff C added,the resident had some bad wounds to his/her legs. The facility attempted to give the resident options which included different places to elevate his/her legs, but was non-compliant with elevating his/her legs. On 2/16/16 at 5 PM, administrative nursing staff C reported the resident was not seen by mobile wound care, related to the physician never wrote an order to resume the visits since readmission. Staff C added the facility staff completed the dressing changes and should have been completed every shift and as needed. Staff C was unable to locate an order or documentation of the completion of the wound dressing every shift, as ordered by the physician. On 2/18/16 at 11:40 AM, licensed nursing staff D reported the resident admitted with red and yellow open wounds with slough on the front and back of his/her lower legs. The treatment included to clean with a sodium solution and apply silver sulfadizine ointment twice a day, in which staff D completed once during his/her shift. During the resident ' s stay, the wounds failed to improve. When the resident left the facility (1/28/15) staff D failed to complete the dressing change that morning related to he/she left so early. Staff D confirmed there was an increase in drainage during this stay. The resident had pain, uncomfortable when the wounds were cleaned. Staff D reported that he/she had not completed the any wound measurements, as he/she was not the one at the facility to measure the wounds. When questioned about the 1/16/16 note, staff D confirmed he/she failed to document a description of the resident's wounds. Staff D reported the resident was seen by the mobile wound care company, and he/she was not sure if wound care or the facility staff completed the measurements. On 2/18/16 at 12:37 PM, administrative nursing staff B reported the mobile wound care assistance referred to, in the physician's progress notes, indicated the mobile wound care team assisted with monitoring of the resident's wounds. The physicians typically put the progress notes in the residents' charts and write orders on the telephone order sheets. It was not past practice for the facility staff to review the physician's progress notes. Staff B confirmed the facility failed to attempt to clarify the statement related to mobile wound care assistance. The mobile wound care followed the resident ' s wounds for a period of time at one point, but not during this stay. Staff B added, if the resident was not being seen by an outside company, the facility should be monitoring the wounds on a weekly basis. Monitoring would include an assessment of the site, what the wound looked like, the size, and current treatment. A lack of wound monitoring was identified and a different tracking system started approximately 2 weeks ago. Staff B confirmed, at the time from 12/18/15 to 1/24/16, the facility lacked this current tracking system. On 2/18/16 at 4:20 PM, physician G confirmed the resident had chronic stasis ulcer wounds to his/her lower legs. The resident had been to a speciality hospital at least twice related to increased drainage. The resident returned to the facility, a few weeks later, the wounds worsen and he/she went back out to the speciality hospital. The resident had at least one open area, increased drainage, constant sloughing material, and a wound culture related to an increase in odor. Physician G reported the mobile wound care team did see the resident during this stay and the wounds were not doing well. Physician G was not aware the resident was not being seen by the mobile wound care team during this stay, and replied in the past, the mobile wound care visits resumed upon the resident returning to the facility. Physician G agreed the facility should have measured and assessed the resident ' s wounds. The facility's Skin Integrity Management, with the revision date of 12/8/14, directed staff to complete comprehensive evaluation of the patient upon admission/re-admission to the Center (the facility). Identify patient's skin integrity status and need for prevention, intervention, or treatment modalities through review of all appropriate assessment information. Perform skin inspection on admission/re-admission and weekly. Perform wound observations and measurements and complete the Skin Integrity Report upon initial identification of altered skin integrity, weekly, and with anticipated decline of wound. Perform daily monitoring of wounds or dressings for presence of complications or declines and document. For wounds requiring daily dressing change or wounds without a dressing, monitor for signs of decline in the wound status. If unanticipated decline in wound, surrounding tissue, or new or increased wound pain, complete the skin Integrity Report and notify the physician/ mid-level provider. The facility failed to consistently provide treatments, failed to ensure communication between the facility and the physicians involved to ensure the continuity of care, failed to complete assessments and measurements to adequately monitor, and failed to timely obtain wound cultures to ensure the timely initiation of antibiotics for this resident's worsening wounds. This resident's wounds worsened, as evidenced by an increase in drainage and odor to the wounds with a culture which revealed 3 separate bacterial species.