Every finding on record at Amelia Manor Nursing Home

Based on record review, observations and interview, the facility failed to ensure that a resident's enteral feeding was properly labeled for 1 (#2) out of 1 (#2) sampled residents reviewed for tube feeding.Findings: Review of the facility's policy titled, Enteral Tube Feeding via Continuous Pump, with a last review date of January 2026, revealed under the heading Initiate Feeding read, in part.5. On the formula label document initials, date and time the formula was hung/administered. Review of Resident #2's electronic health record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, dysphagia, severe protein calorie malnutrition, and encounter for attention to gastrostomy. Review of Resident #2's April 2026 physician's orders revealed an order dated 02/26/2025 that read in part.Enteral Feed Order every night shift.Change feeding administration set daily, label the formula container, syringe and administration set with resident's name, date, time and nurse's initial. On 04/06/2026 at 9:27 a.m., an observation of Resident #2's tube feeding bag and administration set revealed the formula bag had no label. On 04/06/2026 at 9:48 a.m., an interview was conducted with S5LPN who stated that tube feeding bags should be labeled with the resident's name, date, time, and nurse's initial. An observation was made with S5LPN of Resident #2's tube feeding. She confirmed the resident's tube feeding bag was not labeled, and should have been.

Based on record review and interview, the facility failed to ensure the State Ombudsman Office was notified of a resident discharge for 1 (#87) out of 1 discharge record reviewed. Findings: Review of Resident #87's electronic health record revealed he was admitted to the facility on [DATE] for short term respite care. His diagnoses included, but were not limited to: hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right dominant side, spastic hemiplegia affecting right dominant side, bipolar disorder, major depressive disorder, recurrent moderate, and anxiety disorder.Review of the facility's Notice of Transfer or Discharge form revealed Resident #87 was discharged from the facility on 02/23/2026. There was no evidence the State Ombudsman Office was notified of a resident's discharge.On 04/07/2026 at 3:55 p.m., an interview with S6SSD was conducted. She stated only residents who were emergency transfers are listed on the Emergency Transfer Log. She stated for the non-emergent discharges, the nurses would give her a slip to inform her of the discharge and she informs the State Ombudsman Office via email. At that time, S6SSD reviewed her emails and stated she was not able to provide a copy of the email sent to the State Ombudsman Office notifying them of Resident #87's discharge. 04/07/2026 at 4:20 p.m., a second interview with S6SSD was conducted. S6SSD stated that she was unaware that she needed to send a copy of the written Notice of Transfer for non-emergency discharges to the State Ombudsman Office after a resident was discharged .

Based on observation, interview and record and policy review, the facility failed to provide respiratory care consistent with professional standards of practice, by failing to label a nebulizer tubing and mask with a date, and store the mask in a bag when not in use for 1(#5) of 1 residents investigated for respiratory care.Findings:On 04/08/2026, a review of the facility's policy titled, The Facility Oxygen Administration which was last reviewed on 01/2026, read in part: Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration . Steps in the Procedure .19. When not in use oxygen tubing will be stored in a plastic bag with date. 20. Change oxygen tubing weekly and label with date. 21. When not in use, store nasal cannula or mask in bag.Review of Resident #5's Electronic Health Record (EHR) revealed she was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, primary lateral sclerosis, atherosclerotic heart disease of native coronary artery without angina pectoris and essential primary hypertension.Review of Resident #5's quarterly minimum data set (MDS) dated [DATE] revealed in part: Section C0500 that the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating her cognition was intact.Review of Resident #5's physician orders revealed an order written on 06/02/2025, which read, change nebulizer tubing and mask q (every) week on Friday pm (afternoon) if used. Date and initial tubing every night shift every Fri (Friday).Review of Resident #5's electronic Medication Administration Record (eMAR) revealed S4LPN administered Albuterol Sulfate Nebulization Solution to the resident on 04/06/2026 at 1:52 p.m., On 04/06/2026 at 9:24 a.m., an observation and an interview was conducted with Resident #5. A nebulizer mask attached to tubing was laying across the top of the resident's refrigerator. The tubing and/or mask were not labeled with a date, and were not stored in a bag. Resident #5 stated the nurse took it off her and placed it on her refrigerator.Review of Resident #5's electronic Medication Administration Record (eMAR) revealed S4LPN administered Albuterol Sulfate Nebulization Solution to the resident on 04/07/2026 at 8:28 a.m.On 04/07/2026 at 10:50 a.m., a second observation and an interview was conducted with Resident #5. A nebulizer mask attached to tubing was laying across the resident's refrigerator. It was not labeled or stored in a bag. The resident stated the nurse placed her tubing with mask on her refrigerator after she gave her treatment.On 04/07/2026 at 10:56 a.m., an observation, review of Resident #5's eMAR, and an interview was conducted with S4LPN. She confirmed the resident's nebulizer tubing was not dated or initialed and was not in a bag. She stated the night nurse must have given the resident a treatment and not labeled or stored the tubing and mask. A review of the resident's eMAR with S4LPN revealed S4LPN signed for the nebulizer treatment on 04/06/2026 at 1:52 p.m., and on 04/07/2026 at 8:28 a.m. S4LPN confirmed she gave the treatments and did not label the tubing with a date or stored it in a bag, but should have.On 04/08/2026 at 4:36 p.m. an interview was conducted with S2IC who was responsible for the facility's infection control program. She stated that the facility's policy was to label nebulizer tubing with the date and store the mask in a bag when not in use. On 04/08/2026 at 5:00 p.m., the oxygen policy was reviewed with S7ADON. She stated the policy for oxygen tubing and mask storage was the same for nebulizer tubing and mask storage and that staff should follow the policy.

Based on observation, interview, and record review, the facility failed to ensure the nurse maintained infection control practices while administering wound care treatments for 1 resident (#40) out of 2 residents reviewed for wound care in a sample of 32 residents. Findings: Review of the facility's policy titled, Handwashing/Hand Hygiene, with a revision date of December 2025, read in part: Hand hygiene is indicated: d. before moving from work on a soiled body site to a clean body site on the same resident;.h. after glove removal. Review of Resident #40's Electronic Health Record (EHR) revealed the resident was admitted to the facility on [DATE] with diagnoses including, but not limited to, cerebral infarction and pressure ulcer of sacral region stage 4. Review of Resident #40's current physician's orders revealed the following orders: -Dakins (1/4 strength) External Solution 0.125 % (Sodium Hypochlorite) Apply to sacrococcygeal topically every day shift for pressure wound. Cleanse, apply collagen, calcium alginate then cover with a dressing. Ordered on 02/17/2026. -Mupirocin External Ointment 2% (Mupirocin) Apply to left knee abrasion. Clean with wound cleanser or NS (Normal Saline), apply with collagen, cover with a dry dressing. Ordered on 02/17/2026. On 04/07/2026 at 9:31 a.m., an observation was made of S3TN perform the resident's wound care. During wound care, S3TN removed the soiled dressing to Resident #40's knee. S3TN removed her used gloves and put on clean gloves. She did not perform hand hygiene between glove changes. She then pat the resident's wound with dry gauze, changed her gloves, and did not perform hand hygiene prior to putting on new clean gloves. S3TN applied Mupirocin to the resident's wound, removed her used gloves, put on clean gloves, but did not perform hand hygiene between glove changes. She then applied a clean dressing to the resident's knee. S3TN proceeded to perform wound care to Resident #40's saccrococcygeal wound. She applied clean gloves and removed the resident's soiled dressing. S3TN removed her used gloves, put on clean gloves, and did not perform hand hygiene between glove changes. She then cleaned the resident's saccrococcygeal wound, removed her gloves, and did not perform hand hygiene. S3TN applied clean gloves, cleaned the resident's wound a second time, and removed her gloves. She then put on clean gloves and did not perform hand hygiene between glove changes. She pat the resident's wound dry with dry gauze, removed her used gloves, and put on clean gloves. She did not perform hand hygiene prior to putting on the clean gloves. On 04/07/2026 at 10:00 a.m., an interview was conducted with S3TN. S3TN confirmed that she did not sanitize her hands between glove changes during Resident #40's wound care and knew she was supposed to, but she forgot. On 04/08/2026 at 4:36 p.m., an interview was conducted with S2IC who was responsible for overseeing infection control at the facility. S2IC stated the facility's policy was to perform hand hygiene before applying and after removing gloves during wound care and anytime gloves were used for resident care.

Based on observations, interviews and record review, the facility failed to ensure a resident's plan of care was implemented for 1 (Resident #51) out of 32 sampled residents. The facility failed to ensure Resident #51's splint was applied on her left hand. Findings: A review of Resident #51's Admission Record revealed she was admitted to the facility on [DATE] with diagnoses that included in part, cerebral infarction. A review of Resident #51's Order Summary Report revealed a physician's order, dated 02/06/2025 that read, left hand splint to be worn during the day, take off at night and for showers. A review of Resident #51's Care Plan Report revealed a care plan intervention initiated on 02/07/2025 that read, left hand splint to be worn during the day, take off at night and for showers. On 03/18/2025 at 9:27 AM, an observation was made of Resident #51 in her room. No splint was observed on her left hand. On 03/18/2025 at 10:07 AM, a second observation was made of Resident #51 in her room. No splint was observed on her left hand. A concurrent interview and observation was conducted with S5CNA (Certified Nursing Assistant), S5CNA confirmed there was no splint on Resident #51's left hand. On 03/18/2025 at 10:40 AM, an observation and interview was conducted with S3LPN (Licensed Practical Nurse). S3LPN confirmed that Resident #51's splint was not on her left hand and it should have been.

Based on record review, interviews, and review of the facility's policy and procedure, the facility failed to ensure all allegations of injuries of unknown source with serious bodily injury was reported immediately, or within 2 hours of the allegation to the state survey agency for 1 (#1) of 4 (#1, #2, #3 and #R1) residents sampled with facility reported incidents. Findings: On 09/10/2024, a review of the facility's policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating with a last reviewed date of 03/11/2024 read in part: Policy Statement: All reports of resident abuse (including injuries of unknown origin) . are reported to local, state and federal agencies (as required by current regulations) . 1. If resident . injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following applicable persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility . 3. Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury . Review of Resident #1's record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Fracture of Right Femur, Muscle Wasting and Atrophy, and Heart Failure. Review of Resident #1's Significant Change Minimum Data Set (MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) of 3 indicating his cognition was severely impaired. Review Resident #1's Incident Report completed on 08/19/2024 at 1:50 p.m. by S4LPN (Licensed Practical Nurse), read in part: . Informed by CNA (Certified Nursing Assistant) that resident was found on the floor in supine position; Head to toe assessment performed and bruising noted to the L (left) and R (right) hand; skin tear to R upper and c/o (complaints of) pain w/ (with) guarding to the R hip area . Review of the investigation submitted for Statewide Incident Management System (SIMS) Incident ID: 206829 revealed, in part . Entered: 08/21/2024, 11:13 a.m. 08/20/2024, 12:00 p.m. Review of Resident #1's right hip x-ray results revealed the following in part: examination date 08/19/2024 at 10:24 p.m.; reported date: 08/20/2024 at 7:35 p.m. an acute intertrochanteric femoral fracture with mild displacement with varus angulation. Review of Resident #1's progress notes documented by S5LPN revealed the following in part: 08/20/2024 at 1:23 a.m., S5LPN received Xray results. Right hip Acute intertrochanteric femoral fracture with mild displacement with varus angulation . New order to send resident to the ER (emergency room ) for treatment . I called the on-call number. No one answered . Multiple attempts were made to contact S5LPN via phone for interview on 09/09/2024 at 2:50 p.m., at 3:54 p.m., and at 4:08 p.m., and on 09/10/2024 at 8:44 a.m., at 9:40 a.m., and at 11:00 a.m. S5LPN failed to return any phone calls and was unable to be interviewed. On 09/10/2024 at 11:10 a.m. an interview was attempted with Resident #1. Resident #1 is not able to be interviewed due to unable to answer questions appropriately and he does not remember the cause of his right femur fracture. On 09/10/2024 at 11:26 a.m., an interview was conducted with S3ADON (Assistant Director of Nursing). S3ADON stated she was on call on 08/20/2024. She stated S5LPN did call the on call phone, but she (S3ADON) did not answer the phone due to her not hearing it. She stated on 08/20/2024 she called the facility at around 6:45 a.m. and was notified that Resident #1 sustained a right hip fracture and was sent to the ER. She confirmed that she notified S1ADM (Administrator) verbally of Resident #1's right femoral fracture on 08/20/2024 at around 8:15 a.m. in a morning meeting at the facility. She stated she did not have access to report incidents to the state survey agency. Multiple attempts were made to contact S1ADM via phone for interview on 09/10/2024 at 2:12 p.m., at 2:27 p.m., and at 3:12 p.m. S1ADM failed to return any phone calls and was unable to be interviewed. On 09/10/2024 at 3:39 p.m., an interview was conducted with S2DON (Director of Nursing). S2DON stated that S1ADM was currently on vacation and may not be able to take calls. She stated she reviewed Resident #1's x-ray results on 08/20/2024 before coming to work at around 8:00 a.m. and she forwarded the x-ray results to S1ADM on 08/20/2024 at around 8:00 a.m. She confirmed the right femur fracture was an injury of unknown origin and that's why an in-service was completed with staff after this incident on 08/21/2024 to report all injury of unknown origin to the administrator or DON immediately because these must be reported to LDH (Louisiana Department of Health) within 2 hours. She stated S1ADM entered the facility reported incident to the state survey agency on 08/21/2024 at 11:13 a.m. S2DON confirmed this should have reported to the state survey agency within 2 hours of notification for resident #1's injury of unknown source with serious bodily injury.

Based on record review and interview, the facility failed to ensure the resident's Minimum Data Set (MDS) assessment accurately reflected the status of 1 (Resident #2) out of 3 (Resident #1, #2, and #3) sampled residents by failing to ensure that Resident #2 was coded correctly for the use of a wander guard. Findings: Resident #2 Review of Resident #2's health record revealed that she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Alzheimer's Disease, Peripheral Vascular Disease, and Hypertension. Review of Resident #2's most recent Annual Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) of 99, indicating the resident was unable to cooperate. Further Review of Resident #2's most recent MDS dated [DATE] Section P - Restraints and Alarms, P0200 Alarms, E. Wander/elopement Alarm, revealed it was coded as 0. Not used. Review of the Wandering Risk Scale dated 03/16/2024 revealed in Section E. History of Wandering 2. Has history of wandering. Further review of Section J. Comments, Wander guard remains in place. No concerns noted. Review of Resident #2's active physician's orders dated June 2024 revealed an order on 06/23/2024 read in part, Wander Alert Bracelet (Wanderguard) Check for placement with skin intact every shift, census check every 1 hour every shift. On 06/04/2024 at 10:22 a.m., an interview and record review was conducted with S2MDSC (Minimum Data Set Coordinator). She confirmed that Resident #2 was using wanderguard daily because she had a history of wandering. S2MDSC also confirmed that Resident #2's MDS dated [DATE] had not been coded for using a wanderguard daily and should have been.

Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infections as evidence by S3CNA failing to: 1. utilize the proper PPE (Personal Protective Equipment) while providing care to Resident #2 who was on Contact Precautions. 2. perform hand hygiene before entering and exiting Resident #2's room. 3. disinfect the vital sign machine and blood pressure cuff after use. The facility had a census of 88. Findings: On 06/04/2024, a review of the facility's policy, Isolation - Categories of Transmission-Based Precautions, with a last reviewed date of 03/08/2024, revealed in part, the following, . Contact Precautions: . 2. Contact precautions are also used in situations when a resident is experiencing wound drainage, fecal incontinence or diarrhea, or other discharges from the body that cannot be contained and suggest an increased potential for extensive environmental contamination and risk of transmission of a pathogen, even before a specific organism has been identified . 7. Staff and visitors wear gloves (clean, non-sterile) when entering the room . b. Gloves are removed and hand hygiene performed before leaving the room . 8. Staff and visitors wear disposable gown when entering the room and remove before leaving the room . Review of facility's sign posted on the outside of Resident #2's room, revealed in part, the following, Contact Precautions . 2. Gloves - wear gloves when entering the room . removed gloves before leaving patients room. 3. Wash hands - with soap and water immediately after glove removal and before leaving patients room, 4. Gown - wear if you anticipate that your clothes will have contact with the patient, environmental surfaces or items in the patient's room or if the patient has any of the following: incontinent, diarrhea . removed gown before leaving the patient's environment . 6. If common equipment is used, clean and disinfect . Review of Resident #2's physician's orders revealed an order dated 06/03/2024 that read, Contact isolation precautions from now until 3 days after symptoms of Norovirus have resolved. Contact precautions include wearing gown and gloves in resident's room. Perform hand hygiene with soap and water before and after donning PPE. Limit resident transport. On 06/04/2024 at 9:14 a.m., S3CNA was observed entering Resident #2's room with the vital sign machine and blood pressure cuff. She did not wear gloves or gown before entering Resident #2's room. S3CNA obtained Resident #2's vitals and exited the room. S3CNA did not perform hand hygiene prior to entering Resident #2's room or after exiting the room. S3CNA did not sanitize the vital sign machine or the blood pressure cuff after use. On 06/04/2024 at 9:16 a.m., an interview was conducted with S3CNA. She confirmed Resident #2 was having diarrhea, and did not notice the Contact Precaution sign on Resident #2's door. She stated that she did not sanitize her hands before or after contact with Resident #2 and did not don PPE before entering into Resident #2's room. S3CNA also stated that she did not sanitize the vital sign machine or the blood pressure cuff prior to or after use. S3CNA stated that she should have sanitized vital sign machine and blood pressure cuff prior to entering Resident #2's room. She stated that she should have sanitized her hands, wore gloves and gown prior to entering Resident #2's room. S3CNA also stated that she should have sanitized the vital sign machine and blood pressure cuff after use. On 06/04/2024 at 10:10 a.m., an interview was conducted with S1ICRN (Infection Control Registered Nurse). S1ICRN stated that when Contact Precautions are in place for residents staff should perform hand hygiene before entering and upon exiting the resident's room. S1ICRN also stated that proper PPE should be utilized which consist of donning gloves and gown before entering into the room. She also stated that the vital sign machine and blood pressure cuff should be sanitized before and after use and between residents.

Based on observations, review of policy and procedure and interviews, the facility failed to store, distribute, and serve food in accordance with professional standards for food service safety by failing to follow appropriate food handling practices as evidenced by: 1. One opened package of bread on the counter not labeled with the date. 2. Food residue noted on the deep fryer and layer of oil and debris noted on the floor underneath the deep fryer. 3. Food storage: A. Walk-in cooler: 1. A container of onion mix not labeled with the date it had been prepared. 2. Two bags of ham opened and placed in a zip log bag not labeled with the date. 3. One bag of lettuce opened and not labeled with the date. 4. Four cucumbers with texture changes indicated the items were spoiled. 4. Failure to distribute food under sanitary conditions for Resident #61. The total amount of residents that ate out of the kitchen was 89 residents. Findings: Review of the facility's policy, Sanitization, last reviewed on 03/2024, revealed in part, the following, Policy Statement: The food service area is maintained in a clean and sanitary manner. Policy Interpretation and Implementation: . 2. Equipment are kept clean . 3. All equipment, food contact surfaces and utensils are cleaned and sanitized using heat or chemical sanitizing solutions . Review of the facility's policy, Refrigerators and Freezers, last reviewed on 03/2024, revealed in part, the following, Policy Statement: This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation and will observe food expirations guidelines. Policy Interpretation and Implementation: . 7. use by dates are indicated once food is opened. On 03/11/2024 at 8:20 a.m., an initial tour of the facility's kitchen was conducted with S4DM (Dietary Manager). S4DM confirmed the above mentioned items were not labeled or dated and should have been, and spoiled items should not be in the walk-in cooler. S4DM stated the deep fryer was last used on 03/08/2024 and it should have been cleaned after it was used and confirmed that oil and debris should not be under the deep fryer and that should have been cleaned. On 03/11/2024 at 2:03 p.m., a follow up observation of the facility's kitchen was conducted with S1ADM (Administrator). S1ADM confirmed that after food items are opened they should be labeled with the date, spoiled food items should not be in the walk-in cooler, the deep fryer should be cleaned after every use and oil and debris should have been cleaned from under the deep fryer. 47965 Resident #61: Resident #61 was admitted to the facility on [DATE] with diagnoses including, but were not limited to, Chronic Kidney Disease, Morbid Obesity Due to Excess Calories, and Aphasia Following Cerebral Infarction. On 03/12/2024 at 11:58 a.m., an observation was made of S13CNA (Certified Nursing Assistant) delivering Resident #61's lunch tray to her room. The resident's paper wrapped straw fell from her tray and onto the floor. S13CNA picked up the straw, placed it on the resident's tray and delivered the tray to the resident. On 03/12/2024 at 12:00 p.m., an interview was conducted with S13CNA. S13CNA confirmed that she picked up the paper wrapped straw from the floor and placed it on Resident # 61's tray and delivered it to the resident. S13CNA stated she should have discarded the straw and not given it to the resident. On 03/12/2024 at 12:14 p.m., an interview was conducted with S2DON (Registered Nurse, Director of nursing, Infection Preventionist). S2DON stated the CNAs are in-serviced on infection control, and that S13CNA should not have picked up a straw from the floor, place it on the resident's tray, and deliver the tray to the resident.

Based on record review and interview, the facility failed to develop and implement a comprehensive patient-centered care plan for 2 residents (Resident # 6 and Resident # 84) out of a total sample of 30 residents. Findings: On 03/13/2024, a review of the policy dated 03/2024 titled Care Plans, Comprehensive Person-Centered read in part, Policy Statement, A comprehensive, person-centered care plan that includes measureable objectives and timetable to meet the residents physical, psychosocial and functional needs is developed and implemented for each resident. Resident #6 Review of Resident #6's medical record revealed that she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Lobar Pneumonia. Review of Resident #6's physician's orders revealed an order dated 01/15/2024 that read: O2 (oxygen) at 2L/MIN (liters per minute) continuously/titrate as needed. Review of Resident #6's Comprehensive Care Plan failed to reveal a care plan had been developed for oxygen use. Observation on 03/11/2024 at 9:47 a.m. revealed Resident #6 in bed with oxygen via nasal cannula in place. Observation on 03/12/2024 at 9:35 a.m. revealed Resident #6 in bed with oxygen via nasal cannula in place. On 3/12/2024 at 10:09 a.m., an interview was conducted with S8MDSLPN (Minimum Data Set, Licensed Practical Nurse). She reviewed Resident #6's medical record and confirmed the resident had an order for oxygen on 01/15/2024. S8MDSLPN then reviewed the care plan and confirmed Resident #6 had not been care planned for use of the ordered oxygen with appropriate interventions, and should have been. 46149 Resident #84 Review of Resident #84's EHR (Electronic Health Record) revealed the resident was admitted to the facility on [DATE] with diagnoses including: Unspecified Dementia and Hemiplegia and Hemiparesis following Unspecified Cerebrovascular Disease Affecting Left Non - Dominant Side. Further review of Resident #84's EHR revealed a physician's order dated 07/13/2023 that read: Pt. (Patient) to have divided plate with all meals. On 03/11/2024 at 12:00 p.m., an observation was made of Resident #84 eating lunch. The resident did not have a divided plate. 03/11/2024 at 12:15 p.m., an interview was conducted with S9LPN (Licensed Practical Nurse). S9LPN confirmed Resident #84 had an order for a divided plate with all meals. S9LPN then observed the resident's lunch plate and confirmed the resident did not have a divided plate and should have had a divided plate.

Based on observation, policy review and interview, the facility failed to complete an accurate facility-wide assessment that reflected the resident population. This was evidenced by failure to address or include Mexican ethnic or cultural factors for 1(#48) out of a total sample of 30 residents. The facility's census was 92 residents. Findings: On 03/12/2024 at 2:05 p.m., a record review was conducted of __________Facility Assessment March 2024 with a review date of 03/08/2024. The facility assessment revealed in part: Ethnic, cultural, or religious factors . Further review of the facility's assessment failed to include ethnic or cultural factors that reflected the Mexican resident population. On 03/13/2024 at 12:21 p.m., a review of the facility's Facility Assessment Policy which was reviewed per annual policy and procedure review in March 2024 revealed: Policy Statement. A facility assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our residents during day-to-day operations. Determining our capacity to meet the needs of and care for our residents during emergencies is included in this assessment. Policy Interpretation and Implementation .3. The facility assessment includes a detailed review of the resident population. This part of the assessment includes .d. religious, ethnic or cultural factors that affect the delivery of care and services, such as .(4) language translation requirements. Resident # 48 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Unspecified Dementia and Major Depressive Disorder. A review of Resident # 48's quarterly MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 02/21/2024 revealed in Section A1005. Ethnicity. B., an answer of Yes to Mexican, Mexican American, Chicano/a. A review of Resident # 48's plan of care with a revision date of 05/23/2023 revealed that she was care planned for having a communication problem r/t (related to) language barrier and that she communicated via Spanish. On 03/12/2024 at 11:35 a.m., an observation was made of Resident # 48 in the communal dining room. The resident was observed wearing a clothing protector during lunch. S11CNA (Certified Nursing Assistant) was observed attempting to remove the resident's clothing protector when she was finished eating, but the resident appeared resistant to S11CNA. Resident # 48 was observed crossing her arms across her chest and said no, no, no. S11CNA was unable to communicate to the resident the reason for removing the clothing protector because she did not speak the resident's language. On 03/12/2024 at 12:16 p.m., an interview and review of _______ Facility Assessment March 2024 was conducted with S1ADM (Administrator). S1ADM confirmed that the assessment failed to address any ethnic, cultural, or religious factors for residents who did not speak English. She also confirmed there was no language translation requirements to address how to communicate with Resident # 48, who communicated via Spanish.

Based on observation, interview, and policy and procedures review, the facility failed to ensure menus met the nutritional needs of the residents and were followed as evidenced by: 1. No menu posted in resident areas, in a position and in print large enough for resident to read them. 2. The kitchen staff failing to have knowledge of recipes to be followed when preparing pureed foods. This deficient practice had the potential to contribute to an unpleasant dining experience, decreased intake, altered nutritional needs and weight loss for the 14 residents who consumed pureed diets. Findings: Review of the facility's policy, Menu, last reviewed on 03/2024, revealed in part, the following: Policy Statement: Menus are developed and prepared to meet resident choices including religious, culture and ethnic needs while following established national guidelines for nutritional adequacy. On 03/11/2024 at 9:57 a.m., an observation was made of S5DC (Dietary Cook) preparing pureed lunch meals. S5DC prepared an unmeasured amount of chicken by blending pieces of chicken into the blender and added an unmeasured amount of water. Next, S5DC was observed transferring an unmeasured amount of brussel sprouts from the container to the blender and then added and unmeasured amount of water and blended all the ingredients. There were no recipe(s) present during the observed pureed lunch meal preparation by S5DC. On 03/11/2024 at 10:35 a.m., an interview was conducted with S5DC who confirmed she was one of the cooks at the facility and she often prepared puree meals. She stated there were 14 residents in the building that required pureed meals. She stated that she was never notified that she had to follow a recipe when preparing puree meals and confirmed she prepared puree meals for residents based off of her judgement. On 03/11/2024 at 11:15 a.m., an interview was conducted with S4DM (Dietary Maneger). S4DM stated she had received recipes for puree diets and the recipes were currently kept in a binder in her office. She confirmed that she and the dietary cooks had never followed recipes while preparing puree meals. She stated that the recipe binder was the first time I have this binder. On 03/11/2024 at 12:23 p.m., a phone interview was conducted with S3RD (Registered Dietician). She stated that the menu for the therapeutic diets also came with a recipe. She states she sends the facility recipes for therapeutic diets every six months. She confirmed that when the dietary cooks or dietary manager were preparing puree meals, a puree recipe should be followed to ensure the nutritional needs were met for the residents who consumed puree meals. On 03/11/2024 at 4:30 p.m., an observation was made of the dining area and there was not a menu posted for residents. At this time, an interview was conducted with S4DM. S4DM stated she puts the menu on the large white board in the dining area but did not today because she did not have time.

Based on interviews and record reviews, the facility failed to ensure consent was obtained from the Resident's Representative prior to purchasing a burial policy for a resident who did not have the mental capacity to consent for 1 (#51) out of 1 sampled residents in a final sample of 30 residents. Findings: Review of Resident #51's medical record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Alzheimer's Disease, Schizoaffective Disorder, Manic Episode Severe with Psychotic Symptoms, Anxiety Disorder, Peripheral Vascular Disease, and Hypertension. Review of Resident #51's Annual MDS (Minimum Data Set) Admission assessment with an ARD (Assessment Reference Date) of 12/2022 revealed a BIMS (Brief Interview for Mental Status) score of 06, which indicated severe cognitive impairment. Review of Resident #51's facesheet revealed the resident had a Resident Representative. Review of Personal Funds Statement dated 1/01/2023-3/12/2023 revealed a charge withdrawn on 2/18/2023 of $1529.81 to burial insurance policy. Review of Resident #51's signed Burial Insurance Policy form revealed Resident #51's signature on both signature lines. Review of Burial Insurance Policy form revealed the following statement in part .Has the proposed insured ever been diagnosed , treated, tested positive for, on been given medical advice by a member of the medical profession for any of the following conditions? . Alzheimer's ; Resident #51 signed attesting that the answer was no to the question. On 3/12/2024 at 10:34 a.m., an interview was conducted with S10BOA (Business Office Assistant). She recalls purchasing a burial policy with the previous business office manager. S10BOA stated the Residents funds could not exceed $2000 so they had Resident #51 sign the policy. She stated she does not recall them contacting the Resident Representative for notification of the purchase. On 3/13/24 at 9:11 a.m., a phone interview was conducted with Resident#51's daughter. She stated she and the resident's representative were unaware the facility purchased a burial policy for their mother. She stated the only reason she realized her mother had that the policy was because her quarterly statement listed the withdrawal. The daughter also stated the burial insurance policy form was filled out inaccurately. The Resident Representative's name on the policy was spelled incorrectly. The policy was signed indicating she did not have Alzheimer's and she did have Alzheimer's disease. Resident #51's daughter further stated that the resident has been confused since her admission to the facility. On 3/13/2024 at 9:53 a.m., an interview was conducted with S1ADM (Administrator). She confirmed the burial policy was filled out inaccurately, because the Resident did have a diagnosis of Alzheimer's Disease in 2023, and also confirmed the Contingent Beneficiary's name was spelled incorrectly. S1ADM could not provide evidence that the previous business office manager obtained consent from Resident #51's Resident Representative prior to purchasing the policy on behalf of the resident. On 3/13/2024, a phone interview was conducted with the Resident Representative. She stated she was not informed that the facility was going to be purchasing a burial policy for the Resident. Resident Representative further stated after the policy was purchased without her knowledge, she reviewed the paperwork and identified that the funeral home, and the contingent beneficiary were both incorrect. She also stated she does not believe that Resident #51 signed the paperwork, because the Resident does not remember how to read or write.

Based on observations and interview, the facility failed to properly label respiratory equipment for 1 resident (#6) out of 1 (#6) resident investigated for respiratory care. Findings: Review of Resident #6's medical record revealed that she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Lobar Pneumonia. Review of Resident #6's physician's orders revealed an order dated 01/15/2024 that read: O2 (oxygen) at 2L/MIN (liters per minute) continuously/titrate as needed. On 03/11/2024 at 9:47 a.m., an observation was made of the Resident in her room using oxygen via nasal cannula. The oxygen tubing was not labeled with a date. On 03/11/2024 at 9:52 a.m., an interview was conducted with S7LPN (Licensed Practical Nurse). S7LPN was unsure of the date that the tubing was changed. She confirmed the Resident's oxygen tubing did not have a label on it and it should have.

Based on record review and interview the facility failed to ensure appropriate care and services had been provided for 1 (Resident #21) of 1 resident investigated for dialysis. The facility failed to ensure Resident #21 was accurately assessed and monitored for the care of his dialysis access site following dialysis. Findings: Review of the facility's policies on 3/13/2024 revealed policy dated 3/2024, titled Hemodialysis read in part, Policy: This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis. 8. The nurse will monitor and document the status of the resident's access site(s) upon return from the dialysis treatment to observe for bleeding or other complications. Review of Resident #21's electronic medical record revealed he was admitted to the facility on [DATE] with diagnoses that included End Stage Renal Disease, Type 2 Diabetes Mellitus with Diabetic Secondary to Chronic Kidney Disease, Thrombocytopenia and Anemia in Chronic Kidney Disease. Review of Resident #21's Significant Change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2/28/2024 revealed he had a BIMS (Brief Interview for Mental Status of 14, indicating he was cognitively intact. Section O (Special Treatment, Procedures and Programs) revealed he was coded for receiving Dialysis while a resident. Review of Resident #21's communication form titled Resident Dialysis Form read in part, Drsng (Dressing) C/D/I (Clean/Dry/Intact) with a Yes or No box that indicated if this assessment had been done. On 2/22/2024, 2/24/2024, 2/27/2024 and 3/09/2024 dressing assessment post dialysis was incomplete. There were no boxes checked that indicated an assessment had been completed. 03/12/2024 at 12:11 p.m., interview was conducted with Resident #21 who was cognitively intact. He stated that he went to dialysis on Tuesdays, Thursdays and Saturdays. He stated that no one checked his dialysis access site when he returned from dialysis. On 03/12/2024 at 12:30 p.m., an interview and record review with S2DON (Director of Nursing) was conducted and she confirmed that Resident #21's dialysis site had not been assessed after dialysis on 02/22/2024, 02/24/2024, 02/27/2024 and 03/09/2024.

Based on observation and interview, the facility failed to ensure medications were stored according to professional standards of practice as evidenced by loose pills found in the bottom of medication cart drawers for 1 (Cart B) of 2 medication carts (Cart B, Cart C ) reviewed. Findings: Review of the facility's policy titled Medication Labeling and Storage dated 03/08/2024 and reviewed on 03/13/2024 read in part .Medication Storage . 2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. On 03/13/2024 at 9:40 a.m., an observation was made of Medication Cart B with S6LPN (Licensed Practical Nurse). Observation of the second drawer of the medication cart revealed 6 loose pills at the bottom of the drawer. The pills included the following: 1 red oblong tablet, 2 large white round tablets, 1 small white round tablet, 1 blue round tablet, and 1 orange round tablet. S6LPN could not identify the loose pills. S6LPN also stated that the nurses were responsible for ensuring the medication carts were free from loose pillls. S6LPN confirmed that the loose pills should not have been in the medication cart.

Based on record review, and interview the facility failed to provide quarterly statements for resident personal funds for 1 (#1) resident out of 1 resident (#1) reviewed for personal funds. Findings: Resident #1 MDS (Minimum Data Set) dated 06/13/2023 revealed that a Brief Interview for Mental Status (BIMS) score of 04 which indicated severe cognitive impairment. Review of the facility's policy titled Resident Trust Fund revealed, in part: Policy Interpretation and Implementation: 4. Quarterly statements reflecting the interest earned and balance of the account are to be mailed to all residents and or responsible party. Review of Resident #1's Medical Chart revealed her daughter as the Responsible Party (RP). During a phone interview on 09/11/2023 at 1:00 p.m., Resident #1's daughter stated that she and her sister who is the responsible party, were not aware of how much the resident pays monthly for services. She stated that when she asked S3BA (Business Assistant) about the resident's bank statement, she was told she couldn't receive that information. During an interview on 09/12/2023 at 8:10 a.m., an interview was conducted with S3BA (Business Assistant) who stated that she had spoken with Resident #1's daughters and explained that they need to obtain a Power of Attorney (POA) before they could receive the quarterly financial statements. S3BA confirmed that she had not sent out any quarterly financial statements to the resident's responsible party.

Based on record reviews and interviews, the facility failed to ensure that charges were not imposed against the personal funds of a resident for personal liability for 1 (#1) out of 5 sampled residents. Findings: Review of Resident #1's record revealed she was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, Aphasia, Schizoaffective disorder, Bipolar type, Manic episode, Severe with psychotic symptoms, and Cognitive communication deficit. Review of the resident's Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) score of 04, indicating severe cognitive impairment. Reviewed a document titled Provider Decision Letter dated 03/03/2023 which read in part: You must pay part of the cost for your nursing facility/waiver services each month.01/01/2023 - 02/28/2023 monthly amount $1,650.00. Further review revealed payment as of 03/03/2023 - continuing was $1,501.00. Review of a document titled Trust Transaction History dated 03/03/2023 - 05/25/2023 revealed on 03/03/2023 - 03/06/2023 payment from Resident #1's trust was $1,650.00, a $149.00 overture, and on 04/05/2023 - 04/05/2023 resident paid $1,644.40 a $143.40 overture. Review of a document titled A/R (Account Receivable) by Service Date from 01/2023 - 08/2023 did not reveal that Resident #1's account was credited for 03/2023 or 04/2023 withdrawals. On 09/12/2023 at 11:34 a.m., an interview was conducted with S3BA (Business Assistant) who confirmed that Resident #1's account was supposed to be charged $1,501.00, and that the account had not been credited for previous withdrawals on 03/2023 and 04/2023. On 09/13/2023 at 10:50 a.m., during the exit interview, S1ADM (Administrator) confirmed that Resident #1's account had not been credited for the 03/2023 and 04/2023 withdrawals.

Based on record review and interview, the facility's staff failed to notify the resident's representative and/or the resident's physician of a change in the resident's condition for 1 (#1) of 5 (#1 - #5) sampled residents. Findings: Review of the facility's policy, Change in a Resident's Condition or Status revealed in part: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.) .The nurse will notify the resident's attending physician on call when there has been a(an): accident or incident involving the resident; discovery of injuries of an unknown source; .need to transfer the resident to a hospital/treatment center; .specific instruction to notify the physician of changes in the resident's condition .a nurse will notify the resident's representative when: the resident is involved in any accident or incident that results in any injury including injuries of an unknown source; there is a significant change in the resident's physical, mental, or psychosocial status .it is necessary to transfer the resident to a hospital/treatment center .Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. Resident #1 Review of Resident #1's medical record revealed she was admitted on [DATE]. The resident had diagnoses including Alzheimer's disease, Peripheral vascular disease, Moderate protein-calorie malnutrition, and Schizoaffective disorder, Bipolar type. Review of the resident's quarterly MDS (Minimum Data Set) dated 06/13/2023 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 04, indicating severe cognitive impairment. Review of the resident's care plan revealed the resident had a responsible party (RP) that should be notified of any changes in the resident's condition and of any new orders. On 09/12/2023 at 7:40 a.m., an observation of Resident #1 was conducted with S4TX (Treatment Nurse) which revealed a reddened area to the right inner ankle. S4TX palpated the area, and the resident denied any pain at that time. S4TX stated that she had not observed this change before, and added that she would notify the physician. On 09/13/2023 at 9:02 a.m., an observation of Resident #1's electronic record was conducted with S2ADON (Assistant Director of Nursing). S2ADON was asked if any new orders were written for the resident, and she stated that no new orders were written on 09/12/2023. Observation of the nurse's notes did not reveal any documentation of a new wound or skin changes on 09/12/2023. Review of skin assessment did not reveal any documentation of new skin issues on 09/12/2023. Further observation and interview was conducted with S2ADON, who observed the reddened area to Resident #1's right inner ankle. Upon palpation, the resident withdrew her leg away from S2ADON. S2ADON asked the resident if the area was painful. The resident stated yes, the area was painful. S2ADON confirmed that S4TX should have notified the physician, documented the finding in the nurse's notes, and notified the resident's responsible party. On 09/13/2023 at 9:24 a.m., an interview was conducted with S4TX who confirmed that she did not notify the physician, document the change in condition, or notify the resident's responsible party, and that she should have.

Based on record review, and interview, the facility failed to ensure a resident who was unable to carry out Activities of Daily Living (ADLs) received the necessary services to maintain good grooming and personal hygiene for 2 (#2, #4) of 5 (#1- #5) residents reviewed for ADLs. The facility failed to provide baths/showers for Resident #2, and #4. Findings: Review of a facility document titled Bath, Shower/Tub read in part: Documentation: 1. Date and time the shower/tub bath was performed 2. Name and title of the individual(s) who assisted the resident. 5. If the resident refused, the reason why and intervention taken. Reporting: 1. Notify the supervisor if resident refuses the shower/tub bath. Review of Resident #2's clinical record revealed he was admitted on [DATE] and had diagnoses of Blindness of the right eye, Diabetes Mellitus, Chronic kidney disease, stage 3, Atherosclerotic heart disease, and Dementia. Review of Resident's care plan dated 12/15/2022 read in part, ADL self-care performance deficit related to Dementia with interventions that included bathing/showering, physical assist required. Review of Resident's Minimum Data Set (MDS) dated [DATE] read in part: Brief Interview for Mental Status (BIMS) score of 04 which indicated severe cognitive impairment. Functional status - personal hygiene requires extensive assistance with one person assist. Review of a facility document titled Shower Schedule which revealed Resident #2's bath/shower days were on Tuesday's, Thursday's, and Saturday's. Review of a facility document titled Documentation Survey Report v2 dated 07/2023 - 09/11/2023 revealed that on 07/06/2023, 07/11/2023, 07/14/2023, 07/15/2023, 08/24/2023, and 09/05/2023 Resident #2 did not receive a bath/shower. On 09/12/2023 at 2:00 p.m., an interview was conducted with S2ADON (Assistant Director of Nursing) who confirmed that on the above listed days, Resident #2 did not receive a bath/shower per his bath schedule nor was there documentation that Resident #2 refused a bath/shower. Resident #4 Review of Resident #4 electronic record revealed an admitted [DATE] with diagnoses including Portal hypertension, Cirrhosis of liver, Metabolic encephalopathy, and Alcohol dependence. Review of Resident's care plan dated 02/02/2023 read in part, ADL self-care performance deficit related to Dementia with intervention that included bathing/showering assist with one person assist. Review of Resident's Minimum Data Set (MDS) dated [DATE] read in part: Brief Interview for Mental Status (BIMS) score of 05 which indicated severe cognitive impairment. Functional status - personal hygiene requires oversight, encouragement or cueing, with setup assistance only. Review of a facility document titled Shower Schedule which revealed Resident #4's bath/shower days were on Monday's, Wednesday's, and Friday's. Review of a facility document titled Documentation Survey Report v2 dated 07/2023 - 09/11/2023 revealed that on 07/10/2023, 07/12/2023, 07/14/2023, 07/17/2023, and 07/19/2023 Resident #4 did not receive a bath/shower per his bath schedule. On 09/12/2023 at 2:00 p.m., an interview was conducted with S2ADON who confirmed that on the above listed dates, the resident did not receive his bath/shower as scheduled nor was there documentation that Resident #4 refused a bath/shower.

Based on record review and interview, the facility failed to assure 1 (#6) resident received the necessary care and services to attain or maintain the highest practicable physical well-being when the facility failed to follow a physician's orders [REDACTED].#1 - #8) sampled residents. The resident was sent to the hospital on 4-9-14, returned to the facility on [DATE] with an order for [REDACTED]. This deficient practice had the potential to effect 8 (#7, #8, #R1-R6) residents on [MEDICATION NAME] with physicians' orders for PT/INRs according to a list of residents on [MEDICATION NAME] provided by the facility and 1 (#6) resident chosen as a sample who was out of the facility. Findings: Resident #6: A record review showed this resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of nurses' notes showed on 4-9-14 at 10:25 a.m.., this resident was sent to the hospital for evaluation and was found to have had an embolic stroke. The resident returned to the facility on [DATE] with a physician's orders [REDACTED]. The facility failed to do the PT/INR. Eleven days later, nurses notes on 5-4-14 showed documentation that the resident was found to have cold lower extremities with a very warm upper body. The lower extremities were also found to be splotchy in appearance. The resident was transferred to the hospital at 5:35 a.m. where a blood clot was found, an embolectomy was performed and the resident remained in the hospital at the time of this report. During an interview on 5-7-14 at 9:50 a.m. with staff #S1DON, she stated this resident was currently in the hospital. She stated that this resident's physician had called and told her that surgery had to be done to remove a clot. Staff #S1DON was asked if the PT/INR had been done that had been ordered on 4-23-14 and she stated it had not been done. She stated that staff #S5RN was a new employee and had given the order verbally to staff #S6Ward Clerk and the order should have been given to staff #S6 in a written format. She was asked what the facility's system was to assure orders were carried out when a resident returned to the facility and she stated that a nurse should give the order in a written format to the ward clerk so that the ward clerk could make a lab slip and schedule the lab work. She was asked why the physician had ordered the PT/INR and she stated the physician had told her that the PT/INR was high while the resident was in the hospital and he wanted it rechecked. She stated she was guessing that the doctor was checking up on this resident's [DIAGNOSES REDACTED]. During an interview on 5-7-14 at 11:15 a.m. with staff #3 Medical Director (resident's physician), he stated this resident had been in the hospital 4-9-14 through 4-23-14 for an embolic stroke. He stated the resident was on [MEDICATION NAME] while in the hospital but the [MEDICATION NAME] had been stopped when a lab value on a PT/INR was high. He stated he had ordered the PT/INR on 4-23-14 when the resident returned to the facility because he wanted to monitor the PT/INR value and put the resident back on [MEDICATION NAME] if the value indicated it was okay to do so. He stated he never got the lab work results he had ordered on this resident. He stated the resident "threw a clot". He stated he felt the main reason for the resident "throwing the clot" was that the blood was too thick. He stated if he had gotten the lab results and the lab results were not too high, he would have put the resident back on [MEDICATION NAME]. He stated this resident has other problems including [MEDICAL CONDITION] and that she was currently on a ventilator. Records were obtained from the hospital. A review of the records for the admission on 4-9-14 through 4-23-14 showed this resident was seen in the emergency roiagnom on [DATE] at 11:45 a.m. with right arm weakness, right leg weakness altered mental status, right facial droop and unable to speak more than a few words when she was normally able to speak. Blood tests were ordered including PTT and PT. The resident was admitted as an inpatient at 13:00 hours. A review of the MAR (Medication Administration Record) was reviewed and the resident received [MEDICATION NAME] ([MEDICATION NAME] 5 mg) on 4-15-14, 4-16-14, 4-17-14, 4-18-14, 4-19-14, 4-20-14, 4-21-14 and 4-22-14. The [MEDICATION NAME] was discontinued and the resident was discharged on [DATE] and returned to the facility. Further record review revealed the resident remained in the facility until 5-4-14. Nurses' notes on 5-4-14 showed the resident was found to have cold lower extremities and very warm upper body. The resident was sent back to the hospital. Hospital records were reviewed after the admission on 5-4-14. The final report showed the patient was known in be in chronic [MEDICAL CONDITION] and that it was unknown how well managed her anticoagulation was. The final report showed that bilateral aortoiliac and femoral embolectomies were performed. The preoperative [DIAGNOSES REDACTED]. The report indicated the patient was brought to the emergency room with rapid [MEDICAL CONDITION] with an uncontrolled rate and had severely mottled, cold and immobile legs bilaterally up to the upper thigh. There were no femoral pulses palpable. The embolectomies were done and the resident was started on IV [MEDICATION NAME]. Progress notes dated 5-7-14 showed the resident remained in the hospital, was on vent support, IV [MEDICATION NAME] and IV antibiotics.

Based on record review and interview, the facility failed to maintain acceptable standards of practice as defined by the Nurse Practice Act of Louisiana, Louisiana Revised Statutes 37:911 for Registered Nurses by failing to follow a physician's orders [REDACTED].#6, #8) residents out of 3 (#6, #7, #8) residents looked at who required PT/INR labs out of a total sample of 8 (#1 - #8) residents. Resident #6 had recently suffered an embolic stroke, was sent to the hospital on 4-9-14 and returned to the facility on [DATE] with an order for [REDACTED]. This deficient practice had the potential to effect 8 (#7, #8, #R1-R6) residents on [MEDICATION NAME] with physicians' orders for PT/INRs according to a list of residents on [MEDICATION NAME] provided by the facility and 1 (#6) resident chosen as a sample who was out of the facility. Findings: 1. Resident 6: A record review revealed this resident was admitted to the facility on [DATE]. Further record review showed this resident was sent to the hospital on 4-9-14 for right sided weakness. The resident returned to the facility on [DATE]. A review of the physician's orders [REDACTED]. During an interview on 5-7-14 at 11:15 a.m. with staff #S3Medical Director, he stated this resident was hospitalized from 4-9-14 to 4-23-14 due to an embolic stroke. He stated this resident was on [MEDICATION NAME] while in the hospital but after a PT/INR lab revealed high values, the resident was taken off the [MEDICATION NAME]. He stated he ordered PT/INR lab work on her return to the facility on [DATE] because he wanted to put her back on [MEDICATION NAME] when her lab values were in acceptable range. A review of the care plan showed a problem was documented as at risk [MEDICAL CONDITION] to [DIAGNOSES REDACTED]. During an interview on 5-7-14 at 2:40 p.m. with staff #S2RSD (Residential Service Director), she stated if a resident had a physician's orders [REDACTED]. She stated she was unaware this resident had been on [MEDICATION NAME] while in the hospital and that the PT/INRs were ordered by the physician in order for the physician to know whether or not he could put the resident back on [MEDICATION NAME]. During a subsequent interview on 5-7-14 at 2:45 p.m., she reviewed the care plan and confirmed the PT/INR lab work had not been put on the care plan. 2. Resident #8: During an interview and observation on 5-7-14 at 10:45 a.m., this resident was seated in the dining area. She was asked if she had weekly blood work and she stated that she did have weekly blood work because she was on [MEDICATION NAME]. She stated that once in a while "it goes berserk" but then they adjust her medication and it gets okay. A record review revealed this resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the current physician's orders [REDACTED]. (milligrams) every evening. A review of the care plan showed this resident had a problem documented as history of [MEDICAL CONDITION]. A review of the interventions did not reveal the need for PT/INR lab work had been included. During an interview on 5-7-14 at 2:40 p.m. with staff #S2RSD (Residential Service Director), she stated if a resident had a physician's orders [REDACTED]. During a subsequent interview on 5-7-14 at 2:45 p.m., she reviewed the care plan and confirmed the PT/INR lab work had not been put on the care plan.