Every finding on record at Colonial Oaks Living Center

Based on observations and interviews, the facility failed to ensure food from the facility's kitchen was palatable in flavor as required. Findings:Resident #1 Review of Resident #1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/18/2026 revealed, in part, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated Resident #1 was cognitively intact. In an interview on 05/03/2026 at 10:05AM, Resident #1 indicated the facility's food was terrible. Resident #1 further indicated the facility's food was cooked badly and not seasoned. In an interview on 05/05/2026 at 1:27PM, Resident #1 indicated the Brussel sprouts served for dinner on 05/04/2026 were mushy and not good. Resident #30 Review of Resident #30's Quarterly MDS with an ARD of 03/25/2026 revealed, in part, Resident #30 had a BIMS score of 13, which indicated Resident #30 was cognitively intact. In an interview on 05/03/2026 at 9:30AM, Resident #30 indicated the facility's food tasted horrible. In an interview on 05/04/2026 at 8:26AM, Resident #30 indicated she did not eat her breakfast because it did not taste good and it was cold. In an interview on 05/05/2026 at 8:10AM, Resident #30 indicated the taste of the food was not any better and she had not planned to eat any of her breakfast. Resident #30 further indicated the lunch and dinner she had yesterday (05/04/2026) was horrible. Resident #58 Review of Resident #58's MDS with an ARD of 01/28/2026 revealed, in part, Resident #58 had a BIMS score of 14 which indicated Resident #58 was cognitively intact. In an interview on 05/05/2026 at 10:28AM, Resident #58 indicated the Brussel sprouts, which were served on 05/04/2026, were nasty and she could not eat them. Resident #70 Review of Resident #70's Significant Change MDS with an ARD of 02/10/2026 revealed, in part, Resident #70 had a BIMS score of 13, which indicated Resident #70 was cognitively intact. In an interview on 05/05/2026 at 1:20PM, Resident #70 indicated the lunch that was served today (05/05/2026) was terrible. A test tray was tasted for palatability on 5/04/2026 at 12:36PM, and the surveyors found the turnip greens were bitter and not palatable and was not able to be consumed. A test tray was tasted for palatability on 05/04/2026 at 5:04PM, and the surveyors found the Brussel sprouts to have been overcooked/mushy, not seasoned, bitter, and not palatable. In an interview on 05/05/2026 at 1:45PM, S2Culinary Supervisor indicated the Brussel sprouts that were served on 05/05/2026 were overcooked and should not have been served to the residents.

Based on observations, interviews, and record reviews, the facility failed to ensure the advance prepared menus, approved by the facility's dietician, were followed for 3 (05/03/2026, 05/04/2026, 05/05/2026) of 3 days of observation of the facility's served meals. Findings:Review of the facility's dietician approved Week 1 2026 Spring/Summer Menu revealed, in part, on 05/03/2026, the facility was to serve broccoli rice casserole for lunch. Further review revealed on 05/04/2026, the facility was to serve turkey tetrazzini for dinner. Further revealed, on 05/05/2026, the facility was to serve fried chicken and a chocolate cherry bar for lunch. In an interview on 05/03/2026 at 9:44AM, Resident #28 indicated the facility always served the same food. In an interview 05/03/2026 9:56AM, Resident #70 indicated the facility's food was repetitive and the facility always served them rice. Observation of lunch on 05/03/2026 at 12:27PM revealed the facility's residents were served, in part, white rice instead of the broccoli rice casserole that was listed on the above mentioned dietician approved menu. Observation of dinner on 05/04/2026 at 5:01PM revealed the facility's residents were served, in part, mashed potatoes and roast beef instead of the turkey tetrazzini that was listed on the above mentioned dietician approved menu. Observation of lunch on 05/05/2026 at 12:30PM revealed the facility's residents were served, in part, baked chicken and a yellow cake-like dessert instead of the fried chicken and chocolate cherry bar listed on the above mentioned dietician approved menu. In an interview on 05/05/2026 at 12:36PM, S2Culinary Supervisor indicated he does not get the menu substitutions approved by the dietician prior to serving the substitutions to the residents. S2Culinary Supervisor further indicated he presented the menu substitutions to the dietician after they had already been served to the residents. S2Culinary Supervisor further confirmed there were some substitutions made to the menu for the week of 05/03/2026 through 05/05/2026 such as roast beef and mashed potatoes for turkey tetrazzini for dinner on 05/04/2026, and baked chicken for fried chicken and a lemon dessert instead of a chocolate cherry bar for lunch on 05/05/2026. S2Culinary Supervisor offered no further information that disputed the above mentioned deficient practice. In an interview on 05/05/2026 1:45PM, S2Culinary Supervisor confirmed the facility did not follow a menu that was approved by the dietician.

Based on observation, interviews and record reviews, the facility failed to ensure an ordered pain medication was available for 1 (Resident #7) of 1 sampled resident reviewed for medication availability. Findings:Review of Resident #7's May 2026 physician's orders revealed, in part, an order to administer Resident #7 oxycodone hydrochloride (HCI) (a type of medication used to treat pain) 5 milligrams (mg) by mouth (po) every 4 hours as needed for pain. In an interview on 05/04/2026 at 2:00PM, Resident #7 indicated she requested pain medication for pain this morning. Further, Resident #7 indicated the nurse (S3Licensed Practical Nurse) informed her the facility did not have oxycodone 5 mg po as per the doctor's order. Review of Resident #7's May 2026 electronic medication administration record (EMAR) revealed, in part, Resident #7 had not been administered oxycodone HCI 5 mg by mouth on 05/04/2026.Observation on 05/04/2026 at 2:01PM revealed there was no oxycodone HCI 5mg tablets available on the medication cart for Resident #7.In an interview on 05/04/2026 at 2:02PM, S3Licensed Practical Nurse indicated the facility did not have oxycodone HCI 5 mg tablets available for Resident #7.In an interview on 05/04/2026 at 2:55PM, S1Director of Nursing indicated the facility did not have oxycodone HCI 5 mg tablets on hand as pain medication for Resident #7 and should have.

Based on interviews and record reviews, the facility nursing staff failed to document assistance provided with bathing, oral care, and eating for 1 (Resident #1) of 3 residents reviewed for activities of daily living care provided. Findings:Review of Resident #1's Quarterly Minimum Data Set with an Assessment Reference Date of 12/09/2025 revealed, in part, Resident #1 had a diagnosis of Parkinson's disease (a progressive neurological disorder that affects movement) and required substantial/maximum assistance from staff with bathing, oral hygiene, and eating. Review of Resident #1's care plan revealed, in part, Resident #1 required assistance with Activities of Daily Living and staff were to assist Resident #1 with bathing, hygiene, and eating. Further review revealed Resident #1 had essential tremors (involuntary shaking in the hands) and staff were to monitor and document Resident #1's ability to perform Activities of Daily Living. Review of Resident #1's December 2025 Documentation Survey Report v2 revealed, in part, there was no documented evidence staff provided bathing assistance to Resident #1 on 12/15/2025, 12/22/2025, and 12/29/2025. Further review revealed there was no documented evidence staff provided oral care assistance to Resident #1 for the day shift on 12/06/2025, 12/25/2025, 12/26/2025, 12/28/2025, 12/31/2025; and the evening shift on 12/25/2025, 12/17/2025, 12/22/2025, 12/23/2025, 12/24/2025, and 12/29/2025. Further review revealed there was no documented evidence staff provided eating assistance to Resident #1 for the day or evening shift on 12/06/2025, 12/25/2025, 12/26/2025, 12/28/2025, and 12/31/2025; and the night shift on 12/15/2025, 12/17/2025, 12/22/2025, 12/23/2025, 12/24/2025, and 12/29/2025. Review of Resident #1's January 2026 Documentation Survey Report v2 revealed, in part, there was no documented evidence staff provided bathing assistance to Resident #1 on 01/12/2026. Further review revealed there was no documented evidence staff provided oral care assistance to Resident #1 for the day shift on 01/01/2026, 01/06/2026, 01/10/2026; and the evening shift on 01/08/2026, 01/10/2026, and 01/12/2026. Further review revealed there was no documented evidence staff provided eating assistance to Resident #1 for the day or evening shift on 01/01/2026, 01/06/2026, 01/10/2026; and the night shift on 01/08/2026, 01/10/2026, and 01/12/2026. In an interview on 02/25/2026 at 3:16PM, S1Assistant Director of Nursing verified the above mentioned Activity of Daily Living documentation for Resident #1 was not documented by staff as having been performed and should have.

Based on observations, interviews, and record reviews, the facility failed to ensure the kitchen's dishwasher and 3 compartment sink parameters were maintained to correctly sanitize dinnerware. Findings: Observation on 04/08/2025 at 8:10AM revealed after multiple attempts the dishwasher temperature gauge read 90 degrees Fahrenheit ( F). In an interview on 04/08/2025 at 8:11AM, S10Culinary Aide (CA) indicated the dishwasher's water wash temperature was 90 F. S10CA further indicated they were using a sanitizer for the dinnerware. In an interview on 04/08/2025 at 8:12AM, S9Dietary Manager (DM) indicated the dish machine's water temperature was not getting to 150 F as it should. S9DM further indicated the facility needed to install a hot water heater to raise the dishwasher water temperatures, and S9DM was not sure how many parts per million (PPM) the sanitizer needed to be in order to sanitize the dinnerware. S9DM further indicated according to the Dishwasher Temperature Log, the wash temperature should be 150 F and the rinse temperature should be 180 F. Review of the facility's Dishmachine Temperature Log (High Temperature) revealed from 04/01/2025 to 04/07/2025 staff were documenting a wash temperature of 150 F and a rinse temperature of 180 F for breakfast, lunch, and dinner with no documentation of the sanitizer PPM. In an interview on 04/08/2025 at 8:15AM, S9DM first indicated the 3 compartment sink's sanitizer final rinse should be 2 PPM. S9DM then opened the Pot Pan Sink documentation and stated according to the Pot Pan Sink form, the 3 compartment sink should have a reading of 180 to 200 PPM. Observation on 04/08/2025 at 8:16AM revealed the test strip of the 3 compartment sink's sanitizer final rinse was 0 PPM as indicated on the test strip. In an interview on 04/08/2025 at 2:00PM, S9DM indicated the dishwasher's water temp went up to about 146 F earlier but maintained this temperature only for a minute. S9DM indicated the facility had used the dishwasher to wash dishes for the residents. In an interview on 04/08/2025 at 2:10PM, S1Administrator confirmed the above findings and indicated staff were still using the dishwasher to wash the dinnerware.

Based on observation, interviews, and record review, the facility failed to ensure that a medication cart was secured while unattended for 1 (Medication Cart a) of 4 (Mediation Cart a, Medication Cart b, Medication Cart c, Medication Cart d) medication carts observed. Findings: Review of the facility's Medication Administration policy and procedure dated 10/04/2024 revealed, in part, medications must be secured at all times and not left unattended. Further review revealed, medication cart drawers should be locked when not in use. Observation on 04/06/2025 at 9:22AM revealed, Medication Cart a was left unlocked and unattended by S8Licensed Practical Nurse (LPN). In an interview on 04/06/2025 at 9:35AM, S8LPN indicated a medication cart should always be locked if unattended. In an interview on 04/08/2025 at 2:45PM, S2Director of Nursing (DON) confirmed all medication carts should have been locked while unattended. In an interview on 04/08/2025 at 2:50PM, S1Administrator confirmed medication carts should have been locked if left unattended.

Based on observations, interviews, and record reviews the facility failed to ensure oxygen personal care items were contained in plastic bags when not in use for 2 ( Resident #133, Resident #135) of 6 (Resident #40, Resident #50, Resident #133, Resident #134, Resident #155, Resident #185) sampled residents investigated for oxygen use. Findings: Resident #133 Review of the facility's BIPAP (Bilevel Positive Airway Pressure) and CPAP (Continuous Positive Airway Pressure) Machine Cleaning Policy and Procedure dated 11/04/2014 revealed, in part, store mouthpiece, and mask in plastic bag when not in use. Review of Resident #133's Physician's Orders dated April 2025 revealed, in part, Resident #133 was on Continuous Positive Airway Pressure (CPAP) nightly at bedtime. Observation on 04/06/2025 at 10:32AM revealed Resident #133's CPAP mask and tubing was on the nightstand and was not contained in a plastic bag. Observation on 04/06/2025 at 3:42PM revealed Resident #133's CPAP mask and tubing was on the nightstand and not contained in a plastic bag. In an interview on 04/06/2025 at 3:46PM, S11Licensed Practical Nurse (LPN) indicated Resident #133's CPAP should have been contained in a plastic bag with Resident #133's name and room number written on the bag. Observation on 04/07/2025 at 11:42AM revealed Resident # 133's CPAP mask and tubing was on the nightstand and not contained in a plastic bag. In an interview on 04/07/2025 at 11:46AM, S12LPN indicated Resident #133's CPAP was not in a plastic bag. Resident #135 Review of the facility's Oxygen Concentrator Cleaning Policy and Procedure dated 11/16/2014 revealed, in part, oxygen masks must be stored mask in plastic bag when not in use. Review of Resident #135's Physician's Orders dated April 2025 revealed, in part, Levalbuterol HCCL Nebulization solution (a medication used to relax the muscles of the airway) 0.63miligrams/milliliter inhale orally two times a day for wheezing, Observation on 04/06/2025 at 3:35PM revealed Resident #135's breathing treatment mask was on the nightstand and not contained in a plastic bag. In an interview on 04/06/2025 at 3:45PM, S11Licensed Practical Nurse indicated Resident #135's breathing treatment mask was not in a plastic bag, but should have been contained in a plastic bag with the resident's name and room number written on it. In an interview 04/07/2025 at 2:45PM, S2Director of Nursing indicated respiratory equipment for Resident #133 and Resident #135 should have been contained in a plastic bag.

Based on interviews and record reviews, the facility failed to ensure a resident's physical chart did not contain conflicting advance directive documents for 1 (Resident #11) of 3 (Resident #11, Resident #71, Resident #134) sampled residents investigated for advanced directives. Findings: Review of the facility's Advance Directive policy and procedure dated [DATE] revealed, in part, previously revised advanced directives should be removed from a resident's chart and placed in the resident's file in medical records. Further review revealed only the active advanced directive should remain on the chart. Review of Resident #11's physical chart revealed, in part, a Louisiana Physician Orders for Scope of Treatment (LaPOST) form dated [DATE], which indicated Resident #11 was a full code status (a healthcare provider should perform cardiopulmonary resuscitation [CPR] [an emergency procedure that combines chest compressions and rescue breathing to keep blood circulating] if a resident's heart stopped beating or a resident stopped breathing). Further review revealed an Advance Directive Consent form dated [DATE], which indicated Resident #11's code status was Do Not Resuscitate (DNR) (a healthcare provider should not perform CPR if a resident's heart stopped beating or a resident stopped breathing). Review of Resident #11's Electronic Medical Record (EMR) revealed, in part, Resident #11 was a DNR. Review of Resident #11's [DATE] physician's orders revealed, in part, an order dated [DATE] which indicated Resident #11's code status was DNR. Review of Resident #11's care plan, created on [DATE]with a review date of [DATE] revealed, in part, Resident #11's code status was DNR with an approach that included Resident #11's current advanced directive would be located in her medical record. In an interview on [DATE] at 10:39AM, S16Ward Clerk/Certified Nursing Assistant (CNA) indicated Resident #11's physical chart should only contain the most recent advanced directive and code status information. S16Ward Clerk/CNA further indicated outdated and conflicting advanced directive documents could be confusing and should be removed. In an interview on [DATE] at 9:49AM, S17Licensed Practical Nurse (LPN) indicated Resident #11 was a DNR. S17LPN further indicated if Resident #11 would go into cardiac arrest she would not provide CPR or initiate resuscitation efforts. In an interview on [DATE] at 2:32PM, S2Director of Nursing (DON) indicated Resident #11 should not have more than one advanced directive in her chart. S2DON further indicated the LaPOST dated [DATE], that indicated Resident #11 was a full code should have been removed from Resident #11's chart when the advance directive dated [DATE] was signed and placed in Resident #11's chart. In an interview on [DATE] at 3:00PM, S1Administrator confirmed Resident #11 should not have had contradicting advanced directives in her physical chart.

Based on observations and interviews, the facility failed to ensure the shower room floors were maintained in a clean manner for 2 (Shower room e, Shower room f) of 3 (Shower room d, Shower room e, Shower room f) shower rooms observed for cleanliness. Findings: In an interview on 04/06/2025 at 9:54AM, Resident #44 indicated the shower room was dirty. Observation of Shower room f on 04/06/2025 at 10:06AM revealed the floors had a buildup of an unknown black substance between the floor tiles throughout the floor of Shower room f. Observation of Shower room e on 04/06/2025 at 10:08AM revealed the floors had a buildup of an unknown black substance between the floor tiles throughout the floor of Shower room e. In an interview on 04/06/2025 at 10:12AM, S13Certified Nursing Assistant indicated the floors in Shower rooms e and f were dirty and needed to be cleaned. In an interview on 04/07/2025 at 10:27AM, S14Housekeeping Supervisor confirmed Shower room e and Shower room f had a buildup of an unknown black substance between the floor tiles throughout the floors and needed to be cleaned. In an interview on 04/07/2025 at 10:36AM, S1Administrator confirmed the floors in Shower room e and Shower room f needed to be cleaned. In an interview on 04/07/2025 at 11:36AM, S15Floor Tech/Porter indicated it has been over a month since he cleaned the floors in Shower room e and Shower room f.

Based on observations, interviews, and record reviews, the facility failed to ensure staff answered call bells to assist residents in a timely manner for 3 (Resident #7, Resident #48, Resident #333) of 24 (Resident #1, Resident #3, Resident #4, Resident #6, Resident #7, Resident #8, Resident #9, Resident #14, Resident #20, Resident #21, Resident #33, Resident #35, Resident #37, Resident #41, Resident #43, Resident #46, Resident #47, Resident #48, Resident #51, Resident #52, Resident #56, Resident #65, Resident #76, Resident #333) initial pool residents reviewed for call bell use. Findings: Resident #333 Review of Resident #333's discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/28/2025 revealed, in part, Resident #333's cognition was moderately impaired and Resident #333 was incontinent of bowel and bladder. In an interview on 04/06/2025 at 9:40AM, Resident #333 indicated on 04/05/2025 she had to wait approximately 6 hours, from 6:00AM to 12:00 PM, to receive incontinence care from staff. Resident #333 further indicated the wait time for staff assistance was approximately 30 to 60 minutes after pressing the call light. Resident #48 In an interview on 04/06/2025 at 9:41AM, Resident #48, who resided in Room j indicated when she pressed the call light button for staff assistance, Resident #48's wait time was usually 45 to 60 minutes. Resident #7 Observation on 04/06/2025 at 9:47AM revealed the call light, in the hallway, above the doorway for Room i started blinking and ringing. Further observation at approximately 9:52AM revealed an announcement from the speaker in the hallway that indicated Resident #7, in Room i, needed assistance from staff. Observation also revealed at 9:58AM, a 2nd announcement from the speaker in the hallway which indicated staff was needed in Room i, and at the same time, a staff member passed the blinking and ringing call light above the doorway of Room i, and entered Room h, which was next to Room i. Further observation revealed at 10:10AM, a staff member passed by the blinking and ringing call light in the hallway above the doorway of Room i, and entered Room j, which was also next to Room i. Observation further revealed at 10:18AM, staff went into Room i to assist Resident #7. In an interview on 04/06/2025 at 9:46AM, Resident #7 indicated when she pressed the call light button for assistance from staff, Resident #7 usually had to wait at least 45 minutes. In an interview on 04/08/2025 at 3:01PM, S2Director of Nursing confirmed that waiting approximately 30 minutes for staff assistance, after the call light button was pressed, was too long for the resident to wait for assistance.

Based on observations, interviews, and record reviews, the facility failed to ensure a resident's individualized fall prevention interventions were implemented to prevent future falls for 1 (Resident #3) of 3 (Resident #1, Resident #2, Resident #3) sampled residents reviewed for accidents. Findings: Review of the facility's Fall Protocol policy and procedure dated 10/14/2014 revealed, in part, the purpose of the fall protocol was to initiate preventative fall approaches and provide appropriate interventions to prevent falls. Review of Resident #3's medical record revealed, in part, Resident #3 was admitted to the facility on [DATE] with diagnose, which included, cognitive communication deficit, abnormalities of gait and mobility, and generalized muscle weakness. Review of Resident #3's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/03/2025 revealed, in part, Resident #3 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated Resident #3 had moderate cognitive impairment. Further review revealed Resident #3 used a manual wheelchair for mobility Review of the facility's Incident Log dated 06/2024 through 01/2025 revealed, in part, Resident #3 had sustained the following falls: - 01/27/2025- unwitnessed fall; - 01/15/2025- unwitnessed fall; - 12/30/2024- unwitnessed fall; - 11/11/2024- unwitnessed fall; - 10/29/2024- unwitnessed fall; - 10/03/2024- unwitnessed fall; - 10/01/2024- unwitnessed fall; - 09/22/2024- unwitnessed fall; - 09/17/2024- unwitnessed fall; - 09/03/2024- unwitnessed fall; - 08/21/2024- unwitnessed fall; - 08/20/2024- unwitnessed fall; - 08/06/2024- unwitnessed fall; - 07/31/2024- unwitnessed fall; - 07/24/2024- witnessed fall; and, - 06/19/2024- unwitnessed fall with a skin tear injury. Review of Resident #3's fall risk evaluation dated 12/31/2024 revealed, in part, Resident #3 should be considered a high risk for falls. Review of Resident #3's care plan with a start date of 07/21/2024 and a review date of 04/17/2025 revealed, in part, Resident #3 was at risk for falls related to unsteadiness. Further review revealed the following interventions: - The facility will place a call don't fall visual reminder sign in Resident #3's view; - Resident #3 will have a bed alarm; and, - Fluorescent tape will be placed on Resident #3's wheelchair brake handles. Observation of Resident #3's room on 02/04/2025 at 9:15AM revealed there was no visual call for assistance reminder sign in Resident #3's room. Observation of Resident #3's wheelchair on 02/04/2025 at 9:30AM revealed there was no florescent tape on the wheelchair brake handles. Further observation revealed there was no bed alarm in place on Resident #3's bed. In an interview on 02/04/2025 at 10:00AM, S9Licensed Practical Nurse (LPN) indicated there was no visual call for assistance reminder sign in Resident #3's room and should have been. In an interview on 02/04/2025 at 10:20AM, S2Director of Nursing (DON) confirmed there was no visual call for assistance reminder sign in Resident #3's room and should have been. S2DON further indicated Resident #3's bed alarm sensing pad was not in his room and available for use. Observation on 02/05/2025 at 9:55AM revealed Resident #3 was lying in bed without a bed alarm in place. In an interview on 02/05/2025 at 10:00AM, S2DON confirmed there was no florescent tape on Resident #3's wheelchair brakes and should have been. S2DON further confirmed Resident #3 did not have a working bed alarm on 02/04/2025 and 02/05/2025 and should have. In an interview on 02/05/2025 at 12:30PM, S1Administrator confirmed Resident #3's individualized care plan interventions to prevent falls should have been implemented in accordance with Resident #3's plan of care.

Based on observations, interviews, and record reviews, the facility failed to follow a physician's order to ensure a pressure relieving cushion was in place on a resident's wheelchair for 1 (Resident #3) of 3 (Resident #1, Resident #2, Resident #3) sampled residents reviewed for quality of care. Findings: Review of Resident #3's February 2025 physician's orders revealed, in part, an order dated 07/01/2024 for a pressure relieving cushion to be used on Resident #3's wheelchair. Review of Resident #3's care plan with a start date of 07/21/2024 and a review date of 04/17/2025 revealed, in part, Resident #3 was at high risk for skin breakdown. Further review revealed an intervention for the facility to place a pressure reducing device/product on Resident #3's wheelchair. Review of Resident #3's Braden Scale assessment dated [DATE] revealed, in part, Resident #3 had a total score of 18.0, which indicated Resident #3 was at a risk of skin breakdown and/or developing a pressure ulcer. Observation on 02/03/2025 at 11:30AM, revealed Resident #3 was sitting in his wheelchair without a pressure relieving cushion as ordered. Observation on 02/04/2025 at 9:30AM, revealed Resident #3 was sitting in his wheelchair without a pressure relieving cushion as ordered. In an interview on 02/04/2025 at 9:45AM, Resident #3 indicated he did not have a pressure relieving cushion to sit on while using his wheelchair. In an interview on 02/05/2025 at 10:10AM, S9Licensed Practical Nurse (LPN) indicated Resident #3 was at risk for skin breakdown. S9LPN further indicated she did not know the location of Resident #3's pressure relieving cushion. In an interview on 02/05/2025 at 10:00AM, S2Director of Nursing (DON) confirmed Resident #3 did not have a pressure relieving cushion on his wheelchair as ordered and should have. In an interview on 02/05/2025 at 12:30PM, S1Administrator confirmed all of Resident #3's pressure ulcer prevention measures should have been implemented as ordered.

Based on interviews and record reviews, the facility failed to deliver care per professional standards by failing to ensure a physician's orders for daily weights was followed for 1 (Resident #3) of 3 (Resident #1, Resident #2, Resident #3) sampled residents investigated for nursing services. Findings: Review of the May 2023 Louisiana Administrative Code, Title 46, Part XLVII revealed, in part: the registered nurse retained the accountability for the total nursing care of the individual, and was responsible for and accountable to each consumer of nursing care for the quality of nursing care he or she received, regardless of whether the care was provided solely by the registered nurse or by the registered nurse in conjunction with other licensed or unlicensed assistive personnel. Further review revealed, in part, the plan for nursing care was implemented according to the following criteria: nursing actions were consistent with the plan for nursing care and nursing actions were documented by written records. Review of Resident #3's February 2025 physician's orders revealed, in part, an order dated 11/07/2024 for daily weights to be obtained for Resident #3. Review of the facility's Restorative Aide Log Book revealed, in part, no documented evidence, and the facility did not provide any documented evidence, Resident #3 was weighed daily as ordered. Review of Resident #3's weight summary report revealed, in part, the following weight entries: - 01/09/2025: 166.0 pounds (lbs); - 12/10/2024: 175.0 lbs; and, - 11/10/2024: 183.0 lbs. There was no documented evidence, and the facility did not present any documented evidence Resident #3's weight was obtained on any other day since 11/07/2024. In an interview on 02/03/2025 at 2:45PM, S14CNA/Restorative Aide (RA) indicated there were no residents who currently received daily weight checks. In an interview on 02/04/2025 at 10:30AM, S13CNA/RA indicated there were no residents who currently received daily weight checks. In an interview on 02/05/2025 at 9:12AM, S3Assistant Director of Nursing (ADON) confirmed Resident #3 had an active physician orders for daily weights. S3ADON further confirmed the facility could not provide any documented evidence daily weights were completed as ordered. In an interview on 02/05/2025 at 10:00AM, S2Director of Nursing (DON) confirmed the facility could not provide any documented evidence Resident #3's daily weights were performed as ordered and should have been. In an interview on 02/05/2025 at 12:30PM, S1Administrator confirmed Resident #3's daily weights should have been performed as ordered.

Based on interviews and record reviews, the facility failed to ensure the required number of Certified Nursing Assistants (CNAs) were present and working in the facility for 2 (01/13/2025 and 01/14/2025) of 3 (01/12/2025, 01/13/2025, and 01/14/2025) days reviewed for sufficient staffing. Findings: Review of the Facility's Assessment, last updated on 01/01/2025 revealed, in part, the number or range of CNAs needed to provide competent support and care to the facility's residents, every day and during emergencies, was 6 to 9 CNAs during the day shift 6:00AM to 2:00PM) on weekdays. Review of the facility's CNA schedule for 01/13/2025 revealed, in part, eight CNAs were scheduled to work the 6:00AM to 2:00PM shift. Review of the facility's CNA's time sheets dated 01/12/2025 to 01/13/2025, revealed in part, on 01/13/2025, between 6:00AM to 6:02AM, S16CNA and S17CNA were clocked in for a total of two CNAs working in the facility. Further review revealed on 01/13/2025 between 6:02AM to 6:06AM, S16CNA, S17CNA, and S18CNA were clocked in for a total of three CNAs working in the facility. Further review revealed on 01/13/2025 between 6:06AM and 6:17AM, S16CNA, S18CNA, S17CNA, and S23CNA were clocked in for a total of four CNAs working in the facility. Further review revealed on 01/13/2025 between 6:17AM to 6:20AM, S16CNA, S18CNA, S17CNA, S23CNA and S24CNA clocked in for a total of five CNAs working in the facility. Further review revealed on 01/13/2025 from 6:20AM to 6:22AM, S16CNA, S18CNA, S23CNA, and S24CNA clocked in for a total of four CNAs working in the facility. Further review revealed on 01/13/2025 between 6:22AM to 7:07AM, S16CNA, S18CNA, S23CNA, S24CNA, and S25CNA were clocked in for a total of five CNAs working in the facility. Review of the facility's CNA schedule for 01/14/2025 revealed, in part, eight CNAs were scheduled to work the 6:00AM to 2:00PM shift. Review of the facility's CNA's time sheets from 01/13/2025 to 01/14/2025, revealed in part, on 01/14/2025, between 6:01AM to 6:03AM, S16CNA, S19CNA, S20CNA, S21CNA and S22CNA were clocked in for a total of five CNAs working in the facility. Further review revealed on 01/14/2025 between 6:03AM to 6:06AM, S16CNA, S20CNA, S21CNA, and S22CNA were clocked in for a total of four CNAs working in the facility. Further review revealed on 01/14/2025 between 6:06AM to 6:15AM, S16CNA, S20CNA, S21CNA, S22CNA, and S23CNA were clocked in for a total of five CNAs working in the facility. There was no documented evidence, and the facility did not present any documented evidence, any other staff was working as a CNA during the above mentioned timeframes. In an interview on 02/05/2025 at 10:15AM, S14CNA/Restorative Aid indicated there were usually 4 CNAs and 2 CNA/Restorative aides scheduled on the custodial unit of the facility and 2 CNAs scheduled on the skilled nursing unit of the facility during the day shift on weekdays, Monday through Friday. S14CNA/Restorative Aid further indicated three CNAs would not have been an adequate amount of staff to provide care to the residents. In an interview on 02/05/2025 at 10:30AM, S6CNA Supervisor indicated she was in charge of making the facility's CNA schedule. S6CNA Supervisor further indicated she scheduled 4 to 5 CNAs on the custodial unit of the facility and 1 to 2 CNA/Restorative Aides on the custodial unit of the facility depending on the resident's needs during the day shift on weekdays, Monday through Friday. S6CNA Supervisor further indicated the facility should have at least seven CNAs and/or CNA/Restorative Aides working in the facility during the day shift on weekdays (6:00AM to 2:00PM.) In an interview on 02/05/2025 at 10:32AM, S2Director of Nursing indicated there should be at least 4 CNAs scheduled for the custodial unit of the facility and 2 CNAs scheduled on the skilled nursing unit during the day shift on weekdays, Monday through Friday. S2DON further indicated the facility should have the required number of CNAs working in the facility as per the Facility Assessment. In an interview on 02/05/2025 at 12:38AM, S1Administrator acknowledged the facility should have the required number of CNAs working in the facility as per the Facility Assessment.

Based on interviews and record reviews, the facility failed to maintain a system to reconcile controlled drugs for 3 (Medication Cart a, Medication Cart b, Medication Cart d) of 4 (Medication Cart a, Medication Cart b, Medication Cart c, Medication Cart d) medication carts reviewed for the reconciliation documentation of controlled substances. Findings: Medication Cart a Review of S15Licensed Practical Nurse (LPN)'s 01/14/2025 time sheet revealed, in part, S15LPN clocked out from her shift (11:00PM to 7:00AM) at 7:03AM on 01/14/2025. Review of S10LPN's 01/14/2025 time sheet revealed, in part, S10LPN clocked in for her shift (7:00AM to 3:00PM) at 7:33AM on 01/14/2025. Review of the facility's January 2025 Medication Cart a's Controlled Drugs-Count Record revealed, in part, on 01/14/2025 S15LPN documented with her initials that she was the nurse scheduled for the 11:00PM to 7:00AM shift and had reconciled the controlled substances on Medication Cart a with S10LPN. Further review revealed on 01/14/2025 S10LPN documented with her initials that she was the nurse scheduled for the 7:00AM to 3:00PM shift and had reconciled the controlled substances of Medication Cart a with S15LPN. Medication Cart b Review of S12LPN's 01/13/2025 time sheet revealed, in part, S15LPN clocked out from her shift (11:00PM to 7:00AM) at 6:59AM on 01/13/2025. Review of S9LPN's 01/13/2025 time sheet revealed, in part, S9LPN clocked in for her shift (7:00AM to 3:00PM) at 7:21AM on 01/13/2025. Review of the facility's January 2025 Medication Cart b's Controlled Drugs-Count Record revealed, in part, on 01/13/2025 S12LPN documented with her initials that she was the nurse scheduled for the 11:00PM to 7:00AM shift and had reconciled the controlled substances on Medication Cart b with S9LPN. Further review revealed on 01/13/2025 S9LPN documented with her initials that she was the nurse scheduled for the 7:00AM to 3:00PM shift and had reconciled the controlled substances of Medication Cart b with S12LPN. Medication Cart d Review of S7LPN's 01/13/2025 time sheet revealed, in part, S7LPN clocked out from her shift (7:00AM to 3:00PM) at 2:57PM on 01/13/2025. Review of S8LPN's 01/13/2025 time sheet revealed, in part S8LPN clocked in for her shift (3:00PM to 11:00PM) at 4:22PM on 01/13/2025. Review of the facility's January 2025 Medication Cart d's Controlled Drugs-Count Record revealed, in part, on 01/13/2025 S7LPN documented with her initials that she was the nurse scheduled for the 7:00AM to 3:00PM shift and had reconciled the controlled substances on Medication Cart d with S8LPN. Further review revealed on 01/13/2025 S8LPN documented with her initials that she was the nurse scheduled for the 3:00PM to 11:00PM shift and had reconciled the controlled substances of Medication Cart d with S7LPN. In an interview on 02/05/2025 at 11:12AM, S7LPN indicated she often counts controlled medications for Medication Cart d at shift change with S4Clinical Care Coordinator when S8LPN did not arrived to the facility at shift change. S7LPN acknowledged if she and S4Cliniclal Care Coordinator were counting controlled medications together, S4Clinical Care Coordinator should be initialing the Controlled Drugs-Count Record. In an interview on 02/05/2025 at 11:52AM, S4Clinical Care Coordinator indicated she reconciled controlled medications with S7LPN on 01/13/2025. S4Clinical Care Coordinator further indicated she normally did not sign the Controlled Drugs-Count Record sheet because she was not the oncoming scheduled nurse. In an interview on 02/05/2025 12:01PM, S5Minimum Data Set (MDS) LPN indicated he reconciled the controlled medications when he took over Medication Cart a on 01/14/2025 from S15LPN and Medication Cart b on 01/13/2025 from S12LPN when their relief had not arrived at shift change. S5MDS LPN further indicated he did not initial the Controlled Drugs-Count Record when he counted controlled medications with another nurse and should have. In an interview on 02/05/2025 at 11:27AM, S2Director of Nursing (DON) acknowledged if nurses were reconciling controlled medications with each other, they should be initialing to verify that they had reconciled the controlled medications on the Controlled Drugs-Count Record sheet. In an interview on 02/05/2025 at 12:38PM, S1Administrator acknowledged the nurses should have been initialing the Controlled Drugs-Count Record sheet when they reconciled controlled substances together.

Based on observation, interviews, and record review, the facility failed to ensure a Resident's electronic Medication Administration Record (eMAR) was accurately documented for 1 (Resident #3) of 3 (Resident #1, Resident #2, Resident #3) sampled residents reviewed for accurate medical record documentation. Findings: Review of the facility's Licensed Practical Nurse (LPN) job description dated 10/2024 revealed, in part, it was the responsibility of the LPN to have knowledge of federal and state laws and regulations related to resident care and to carry out the assigned duties and responsibilities in accordance with current existing federal and state regulations. Review of Resident #3's February 2025 physician's orders revealed, in part, an order dated 07/01/2024 for a pressure relieving cushion to be used on Resident #3's wheelchair. Review of Resident #3's February 2025 electronic Medication Administrator Record (eMAR) revealed, in part, S9Licensed Practical Nurse documented Resident #3 had a pressure relieving cushion on his wheelchair on 02/05/2025. Observation on 02/05/2025 at 9:50AM revealed Resident #3 lying in his bed. Further observation revealed no pressure relieving cushion on Resident #3's wheelchair or in Resident #3's room. In an interview on 02/05/2025 at 10:10AM, S9LPN indicated she did not visualize Resident #3's pressure reliving cushion this shift. S9LPN further indicated she did not know where Resident #3's wheelchair pressure relieving cushion was or the last time she saw it. Review of Resident #3's Medication Administration Audit Report revealed, in part, S9LPN documented in Resident #3's eMAR on 02/05/2025 at 10:06AM she had verified Resident #3's pressure relieving cushion was in place on his wheelchair as ordered. In an interview on 02/05/2025 at 11:20AM, S2Director of Nursing (DON) acknowledged S9LPN should not have documented Resident #3's wheelchair had a pressure relieving cushion when Resident #3's wheelchair did not have one. S2DON confirmed the above mentioned eMAR for Resident #3 was inaccurate and should not have been. In an interview on 02/05/2025 at 12:30PM, S1Administrator confirmed Resident #3's medical record documentation was not accurate and should have been.

The facility failed to ensure the discharge process was followed by failing to: 1. Ensure a resident's discharge location was accurate (Resident #1); 2. Ensure a resident and/or resident's responsible party (RP) was provided information in order to select a home health agency (Resident #1); and, 3. Ensure the resident and/or RP received the discharge summary and instructions prior to discharge (Resident #1). This deficient practice was identified for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) sampled residents investigated for discharge planning. Findings: Review of Discharge-Transfer of a Resident Policy and Procedure effective 08/21/2017 revealed, in part, the purpose of the policy and procedure was to ensure a safe departure from the facility and provide sufficient information for after care of the resident. Further review revealed when a resident was discharged , the facility must complete the Discharge Summary/Instructions assessment and review the assessment with the resident and/or RP prior to discharge. Review revealed the resident and/or RP must sign a copy of the assessment form to indicate they have received and understood the instructions, and a copy of the assessment form should be given to the resident and/or RP. The signed copy of the assessment form should be placed in the resident's record. Review of Resident #1's Admission Minimum Data Set with an Assessment Reference Date of 03/31/2024 revealed, in part, Resident #1 was admitted to the facility from the hospital on 03/06/2024 with a goal to be discharged back into the community. Review of Resident #1's care plan with a start date of 03/25/2024 revealed, in part, Resident #1 was care planned to return to her home with interventions for staff to assist Resident #1 with obtaining community resources for discharge, accommodate for Resident #1's discharge goals of care and treatment, and arrange and/or notify Resident #1 of the home health agency of Resident #1's choosing. Review of Resident #1's Face Sheet revealed Resident #1's address and Resident #1's Responsible Party's address were the same location. Review of Resident #1's note written by S4Social Services Director (SSD) on 03/08/2024 at 8:32 a.m. revealed, in part, prior to admission, Resident #1 resided in a senior living community. Further review revealed Resident #1 planned to be discharged to the community after she completed therapy. Review of the facility's Detail Admission/Discharge Report from 04/03/2024 through 06/03/2024 revealed, in part, Resident #1 was discharged home from the facility on 05/02/2024 with home health care. Review of Resident #1's Discharge Summary/Instructions revealed, in part, on 05/02/2024, Resident #1 was discharged home with home health services. Further review revealed Resident #1's RP's address was listed as Resident #1's discharge address. Review of the discharge instructions revealed no signature present to confirm the above mentioned information was provided. There was no documented evidence, and the facility was unable to provide any documented evidence Resident #1 and/or Resident #1's RP was provided discharge instructions or signed the Discharge Summary/Instructions assessment form to acknowledge receipt of the discharge instructions. There was no documented evidence, and the facility was unable to provide any documented evidence Resident #1 and/or Resident #1's RP was provided a list of compiled home health agencies to pick from. In an interview on 05/31/2024 at 3:20 p.m., Resident #1's granddaughter indicated there were issues with Resident #1's discharge because the facility had set up Resident #1 to be discharged to Resident #1's RP's address instead of Resident #1's home address. Resident #1's granddaughter further indicated at discharge, Resident #1 nor Resident #1's RP were provided information regarding the location Resident #1 was being discharged to. Resident #1's granddaughter also indicated Resident #1 and Resident #1's RP were not provided a list of home health agencies to choose from. In an interview on 06/04/2024 at 12:39 p.m., S2Licensed Practical Nurse (LPN) confirmed when she discharged a resident, a copy of the discharge instructions were provided to the resident and/or the resident's family. S2LPN further indicated she would obtain the resident and/or the resident's family's signature on the discharge instructions and then would place the copy in the resident's chart. S2LPN further indicated she would have the resident and/or resident's family sign the instructions to acknowledge the discharge instructions were provided to them prior to the discharge. In an interview on 06/05/2024 at 11:33 a.m., S3LPN confirmed she was the nurse who discharged Resident #1. S3LPN further confirmed she did not get the discharge summary form signed by Resident #1 or Resident #1's RP. S3LPN indicated she did not go over Resident #1's discharge arrangements with Resident #1 or Resident #1's RP at the time of the discharge. In an interview on 06/05/2024 at 11:45 a.m., S2Director of Nursing (DON) indicated she was aware Resident #1 planned to return to her own address when discharged . S2DON confirmed Resident #1's Discharge Summary/Instructions revealed Resident #1 was discharged to Resident #1's RP's address, which was incorrect. S2DON stated Resident #1's Discharge Summary/Instructions form should have been reviewed and signed by Resident #1 and/or Resident #1's RP to ensure Resident #1 and/or Resident #1's RP were aware of all discharge arrangements prior to discharge. S2DON indicated reviewing the discharge arrangements prior to discharge could have caught the error of Resident #1's discharge location. S2DON confirmed S4SSD should have confirmed Resident #1's discharge address of the prior to initiating and setting up discharge. In an interview on 06/05/2024 at 12:56 p.m., S4SSD indicated when in Resident #1's care plan meeting, Resident #1's family said Resident #1 would return home on discharge, and S4SSD assumed the address on Resident #1's face sheet was Resident #1's home address. S4SSD stated she could not recall if she ever specifically verified that Resident #1 was going back to the address on Resident #1's face sheet. S4SSD confirmed Resident #1's discharge address was incorrect, and S4SSD should have verified the discharge location during the discharge process. S4SSD confirmed she had not provided Resident #1 and/or Resident #1's RP a list of available home health agencies to choose an agency from.

Based on observations, interviews, and record review the facility failed to ensure an enteral feeding bag (which contains an enteral formula for purpose of supplying nutrients directly into the stomach) was properly labeled to include the date and time of initiation and the rate of infusion. This practice was identified for 1(Resident#1) of 1 (Resident #1) sampled for enteral feeding. Findings: Review of Texas Health and Human Services Evidence-Based Best Practice for Nutritional Support revealed, in part, enteral feeding should include a label with resident's name, date and time of initiation, and the infusion rate. Observation on 04/07/2024 at 10:43 a.m. revealed Resident #31's enteral feeding bag was not labeled with date or time of initiation or the infusion rate of the feeding. Observation on 04/08/2024 at 10:15 a.m. revealed Resident #31's enteral feeding bag was not labeled with the time of initiation or the infusion rate of the feeding. Observation on 04/09/2024 at 9:22 a.m. revealed Resident #31's enteral feeding bag was not labeled with the infusion rate of the feeding. Observation on 04/11/2024 at 9:58 a.m. revealed Resident #31's enteral feeding bag was not labeled with the time of initiation. In an interview on 04/11/2024 at 2:03 p.m., S2Director of Nursing indicated it is professional standard of practice for enteral feeding bag to be labeled to include the date and time of initiation and infusion rate. In an interview on 04/11/2024 at 2:04 p.m., S1Administrator indicated it is professional standards of practice for enteral feeding bag to be labeled to include the date and time of initiation and infusion rate.

Based on observations and interviews, the facility failed to ensure an indwelling urinary catheter (a tubing that goes into the bladder to drain urine) drainage bag and catheter tubing did not touch the floor to prevent infections for 3 (Resident #7, Resident #71, Resident #341) of 3 (Resident #7, Resident #71, Resident #341) sampled residents reviewed for catheter use. Findings: Review of Healthcare Infection Control Practices Advisory Committee, Guidelines for Prevention of Catheter Associated Urinary Tract Infections 2009, revised on June 09, 2019 revealed, in part, not to rest the urinary catheter bag on the floor. Resident #7 Observation on 04/07/24 at 10:21 a.m. revealed Resident #7's indwelling urinary catheter drainage bag was hanging from the bedrail and lying on the floor. Observation on 04/08/2024 at 10:04 a.m. revealed Resident #7's indwelling urinary catheter drainage bag was hanging from bedrail and lying on the floor. Observation on 04/08/2024 at 11:55 a.m. revealed Resident #7 indwelling urinary catheter draining bag was hanging from bed rail and lying on the floor. Observation on 04/08/2024 at 2:25 p.m. revealed Resident #7's indwelling urinary catheter drainage bag was hanging from the bedrail and lying on the floor. Observation on 04/09/2024 at 9:34 a.m. revealed Resident #7's indwelling urinary catheter drainage bag was hanging from bedrail and lying on the floor. Resident #71 Observation on 04/08/2024 at 12:24 p.m. revealed Resident #71's indwelling urinary catheter drainage bag was hanging from the bottom of the wheelchair and the catheter tubing was handing down and touching the floor. Resident #341 Observation on 04/07/2024 at 1:43 p.m. revealed Resident #341's indwelling urinary catheter drainage bag and catheter tubing was lying flat on the floor next to the bed. Observation on 04/08/2024 at 9:54 a.m. revealed Resident #341's indwelling urinary catheter drainage bag was hanging from the bottom of the wheelchair. Further observation revealed the bottom of catheter drainage bag was touching the floor and the catheter tubing was handing down and touching the floor. Observation on 04/09/2024 at 9:14 a.m. revealed Resident #341's indwelling urinary catheter drainage bag and tubing was lying flat on the floor next to the bed. In an interview on 04/09/2024 at 12:25 p.m., S2Director of Nursing indicated a resident's indwelling urinary catheter drainage bag and catheter tubing should not be laying on the floor due to increased risk for infection. In an interview on 04/11/2024 at 2:03 p.m., S1Administrator indicated professional standards of practice was to keep indwelling urinary catheter drainage bags and catheter tubing off the floor. 49259

Based on observation and interview the facility failed to ensure a resident's bathroom door would close. This was identified for 1 (Resident #144) of 2 Resident (#141 and Resident #144) sampled residents for environment. Findings: In an interview on 04/07/2024 at 10:53 a.m., Resident #144 indicated his bathroom door could not close all the way. Observation on 04/08/2024 at 8:49 a.m. revealed Resident #144's bathroom door was unable to be closed all the way. Observation on 04/08/2024 at 2:05 p.m. revealed Resident #144 bathroom door was unable to be closed all the way. Observation on 04/09/2024 at 10:14 a.m. revealed S4Certified Nursing Assistant (CNA) tried to close Resident #144's bathroom door and was unable to close it all the way. In an interview on 04/09/2024 at 10:15 a.m., S4CNA indicated she could not close Resident #144's bathroom door all the way. In an interview on 04/09/2024 at 10:40 a.m., S5Housekeeping Supervisor indicated the bathroom door cannot close all the way and it should. In an interview on 04/09/2024 at 11:20 a.m., S2Director of Nursing indicated Resident #144's bathroom door did not close and it should.