Every finding on record at Harmony House Nursing and Rehabilitation Center, I

Based on observation, record review, and interview, the facility failed to store, prepare, and distribute and serve foods in a sanitary manner by: 1. Failing to clean the dry food storage room.2. Storing a styrofoam cup inside a bin of sugar.This had the potential to affect 85 residents served meals on 09/29/2025 according to S1 Administrator. Findings:Review of the facility's undated Cleaning Schedule policy provided by S1 Administrator on 10/01/2025 revealed:Daily cleaning schedule: 8. Food Storage - dust mop, wet mop, and dust shelves, check food arrangements, put up new deliveries as needed. Observation of the kitchen on 09/29/2025 at 8:00 a.m. with S5 Dietary Manager revealed dirt, dust, and food debris on the floor beneath the metal shelves that stored food in the dry food storage room. Further observation of the kitchen with S5 Dietary Manager revealed a bin of sugar with a styrofoam cup used for scooping stored inside the bin. During an interview on 09/29/2025 at 8:00 a.m. S5 Dietary Manager confirmed the kitchen's dry food storage room should have been cleaned and the styrofoam cup should not have been stored inside of the bin of sugar.

Based on record review, observations, and interviews, the facility failed to ensure residents were free from physical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms for 1 (#13) of 1 (#13) resident reviewed for restraints. The facility failed to ensure Resident #13's pre-restraint assessment was completed and a written consent was obtained prior to the use of lap tray. Findings:Review of the facility's undated policy for Restraints: Physical revealed in part:Policy:A physical restraint is defined as any manual method or mechanical, physical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Physical restraints include, but are not limited to, leg restraints, arm restraints, hand mitts, soft ties or vests, lap cushions and lap trays the resident cannot remove easily. Also included as restraints are facility practices that meet the definition of a restraint, such as:3. Using devices in conjunction with a chair such as trays, tables, bars or belts that the resident cannot remove easily that prevent a resident from rising out of the chair.4. Placing a resident in a chair that prevents rising.Restraint use should be a last resort and only used after all other measures of dealing with the problem have been exhausted. Informed consent must be obtained prior to initiation of a restraint. The facility must explain, in the context of the individual resident's condition and circumstances, the potential risks and benefits of all options under consideration including using a restraint, not using a restraint, and alternatives to restraint use. If the restraint use is considered, that facility will explain how the use of restraints would treat the resident's medical condition and assist the resident in attaining or maintaining their highest practicable level of physical or psychological well being. Review of Resident #13's medical record revealed an initial admission date of 02/18/2025 with diagnoses that included, in part, restlessness and agitation, hypotension unspecified, Alzheimer's disease unspecified, dementia, and schizophrenia unspecified. Review of Resident #13's physician orders revealed an order dated 04/09/2025 for geri (geriatric) chair with lap tray for positioning to enable resident to be out of bed related to muscle wasting, unsteadiness on feet, and reduced mobility. Monitor every 30 minutes, release every 2 hours for 10 minutes for range of motion and toileting needs, as appropriate. Review of Resident #13's September 2025 MAR (Medication Administration Record) revealed the order for geri chair with lap tray was documented as in place. Review of Resident #13's 07/28/2025 quarterly MDS (Minimum Data Set) assessment revealed Resident #13 had a BIMS (Brief Interview Mental Status) score of 3, which indicated severe cognitive impairment. Further review of Resident #13's 07/28/2025 quarterly MDS revealed Resident #13 was dependent with all ADLs (Activities of Daily Living) and chair/bed-to-chair transfers. Review of Resident #13's medical record failed to reveal a pre-restraint assessment was completed and a written consent was obtained prior to the use of Resident #13's lap tray. Observation on 09/30/2025 at 3:28 p.m. revealed Resident #13 was seated in a geri chair with a lap tray in place. Observation on 10/01/2025 at 8:45 a.m. revealed Resident #13 was seated in geri chair with a lap tray in place. During an interview on 10/01/2025 at 1:00 p.m. S7 RN (Registered Nurse) and S8 MDS Nurse reviewed Resident #13's physician orders and reported since the lap tray was being used as a positioning device, it was not considered a restraint and did not require a consent or restraint assessment. During an interview on 10/01/2025 at 2:00 p.m. S2 DON (Director of Nursing) reported the lap tray on Resident #13's geri chair was utilized so Resident #13 could get out of bed and was not used as a restraint. S2 DON further confirmed there was not a pre-restraint assessment completed or a written consent in place prior to use of Resident #13's lap tray.

Based on record review, observation and interview, the facility failed to ensure the resident's environment remained free of accident hazards by failing to ensure a spray bottle labeled as Floor Cleaner was removed from resident's room for 1 (#120) of 4 (#4, #17, #61, & #120) residents reviewed for accidents. Findings: Review of the facility's undated General Policies housekeeping policy revealed in part: Objectives C. maintain an environment that is clean, safe, pleasant, and functional.An observation on 09/29/2025 at 8:09 a.m. revealed a spray bottle labeled as Floor Cleaner was sitting on Resident #120's sink. Further observation revealed the spray bottle labeled as Floor Cleaner contained the following ingredients: water, hydroxypropyl beta cyclodextrin, ethanol, didecyldimethyl ammonium chloride, and perfume.During an interview on 09/29/2025 at 8:12 a.m. S6 LPN (Licensed Practical Nurse) confirmed spray bottle labeled as Floor Cleaner was on Resident #120's sink and should not have been left in the room.

Based on record review, observation and interview, the facility failed to ensure proper infection control techniques were practiced to prevent urinary tract infection (UTI) for 1 (#64) of 2 (#1, #64) residents reviewed for indwelling urinary catheter. Findings:Review of the facility's Catheter Management undated policy revealed in part:Policy: Catheter management is the routine care administered when an indwelling urinary catheter is in place. This routine care protects the resident from infection, injury and promotes comfort.6. Maintain closed drainage system:a. check attachment of tubing to the catheter and note any leaks. Allow some slack in the tubing before securing with a catheter leg strap.b. watch for kinking in the tubing that can interfere with patency and free flow of urine. Never allow the bag or tubing to touch the floor. Review of Resident #64's medical record revealed an admit date of 07/28/2025 with the following diagnoses, in part, bipolar disorder, benign prostatic hyperplasia (BPH) and urinary tract infection. Review of Resident #64's current comprehensive care plan revealed Resident #64 has an indwelling urinary catheter related to BPH with interventions in place to prevent catheter-related trauma. An observation on 09/30/2025 at 10:30 a.m. revealed Resident #64 sitting in a wheelchair in his room. Further observation revealed Resident #64's indwelling urinary catheter tubing exited from left pant leg and was lying on the floor under the front left wheel of Resident #64's wheelchair. During an interview on 09/30/2025 at 10:30 a.m. S4RN (Registered Nurse) acknowledged Resident #64's indwelling urinary catheter tubing was lying on the floor under the front left wheel of Resident #64's wheelchair. S4RN reported Resident #64's catheter tubing should have been secured to prevent the tubing from lying on the floor.

Based on record review and interview the facility failed to ensure residents maintained acceptable parameters of nutritional status for 1 (#89) of 4 (#15, #37, #89, #93) residents reviewed for nutrition. The facility failed to ensure a dietary recommendation to increase Resident #89's dietary supplement had been implemented. Findings:Review of Resident #89's medical record revealed an admission date of 09/13/2025 with diagnoses that included, in part, mild protein-calorie malnutrition, deficiency of other vitamins, pressure ulcer of right buttock stage 2, major depressive disorder recurrent moderate, chronic ischemic heart disease, and dementia. Review of Resident #89's 07/22/2025 Quarterly MDS (Minimum Data Set) assessment revealed Resident #89 had a BIMS (Brief Interview Mental Status) score of 3, which indicated severe cognitive impairment. Review of Resident #89's physician orders revealed an order dated 08/14/2025 for ____ house supplement - two times a day related to mild protein-calorie malnutrition - Give 240cc (cubic centimeters). Document % of intake - 1=1-25% 2=26-50% 3=51-75% 4=76-100% 5=Refused. Review of Resident #89's weights revealed the following weights, in part: On 08/06/2025 a weight of 139.0 pounds; on 05/09/2025 a weight of 147.0 pounds; on 01/06/2025 a weight of 156.0 pounds. Further review of the above weights revealed greater than 5% weight loss from 05/09/2025 and greater than 10% weight loss from 01/06/2025. Review of Resident #89's dietician note dated 09/25/2025 revealed: Reviewed due to weight and resident having pressure ulcer . 10 pound loss noted from 07/07/2025. Recommend: increase house supplement to 240 mls (milliliters) TID (three times a day). Review of Resident #89's physician orders failed to reveal the dietician's 09/25/2025 recommendation to increase house supplement to 240mls TID had been implemented. During an interview on 10/01/2025 at 10:40am S2 DON (Director of Nursing) reviewed Resident #89's 09/25/2025 dietician note and physician orders and confirmed the dietician's recommendation to increase house supplement to TID had not been implemented.

Based on record reviews and interview the facility failed to ensure there was a sufficient number of skilled licensed nurses, nurse aides, and other nursing personnel to provide care and respond to each resident's basic needs. The facility failed to provide the minimum required staffing hours for 14 of 25 weekend days. Findings: Review of the facility's PBJ (Payroll Based Journal) Staffing Data Report for FY (Fiscal Year) Quarter 2 2023 (January 1-March 31) revealed the submitted weekend staffing data was excessively low. Review of the facility's Staffing Pattern forms for weekends from Fiscal Year Quarter 2 revealed the facility: Provided 210.8 hours on 01/01/2023 and were required to provide 260.8 hours. Provided 262.5 hours on 01/22/2023 and were required to provide 265.5 hours. Provided 220 hours on 02/05/2023 and were required to provide 267.9 hours. Provided 259 hours on 02/11/2023 and were required to provide 267.9 hours. Provided 244.5 hours on 02/12/2023 and were required to provide 265.5 hours. Provided 247.5 hours on 02/18/2023 and were required to provide 267.9 hours. Provided 225 hours on 02/19/2023 and were required to provide 267.9 hours. Provided 265.7 hours on 02/25/2023 and were required to provide 267.9 hours. Provided 249 hours on 02/26/2023 and were required to provide 267.9 hours. Provided 248.75 hours on 03/04/2023 and were required to provide 267.9 hours. Provided 247.5 hours on 03/05/2023 and were required to provide 267.9 hours. Provided 251.2 hours on 03/12/2023 and were required to provide 265.5 hours. Provided 266.5 hours on 03/19/2023 and were required to provide 267.9 hours. Provided 256.2 hours on 03/26/2023 and were required to provide 267.9 hours. During an interview on 08/01/2023 at 9:15 a.m. S2 Administrator In Training and S1 Administrator confirmed the facility did not provide the minimum required hours on 01/01/2023, 01/22/2023, 02/05/2023, 02/11/2023, 02/12/2023, 02/18/2023, 02/19/2023, 02/25/2023, 02/26/2023, 03/04/2023, 03/05/2023, 03/12/2023, 03/19/2023, 03/26/2023 and should have.

Based on record review and interview the facility failed to ensure a resident with an indwelling catheter received appropriate care and services to prevent urinary tract infections for 1 (#73) of 2 (#54, #73) residents reviewed for urinary catheter or UTI (urinary tract infection). The facility failed to ensure Resident #73's indwelling catheter was changed as ordered. Findings: Review of Resident #73's medical record revealed Resident #73 had an admitted [DATE], with a readmission on 06/22/2023, and had diagnoses that included, in part, benign prostatic hyperplasia with lower urinary tract symptoms, other obstructive and reflux uropathy, other retention of urine, unspecified kidney failure, type 2 diabetes mellitus, atherosclerotic heart disease, vascular dementia, and essential hypertension. Review of Resident #73's physician orders revealed: -07/23/2023 order for Change 24Fr (French)/30cc (cubic centimeters) foley catheter monthly. -06/22/2023 Foley catheter at all times for urine collection related to retention Review of Resident #73's June, July and August 2023 MAR (medication administration record) failed to reveal Resident #73's catheter had been changed since Resident #73's readmission on 06/22/2023 when Resident #73 had a catheter. Review of June and July 2023 progress notes failed to reveal Resident #73's foley catheter had been changed. Review of Resident #73's MDS (minimum data set) with assessment reference date of 06/27/2023 revealed Resident #73 had a BIMS (brief interview mental status) score of 9, indicating Resident #73 was moderately impaired cognitively. Resident #73's 06/27/2023 MDS further revealed Resident #73 had an indwelling catheter. During an interview on 08/02/2023 at 7:54 a.m. Resident #73 responded yes when asked if he had a catheter and a bag that hung on his leg. Resident #73 further reported he had the catheter about a month and the catheter had not been changed since it was put in. During an interview on 08/02/2023 at 9:12 a.m. S5 LPN (Licensed Practical Nurse) reported Resident #73's catheter was put in outside the facility about 2 months ago. S5 LPN further reviewed Resident #73's medical record and confirmed Resident #73's foley catheter had not been changed since 06/22/2023 and should have been changed monthly.

Based on record reviews and interviews, the facility failed to ensure a resident's medical record reflected the resident's advance directive choices for 1 (#109) of 29 sampled residents. The facility failed to ensure each of Resident #109's code status documentation was in agreement. Findings: Review of Code Blue-Licensed Nursing Staff document provided by S3 DON (Director of Nursing), who reported the document was used for staff training revealed: This procedure is to be followed when any resident is found unresponsive, no breathing or no normal breathing (gasping). . 3. Licensed Nursing Staff to establish code status: Review the resident's medical record, this is the most reliable way to know the resident's code status. The chart review is critical and is to be done quickly while the resident is being assessed, prior to initiating CPR (Cardiopulmonary Resuscitation). Review of Resident #109's medical record revealed an admitted [DATE] with diagnoses that included, in part, type 2 diabetes mellitus, essential hypertension, metabolic encephalopathy, atherosclerotic heart disease of native coronary artery without angina pectoris, chronic viral hepatitis C, major depressive disorder, nicotine dependence and vascular dementia. Review of Resident #109's current physician orders revealed a [DATE] order for Initiate CPR (cardiopulmonary resuscitation). Review of document titled Declaration Competent Resident signed by resident on [DATE] revealed: -Declaration made this May day of 2023 (month, year). I, [NAME] being of sound mind, willfully and voluntarily make known my desire that my dying shall not be artificially prolonged under the circumstances set forth below, do here by declare: . __check mark__Do use CPR In the absence of my ability to give directions regarding the use of such life-sustaining procedure, it is my intention that this declaration shall be honored by my family and physician as the final expression of my legal right to refuse medical and surgical treatment and accept the consequences from such refusal. Review of Resident #109's paper chart binder revealed an orange sticker on the spine that read DNR, indicating Resident #109 was a DNR. During an interview on [DATE] at 2:40 p.m. S5 LPN (Licensed Practical Nurse) reported if a resident's code status was needed quickly she would look at either the DNR list on back of door at the nurse's station, the spine of the resident's paper chart binder or the code status list on the medication cart. S5 LPN observed the DNR list and the spine of Resident #109's paper chart binder and reported they did not agree and should have. During an interview on [DATE] at 2:55 p.m. S2 AIT (Administrator in Training) reported Resident #109 had never been a DNR and the DNR sticker should not have been on the spine of the paper chart binder.

Based on record review and interviews the facility failed to ensure a resident's plan of care was implemented for 1 (#1) of 5 (#1, #5, #6, #53, #109) residents who were reviewed for unnecessary medications. The facility failed to ensure resident #1's insulin was given as ordered by a physician. Findings: Review of the facility's Insulin Guidelines policy revealed the following; 1. Insulin is administered following doctors orders with an insulin syringe. Review of resident #1's medical record revealed an admitted [DATE] with a diagnosis of but not limited to Type 2 Diabetes Mellitus and long term use of insulin. Review of resident #1's July 2023 Physicians Orders revealed an order for Novolin N 100 units/ml (millimeter) vial, inject 30 units subcutaneously every morning. Review of resident #1's Comprehensive plan of care revealed a problem of Potential for altered nutrition with the approach of administer insulin as ordered. Review of resident #1's July 2023's MAR (medication administration record) revealed Novolin N 30 units was documented as not given at 6:30 a.m. on 07/10/2023 and 07/11/2023. During an interview on 08/02/2023 at 9:00 a.m. S4 Corporate Nurse and S3 DON (Director of Nurses) confirmed resident #1 was not administered insulin as ordered on 07/10/2023 and 07/11/2023. During an interview on 08/02/2023 at 10:37 a.m. S2 Administrator in Training confirmed resident #1 was not administered insulin on 07/10/2023 and 07/11/2023 as ordered because it was not in stock at the facility.

Based on record reviews and interview, the facility failed to ensure individuals with convictions barring employment were not employed by the facility for 1 (S2 CNA [Certified Nursing Assistant] Student) of 5 (S2 CNA Student, S3 CNA, S4 CNA, S5 CNA, S6 CNA) personnel records reviewed. Findings: Review of the facility's Screening: Criminal Background Checks policy revealed in part: It is the responsibility of all employers that employ non-licensed persons or ambulance personnel to know which convictions bar employment. Louisiana Revised Statute 40:1203.3 covers criminal convictions that bar an employer from hiring a non-licensed person or ambulance personnel. Those criminal convictions are listed in the following table .14:67 Theft-Felony .*if results of the Criminal Background Check reveal that a non-licensed person or any licensed ambulance personnel hired on a temporary basis or any other person who is an employee has been convicted of any of the offenses listed above, the employer shall immediately terminate the person's employment. Review of S2 CNA Student's personnel file revealed a hire date 09/09/2022, and a criminal background check completed on 08/23/2022. Further review revealed S2 CNA Student was a felon with a conviction of charge R.S. 14:67 Theft of goods over $500. Further review revealed no documentation the charge had been reduced. During an interview on 01/10/2023 at 4:15 p.m., S1 Administrator verified S2 CNA Student's background check showed a conviction that would be deemed a conviction barring employment, and the employee should not have been hired to work at the facility.

Based on record reviews and interviews the facility failed to monitor 1 (#4) out 6 (#1, #2, #3, #4, #5, #6) sampled residents reviewed for unnecessary medications. The facility failed to monitor Resident #4 for target behaviors, moods and side effects of [CONDITION(S)] (antipsychotic and depression medications). Findings: Review of Resident #4's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident #4's March 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] 50mg (milligram) tablet one daily for depression [MEDICATION(S)] 7.5mg tablet one by mouth at bedtime for mood [MEDICATION(S)] DR (delayed release) 500mg tablet one by mouth twice daily for mood Review of Resident #4's March 2022 MAR (Medication Administration Record) with S5 LPN (Licensed Practical Nurse) failed to reveal monitoring for behaviors, moods and side effects of [CONDITION(S)] medications (antipsychotics and depression medications). During an interview on 3/23/2022 at 12:10 PM S5 LPN confirmed Resident #4 should have been monitored for behaviors, moods and side effects while receiving [CONDITION(S)] medications and had not been. During an interview on 3/23/2022 at 1:00 PM S2 DON (Director of Nursing) confirmed Resident #4 was not monitored for moods, behaviors and side effects while receiving [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)] and should have been.

Based on observation and interview the facility failed to ensure 2 (#3, #4) out of 6 (#1, #2, #3, #4, #5, #6) sampled residents had a clean/ safe environment as evidenced by cove base not attached to the wall, standing water settled around the seal of toilet, and floors in disrepair. Findings: Observation of the physical environment on 3/23/2022 at 9:00 AM of Resident #3 and #4's shared bathroom with S4 Maintenance revealed the cove base was not attached to the wall, water settled around the seal of the toilet, and the bathroom floor was buckled under the sink. Observation of flooring revealed there were rows of tiles leading into Resident #3 and #4 shared bathroom that were not secured to the floor. During an interview on 3/23/2022 at 9:00 AM S4 Maintenance confirmed the cove base was not attached to the wall, there was water around the seal of the toilet, and the bathroom floor was buckled under the sink. S4 Maintenance reported there were ongoing issues with the building's foundation; especially after rain. Observation on 3/23/2022 at 9:05 AM revealed S4 Maintenance had housekeeping staff mop Resident #3 and Resident #4's bathroom floor, then flush the toilet in resident #3 and #4's bathroom and again the floor was wet around toilet seal. During an interview on 3/23/2022 at 11:00 AM S4 Maintenance reported he could not correct the foundation issues he could only continue to repeatedly make temporary repairs to the building.

FACILITY Based on observations and interviews the facility failed to ensure necessary maintenance services to maintain the facility in good repair for 3 (#15, #49, #94) out of 3 residents reviewed for environment. Findings: Observation on 07/20/21 at 2:17 PM of Resident #15's room revealed missing floor tiles for about 5 feet in length by 2 feet in width between the resident's bed and back wall. Observation on 7/21/21 at 9:00 AM revealed Resident #15's room revealed about 5 feet in length by 2 feet in width between her bed and the back wall. Further observation of resident #15's room revealed broken sheet rock, missing base board and bathroom door facing was broken and not intact. Observation on 7/21/21 at 8:51AM of Resident #49's room with S9 Maintenance revealed missing floor tiles at the far wall for the length of the room and about five rows deep that led into the bathroom. During an interview on 7/21/2021 at 8:51AM S9 Maintenance reported he has to keep replacing the floor tiles in Resident #49's room because it gets wet from the bathroom and the tiles come up. Observation on 7/18/2021 at 11:53AM of Resident #94's room revealed 2 floor tiles that were not attached to the floor leading to the bathroom. Observation on 7/21/21 at 9:00AM of Resident #94's room revealed 2 floor tiles that were not attached to the floor leading to the bathroom. During an interview on 7/21/21 at 9:04AM S10 Administrator observed the missing floor tiles in Resident #49's room and reported the tiles came up after a flood from all the rain. S1 Administrator was then informed of the missing floor tiles in Resident #15 & #94's room and reported he was aware. Surveyor then requested work orders for past tile replacement. During an interview on 7/21/2021 at 9:20 AM S9 Maintenance reported he was aware of the maintenance issues in the rooms for Residents #15, #49, and #94. S9 Maintenance reported he did not keep the completed work orders and did not have any documentation of floor tile repairs for Residents #15, #49, and #94.

Based on record review and interviews the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 (#307) of 6 (#40, #56, #61, #92,#157, #307) residents reviewed for unnecessary medications by failing to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Findings: Review of Resident #307's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #307's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 7/9/21 order: [MEDICATION(S)] Flextouch 100 unit/ml (units per milliliter) inject 16 units subcutaneously once a day (This medication is a long acting insulin used to manage your blood sugar) 7/9/21 order: [MEDICATION(S)] 1.5mg/0.5ml pen inject one pen injector subcutaneously once a week. ([MEDICATION(S)] is a diabetes medication that helps your body release its own insulin) 7/11/21-[MEDICATION(S)] R 500 unit/ml Kwikpen (per sliding scale based on blood glucose level), 0-199=zero units, 200-250=2 units, 251-300=4 units, 301-350=6 units, 351-400=9units, 401--1000=12 units, recheck in one hour and notify Nurse Practioner if greater than 400. ([MEDICATION(S)] R is a short acting insulin) Further record review revealed Resident #307's blood sugar was 568mg/dl (milligrams per deciliter) at 5:31PM on 7/11/21. Review of nurses' notes and July 2021 MAR (Medication Administration Record) failed to reveal Resident #307 received any sliding scale [MEDICATION(S)] R as ordered for his 568 blood glucose level on 7/11/21. Further review failed to reveal his blood glucose was rechecked in one hour or the physician/nurse practioner was notified. Review of the July 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The first documented dose of [MEDICATION(S)] administration was on 7/13/21 and the first documentation of [MEDICATION(S)] being given was on 7/20/21. In an interview on 7/21/21 at 10:20AM, S8 LPN (Licensed Practical Nurse), who documented Resident #307's blood glucose of 568 on 7/11/21, confirmed she was unable to find any documentation in the medical record of treating the resident with [MEDICATION(S)] R sliding scale insulin, rechecking the level in one hour, or notifying the resident's physician. In an interview on 7/21/21 at 12:07PM, S1DON (Director of Nurses) confirmed the [MEDICATION(S)] was not documented as given until 07/20/21 and the [MEDICATION(S)] was not documented as given until 7/13/21. S1 DON acknowledged there was no documentation of the [MEDICATION(S)] R sliding scale being administered for the 568 blood glucose level, the blood glucose being rechecked in one hour, or the physician/nurse practioner being notified for a blood sugar over 400.

Based on observations and interview, the facility failed to ensure dietary services were provided in a sanitary environment for residents served meals from the kitchen. The facility failed to ensure dietary staff followed proper sanitation and food handling practices by not wearing hairnets, sanitizing their hands and correctly performing chemical and temperature checks for the dish machine or 3 compartment sinks. According to the facility's Resident Census and Condition form the facility had a total census of 110 resident. Findings: Observation of the kitchen on 7/18/2021 at 9:11 am revealed the breakfast food on the steam table. Observation revealed kitchen staff working with the food, placing the food on the plates, on the food carts, touching the feeding utensils and food trays. The dietary staff did not have hairnets on. The dietary staff were not washing and sanitizing their hands. Observation on 7/18/2021 at 9:15 am revealed S3 Dietary Worker working in the kitchen did not have a hairnet. S3 Dietary Worker mopped a spill from the kitchen floor and did not wash or sanitize her hands before entering the kitchen and working with the food. Observation on 7/18/2021 at 9:22 am revealed S4 Dietary Worker enter the kitchen without a hairnet on and failed to wash and sanitize her hands. S4 Dietary Worker was observed touching the dishes, and other kitchen food containers. During an interview on 7/18/2021 at 11:23 am S2 Dietary Manager confirmed hands were to be cleaned and sanitized before entering the kitchen for work. S2 Dietary Manager confirmed if you leave the kitchen for any reason you are to wash and sanitize your hands again before returning to work in the kitchen. She reported anyone entering the kitchen was to have a hairnet on. S2 Dietary Manager confirmed they have a hand washing station and hand sanitizer that should have been used. Review of the July 2021 Temperature/Chemical Log (Dish machine or Pot/Pan sink or other sanitizing solutions) with the Dietary Manager revealed the temperature and chemicals were not checked July 14, 15, 16, 17 and 18. Further review of the 3-Compartment Sink chemical check logs failed to reveal the chemicals where checked July 14, 15, 16, 17 and 18. During an interview on 7/18/2021 at 11:30 am S2 Dietary Manager confirmed the Temperature/Chemicals for the dishwasher and the 3-Compartment sink should be checked daily and they were not. S2 Dietary Manager reported she had a lot of new staff and she was still working on getting everyone trained. Observation on 7/19/2021 at 12:00 pm revealed S5 Dietary Worker working in the kitchen without a hairnet. S5 Dietary Worker was placing food on the residents' plates, pulling at her pants, touching her face with her bare hands and handling the food and utensils without washing or sanitizing her hands.

Based on interviews and record review the facility failed to ensure dietary choices were honored for 1 of 1 (#97) residents reviewed for dietary choices. The facility continued to serve resident #97 food she disliked and did not eat. The facility had a total census of 110 resident. Findings: During an interview on 7/19/2021 at 10:45 am Resident #97 reported she had talked with the Dietician on several occasions to let her know her food preferences. Resident #97 reported the Dietician listed the foods she does not eat on her meal ticket. Resident #97 reported the dietary staff continue to send her foods she does not eat on her tray. Resident #97 said, for example she do not eat breakfast sausages and it was served on her tray yesterday morning. Resident #97 reported you are never made aware of what the alternate meal will be. Review of resident #97's Quarterly MDS (minimum data set) with ARD (assessment reference data) 6/21/2021 revealed a BIMS score (brief interview for mental status) of 15 out of 15 indicating the resident was cognitively intact. Review of resident #97's Comprehensive Care Plan revealed a potential for altered nutrition and dehydration. Some approaches included determine food preferences, monitor % meal intake and offer alternate if less than 50% consumed. Review of resident #97's July 2021 Physician orders revealed an order dated 12/7/2021 Regular Diet. Review of the facility's most recent Nutrition Screening and Evaluation dated 3/27/2020 completed by the previous dietary manager documented resident consumes 75 - 100 % of her Regular Diet. She eats in her room self-fed. She has no chewing or swallowing problems. HT: 64 WT. 236 #, IBW- 108-132# She voices no food complaints and voices she dislikes bologna, salami, turkey pot pie, mixed vegetables, breakfast sausage, dark meat chicken she has a food preferences of white chicken and bacon for breakfast, no skin issues noted. During an interview on 7/20/2021 at 12:00 pm S2 Dietary Manager reported she has new employees working in the kitchen and they just got the meal tickets mixed up. S2 Dietary Manager reported she had talked with resident #97 and she is aware of her likes and dislikes. S2 Dietary Manager reported resident #97 likes pasta but we do not serve a lot of pasta. During an interview on 7/20/2021 at 1:00 pm resident #97 reported today for breakfast she received toast and eggs on her tray, something she does not eat. Review of resident #97's meal ticket on her lunch tray 7/20/2021 at 1:00 pm revealed a list of her dislikes and a special note on the meal ticket listed the additional dislikes and food preferences.

Based on observation and interview the facility failed to ensure the nurse staffing data was posted daily at the beginning of each shift readily accessible to residents and/or visitors. The facility had a total census of 110 residents. Findings: Observation on 7/19/21 at 10:45 AM with S1 DON (Director of Nursing) revealed the daily nurse staffing data that was posted had a date of 7/15/2021. Further observation revealed the posted nurse staffing data had not been updated since 7/15/21. During an interview on 7/19/2021 at 10:45 AM S1 DON confirmed the nurse staffing data was not posted since 7/15/2021 and it should have been posted daily.

Based on record review, observations and interviews the facility failed to ensure ADLs (activities of daily living) were performed for 1 of 1 (#49) resident reviewed for activities of daily living. The facility failed to ensure resident #49 received nail care. Findings: Observation on 07/18/2021 at 10:56 am revealed resident #49's fingernails were long and had brown build-up under nail beds. During an interview on 7/18/201 at 10:56 am resident #49 reported he would like to have his fingernails cut. Review of resident #49's record revealed resident was care planned for a self- care ADL deficit with interventions that included assistance needed with bathing, hygiene, dressing, grooming and fingernails cleaned and trimmed as needed. Observation on 7/20/2021 at 8:50 am revealed resident #49's finger nails were long and jagged, with brown build-up under nails. During an interview on 7/20/2021 at 8:51 am, S6 CNA (Certified Nursing Assistant) acknowledged resident #49's finger nails were long and should have been cut. During an interview on 7/20/2021 at 8:52 am S7 Activities Director confirmed resident #49's nails were long and needed to be trimmed and cleaned up. During an interview on 7/20/2021 at 8:55 am S1 DON (Director of Nursing) acknowledged resident #49's nails were long and needed to be trimmed.

Based on record review and staff interview, the facility failed to coordinate assessment with the PASARR program by failing to refer residents with newly evident or possible serious mental disorder, intellectual disability, or related conditions for review by the State-designated Level II authority for 8 (# 10, 23, 25, 29, 69, 85, 87, and 109) of 9 (# 10 ,23, 25, 29, 49, 69, 85, 87, and 109,) reviewed for PASARR out of a total of 10 system identified residents having [DIAGNOSES REDACTED]. Findings: Resident #10 was admitted to this facility 1/25/18. Review of Form 142, Notice of Medical Certification, revealed Resident #10 was approved for nursing facility admission through medical eligibility on 4/3/17. Record review revealed Resident #10 carried a [DIAGNOSES REDACTED]. Review of the MDS with an ARD of 9/11/19 revealed the facility currently identified Resident #10 with [DIAGNOSES REDACTED]. Resident #10 had in-patient psychiatric admissions on 4/18/18, 7/27/18, 8/18/18, 6/1/19, and 9/11/19. The facility had no documented evidence Resident #10 was referred/reviewed by the State's Level II authority. Resident #23 was admitted to this facility on 8/1/17. Review of Form 142, Notice of Medical Certification, revealed Resident #23 was approved for nursing facility admission through medical eligibility on 9/20/16. Record review revealed a [DIAGNOSES REDACTED].#23 which included a [DIAGNOSES REDACTED]. Review of the Resident #23's MDS with an ARD of 6/19/19 revealed the facility currently identified a [MEDICAL CONDITION] diagnosis. The facility had no documented evidence that this resident was referred to the State's Level II authority for review. Resident #25 was admitted to this facility on 9/30/10. Review of Form 142, Notice of Medical Certification, revealed Resident #25 was approved for nursing facility admission through medical eligibility on 9/22/04. This 142 form indicated the resident's [DIAGNOSES REDACTED]. The facility had no documented evidence of the Level I PASARR utilized at that time. Record review revealed Resident #25 was diagnosed with [REDACTED]. Review of the facility's MDS with an ARD of 6/19/19 revealed the facility identified Resident #25 with [DIAGNOSES REDACTED]. The facility had no documented evidence of Resident #25 being referred to the Level II Authority for review and approval. Resident #29 was admitted to this facility on 8/24/2006 on a court commitment. Review of Form 142, Notice of Medical Certification revealed Resident #29 was approved for nursing facility admission through medical eligibility on 8/24/06. Record review revealed Resident #29 had [DIAGNOSES REDACTED]. Review of Resident #29's MDS with an ARD of 6/24/19, revealed the facility currently identified a [DIAGNOSES REDACTED]. Further review revealed Resident #29 had in-patient psychiatric stays on 7/19/11, 5/15/14, 5/19/14, 10/18/14, 11/21/14, 6/5/15, 3/8/16, 4/16/17, and 4/28/17. Record review revealed no documented evidence that Resident #29 had ever been referred for a Level II evaluation. Resident #69 was admitted to the facility on [DATE] by court commitment. Review of Form 142, Notice of Medical Certification, revealed Resident #69 was approved for nursing facility admission through medical eligibility on 10/3/2008. The Form 142 also revealed that Vendor payment to the nursing facility is approved effective 11/18/19; Level II necessary with admission. The facility had no documented evidence of this Level II on file. Record review revealed a [DIAGNOSES REDACTED]. There was no documented evidence that Resident #69 was referred to the State's Level II Authority for review for potential mental health service needs. Resident #85 was admitted to this facility on 9/11/12. Review of Form 142, Notice of Medical Certification, revealed Resident #85 was approved for nursing facility admission through medical eligibility effective 9/7/12. Review of Resident #85's record revealed [DIAGNOSES REDACTED]. Review of Resident #85's MDS with an ARD of 8/8/19 revealed the facility currently identified the [DIAGNOSES REDACTED]. Further record review revealed Resident #85 had in-patient psychiatric admissions on 3/8/04, 6/3/15, 8/10/16, 8/15/17, and 8/28/17. There was no documented evidence that Resident #85 was referred to the State's Level II authority for review. Resident #87 was admitted to this nursing facility on 9/18/18. Revie of Form 142, Notice of Medical Certification, revealed Resident #87 was approved for nursing facility admission on 10/16/15 through medical eligibility. Record review revealed a [DIAGNOSES REDACTED]. Review of the MDS with an ARD of 8/12/19 revealed the facility currently identified Resident #87 with [DIAGNOSES REDACTED].#87 was reviewed by the State's Level II authority. Resident #109 was admitted to this nursing facility on 8/28/14. Review of Form 142, Notice of Medical Certification, revealed Resident #109 was approved for nursing facility admission on 12/9/14 through medical eligibility. Record review of Resident #109 revealed a [DIAGNOSES REDACTED]. Record review revealed Resident #109 was admitted to an in-patient psychiatric hospital on [DATE], and 9/11/19. There was no documented evidence that Resident #109's records were submitted to the State's Level II authority for review. During an interview and review of the above resident records with S2CN and S3SSD, on 9/19/19 starting at 9:00 AM, S2CN reviewed the records listed above and confirmed that the facility did not currently have documented evidence of Level II referrals on these residents, but were checking with the State's Level II authority. During an interview with S1ADM on 9/19/19 at 8:40 AM, S1ADM stated that the facility contacted the State's Level II authority, and they were informed that the State had no record of Level II evaluations on file for the above residents. .

Based on observations, staff interviews and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by: 1. Personnel failing to handle, store and process linens so as to prevent the spread of infection; 2. Failing to have contact isolation sign posted on the door, and a staff member not putting on the required Personal Protective Equipment (PPE) for 1 (#260) out of 1 (#260) residents on transmission based precautions. This deficient practice had the potential to affect the facility's census of 113 residents. Findings: #1 Observation during a tour of the facility's laundry area on 09/19/19 at 09:30 AM with S7LW revealed dirty clothes were stored on the floor between two washing machines. Further observations behind the washing machine located next to the dryers revealed a large amount of lint and dust on the water hose, the electrical cords and the air vent of the washing machine. Interview on 9/19/19 at 9:30 AM with S7LW revealed the clothes on the floor between the two washing machines were dirty and that they should have been stored in the dirty clothes barrels until they were placed in the washing machine. Interview on 9/19/19 at 9:35 AM with S8HS confirmed that dirty clothes should not be placed on the floor and that they should have been stored in the dirty clothes barrels until being placed in the washing machine for washing. Further interview with S8HS confirmed there was a large amount of lint and dust on the water hose, the electrical cords and the air vent of the washing machine next to the dryers and it should not have been. #2 Review of Resident #260's (MONTH) 2019 Physician order [REDACTED]. Review the facility's Contact precautions Policy and Procedure revealed in part: Implementation: place a contact precautions sign outside the patient's room door, as required by facility to notify anyone entering the room of the situation. Put on a gown and gloves before entering the patient's room An observation on 09/16/19 at 10:00 AM, revealed S5RN entering Resident #260's room wearing a mask, gown, and gloves. Further observation did not reveal any Precaution sign posted on the door. S5RN stated at that time that Resident #260 was on isolation precaution for VRE and had just returned from the hospital for a fistula revision, and she was checking the site. Further observation revealed a plastic three drawer bin near the doorway containing a box of gloves, face mask, and yellow isolation gowns. On 09/16/19 at 10:15 AM, an interview was conducted with S4DON. S4SDON was asked how visitors for Resident #260 would be made aware of isolation precautions and the steps to take for this precaution? S4DON pointed to the isolation supply cart outside the door. When asked specifically about outside visitors who may be unaware of what the cart represented, would be made aware of precaution procedures. He confirmed that a sign should be on the door to alert visitors of the Contact Isolation Precaution. On 09/17/19 at 08:22 AM, an observation was made of Resident #260 being fed by S6CN[NAME] S6CNA was observed not wearing gloves and gown while feeding the resident. S6CNA confirmed the resident was still on contact isolation, and stated he was only in the room to feed the resident and did not have to wear gown and gloves. On 09/17/19 at 08:25 AM, an interview was conducted with S5RN. She revealed that S6CNA should have worn gown and gloves while feeding the resident. She observed S6CNA in the room feeding Resident #260 without donning PPE. She stated S6CNA needed to be re-trained on the procedure and she would do so immediately. On 09/17/19 at 08:50 AM, an interview was conducted with S4DON. He confirmed S6CNA should have worn the required PPE for Contact Precautions when feeding Resident #260.