Every finding on record at Gueydan Memorial Guest Home

Based on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 3 (#2, #13, and #42) residents out of 29 sampled residents. Findings: Resident #2 Review of Resident #2's Electronic Health Record (EHR) revealed the resident was admitted to the facility on [DATE] with a diagnoses which included, but were not limited to, type 2 diabetes mellitus with diabetic neuropathy. Review of Resident #2's Quarterly Minimum Data Set (MDS) with an assessment reference date of 07/01/2025 revealed Section N0415 (J) Hypoglycemic was coded no which indicated the resident did not receive a hypoglycemic in the 7 day look back period. Review of Resident #2's Medication Administration Record (MAR) revealed that Lantus and Novolog were administered 06/25/2025 through 07/01/2025. On 08/26/2025 at 4:02 p.m., an interview and review of Resident #2's MDS with an assessment date of 07/01/2025 was conducted with S4MDS. S4MDS confirmed that yes should have been coded for section N0415 (J) Hypoglycemic and was not. Resident #13 Review of Resident #13's Electronic Health Record revealed the resident was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, dementia in other diseases classified elsewhere with behavioral disturbance and repeated falls. Review of Resident #13's Quarterly MDS with an assessment reference date of 07/25/2025 revealed Sections P0200 (A) Bed alarm and P0200 (B) Chair alarm were coded as not used which indicated the resident did not utilize a bed or chair alarm during the 7 day look back period. Review of Resident #13's physician's order revealed an order dated 01/24/2024 for clip alarm to resident at all times due to poor safety awareness, q (every) 1 hour checks. Review of Resident #13's July 2025 MAR revealed that that her clip alarm was in place at all times for the entire month. On 08/26/2025 at 4:15 p.m., an interview and review of Resident #13's MDS dated [DATE] was conducted with S4MDS. S4MDS confirmed that the resident used a chair alarm and a bed alarm for the month of July 2025. She confirmed Sections P0200 (A) Bed alarm and P0200 (B) Chair alarm should have been coded as used and were not. Resident #42 Review of Resident #42's EHR revealed the resident was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, type 2 diabetes mellitus without complications and depression, unspecified. Review of Resident #42's significant change in status MDS with an assessment reference date of 05/28/2025 revealed section I5800 Depression (other than bipolar) was coded no indicating the resident did not have an active diagnosis of depression. Section N0415 (J) Hypoglycemic- including insulin was coded no indicating the resident did not receive a hypoglycemic during the 7 day look back period. Review of Resident #42's May 2025 MAR revealed from 05/22/2025 through 05/28/2025 the resident was administered Sertraline for depression and Glimepiride and Pioglitazone as hypoglycemics. On 08/27/2025 at 11:20 a.m. an interview and review of Resident #42's MDS dated [DATE], was conducted with S4MDS. S4MDS confirmed that yes should have been coded for sections section I5800 Depression (other than bipolar). She further confirmed that yes should have been coded for Section N0415 (J) Hypoglycemic.

Based on observation, interview, and policy review, the facility failed to ensure that a resident's enteral feeding was properly labeled for 1 (#5) out of 1 (#5) resident investigated for tube feeding.Findings:On 08/25/2025, a review of the facility's policy titled, Enteral Tube Feeding via Continuous Pump, with a last review date of August 2025, revealed in part.Purpose: The purpose of this procedure is to provide a guideline for the use of a pump for enteral feedings.Initiate Feeding:.5. On the formula label document initials, date and time the formula was hung/administered, and initial that the label was checked against the order. Review of Resident #5's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, muscle wasting and atrophy, dysphagia, and gastrostomy status. Review of Resident #5's August 2025 physician's orders revealed an order dated 07/30/2025 that read in part.Enteral Feed Order every shift.Osmolite 45 ml (milliters) q (every) hour. On 08/25/2025 at 10:47 a.m., an observation of Resident #5's tube feeding bag and administration set revealed the formula bag had no label. On 08/25/2025 at 11:04 a.m., an interview and observation was conducted with S5LPN (Licensed Practical Nurse) who stated that tube feeding bags should be labeled with resident's name, date, time, rate, and nurse's initial. An observation was made with S5LPN of Resident #5's tube feeding, who confirmed the resident's tube feeding bag was not labeled, and should have been.

Based on observation, record review and interview, the facility failed to provide necessary care and services in accordance with professional standards of practice by failing to ensure oxygen was delivered at the ordered rate for 1 (#18) out of 1 (#18) resident investigated for respiratory care.Findings:On 08/25/2025, a review of the facility's policy titled, Oxygen Administration, with a last review date of August 2025, revealed in part.Purpose: The purpose is to provide guidelines for safe oxygen administration. Oxygen shall only be administered by physician order.Steps in the Procedure.4. Turn on the oxygen. Start the flow of oxygen at the rate order by physician. Review of Resident #18's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, chronic obstructive pulmonary disease and pneumonia. Review of Resident #18's Annual MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 07/02/2025 revealed she had a BIMS (Brief Interview for Mental Status) score of 15, indicating she was cognitively intact. Review of Resident #18's August 2025 physician's orders revealed an order dated 03/24/2025 for O2 (oxygen) at 2L (liters) per NC (nasal cannula) QHS (every night) and PRN (as needed). On 08/25/2025 at 11:41 a.m., an observation was made of Resident #18 in the dining room with oxygen on and in place per nasal cannula. The oxygen setting was observed at 4L.On 08/25/2025 at 11:49 a.m., an observation and record review was conducted with S3LPNTX (Licensed Practical Nurse/Treatment Nurse). S3LPNTX observed Resident #18's oxygen setting at 4L. She then reviewed Resident #18's August 2025 physician's orders and confirmed the oxygen should be at 2L. She confirmed the oxygen rate was incorrectly set on 4L and should have been on 2L as per the physician's orders. On 08/27/2025 at 12:09 p.m., an interview was conducted with Resident #18 who stated she does not touch the machine at all.

Based on record review, observation, and interviews, the facility failed to ensure: 1. Resident #13 was assessed for the risk of entrapment from assist bars. 2. Informed consent was obtained from the resident or the resident's representative prior to installation of assist bars for Resident #13. The deficient practice occurred for 1 (Resident #13) of 29 sampled residents. Findings: A review of the facility's policy, Bed Safety and Bed Rails, with a last review date of August 2025, revealed in part: Use of Bed Rails, The resident assessment to determine risk of entrapment includes, but is not limited to : a. medical diagnosis, conditions, symptoms, and/or behavioral symptoms; b. size and weight; c. sleep habits; d. medications; e. acute medical or surgical interventions; f. underlying medical conditions; g. existence of delirium; h. ability to toilet self safely; i. cognition, j. communication; k. mobility (in and out of bed); and i. risk of falling. 8. Before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent. The following information will be included in the consent: a. The assessed medical needs that will be addressed with use of bed rails; b. The resident's risks from the use of bed rails and how these will be mitigated; c. The alternative that were attempted but failed to meet the resident's needs; and d. The alternatives that were considered but not attempted and the reasons. Review of Resident #13's Electronic Health Record revealed the resident was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, dementia in other diseases classified elsewhere with behavioral disturbance, repeated falls, and osteoarthritis. Review of Resident #13's Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 2, which indicated the resident's cognition was severely impaired. Further review revealed that Resident #13 required substantial/maximal assistance with bed turning left and right and was dependent with chair to bed transfers. Review of Resident #13's care plan revealed in part: 5. Resident #13 has an ADL (Activities of Daily Living) self-care performance/functional abilities deficit r/t (related to) Dx (Diagnosis) Osteoarthritis. Resident #13 requires assistance with ADL functioning. Bed mobility: Resident #13 needs assistance of 2 staff for reposition while in bed. May use assist bars x 2 as needed to assist with bed mobility. On 08/26/2025 at 2:00 p.m., an observation of Resident #13 was made, with her in bed, both left and right upper assist bars in the raised position. Review of Resident #13's medical record revealed no evidence of assessment for the risk of entrapment from assist bars nor consent from the resident or the resident's responsible party for the use of assist bars. On 08/27/2025 at 11:26 a.m., an interview and record review was conducted with S1DON (Director of Nursing). S1DON confirmed that the side rail assessment for Resident #13 did not include assessing for the risk of entrapment. She further confirmed that informed consent was not obtained from Resident #13's responsible party nor the resident, prior to the use of assist bars.

Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services, including accurately documenting controlled medication reconciliation in 1 (Med (medication) Cart 1) of 2 (Med Cart 1 and Med Cart 2) med carts for Resident #43. Findings:A review of the facility's policy titled, Controlled Substances with a last review date of 08/2025, read in part, The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medication. The policy also indicated general guidelines, Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow up.A review of Resident #43's electronic medical record revealed she was admitted to the facility on 0721/2022 with a diagnosis that included in part, Anxiety Disorder.A review of Resident #43's physician's orders revealed a start date of 08/16/2025: Lorazepam Oral Tablet 1 mg (milligram) *Controlled Drug* Give 1 tablet by mouth every 4 hours as needed for Anxiety.A review of Resident #43's Lorazepam Oral Tablet 1mg administration details in the EHR (electronic health record) revealed the controlled drug was administered on 08/27/2025 at 8:34 a.m. A review of the facility's form labeled, Individual Resident's Narcotic Record, for Resident #43 failed to reveal the administration of Lorazepam Oral Tablet 1 mg on 08/27/2025 at 8:34 a.m.On 08/27/2025 at 9:20 a.m., a controlled drug count and interview was conducted with S2LPN (Licensed Practical Nurse). A review of Resident #43's Individual Resident's Narcotic Record, for Lorazepam Oral Tablet 1mg give 1 tablet by mouth every 4 hours as needed stated that 30 tablets were supposed to be in the blister pack. Blister pack reviewed with S2LPN for Resident #43's Lorazepam Oral Tablet 1 mg which revealed 29 tablets. S2LPN stated she administered Resident #43's Lorazepam Oral Tablet 1 mg this morning, and forgot to sign it off on the resident's Individual Resident's Narcotic Record. She confirmed that she should have documented on Resident #43's Individual Resident's Narcotic Record, as soon as she administered the medication and she did not. On 08/27/2025 at 10:02 a.m. an interview was conducted with S1DON (Director of Nursing). She confirmed after a narcotic/controlled medication is administered it is to be documented on the resident's Individual Resident's Narcotic Log immediately.

Based on interviews, observations, and record review the facility failed to ensure medications were stored properly in accordance with currently accepted professional principles as evidenced by: 1. failing to discard an expired medication in 1 (Med (medication) Cart 1) of 2 (Med Cart 1 and Med Cart 2) med carts, 2. failing to discard 2 expired medications in 1 (Med Room) of 1 (Med Room), and 3. failing to ensure food was stored separately from medications. Findings:A review of the facility's policy titled, Storage of Medications with a last review date of 08/2025, read in part, The facility stores all drugs and biologicals in safe, secure, and orderly manner. The policy also indicated general guidelines, Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Medications are stored separately from food. On 08/27/2025 at 9:03 a.m., observation was conducted of Med Cart 1 with S2LPN (Licensed Practical Nurse) which revealed the following: 1 Linzess 72 mcg (microgram) bottle with an expiration date of 06/05/2025.On 08/27/2025 at 9:20 a.m., an observation and interview was conducted with S2LPN who confirmed the expiration date on the Linzess 72 mcg bottle was 06/05/2025, and it should have been discarded and not in the med cart.On 08/27/2025 at 9:25 a.m., observation was conducted of the Med Room with S2LPN which revealed the following: 1 Trazadone 100 mg (milligram) blister packet with an expiration date of 04/29/2025. 1 Mirtazapine 15 mg blister packet with an expiration date of 06/14/2025. 1 bottle of Orange Juice in the Medication Only refrigerator. On 08/27/2025 at 9:35 a.m., an observation and interview was conducted with S2LPN who confirmed the expiration date on the Trazadone 100 mg blister packet's expiration date was 04/29/2025, and the Mirtazapine 15 mg blister packet's expiration date was 06/14/2025, and both medications should have been discarded and not in the med room. She also confirmed that food items should not be in the same refrigerator as medications.On 08/27/2025 at 10:02 a.m., an interview was conducted with S1DON (Director of Nursing). She confirmed that no expired medications should be in any med carts or in the med room. She confirmed that food items should not be in the same refrigerator as medications.

Based on interview and record review, the facility failed to ensure the designated interdisciplinary team member obtained the most recent hospice plan of care, and the physician recertification of the terminal illness for 1 (#9) of 1 (#9) resident investigated for hospice care.Findings:On 08/27/2025, a review of the facility's policy titled Hospice Program, read in part: Policy Statement: Hospice services are available to residents at the end of life. Policy Interpretation and Implementation.11.Our facility has designated S1DON (Director of Nursing) to coordinate care provided to the resident by our facility staff and the hospice staff.she is responsible for the following.d. Obtaining the following information from the hospice: 1. The most recent hospice plan of care specific to each resident.3. Physician certification and recertification of the terminal illness specific to each resident.Resident #9 was admitted to the facility on [DATE], with diagnoses that included, but were not limited to atherosclerotic heart disease of native coronary artery without angina pectoris, chronic diastolic (congestive) heart failure, and acute kidney failure.Review of Resident #9's quarterly Minimum Data Set (MDS) dated [DATE], revealed in Section J1400. Prognosis that he had a chronic disease that may result in a life expectancy of less than 6 months.Review of Resident #9's physician orders revealed an order written on 01/20/2025 to admit to hospice service. Further review revealed no order to discharge the resident from hospice service.Review of the Resident #9's medical records revealed no current hospice certification or plan of care. The last certification period and plan of care were dated 04/10/2025 to 07/18/2025.On 08/26/2025 at 4:15 p.m., an interview and review of Resident #9's hospice records was conducted with S3LPN/TX (Licensed Practical Nurse/Treatment Nurse). She confirmed that the resident did not have a current certification and plan of care in his records.On 08/27/2025 at 2:47 p.m., an interview was conducted with S1DON. She stated that she was responsible for obtaining Resident #9's hospice certification and plan of care from the hospice provider. S1DON confirmed that she was aware that the current certification and plan of care were not in the facility and stated that they should have been.

Based on record review and interview, the facility failed to ensure residents' personal funds were available during non-banking hours. This failed practice had the potential to affect 51 residents who deposited funds in the residents' trust fund. The facility's total census was 51 with a census of 49 residents physicially in the nursing home at the time of the survey. Findings: During a resident council meeting conducted with 4 (#8, #11, #24, #37) residents and S9ACT (Activities Director) on 08/05/2024 at 2:05 p.m., the residents were asked about personal funds and petty cash. Resident #24 stated they could not get petty cash on the weekend, and the other residents agreed. Resident #24 reported the only time residents could get cash was when the business office was open during weekdays not weekends. The residents present in the meeting all agreed, they were not aware they should have petty cash available to them at any time, including weekends. On 08/07/2024 at 8:37 a.m., an interview was conducted with S3SSD (Social Services Director), she reported she was responsible for resident's petty cash. S3SSD stated petty cash was only available to resident's Monday through Friday except for holidays. S3SSD confirmed petty cash was not available to residents on weekends when the business office was closed. S3SSD stated she was not aware petty cash needed to be available to resident at all times.

Based on record review and interviews, the facility failed to ensure residents received mail on Saturdays. This had the potential to affect 49 residents residing in the facility. Findings: On 08/05/2024 at 2:05 p.m., during a resident council meeting, Residents #11, #24 and #37 each stated they do not receive their unopened mail on Saturdays. Residents #11 and #24 stated they only get their mail when the office is open Monday through Friday. On 08/07/2024 at 10:52 a.m., an interview was conducted with S4SEC (Secretary/Transportation Supervisor/Medical Record). She reported there was no one in the business office on Saturdays to deliver mail to residents. S4SEC stated the Saturday mail was delivered to residents first thing on Monday morning. S4SEC confirmed mail was not delivered to residents on Saturdays.

Based on record reviews and interviews, the facility failed to ensure that their grievance policy and procedure was followed. The facility failed to ensure the residents and staff were aware of the procedure for filing grievances. The deficient practice had the potential to effect a census of 49 residents. Findings: Review of the facility's policy and procedure titled, Resident Care Grievance Policy, with a revision date of April 2017 and a review date of April 2023, revealed in part: Policy statement: all grievances and complaints filed with the facility will be investigated and corrective actions will be taken to resolve the grievance(s). Policy interpretation and implementation: 2. upon receiving a grievance and complaint report, the grievance officer will begin an investigation into the allegations .5. The grievance officer will record and maintain all grievances and complaints on the Resident Grievance Complaint Log. 6. The resident grievance/complaint investigation report form will be filed with the administrator within 5 working days of the incident. 7. The resident, or person acting on behalf of the resident, will be informed of the findings of the investigation, as well as any corrective actions recommended, within 3 working days of the filing of the grievance or complaint 10. Upon request, a copy of grievance must be given to the resident or representative. Review of facility's grievances from July 01, 2023 to July 31, 2024 revealed only 5 grievances had been filed. Each grievance had a complaint and action taken to solve section. Only 3 of the grievances noted the problem was solved. The other 2 complaints had no for problem solved and were greater than 5 days to be signed by Administrator. On 08/05/2024 at 2:05 p.m., during a resident council meeting, Resident's #8, #11, #24 and #37 each reported they did not know how to file a grievance or who to talk to about filing a grievance. Resident #24 stated residents were not aware if grievances were filed when complaints or issues are voiced. Resident #24 also stated residents do not get feedback or a written resolution when a complaint is reported as to what the resolution was. On 08/06/2024 at 11:17 a.m., an interview was conducted with S3SSD (Social Services Director), she confirmed she was responsible for the facility's grievances. She reported she was not sure of what all should be filed as a grievance. She stated usually S9ACT (Activities Director), would receive the initial complaints from the residents in the mornings, while serving them coffee. S3SSD stated when staff had their morning meetings, S9ACT would inform them of any complaints and administrative staff wouldreview the concern and address. S3SSD stated a grievance/complaint was not completed because if there was a complaint the staff worked to get it resolved at the time. S3SSD again stated she did not know that resident complaints should be filed as a grievance. She confirmed the facility only had 5 grievances for the past year, as she was unaware of what should have been filed as a grievance.

Based on observations, interviews, and review of the facilty's policy and procedures,the facility failed to maintain a clean and sanitary kitchen. This deficient practice had the potential to affect the 44 residents who consumed food from the kitchen. The facility's census was 49. Findings: On 08/05/2024, a review of the facility's policy titled, Fryer with no date of implementation or revision, read in part: After each use, fryer must be drained and thoroughly cleaned. The procedure to use is as follows: 1. Drain grease into thick container after cooled and dispose of . On 08/05/2024, a review of the facility's policy titled, Conventional Oven with no date of implementation or revision, read in part: Wipe oven doors, outside surface and racks with clean damp cloth . The porcelain interior can easily be cleaned with oven cleaners . On 08/05/2024, a review of the facility's policy titled, Pantry with no date of implementation or revision, read in part: . 2. dented can and spoiled foods should be disposed of promptly to prevent contamination of other foods . On 08/05/2024, a review of the facility's policy titled, Refrigerators and Freezers and Walk-in Cooler with no date of implementation or revision, read in part: . 3. Mop floors in walk-in refrigerators daily . On 08/05/2024, a review of the facility's policy titled, Labeling and Dating of Food Received with no date of implementation or revision, read in part: . Once opened, the product should be dated again with the date it was opened . On 08/05/2024, a review of the facility's policy titled, Dietary Services with no date of implementation or revision, read in part: . 2. Hair . cover the hair completely . On 08/05/2024, a review of the facility's policy titled, Ingredient Bins with no date of implementation or revision, read in part: . 6. Scoops used in bins are not to be left in the bin. Scoops are to be kept covered in a protected area conveniently located near the bins. On 08/05/2024 at 8:26 a.m. and initial tour of the kitchen was conducted with S7DM (Dietary Manager). S12CH was observed walking around the kitchen and cleaning the dishes with his beard exposed and not covered. On 08/05/2024 at 9:20 a.m. a second observation was made of S12CH walking past the prep station where food is being prepared for lunch with his beard exposed and not covered. Continued observations of the kitchen with S7DM revealed the following: 1.Equipment: A. Food residue noted on the kitchen fryer. B. Dark black grease noted in the kitchen fryer. C. Build-up of brown substance noted on the outside of the deep freezer. D. Build-up of debris and brown substance inside of the convention oven and the inside of the oven doors. 2. Food storage: A. Refrigerated items: 1. A chicken base container not labeled with the date it was opened. 2. A bag of cheese with multiple areas of black spots noted to the cheese and packaging indicated it was spoiled. B. Dry Storage: 1. Two dented canned goods in the dry storage room. 2. A bag of pasta not labeled with the date it was opened. C. Walk-in Refrigerator: 1. Pitcher of soda not labeled with the date it was prepped. 2. Food residue and debris noted on the floor. D. Main Kitchen: 1. A container of vanilla flavoring not labeled with the date it was opened. 2. A bottle of soda flavoring not labeled with the date it was opened. 3. A container of cream potatoes not labeled with the date it was prepped. 3. S12CH (Cook Help) without a beard restraint while in the kitchen. 4. A scoop noted inside of cereal container. On 08/05/2024 at 1:45 p.m. an interview was conducted with S7DM. S7DM confirmed the findings listed above throughout the kitchen tour. She stated if food items are opened or prepped by staff they must be labeled with the open or prep date. She stated if there are any discolored spots noted on food and if there are dented cans in the pantry it should be discarded immediately. She confirmed the floors in the walk-refrigerator consisted of old food residue and floors should be swept and mopped daily she was unsure when it was last cleaned. She stated that no scoops should be inside any containers they should be stored on the outside of the containers in their designated area. She confirmed the fryer should have been cleaned and the grease was dark and it should have been drained when it was last used on 08/04/2024. She stated the conventional oven consisted of debris and brown substance on the inside and brown substance was noted on the outside of the deep freezer and this should have been cleaned. She confirmed that S12CH should have had a beard covering on this morning while working in the kitchen.

Based on observations, records reviews and interviews the provider failed to ensure that a resident's assessment accurately reflected the resident's status for 3 (#14, #28, #102) residents records reviewed out of a finalized sample of 23 residents as evidenced by: 1. failing to ensure Resident #14's MDS (Minimum Data Set) assessment reflected dialysis; 2. incorrectly identifying physical restraint use on Resident #28's MDS assessment; and 3. failing to ensure Resident #102's MDS assessment reflected oxygen use. Findings: 1. Resident # 14 A review of Resident #14's EMR (Electronic Medical Record) revealed an admitted [DATE] with diagnoses that included End Stage Renal Disease and Dependence on Renal Dialysis. A review of Resident #14's Physician's Orders, revealed and order dated 11/21/2022, that read in part, Dialysis on Monday, Wednesday and Fridays. A review of Resident #14's Quarterly MDS assessment dated [DATE], under Section O-Special Treatments, Procedures, and Programs; dialysis was not indicated. On 08/07/2024 at 12:42 p.m., a concurrent record review and interview was conducted with S5MDS (Minimum Data Set). S5MDS confirmed Resident #14 had an order for and received dialysis 3 times a week. S5MDS confirmed the 05/31/2024 MDS assessment failed to identify Resident #14 received dialysis and should have been indicated. 2. Resident #28 A review of Resident #28's EMR revealed an admitted [DATE] with diagnoses that included, Cognitive Communication Deficit, Dementia, and Primary Generalized Osteoarthritis. A review of Resident #28's Physicians Orders failed to reveal an order for physical restraints. Further review of Resident #28's Care Plan failed to reveal a problem or plan for physical restraints. There was no documentation found elsewhere in the resident's record that physical restraints were used. A review of Resident #28's Quarterly MDS assessment dated [DATE], under Section P-Physical Restraints; bed rail was indicated as used daily. On 08/05/2024 at 10:00 a.m., an observation was conducted of Resident #28 in her room. There was no evidence of any physical restraints. On 08/06/2024 at 9:50 a.m., a second observation was conducted of Resident #28 in her room. There was no evidence of any physical restraints. On 08/06/2024 at 10:00 a.m., a concurrent record review and interview was conducted with S5MDS. S5MDS viewed Resident #28's EMR and was unable to find any indications that physical restraints had been ordered or utilized. S5MDS confirmed the 5/30/2024 MDS assessment indicated that bed rails were used daily as a physical restraint and should not have been coded. 44418 3. Resident #102 A review of Resident #102's EMR revealed an admitted [DATE] with diagnoses that included Pneumonia, Hypoxia, and Heart Failure. A review of Resident #102's Physician's Orders, revealed an order dated 06/24/2024, that read O2 (Oxygen) at 3L (Liters)/NC (per nasal cannula) continuously. A review of Resident #102's Quarterly MDS assessment dated [DATE], under Section O-Special Treatments, Procedures, and Programs; oxygen use was not indicated. On 08/06/2024 at 2:18 p.m., a concurrent record review and interview was conducted with S5MDS. S5MDS confirmed Resident #102's order for oxygen and had received it. S5MDS confirmed the 07/26/2024 MDS assessment failed to identify Resident #102 received oxygen and should have been indicated.

Based on record review, observations, and interviews, the facility failed to ensure residents who smoked were free from potential accidents and hazards, by failing to implement the facility's policy that required unsafe smokers to be provided a smoking apron for 3 (#36, #41 and #43) of 3 (#36, #41 and #43) residents who were care planned as unsafe smokers. The final sample size was 23 residents. Findings: On 08/07/2024, a review of the facility's smoking policy titled, Smoking Policy for Residents, with no documented revision date, read in part .Purpose: To assure that a resident desiring to smoke is allowed to do so in a manner and area which will not compromise his/her safety or that of others in this facility .Resident found to be unsafe smoker will be provided smoking apron and will be supervised by staff member while in smoke room . Resident #36 Review of Resident #36's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Alzheimer's disease, Dementia, Major Depressive Disorder, Anxiety Disorder and Repeated Falls. Review of Resident #36's care plan read in part .is an unsafe smoker .04/28/2022. Resident will smoke only in designated areas and will not burn holes in furniture of clothing .Supervise resident at all times while smoking .08/21/2022 Re-assessed-Remains an unsafe smoker . Resident #41 Review of Resident #41's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Dementia, Cognitive Communication Deficit, Depression, Muscle Wasting and Atrophy and Lack of Coordination. Review of Resident #41's care plan read in part .is an unsafe smoker .07/25/2022 .Will be supervised when smoking at designated times . Resident #43 Review of Resident #43's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Alzheimer's disease, Chronic Obstructive Pulmonary Disease, Asthma, Anxiety Disorder, and Major Depressive Disorder. Review of Resident #43's care plan read in part .is an unsafe smoker .12/21/2023 .will smoke only in designated areas and will not burn holes in furniture or clothing .Supervise at all times while smoking . 08/05/2024 at 10:35 a.m., an interview was conducted with S2DON/IP (Director of Nursing/Infection Preventionist). She stated all five residents who smoke in the facility were considered unsafe smokers. On 08/07/2024 at 12:34 p.m., an observation was made of Resident #36, Resident #41 and Resident #43 in the smoking area smoking cigarettes. The residents were not observed wearing a smoke apron. S13CNASA (Certified Nursing Assistant/Smoke Aide) was observed monitoring the residents in the area. On 08/07/2024 at 12:35 p.m., an interview was conducted with S13CNASA. She stated that Resident #36, Resident #41, and Resident #43 were all unsafe smokers, but that the residents did not require an apron. All residents continued to smoke without an apron. On 08/07/2024 at 12:45 p.m., an interview was conducted with S2DON/IP. She stated that Resident #36, Resident #41 and Resident #43 were not required to wear a smoke apron even though all are considered unsafe smokers. The facility's policy, Smoking Policy for Residents was reviewed with S2DON/IP who confirmed policy stated resident found to be an unsafe smoker should be provided and wear a smoking apron.

Based on record review and interview, the facility failed to maintain an effective infection control and prevention program by failing to conduct yearly review of the infection program policies and procedures. Findings: On 08/06/2024, a review of the facility's policy titled, Infection Prevention and Control Program read in part: Policy Statement: An infection prevention and control program (IPCP) is established and maintained to prove a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections . Further review revealed the policy was last updated on 10/2018. On 08/06/2024 at 9:56 a.m., an interview was conducted with S2DON/IP (Director of Nursing/Infection Preventionist). S2DON/IP stated that she was responsible for oversight of the infection control program. S2DON/IP failed to provide documentation when requested regarding when the facility's IPCP policies and procedures were last reviewed. S2DON/IP stated she was unaware that IPCP policies and procedures were to be reviewed annually.

Based on observation, record review and interview, the facility failed to provide necessary care and services in accordance with professional standards of practice by failing to ensure oxygen was delivered at the ordered rate for 2 (#2, #102) out of 2 (#2, #102) residents investigated for respiratory care in a final sample of 23 residents. Findings: Resident #2 A review of Resident #2's EMR (Electronic Medical Record) revealed an admitted [DATE] with diagnoses that included Pneumonia, Sepsis, and Dementia. A Review of Resident #2's Quarterly MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 06/18/2024 revealed she had a BIMS (Brief Interview for Mental Status) score of 03, indicating severely impaired cognition. Further review of Resident #2's August 2024 physician's orders revealed in part . Oxygen at 2L (Liters) per nasal cannula continuously with an order start date of 12/26/2023. On 08/05/2024 at 11:16 a.m., an observation was made of Resident #2 in the dining room with oxygen on and in place per nasal cannula. The oxygen setting was observed at 3L. On 08/07/2024 at 9:03 a.m., a second observation was made of Resident #2 in her bed with oxygen on and in place per nasal cannula. The oxygen setting was observed at 3L. On 08/07/2024 at 9:45 a.m., a record review and observation was made with S6LPN (Licensed Practical Nurse). S6LPN reviewed Resident #2's August 2024 physician's orders and confirmed the oxygen should be at 2L. She then observed Resident #2's oxygen setting. She confirmed the oxygen rate was incorrectly set on 3L and should have been on 2L as per the physician's orders. 44418 Resident #102 Review of Resident #102's EMR (Electronic Medical Record) revealed an admitted [DATE] with diagnoses that included Pneumonia, Edema, Heart Failure, Tachycardia and Anxiety. Review of Resident #102's August 2024 physician's orders dated 06/24/2024 revealed O2 (oxygen) at 3 L/NC (liters per nasal cannula) continuous related to pneumonia. Review of Resident #102's MAR (Medication Administration Record) for August 2024 revealed O2 at 3L/NC continuously related to pneumonia. Review of Resident #102's Care Plan revealed there was no Focus or Goal related to managing symptoms associated with Pneumonia nor was there an intervention including the continuous use of oxygen. On 08/06/2024 at 2:18 p.m., an interview was conducted with S5MDS (Minimum Data Set nurse). S5MDS reviewed Resident #102's care plan and confirmed the Focus of Pneumonia and intervention of continuous oxygen was not identified. S5MDS confirmed the use of oxygen at 3 L/NC should have been addressed on the care plan.

Based on record review and interviews, the facility failed to ensure an RN (Registered Nurse) was on duty for 8 consecutive hours per day 7 days per week. This deficient practice had the potential to affect all 49 residents residing in the facility. Findings: Review of Time Card Reports for RN hours from January 2024 through March 2024 revealed an RN did not work a total of 8 consecutive hours for the following dates in February 2024: 02/19/2024 S2DON/IP (Director of Nursing/Infection Preventionist) had a clock-in time of 11:50 a.m. and clock-out time of 5:42 p.m. with 5.5 hours worked. No other RN had time on the time card reports. 02/26/2024 S11RN had a clock-in of 5:29 a.m. and clock-out time 12:00 p.m., with 6.35 hours worked. S2DON/IP had a clock-in time of 6:57 a.m. and clock-out time 1:18 p.m. The facility's RN coverage totaled 7 hours and 48 minutes. Further review of time cards for March 2024 revealed no RN for had time documented on the time card report for March 10, 2024. On 08/07/2024 at 11:00 a.m., an interview was conducted with S2DON/IP as she reviewed the time card reports. S2DON/IP confirmed on 02/19/2024 and 02/26/2024 the facility did not have 8 consecutive hours of RN coverage. On 08/07/2024 at 2:45 p.m., an interview was conducted S4SEC (Secretary) who reported S10RN worked on 03/10/2024. S4SEC did not provided a time card report with the reported information by exit conference.

Based on observation, interview, and record review, the facility failed to ensure a resident received a mechanically altered diet as ordered by the physician for 1 (#35) out of 6 (#2, #34, #35, #43, #44, and #102) residents reviewed for dining. Findings: Review of Resident #35's record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Non-infective Gastroenteritis and Colitis and Dysphagia. Review of Resident #35's most recent Admission Minimum Data Set (MDS) dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) score was 14, indicating her cognition was intact. Section K: Swallowing/Nutritional Status was checked for mechanically altered diet. Review of Resident #35's physician's orders revealed an order dated 06/24/2024 that read, NAS (No Added Salt) diet, Finely Chopped texture, Regular Consistency. On 08/05/2024 at 11:55 a.m. an observation was made of Resident #35's meal ticket and meal tray. Resident #35's meal ticket read in part, Finely Chopped. Observations of the meal tray served to the resident revealed 1 whole slice of meat loaf and 1 whole slice of garlic bread. Both items were not finely chopped. On 08/05/2024 at 11:57 a.m. an interview was conducted with S8RN (Registered Nurse). S8RN confirmed that Resident #35 was on a finely chopped diet as ordered by the physician and the items on her meal tray were not finely chopped.

Based on record review and interview, the facility failed to provide the resident and the resident's representative a written notice that specified the duration of the bed-hold policy for 1 (#102) of 1 (#102) residents investigated for hospitalization s in a final sample of 23 residents. This deficient practice had the potential to effect a census of 49. Findings: Review of the facility's policy titled, Bed-Holds and Returns, with a revision date of 04/2024, revealed in part: Policy statement: Resident and/or representatives are informed (in writing) of the facility and state (if applicable) bed-hold policies. Policy interpretation and implementation: 1. all residents/representatives are provided written information regarding the facility bed-hold policies, which address holding or reserving a resident's bed during period of absence (hospitalization or therapeutic leave). Residents are provided written information about these policies at least twice: a. well in advance of any transfer (e.g., in the admission packet); and b. at the time of transfer (or, if the transfer was an emergency, within 24 hours). Review of Resident #102's electronic medical record revealed she was admitted to the facility on [DATE] with diagnoses not limited to: Pneumonia, Hypoxia, Edema, Heart Failure and Anxiety. The resident's quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) score of 14, indicating the resident's cognition was intact. Review of the Ombudsman Notification of Transfer logs from May 2024- August 2024 revealed Resident #102's transfer dates as 05/17/2024, 06/08/2024, 07/19/2024, 07/22/2024 and 07/31/2024. Review of the column titled written notification to resident date revealed the date of the transfer. There was no furhter evidence provided that a written notification had been sent to the resident's RP (responsible party). On 08/06/2024 at 9:30 a.m., an interview was conducted with Resident #102, she stated she did not recall getting a letter/notice of a bed hold when she had gone out to the hospital. On 08/06/2024 at 9:52 a.m., an interview was conducted with S2DON/IP (Director of Nursing/Infection preventionist), she reported the facility does not send out letters for bed-hold when a resident goes out to the hospital. S2DON/IP stated S1ADM (Administrator) informed her that sending a bed-hold letter to the resident/RP was not necessary becasue the facility always had open beds. She also confirmed a letter was not sent to Resident #102 nor the RP when the resident was sent out to the hospital.

Based on observation, record review and interview the provider failed to post the nurse staffing data at the beginning of each shift, which would reflect current daily totals of the number of hours worked by categories of licensed and unlicensed nursing staff directly responsible for resident care. Findings: On 08/16/2023 at 10:35 a.m., an observation of the facility walls was conducted for posting of the facility's current daily totals of number of hours worked by categories of licensed and unlicensed nursing staff directly responsible for resident care. There were no postings observed. On 08/16/2023 at 10:40 a.m., an interview was conducted with S9WC (Ward Clerk), she stated she had the facility's current daily totals of nursing hours lying on the desk at the nurses' station. She reported she is responsible for filling out the daily staff nursing hours. She stated the information for today is not recorded on the form until tomorrow, as they don't know who will call in, so they can't get the actual hours for today. On 08/16/2023 at 1:22 p.m., an interview was conducted with S8ADMSec (Administrative Secretary). She reported the ward clerk is responsible for documenting the daily nursing staffing hours. She confirmed the hours documented on the form are from the previous day, because they are not able to know what the current staffing hours are until the end of the night, because they don't know if someone will call in.

Based on observations and interviews, the facility failed to maintain a safe, sanitary environment evidenced by: 1. Failure to ensure cookware was stored in a sanitary manner. 2. Failure to verify dishwasher temperature and chemical concentration every shift. The deficient practice had the potential to affect a total of 43 out of 43 residents that were served a meal tray from the kitchen. Findings: 1. A walk through observation of the kitchen on 08/14/2023 at 8:20 a.m., revealed 2 large pot lids and 1 oven rack on the floor. An immediate interview on 08/14/2023 at 8:20 a.m., with S2DM (Dietary Manager) who confirmed the pot lids and oven rack were on the floor and should not have been. 2. Further observation of the kitchen on 08/14/2023 revealed an log titled, Dishwasher Temperature/Chemical Record .Month: August 2023. The Lunch temperature and chemical readings were missing 11 days out of 13 days. The Dinner temperature and chemical readings were missing for 9 days out of 9 days. An immediate interview was conducted with S2DM who confirmed the temperature and chemical readings were not done and verified they should be done for every meal.

Based on record review and interview, the facility failed to ensure that each resident received adequate supervision and assistance to prevent accidents for one (#43) out of 4 (#33, #41, #43, #246) residents reviewed for falls. An actual harm occurred for Resident #3 on 6/16/2019 when one CNA present in the shower room was assisting the resident to transfer to a wheelchair after showering. The resident's right knee gave out and the resident was assisted to the floor. The resident, who required two person assistance for transfers, sustained an Acute Displaced Spiral [MEDICAL CONDITION] of the Left Femur. The resident was transferred and admitted into the hospital for a surgical procedure. Findings: Review of resident #3's clinical record revealed that the resident's [DIAGNOSES REDACTED]. Review of the resident's Significant Change MDS (Minimum Data Set) dated 6/2/2019 revealed that the resident's BIMS (Brief Interview Mental Status) score was 3 for severely impaired for cognition. Further review of the resident's MDS dated [DATE] revealed that the resident was coded extensive assistance with two plus person assist for bed mobility and coded extensive assistance with two plus person assist for transfers. The MDS revealed that the resident required extensive assistance with two plus person assist for dressing, for toilet use, and for personal hygiene, and was coded as total dependence for bathing. Review of the resident's current care plan revealed that the resident was at risk for falls. Also, the care plan revealed that the resident required total assistance with two staff for transfers between surfaces; required extensive assistance with two staff for locomotion on and off the unit; required extensive assistance by two staff to dress; required total assistance by two staff for toileting; and required extensive assistance by two staff for personal hygiene care. Review of the resident's Morse Fall Scale assessment dated [DATE] revealed documentation that the resident was assessed to be a high risk for falls. During an attempted interview with Resident #43 on 7/28/19 at 11:01 am, the resident was observed sitting up in her wheelchair in the lobby area watching television. During the interview, the resident stated that she had a fall. Review of the resident's health status note dated 6/16/19 at 11:54 revealed, Called to bath 3, resident sitting on the floor, CNA (certified nursing assistant) stated 'we're transferring her to wheelchair and her knee gave out so we assisted her to floor. Resident c/o pain to lft (left) knee and thigh area, Hoyer lift used to lift and transfer her to w/c (wheelchair). Resident put to bed with lifter to prevent any weight bearing at this time. _______NP (Nurse Practitioner) notified. N.O. (New Order) noted for x-ray of lft femur, knee, and pelvis . Review of the resident's health status note dated 6/16/19 at 17:12 revealed, Verbal report given for x-ray results. L (Left) femur mid-shaft fracture . Verbal order given from _____ NP to transfer to ER (emergency room ) . Review of the resident's x-ray report of Left Femur dated 6/16/19 revealed, .Reason for Study: Trauma/Pain . Impression: .Acute displaced [MEDICAL CONDITION]-shaft of the femur . Review of the facility's investigative report dated 6/17/19 revealed in part, Incident Occurred 6/16/2019 Incident Occurred Time 11:54 am . Incident Report: Called to bath 3, Resident sitting on the floor. ______NP (Nurse Practitioner) notified. N.O. noted for x-ray of lft (left) femur, knee, and pelvis. Mobile x-ray notified .X-ray done revealing mid-shaft femur fracture of left leg. Resident sent to (hospital emergency room ) . Investigation Findings: Resident had surgery the following day. She returned from hospital stay on 6/24/19 . On 7/29/19 at 10:25 am, S4CNA stated that after she showered the resident, she had the resident hold onto the grab bars to stand up. S4CNA stated that she was attempting to dress the resident when the resident's knee gave out. S4CNA stated that S6CNA was in the shower room watching and she came over to help and both of them sat the resident down on the floor and the resident ended up going down on one knee and started complaining of pain in her knee. S4CNA stated that she called the nurse when the resident went down on one knee. On 7/29/19 at 10:45 am, S5LPN (Licensed Practical Nurse) stated that she was called into the shower room and found the resident on the floor. S5LPN stated that S4CNA and S6CNA was in the room with the resident. S5LPN stated the CNAs told her that they had stood her up to dress her and that her knee gave out and the resident went down on one knee. S5LPN stated that the resident was complaining of pain to her knee and thigh and she called the nurse practitioner and an x-ray was done. On 7/29/19 at 2:00 pm, S6CNA stated that she was called to go to the shower room on the hall to help S4CNA with the resident. S6CNA stated that when she entered the room that she saw S4CNA and the resident in the room. S6CNA stated that she saw the resident holding onto the grab bars and going down on the floor. S6CNA stated that she went in and grabbed the back of the resident's pants but she could not hold on and she and S4CNA guided the resident down on the floor. S6CNA stated that they called for the nurse when the resident went down on the floor. S6CNA stated that the resident was a two person assist and that S4CNA was the only staff in the shower room with the resident when she entered the room. On 7/29/19 at 2:15 pm, S2ADON (Assistant Director of Nurses) stated that the resident was assessed to be a two person physical assist because of safety. S2ADON stated that two CNAs should have been with the resident in the shower room when the incident occurred. On 7/29/19 at 2:25 pm, S3CNA Supervisor stated she was informed that both CNAs were in the shower room with the resident at the time the incident occurred. S3CNA Supervisor stated that S6CNA did not tell her that she was not in the shower room with the resident and S4CNA at the time the incident occurred. On 7/29/19 at 2:30 pm, S1DON (Director of Nurses) stated that she was informed that both CNAs were in the shower room with the resident at the time the incident occurred. S1DON stated that S6CNA did not tell her that she was not in the shower room with the resident and S4CNA at the time of the incident.