Every finding on record at Jo Ellen Smith Convalescent Center

Based on interviews and record reviews, the facility failed to ensure a resident's right to refuse life sustaining treatment would be carried out for 2 (Resident #51, Resident #65) of 30 sampled residents screened for advanced directives. Findings:Review of the Louisiana Physician Orders for Scope of Treatment (LaPOST) Handbook for Long Term Care Professionals, dated 01/2024, revealed, in part, if a resident chose to complete the LaPOST form, it must be followed by healthcare providers and must be signed by a physician to be valid. Further review revealed if there was a substantial change in the person's treatment goals including a reversal of a prior directive, a new LaPOST should have been completed and the old LaPOST properly voided. Further review revealed to void the LaPOST form, a line should be drawn through Physician's Orders, VOID written in large letters, and the form should be signed/dated. Review of the facility's Emergency Cardiopulmonary Resuscitation (CPR) (an emergency procedure that combines chest compressions and rescue breathing to keep blood circulating) policy and procedure, with a revision date of [DATE], revealed, in part, if the resident's Do Not Resuscitate (DNR) (a healthcare provider should not perform CPR if a resident's heart stopped beating or a resident stopped breathing) status is unclear, CPR would be initiated. Review of the facility's Advanced Directive policy and procedure, with a revision date of [DATE], revealed, in part, residents had the right to refuse treatment, and residents would not be treated against their own wishes. Resident #51Review of Resident #51's electronic medical record (EMR) revealed, in part, Resident #51 had requested DNR code status. Review of Resident #51's [DATE] physician's orders revealed, in part, an order dated [DATE] for Resident #51 to be a DNR. Review of Resident #51's physical chart revealed, in part, Resident #51 signed a LAPOST form on [DATE] which indicated his wishes were to have a DNR code status. Further review revealed Resident #51's LaPOST form was not signed and/or dated by a physician as required. Further review revealed no other LaPOST forms were noted in Resident #51's physical chart. In an interview on [DATE] at 10:47AM, S9Licensed Practical Nurse (LPN) indicated Resident #51's LaPOST form, which indicated Resident #51 should have a DNR code status, was not signed and dated by a physician as required and therefore was not valid. S9LPN further indicated she would perform CPR on Resident #51 in the event Resident #51 went into cardiac arrest due to the above mentioned LaPOST not being valid. In an interview on [DATE] at 10:50PM, S8LPN indicated Resident #51's LaPOST form, which indicated Resident #51 should have a DNR code status, was not signed and dated by a physician as required and therefore not valid. S8LPN further indicated she would perform CPR on Resident #51 in the event Resident #51 went into cardiac arrest. On [DATE] at 11:20AM, S2Director of Nursing (DON) was presented with a request for all of Resident #51's advanced directive paperwork, LaPOST, and/or code status paperwork. In an interview on [DATE] at 11:20AM, S10LPN indicated if a resident's LaPOST indicated a resident should have a DNR code status, but was not signed by a physician, she would have initiated CPR on that resident in the event the resident went into cardiac arrest. In an interview on [DATE] at 11:30AM, S12LPN indicated if a resident had an electronic order for a DNR, and had a LaPOST that indicated DNR but was not signed by the physician in their physical chart, she would have initiated CPR in the event the resident went into cardiac arrest. In an interview on [DATE] at 11:30AM, S2DON confirmed Resident #51's LaPOST was not signed and dated by a physician. S2DON further confirmed Resident #51's request to be a DNR status and therefore nursing staff should not perform CPR in the event Resident #51 went into cardiac arrest. Resident #65Review of Resident #65's Electronic Medical Record (EMR) revealed, in part, Resident #65 had requested DNR code status. Review of Resident #65's [DATE] physician's orders revealed, in part, an order dated [DATE] which indicated Resident #65's code status was changed to DNR. Review of Resident #65's physical chart revealed, in part, a green sheet of paper with the words full code inside under the advanced directive section. Further review revealed a LaPOST form, dated [DATE], which indicated Resident #65 was a full code status (a healthcare provider should perform CPR if a resident's heart stopped beating or a resident stopped breathing). Further review revealed no other LaPOST forms in Resident #65's physical or electronic charts. Review of Resident #65's care plan, initiated on [DATE], with a target date of [DATE], revealed, in part, Resident #65's code status was full code with an approach that included begin CPR and call 911 as soon as possible and ensure all caregivers were aware of resident's full code status. In an interview on [DATE] at 2:00PM, S4Assistant Director of Nursing (ADON) indicated the resident's updated LaPOST forms are kept in the resident's medical record binders located at the nurse's stations. In an interview on [DATE] at 10:47AM, S9LPN indicated she would check the Resident #65's physical chart to verify Resident #65's code status. S9LPN further indicated inside Resident #65's physical chart, was Resident #65's LaPOST, dated [DATE], which indicated staff should perform CPR and/or attempt resuscitation, was the only LaPOST in Resident #65's physical chart. S9LPN further indicated since Resident #65's LaPOST indicated Resident #65 had a full code status, she would perform CPR on Resident #65 in the event Resident #65 went into cardiac arrest. In an interview on [DATE] at 10:50PM, S8LPN indicated inside Resident #65's physical chart, was Resident #65's LaPOST, dated [DATE], which indicated staff should perform CPR and/or attempt resuscitation, was the only LaPOST in Resident #65's physical chart. S8LPN further indicated since Resident #65's LaPOST indicated Resident #65 had a full code status, she would perform CPR on Resident #65 in the event Resident #65 went into cardiac arrest. On [DATE] at 11:20AM, S2DON was presented with a request for all of Resident #65's advanced directive paperwork, LaPOST, and/or code status paperwork. In an interview on [DATE] at 11:20AM, S10LPN indicated if a resident's record indicated resident was a DNR, she would check the resident's LaPOST for details. S10LPN further indicated there should not be a discrepancy between the code status orders in the computer and the LaPOST or advances directives in the resident's physical chart. In an interview on [DATE] at 11:30AM, S11LPN indicated she would check code status for a resident in the resident's physical chart first using LaPOST. S11LPN further indicated if a resident was a full code, the resident's chart would have a green cover sheet that stated full code. S11LPN further indicated the physical chart and EMR should have the same designation. In an interview on [DATE] at 11:30AM, S12LPN indicated that there should not be a discrepancy in the resident's code statuses. In an interview on [DATE] at 11:30AM, S2DON indicated she could not find any advanced directive and/or LaPOST in Resident #65's EMR that indicated Resident #65 had elected to be a DNR. S2DON further indicated nurses should follow the physician's orders and should not perform CPR on Resident #65 in the event Resident #65 went into cardiac arrest. In an interview on [DATE] at 11:35AM, S5Admissions indicated inside Resident #65's physical chart, was Resident #65's LaPOST, dated [DATE], which indicated staff should perform CPR and/or attempt resuscitation, was the only LaPOST in Resident #65's physical chart. S5Admissions confirmed the LaPOST in Resident #65's physical chart should match the code status on Resident #65's EMR. In an interview on [DATE] at 3:00PM, S1Administrator confirmed Resident #51 and Resident #65 should have had DNR as their code statuses as per their EMR and physician orders. S1Administrator further indicated physical charts were available at the nurse's station but facility staff should not have used resident's physical charts to make decisions regarding a resident's code status. In an interview on [DATE] at 2:55PM, S3Clinical Quality Improvement Nurse (CQIN) confirmed Resident #51's and Resident #65's physical charts were available at the nurse's station but the physical charts should not have been used by the nurses. S3CQIN further indicated Resident #65's care plan should have reflected that Resident #65's code status had changed to a DNR. S3CQIN further confirmed Resident #65's physical chart had a green sheet of paper inside with the words Full Code on it. S3CQIN further confirmed Resident #65's physical chart conflicted with Resident #65's EMR physician's orders and should not have.

Based on observations, interviews, and record reviews, the facility failed to ensure a resident with limited range of motion received appropriate treatment and services for 1(Resident #65) of 1 resident reviewed for limited range of motion. Findings:Review of Resident #65's March 2026 physician's orders revealed, in part, an occupational therapy clarification order, dated 01/26/2026, for skilled occupational therapy provided Resident #65 bilateral upper extremity (BUE) hand rolls, and upon discharge nursing to carryover for application/removal and range of motion. Review of Resident #65's rehabilitation screen, dated 07/07/2025, revealed, in part, Resident #65 had bilateral hand contractures and would be evaluated by Occupational Therapy for hand roll fitting to prevent further decline. Observation on 03/09/2026 at 10:00AM revealed Resident #65 was in her room in her bed. Further observation revealed Resident #65 had bilateral hand contractures without hand rolls in place. In an interview on 03/11/2026 at 11:57AM, S6Occupational Therapist (OT) indicated Resident #65 was last seen by OT on 09/05/2025. S6OT further indicated Resident #65 was provided with bilateral hand rolls and they should be used daily to maintain skin integrity due to Resident #65's bilateral hand contractures. Observation on 03/11/2026 at 12:03PM revealed Resident #65 was in her room in her bed. Further observation revealed Resident #65 had bilateral hand contractures without hand rolls in place. Observation on 03/11/2026 at 12:50PM with S9Licensed Practical Nurse (LPN) revealed Resident #65's right and left hands were contracted, with her fingertips touching Resident #65's palms without hand rolls in place. In an interview on 03/11/2026 at 12:45PM, S9LPN confirmed Resident #65 did not have hand rolls. In an interview on 03/11/1026 at 3:00PM, S2DON confirmed Resident #65 should have hand rolls in place for her hand contractions.

Based on interviews and record reviews, the facility failed to maintain a system to accurately reconcile controlled substances for 2 (Medication Cart b, Medication Cart c) of 3 medication carts reviewed for the reconciliation documentation of controlled substances. Findings: Review of the facility's Controlled Substances policy and procedure, with a revision date of 12/2012, revealed, in part, nursing staff must count controlled medications at the end of each shift. Further review revealed the nurse coming on duty and the nurse going off duty must make the count together. Review of the facility's undated Controlled Drugs-Count Record form, revealed, in part, the nurse's signature acknowledges that they have counted the controlled drugs on hand and have found that the quantity of each medication counted is in agreement with the quantity stated on the Controlled Drug Administration Record. Review of the facility's December 2025 Medication Cart b Controlled Drugs Count Record revealed, in part, there was no signature that indicated the off going nurse had reconciled Medication Cart b's controlled substances with the oncoming nurse on:- 12/09/2025 for the 11:00PM to 7:00AM shift; and,- 12/13/2025 for the 3:00PM to 11:00PM shift.Further review revealed there was no signature that indicated the oncoming nurse had reconciled Medication Cart b's controlled substances with the off going nurse on 12/13/2025 for the 7:00AM to 3:00PM shift. Review of the facility's January 2026 Medication Cart c Controlled Drugs Count Record revealed, in part, there was no signature that indicated the off going nurse had reconciled Medication Cart c's controlled substances with the oncoming nurse on:- 01/29/2026 for the 3:00PM to 11:00PM shift; and,- 01/30/2026 for the 11:00PM to 7:00AM shift. Further review revealed there was no signature that indicated the oncoming nurse had reconciled Medication Cart c's controlled substances with the off going nurse on:- 01/29/2026 for the 7:00AM to 3:00PM shift; and,- 01/30/2026 for the 3:00PM to 11:00PM shift. Review of the facility's February 2026 Medication Cart c Controlled Drugs Count Record revealed, in part, there was no signature that indicated the off going nurse had reconciled Medication Cart c's controlled substances with the oncoming nurse on 02/16/2026 for the 11:00PM to 7:00AM shift. Further review revealed there was no signature that indicated the oncoming nurse had reconciled Medication Cart c's controlled substances with the off going nurse on 02/16/2026 for the 3:00PM to 11:00PM shift. In an interview on 03/10/2026 at 10:05AM, S8Licensed Practical Nurse (LPN) indicated the nurses' signature on the Controlled Drugs Count Record indicated the nurse had counted and accurately reconciled all the controlled substances on that medication cart. S8LPN further indicated the oncoming nurse and the off going nurse should have completed the controlled substance reconciliation and signed the medication cart's Controlled Drugs Count Record at the beginning of every shift. In an interview on 03/11/2026 at 7:50AM, S10LPN indicated the oncoming and off going nurses should have signed the Controlled Drugs Count Record at the end of every shift indicating the controlled substances were correctly reconciled. In an interview on 03/12/2026 at 12:45PM, S2Director of Nursing confirmed the above mentioned Controlled Drugs Count Records were not completed with a nurse's signature at the beginning and/or at the end of the nurse's shift as required, and should have been.

Based on interviews and record reviews, the facility failed to ensure medications were administered per physician's orders for 3 (Resident#1, Resident#2, Resident#3) of 3 residents reviewed for medication administration. Findings:Resident #1 Review of Resident #1's Minimum Data Set with an Assessment Reference Date of 12/10/2025 revealed, in part, Resident #1 had a diagnosis of type 2 diabetes. Review of Resident #1's January 2026 Physician's Orders revealed, in part, an order for Lantus 100 units/milliliter (a medication used to lower blood sugar), inject 26 units subcutaneously (medicine delivered into fatty tissue under the skin) two times a day with a start date of 08/19/2025 to be administered at 8:00AM and 8:00PM. Review of Resident #1's December 2025 Electronic Medication Administration Record revealed, in part, on 12/11/2025, 12/12/2025, 12/16/2025, 12/17/2025, 12/18/2025, 12/19/2025, 12/22/2025, and 12/25/2025 there was no documented evidence Resident #1 received 26 units of Lantus at 8:00AM per physician's orders. Review of Resident #1's January 2026 Electronic Medication Administration Record revealed, in part, on 01/01/2026, 01/02/2026, 01/05/02026, 01/06/2026, 01/08/2026, and 01/12/2026 there was no documented evidence Resident #1 received 26 units of Lantus at 8:00AM per physician's orders. In an interview on 01/15/2026 at 12:25PM, S3Licensed Practical Nurse indicated she did not administer Resident #1's Lantus on the above mentioned physician orders. In an interview on 01/15/2026 at 2:56PM, S1Director of Nursing indicated S3Licensed Practical Nurse had not administered Resident #1's Lantus as mentioned above per his physician's orders and should have. Resident #2 Review of Resident #2's clinical record revealed, in part, Resident #2 was admitted to the facility on [DATE] and had a diagnosis of diabetes mellitus without complications. Review of Resident #2's January 2026 Physician's Orders revealed, in part, an order to administer Ozempic (a medication used to lower blood sugar) 0.25 milligrams subcutaneously once a week on Friday in the morning with a start date of 12/12/2025. Review of Resident #2's January 2026 Electronic Medication Administration Record revealed, in part, Resident #2's Ozempic was not administered on 01/02/2026 in the morning. In an interview on 01/15/2026 at 9:00AM, S3Licensed Practical Nurse indicated she did not administer Resident #2's Ozempic on 01/02/2026 in the morning. In an interview on 01/15/2026 at 2:56PM, S1Director of Nursing indicated Resident #2 should have received her Ozempic as ordered on 01/02/2026. Resident #3 Review of Resident #3's clinical record revealed, in part, Resident #3 was admitted to the facility on [DATE] and had a diagnosis of type 2 diabetes mellitus. Review of Resident #3's January 2026 Physician's Orders revealed, in part, an order to administer Humulin 70/30 (a medication used to help lower blood sugar) 24 units subcutaneously in the morning at 8:00AM before breakfast with a start date of 07/07/2024. Review of Resident #3's December 2025 Electronic Medication Administration Record revealed, in part, on 12/02/2025, 12/05/2025, 12/16/2025, 12/17/2025, 12/23/2025, 12/26/2026, 12/29/2025, and 12/31/2025 there was no documented evidence Resident #3 was administered Humilin 70/30 at 8:00AM per physician's order. Review of Resident #3's January 2026 Electronic Medication Administration Record revealed, in part, on 01/02/2026, 01/05/2026, 01/06/2026, 01/07/2026, and 01/14/2026 there was no documented evidence Resident #3 was administered Humulin 70/30 at 8:00AM as ordered. In an interview on 01/14/2026 at 2:00PM, S3Licensed Practical Nurse indicated she did not administer Resident #3's Humulin 70/30 at 8:00AM on the above mentioned dates, with the exception of 12/23/2025. In an interview on 01/14/2026 at 3:20PM, S6Licensed Practical Nurse indicated she did not administer Resident #3's Humulin 70/30 at 8:00AM on 12/23/2025. In an interview on 01/15/2026 at 2:56PM, S1Director of Nursing indicated Resident #3 should have received Humulin 70/30 as ordered.

Based on interviews and record reviews, the facility failed to ensure blood sugar levels were documented for 2 (Resident #1, Resident #2) of 3 residents reviewed for blood sugar monitoring. Findings:Resident #1 Review of Resident #1's Minimum Data Set with an Assessment Reference Date of 12/10/2025 revealed, in part, Resident #1 had a Brief Interview of Mental Status score of 12, which indicated Resident #1 had moderate cognitive impairment. Further review revealed Resident #1 had a diagnosis of type 2 diabetes. Review of Resident #1's January 2026 Physician's Orders revealed, in part, an order to obtain blood sugar levels prior to meals with a start date of 12/17/2024. Review of Resident #1's December 2025 Electronic Medication Administration Record revealed, in part, on 12/16/2025 and 12/20/2025 at 5:00AM there was no documented evidence Resident #1's blood sugar level was obtained per physician orders. Review of Resident #1's January 2026 Electronic Medication Administration Record revealed, in part, on 01/01/2026 at 5:00AM there was no documented evidence Resident #1's blood sugar level was obtained per physician orders. In an interview on 01/14/2026 at 10:50AM, Resident #1 indicated he was not getting his blood sugar checked in the mornings as required. In an interview on 01/15/2026 at 2:27PM, S4Licensed Practical Nurse indicated she obtained Resident #1's blood sugar level on 12/16/2025 and 12/20/2025 at 5:00AM but did not document the result in Resident #1's Electronic Medication Administration Record. In an interview on 01/15/2026 at 2:56PM, S1Director of Nursing confirmed S4Licensed Practical Nurse did not document Resident #1's blood sugar levels in the Electronic Medication Administration Record on the above mentioned dates and should have. Resident #2 Review of Resident #2's clinical record revealed, in part, Resident #2 was admitted to the facility on [DATE] and had a diagnosis of diabetes mellitus without complication. Review of Resident #2's January 2026 Physician's Orders revealed, in part, an order for NovoLOG injection 100units/milliliters (medication for diabetes) per a sliding scale with parameters for how much NovoLOG to administer after obtaining Resident #2's blood sugar before meals and at bedtime ordered 12/16/2024. Review of Resident #2's December 2025 Electronic Medication Administration Record revealed, in part, on 12/16/2025 and 12/26/2025 at 6:00AM there was no documented evidence Resident #2's blood sugar level was obtained. Review of Resident #2's January 2026 Electronic Medication Administration Record revealed, in part, on 01/06/2026 at 9:00PM there was no documented evidence Resident #2's blood sugar level was obtained. In an interview on 01/15/2026 at 2:19PM, S5Licensed Practice Nurse indicated she obtained Resident #2's blood sugar level on 01/06/2026 at 9:00PM but did not document the result in Resident #2's Electronic Medication Administration Record as required. In an interview on 01/15/2026 at 2:25PM, S4Licensed Practice Nurse indicated she obtained Resident #2's blood sugar level on 12/16/2025 and 12/26/2025 at 6:00AM but did not document the result in Resident #2's Electronic Medication Administration Record as required. In an interview on 01/15/2026 at 2:56PM, S2Director of Nursing indicated Client #2's blood sugar levels should have been documented in Resident #2's Electronic Medication Administration Record on the above mentioned dates.

Based on interviews and record reviews the facility failed to ensure nursing staff administered medications timely as ordered by the physician for 2 (Resident #1, Resident #2) of 3 (Resident #1, Resident #2, Resident #3) sampled residents investigated for pharmacy services. Findings:Review of the facility’s Job Description for Nurse Supervisor last revised 2020 revealed, in part, a medication administration function of the job was to administer medications in accordance with physician orders, regulations, and facility policy. Review of the facility’s Administering Medications policy and procedure, last revised April 2019 revealed, in part, medications are to be administered in accordance with the prescriber’s order, including any required time frame, and medications are to be administered within one hour of the prescribed time, unless otherwise specified. Further review revealed if a medication is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall note on the Medication Administration Record/Electronic Medication Administration Record (MAR/eMAR) and sign or initial the reason for that medication and dose was not given as prescribed. Further review of the Administering Medications policy and procedure revealed the physician would be notified for any medications that are held or refused, so that order can be reviewed as necessary. Resident #1 Review of Resident #2’s July 2025’s Physician Orders revealed, in part: Mirtazapine 30 milligram (mg) oral tablet (a medication used for depression), administer 1 tablet by mouth at bedtime, scheduled for 8:00PM; Melatonin 5 mg oral tablet (a medication used for sleep), administer 4 tablets by mouth at bedtime, scheduled for 8:00PM; Carvedilol 5 mg oral tablet (a medication used for high blood pressure), administer 2 tablets, scheduled for 8:00AM and 8:00PM; Timoptic Ophthalmic Solution 0.5% (a medication used for high eye pressure), administer 1 drop in both eyes, scheduled for 8:00AM and 8:00PM; and, Rouvastatin Calcium 20 mg oral tablet (a medication used for high cholesterol), administer 1 tablet by mouth, scheduled for 8:00PM. Review of Resident #1’s July 2025 Medication Administration Audit Report revealed, in part, the following: the above mentioned medications were administered on 07/01/2025 at 9:28PM; the above mentioned medications were administered on 07/07/2025 at 9:46PM; the above mentioned medications were administered on 07/08/2025 at 9:48PM; and, the above mentioned medications were administered on 07/09/2025 at 9:23PM. In an interview on 08/05/2025 at 11:36AM, S2Assistant Director of Nursing confirmed the above medications for the above mentioned dates and times were not administered timely as ordered by the physician and should have been. In an interview on 08/05/2025 at 11:50AM, S3Admissions Licensed Practical Nurse (LPN) confirmed the above mentioned medications for the above mentioned dates and times were not administered timely as ordered by the physician and should have been. Resident #2 Review of Resident #2’s July 2025’s Physician Orders revealed, in part: Clonidine HCL (medication used to treat elevated blood pressure) 0.3 milligrams (mg), oral tablet, administer two times a day, and scheduled for 8:00AM and 8:00PM; Senna (laxative used to treat constipation) 8.6mg, oral tablet, administer one time a day, and scheduled for 7:00PM; and, Diclofenac Sodium Delayed Release (anti-inflammatory medication used to manage pain) 75mg oral tablet, administer two times a day, and scheduled for 8:00AM and 8:00PM. Review of Resident #2’s Medication Administration Audit Report for 07/13/2025 and 07/15/2025 revealed, in part: Senna (medication used to treat constipation) 8.6 mg, oral tablet, administer one time a day, was scheduled for 7:00PM on 07/13/2025, and was administered at 8:24PM; Diclofenac Sodium delayed release (medication used to treat pain from intervertebral disc degeneration) 75 mg, oral tablet, was scheduled for 8:00PM on 07/15/2025, and was administered at 9:11PM; and, Clonidine Hydrochloride (medication used to treat elevated blood pressure) 0.3 mg, oral tablet, was scheduled for 8:00PM on 07/15/2025, and was administered at 9:11PM. In an interview on 08/04/2025 at 5:23PM, S5LPN indicated Resident #2’s Senna 8.6mg tablet, scheduled for on 07/13/2025 at 7:00PM, was not administered timely as ordered by the physician, and should have been. In an interview on 08/05/2025 at 11:15AM, S2Assistant Director of Nursing (ADON) indicated Resident #2’s above mentioned scheduled medications for the above mentioned dates and times were not administered timely as ordered by the physician and should have been. In an interview on 08/05/2025 at 11:56AM, S3Admissions LPN indicated Resident #2’s above mentioned scheduled medications for the above mentioned dates and times were not administered timely as ordered and should have been.

Based on observation, record reviews, and interviews the facility failed to ensure that controlled drugs were maintained and accurately reconciled for 1(Med Cart A) out of 3 (Med Cart A, Med Cart B, and Med Cart C) medication carts observed for the medication storage facility task. Findings: Observation on 03/19/2025 at 8:55AM revealed a discrepancy on the facility's narcotic count form, on Med Cart A. Further observation revealed S3Licensed Practical Nurse (S3LPN) documented Resident # 184's Testosterone Cypionate (a hormonal replacement) Injection Solution 200 milligrams per milliliters (MG/ML) was administered per the EMAR (Electronic Medication Administration Record), on 03/05/2025, but the narcotic count form on Med Cart A did not have any documentation that this was documented as being administered and the 2 vials were not available for use on Med Cart A. Record review of Resident #184's physician's orders, dated 11/15/2023, revealed, in part, an order for Testosterone Cypionate Injection Solution 200 (MG/ML) to inject 200 mg intramuscularly in the evening every 14 days. Review of facility's records revealed, in part, the narcotic count form in Med Cart A narcotic book indicated 2 vials of Testosterone Cypionate Injection Solution 200mg/ML was available for use. Review of the facility's records revealed, in part, the Controlled Drugs-Count Record form, that was completed by the on-going and off-going nurse of each shift, indicated for the dates of 03/01/2025 to 03/19/2025 the 2 vials of Testosterone Cypionate Injection Solution 200mg/ML was available for use. There was no discrepancies noted. In an interview on 03/19/2025 at 8:57AM, S3LPN indicated the medication was not signed out on the narcotic count form. S3LPN further indicated the 2 vials of Testosterone Cypionate Injection Solution 200mg/ML were administered by another nurse on 03/05/2025 and were not available for use in the Med Cart A. In an interview on 03/19/2025 at 1:06PM, S2DON indicated there was some inconsistencies in reconciling narcotic count form. S2DON further confirmed that she could not provide the narcotic count form for the missing 2 vials of Testosterone Cypionate Injection Solution 200mg/ML on Med Cart A.

Based on interviews and record reviews, the facility failed to ensure a care plan was developed for a resident who smokes to decrease the risk of smoking related accidents for 1 (Resident #31) of 2 (Resident #31, Resident #34) sampled residents investigated for smoking. Findings: Review of Resident #31's Annual Minimum Data Set with an Assessment Reference Date of 12/18/2024 revealed, in part, Resident #31 had a Brief Interview of Mental score of 12 which indicated Resident #31 had moderate cognitive impairment and used tobacco. In an interview on 03/17/2025 at 12:40PM, Resident #31 indicated he was an active smoker. Review of Resident #31's care plan revealed no documented evidence and the facility did not present any documented evidence Resident #31 had a care plan developed to address the risks and interventions of smoking. In an interview on 03/19/2025 at 9:45AM, S11Minimum Data Set (MDS) Nurse indicated all residents who were active smokers required a care plan to address the risk factors and interventions of smoking. S11MDS Nurse confirmed Resident #31 was an active smoker and Resident #31 did not have a care plan developed which addressed the risks and interventions of smoking and should have. In an interview on 03/19/2025 at 4:02PM, S2Director of Nursing confirmed Resident #31 was an active smoker and Resident #31 did not have a care plan developed which addressed the risks and interventions of smoking and should have.

Based on observations, interviews, and record reviews the facility failed to administer a resident's Percutaneous Endoscopic Gastrostomy (PEG) tube (a soft, plastic feeding tube that goes into your stomach used to provide nutrition when oral intake is inadequate) feeding water flush as ordered by the physician for 1 (Resident #104) of 4 (Resident #35, Resident #70, Resident #75, Resident #104) sampled residents reviewed for PEG tube care and services in a total sample of 26. Findings: Review of Resident #104's records revealed, in part, Resident #104 was admitted to the facility on [DATE] with a diagnoses of cerebral infarction, dysphagia (difficulty swallowing), and malnutrition (imbalance of nutrients the body needs and receives.) Review of Resident #104's March 2025 physician orders revealed, in part, an order for Resident #104's PEG tube feeding to include Osmolite 1.5 (a PEG tube feeding formula) at 45 milliliters per hour (ml/hr) continuously via PEG tube pump. Further review revealed an order for Resident #104's PEG tube feeding to include a flush of water at a rate of 130 mL/hr every 4 hours to provide Resident 104 with a total of 780 ml; in addition to the fluid from medication administration flushes. Review of Resident #104's Care Plan, dated 02/17/2025, revealed, in part, Resident #104 had an intervention to be provided with tube feedings/flushes as ordered via feeding pump. Observation on 03/17/2025 at 12:37PM revealed, Resident #104's PEG tube pump was programmed to administer a water flush at a rate of 125 ml/hr every 4 hours, equivalent to 750 ml water flush for 24 hours. Observation on 03/18//2025 at 10:55AM revealed Resident #104's PEG tube pump was programmed to administer a water flush at a rate of 125 ml/hr every 4 hours, equivalent to 750 ml water flush for 24 hours. Observation on 03/18/2025 at 12:19PM revealed Resident #104's PEG tube pump was programmed to administer a water flush at a rate of 125 ml/hr every 4 hours, equivalent to 750 ml water flush for 24 hours. In an interview on 03/18/2025 at 2:24PM, S4Licensed Practical Nurse (LPN) confirmed Resident #104's PEG tube pump was programmed to administer a water flush at a rate of 125 ml/hr every 4 hours. S4LPN further indicated the PEG tube feeding flushes should have been programmed to administer a water flush at a rate of 130 ml/hr every 4 hours as ordered by the physician, and was not. In an interview on 03/19/2025 at 3:38PM, S2Director of Nursing confirmed that the PEG tube feeding flush should have been programmed to administer a water flush at a rate of 130 ml/hr every 4 hours as ordered by the physician, and was not.

Based on record review, observations, and interviews, the facility failed to ensure a resident with a history of falls received care and services to prevent future falls for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) residents reviewed. Findings: Review of Resident #1's minimum data set (MDS) revealed, in part, Resident #1 required extensive assistance with one-person physical assist for bed mobility, transfers, and toilet use. Review of Resident #1's care plan with a problem onset date of 07/10/2024 and updated on 08/22/2024 revealed, in part, Resident #1 would not sustain a serious injury related to falls, with the following interventions: call-light within Resident #1's reach; staff will ensure Resident #1 has no non-skid socks daily; and a mattress will on floor when Resident #1 is in her bed. Review of Resident #1's electronic health records (EHR) revealed, in part, Resident #1 was admitted on [DATE]. Further review revealed Resident #1 had the following diagnoses of: dementia with behavioral disturbance; cerebral edema; non-traumatic intercrainal hemorrhage; urinary tract infection (UTI), mild protein-calorie malnutrition; lack of coordination; and abnormalities of gait and mobility. Review of the facility's incident reports revealed, in part, Resident #1's had two unwitnessed falls that occurred in Resident #1's room on 07/02/2024 at 2:17 p.m. and 07/07/2024 at 10:07 p.m. Observation on 09/04/2024 at 9:25 a.m. revealed Resident #1's door was closed, and upon entering the room, the room was observed to be warm with the floor being slippery with a condensation-like substance. Further observation revealed Resident #1 was lying in bed with no staff present in the room, the call light was observed out of reach, without wearing non-skid socks, and without having a mattress placed on the floor next to Resident #1's bed. In an interview on 09/04/2024 at 3:53 p.m. S2Director of Nursing (S2DON), indicated Resident #1 recently had multiple falls at the facility, and the family requested in the care plan meeting that Resident #1 have a mattress placed on the floor next to her bed. S2DON further indicated the mattress should have been left in Resident #1's room so that it would be available for use, when Resident #1 decided to lie down in her bed. Observation on 09/04/2024 at 4:10 p.m. revealed Resident #1's bedroom door was closed and when S2DON walked into Resident #1's room, S2DON's shoes were slightly sliding from the condensation-like wet substance on Resident #1's floor. Further observation revealed Resident #1's room was also warm and humid. Further observation revealed Resident #1 was lying in bed with no staff present in the room, the call light was observed out of reach, without wearing non-skid socks, and without having a mattress placed on the floor next to Resident #1's bed. Observation also revealed S1Administrator and S4Maintenance attempting to bring a mattress in Resident #1's room. In an interview on 09/04/2024 at 4:10 p.m. S2DON confirmed Resident #1 did not have a mattress in her room to prevent falls, and that the slippery floor was a safety risk for Resident #1.

Based on record review and interview, the facility failed to ensure a resident with a Foley catheter (a medical device that collects urine) was monitored for signs and symptoms of urinary tract infections (UTIs) and catheter care was provided for 1 (Resident #83) of 2 (Resident #46 and Resident #83) residents reviewed for catheters. Findings: Review of Resident #83's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/26/2024 revealed, in part, Resident #83 had a Brief Interview Mental Status Score (BIMS) of 7, which indicated Resident #83 had moderate cognitive impairment. Further review revealed Resident #83 had a Foley catheter. Review of the facility's January 3, 2023 Cather Care, Urinary policy and procedure revealed, in part, staff should review a resident's care plan to assess for any special needs of the resident. Further review of the facility's policy and procedure revealed, in part, staff should provide routine hygiene catheter care with soap and water or equivalent each shift and as needed unless otherwise indicated by physician and will be documented in the EMR (electronic medical record). Further review revealed the following information should be recorded in the resident's medical record, the date and time that catheter care was given, the name and title of the individuals giving catheter care, all assessment data obtained when giving catheter care, character of urine such as color (straw-colored, dark, or red), clarity (cloudy, solid particles, or bloody), any odor, any problems noted at the catheter-ureteral junction during perineal care such as drainage, redness, bleeding, irritation, crusting, or pain, and any problems or complaints made by the resident related to the procedure. Review of Resident #83's care plan revealed Resident #83 had the need for a Foley catheter related to urinary retention on 02/19/2024. Further review of Resident #83's care plan revealed approaches to include providing catheter care every shift and as needed as ordered, assessing urine color, consistency & output as indicated, monitoring for signs and symptoms of urinary tract infection and notifying the physician as needed. Review of Resident #83's Physician's Orders from 02/19/2024 - 03/04/2024 revealed, in part, no orders for a Foley catheter. Review of Resident #83's March 2023 Physician's Orders revealed, in part, orders dated 03/05/2024 to monitor urine color (yellow, bloody, dark and notify md if not yellow) every shift, monitor urine consistency (clear, cloudy mucus) every shift, and provide catheter care every shift. Review of Resident #83's medical record revealed no documented evidence and the facility was unable to present any documented evidence Resident #83's was provided catheter care or was monitored for signs and symptoms of a UTI from 02/19/2024 to 03/04/2024. In an interview on 03/07/2024 at 11:16 a.m., S1Director of Nursing (DON) indicated Resident #83 returned from the hospital with a catheter in February 2024. S1DON confirmed orders for Resident #83's catheter were not put in the EMR until 03/05/2024. S1DON further confirmed no documentation of catheter care or monitoring for signs and symptoms of a urinary tract infection was in Resident #83's electronic Medication Administration Record and it should have been documented.

Based on observation, record review, and interviews, the facility failed to ensure oral medications remained under the direct supervision of S4Licensed Practical Nurse (LPN) for 1 (Resident #R1) of 3 (Resident #R1, Random #R2, Resident #R3) residents observed during medication administration. Findings: Review of the facility's Administering Oral Medications policy and procedure revealed, in part, the purpose of the facility's procedure was to provide guidelines for safe administration of oral medications. Further review revealed the staff member administering medications was to remain with the resident until all medications were ingested. Review of Resident #R1's December 2023 Physician Orders revealed, in part, the following medications: 1.) Venlafaxine (a medication used to treat depression) 37.5 milligram (mg), give 1 tablet by mouth in the morning; 2.) Mobic (a medication used to treat pain and inflammation) 15 mg, give 1 tablet by mouth in the morning; 3.) Metoprolol (a medication used to treat high blood pressure) 100 mg, give 1 tablet by mouth once daily; 4.) Metformin (a medication used to treat elevated blood sugar) 500 mg , give 1 tablet by mouth in the morning; 5.) Furosemide (a medication used to fluid retention) 40 mg, give 1 tablet by mouth in the morning; 6.) Eliquis (a medication used to prevent blood clots) 5 mg, give 1 tablet by mouth 2 times a day; and, 7.) Gabapentin (a medication used to treat seizures and nerve pain) 400 mg, give 1 tablet by mouth 3 times a day. Observation on 12/23/2023 at 8:30 a.m. revealed, in part, S4LPN placed Venlafaxine 37.5 mg tablet, Mobic 15 mg tablet, Metoprolol 100 mg tablet, Metformin 500 mg tablet, Furosemide 40 mg tablet, Eliquis 5 mg tablet, and Gabapentin 400 mg tablet into a medication cup. Further observation revealed S4LPN entered Resident #R1's room with the above mentioned medications and Resident #R1 stated she did not want to take her medications until after she finished eating her breakfast. Further observation revealed S4LPN left the above mentioned medications in a medication cup on Resident #R1's rolling bedside table and exited Resident #R1's room without administering or observing Resident #R1 swallow the oral medications. In an interview on 12/13/2023 at 10:04 a.m., S4LPN confirmed she left the above mentioned medications in a medication cup on Resident #R1's bedside table without verifying Resident #R1 swallowed the medications. S4LPN stated she should have observed Resident #R1 take all her oral medications before exiting Resident #R1's room. In an interview on 12/13/2023 at 10:10 a.m., S2Director of Nursing confirmed S4LPN should not have left the above mentioned medications on Resident #R1's bedside table unsupervised and should have remained with Resident #R1 until all medications were ingested.

Based on observation, record review, and interview, the facility failed to ensure a resident's medication was available to be administered as ordered and notify the physician when a resident's medication was unavailable for 1 (Resident #1) of 3 (Resident #R1, Resident #R2, and Resident #R3) residents observed for medication administration. Findings: Review of Resident #R1's medical record revealed Resident #R1's cognition was intact. Further review revealed a history of Zoster Ocular Disease (a virus that can affect the eye and cause inflammation and blindness). Review of Resident #R1's December 2023 Physician Orders revealed, in part, an order with a start date 11/08/2023 for Erythromycin Ophthalmic Ointment (an ointment used to treat or prevent infection of the eye) 5 milligram/gram, apply to the corner of the left eye lid in the morning. During observation of Resident #R1's medication administration on 12/13/2023 at 8:30 a.m. S4 Licensed Practical Nurse (S4LPN) stated Resident #R1's Erythromycin ointment was not available for use on the medication and the ointment was being refilled by the pharmacy. In an interview on 12/13/2023 at 9:00 a.m. Resident #R1 stated she did not receive the Erythromycin ointment to her left eye this morning because it had not arrived from the pharmacy. Resident #R1 stated the ointment was ordered to prevent eye infection following a procedure she had approximately 2 months ago to close her left eye. In an interview on 12/14/2023 at 11:48 a.m., Resident #R1 stated she did not receive the Erythromycin ointment to her left eye today when she received her morning medications. In an interview on 12/14/2023 and 12:09 p.m., S2Director of Nursing (S2DON) stated a refill order for Erythromycin ointment had been sent to the pharmacy but the ointment was on currently on back order. S2DON stated she was not aware Resident #R1 had run out of Erythromycin ointment. S2DON further stated Resident #R1's physician had not been notified the Erythromycin ointment was not available for use because it is the facility's procedure to notify the physician on the 3rd day a medication is not administered and/or not available. S2DON stated she was not aware the physician should be notified immediately or as soon as possible every time a medication was not administered or available for use. In an interview on 12/14/2023 at 12:23 p.m., S4LPN confirmed Resident #R1 did not receive the Erythromycin ointment to her left eye on 12/13/2023 and 12/14/2023 as scheduled because it had not arrived from the pharmacy. S4LPN further stated she did not notify Resident #R1's physician because Resident #R1 only missed two days of the medication and she is required to notify the physician if the medication was not administered for 3 days. S4LPN stated she was not aware the physician should have been notified as soon as a medication was not available for use. In an interview on 12/14/2023 at 12:31 p.m., S3Assistant Director of Nursing agreed the facility should not be waiting 3 days to notify the physician when a medication is not administered as ordered to a resident.

Based on record review and interviews, the facility failed to ensure a resident with a history of weight loss had their meal intake documented for each meal for 4 (Resident #1, Resident #2, Resident #3, and Resident #4) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents reviewed for weight loss. Findings: Resident #1 Review of Resident #1's face sheet revealed, in part, a diagnosis of moderate protein-calorie malnutrition. Review of Resident #1's care plan for malnutrition revealed, in part, an intervention for facility staff to monitor and record Resident #1's meal ingestion percentage. Review of Resident #1's Meal and Snack Intake Roster from 06/01/2023 through 09/06/2023 revealed, in part, no breakfast meal intake documentation for the months of June 2023, August 2023, and September 2023. Further review revealed the only breakfast meal intake documentation for the month of July 2023 was on 07/12/2023. Review of Resident #1's Meal and Snack Intake Roster from 06/01/2023 through 09/06/2023 revealed, in part, no lunch meal intake documentation for the months of June 2023, August, 2023, and September 2023. Further review revealed the only lunch meal intake documentation for the month of July 2023 was on 07/10/2023 and 07/13/2023. Review of Resident #1's Meal and Snack Intake Roster from 06/01/2023 through 09/06/2023 revealed, in part, no dinner meal intake documentation for the months of August 2023 and September 2023. Further review revealed no dinner meal intake documentation for the following dates: 06/05/2023, 06/09/2023, 06/10/2023, 06/11/2023, 06/14/2023, 06/15/2023, 06/20/2023, 06/21/2023, 06/22/2023, 06/23/2023, 06/24/2023, 06/25/2023, 06/28/2023, 06/29/2023, 07/03/2023, 07/04/2023, 07/05/2023, 07/06/2023, 07/07/2023, 07/08/2023, 07/10/2023, 07/12/2023, and 07/14/2023 through 07/31/2023. There was no documented evidence and the facility was unable to present any documented evidence Resident #1's meal intakes were monitored and/or documented for the above mentioned dates. Resident #2 Review of Resident #2's face sheet revealed, in part, Resident #2 had a diagnosis of unspecified protein-calorie malnutrition. Review of Resident #2's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/02/2023 revealed, in part, Resident #2 was 100 pounds and had weight loss of 5% in last month or 10% in last 6 months and was not on a physician prescribed weight loss regimen. Review of Resident #2's Weight Change Comparison document revealed in part, Resident #2 weighed 113.6 pounds on 06/05/2023 and 102.4 pounds on 08/31/2023, which was a significant weight loss of 9.86% in less than 91 days. Review of Resident #2's weight loss care plan revealed, in part, an intervention for facility staff to monitor and record food intake at each meal. Review of Resident #2's Meal and Snack Intake Roster from 06/01/2023 through 09/06/2023 revealed, in part, no breakfast meal intake documentation for June 2023, July 2023, August 2023, and September 2023. Review of Resident #2's Meal and Snack Intake Roster from 06/01/2023 through 09/06/2023 revealed, in part, no lunch meal intake documentation for June 2023, July 2023, August 2023, and September 2023. Review of Resident #2's Meal and Snack Intake Roster from 06/01/2023 through 09/06/2023 revealed, in part, the only dinner meal intake documentation for the month of June 2023 was on 06/21/2023 and 06/27/2023. Review also revealed the only dinner meal intake documentation for the month of July 2023 was on 07/01/2023, 07/02/2023, 07/14/2023, 07/15/2023, 07/17/2023, and 07/18/2023. Further review revealed no dinner meal intake documentation for August 2023 and September 2023. There was no documented evidence and the facility was unable to present any documented evidence Resident #2's meal intakes were monitored and/or documented for the above mentioned dates. Resident #3 Review of Resident #3's MDS with an ARD of 08/23/2023 revealed, in part, Resident #3 had a diagnosis of malnutrition. Review of Resident #3's altered nutrition care plan revealed, in part, an intervention for staff to monitor Resident #3's intake with every meal. Review of Resident #3's Meal and Snack Intake Roster from 06/01/2023 through 09/06/2023 revealed, in part, no breakfast meal intake documentation for June 2023, August 2023, and September 2023. Further review revealed the only breakfast meal intake documented for July 2023 was on 07/12/2023. Review of Resident #3's Meal and Snack Intake Roster from 06/01/2023 through 09/06/2023 revealed, in part, no lunch meal intake documentation for June 2023, August 2023, and September 2023. Further review revealed the only lunch meal intake documentation for July 2023 was on 07/10/2023 and 07/13/2023. Review of Resident #3's Meal and Snack Intake Roster from 06/01/2023 through 09/06/2023 revealed, in part, no dinner meal intake documentation for August 2023 and September 2023. Further review revealed no documented dinner meal intake on 06/05/2023, 06/09/2023, 06/10/2023, 06/11/2023, 06/14/2023, 06/15/2023, 06/20/2023, 06/21/2023, 06/22/2023, 06/23/2023, 06/24/2023, 06/25/2023, 06/28/2023, 06/29/2023, 06/30/2023, 07/03/2023, 07/04/2023, 07/05/2023, 07/06/2023, 07/07/2023, 07/08/2023, 07/10/2023, 07/12/2023, and 07/14/2023 through 07/31/2023. There was no documented evidence and the facility was unable to present any documented evidence Resident #3's meal intakes were monitored and/or documented for the above mentioned dates. Resident #4 Review of Resident #4's MDS with an ARD of 09/07/2023 revealed, in part, a diagnosis of malnutrition. Review of Resident #4's Weight Change Comparison document revealed, in part, Resident #4 weighed 155 pounds on 08/02/2023 and 141.2 pounds on 08/29/2023, which was a significant weight loss of 13.6% in less than 31 days. Further review revealed Resident #4 weighed 158.6 pounds on 05/30/2023 and 141.2 pounds on 08/29/2023, which was a significant weight loss of 17.2% in less than 91 days. Review of Resident #4's altered nutrition care plan revealed, in part, an intervention for facility staff to monitor Resident #4's meal intake. Review of Resident #4's Meal and Snack Intake Roster from 06/01/2023 through 09/06/2023 revealed, in part, no breakfast meal intake documentation on 06/15/2023, 06/19/2023, 06/23/2023, 06/28/2023, 06/29/2023, 06/30/2023, 07/21/2023, 07/22/2023, 07/28/2023, 08/02/2023, 08/10/2023, 08/11/2023, 08/14/2023, 08/22/2023, 08/23/2023, 08/25/2023, 09/01/2023, and 09/02/2023. Review of Resident #4's Meal and Snack Intake Roster from 06/01/2023 through 09/06/2023 revealed, in part, no lunch meal intake documentation on 06/15/2023, 06/20/2023, 06/21/2023, 06/23/2023, 06/30/2023, 07/01/2023, 07/21/2023, 07/22/2023, 08/01/2023, 08/02/2023, 08/10/2023, 08/11/2023, 08/14/2023, 08/22/2023, 08/23/2023, 09/01/2023, 09/02/2023, and 09/03/2023. Review of Resident #4's Meal and Snack Intake Roster from 06/01/2023 through 09/06/2023 revealed, in part, no dinner meal intake documentation on 06/18/2023, 06/20/2023, 06/21/2023, 07/27/2023, 08/01/2023, and 08/22/2023. There was no documented evidence and the facility was unable to present any documented evidence Resident #4's meal intakes were monitored and/or documented for the above mentioned dates. In an interview on 09/06/2023 at 3:36 p.m., S8Certified Nursing Assistant (CNA) stated each resident's meal intake should be documented by the CNA for each meal. In an interview on 09/06/2023 at 3:38 p.m., S7CNA stated each resident's meal intake should be documented by the CNA for each meal. In an interview on 09/06/2023 at 3:40 p.m., S6MDS Nurse stated meal intakes should be documented for all residents for each meal. S6MDS Nurse stated it was especially important to document meal intakes for residents with weight loss because S5Registered Dietician (RD) utilized the documentation to make dietary recommendations. In an interview on 09/06/2023 at 4:30 p.m., S1Administrator confirmed Resident #1, Resident #2, Resident #3, and Resident #4 had missing meal intake documentation. S1Administrator further stated there was no documented evidence meal intakes were documented for the above mentioned missing dates. In an interview on 09/07/2023 at 10:20 a.m., S2Director of Nursing (DON) confirmed there was missing meal intake documentation for Residents #1, Resident #2, Resident #3, and Resident #4. S2DON stated CNAs should document a resident's meal intake for each meal. S2DON further stated it was especially important for CNAs to document meal intakes for residents who have had a history of weight loss. S2DON confirmed a resident's meal intake documentation was important information utilized by the facility and S5RD. In an interview on 09/07/2023 at 10:51 a.m., S5RD stated a resident with weight loss should have their meal intake documented for every meal. S5RD additionally stated she utilized the resident's meal intake documentation when she made recommendations. In an interview on 09/07/2023 at 11:19 a.m., S4CNA Supervisor confirmed there was missing meal intake documentation. S4CNA Supervisor stated CNAs should be documenting every resident's meal intake for each meal. In an interview on 09/07/2023 at 11:41 a.m., S3Assistant Director of Nursing (ADON) confirmed Resident #1, Resident #2, Resident #3, and Resident #4 had missing meal intake documentation. S3ADON stated meal intake documentation was needed for the S5RD to complete her assessments and provide accurate recommendations for residents with weight loss.

Based on record review, observation, and interview, the facility failed to: 1.) Ensure the Certified Nursing Assistant (CNA) removed gloves and completed hand hygiene during incontinent care for 2 (S5CNA and S6CNA) of 2 (S5CNA and S6CNA) CNA's observed for incontinence care; and 2.) Ensure the Licensed Practical Nurse (LPN) removed gloves and completed hand hygiene prior to performing catheter care for 1 (Resident #1) resident observed for catheter care. 3.) Ensure the Wound Care Nurse removed gloves and completed hand hygiene prior to treating a pressure ulcers for 1(Resident #R6) of 2 (Resident #1 and Resident #R6) observed for wound care. Findings: 1. Review of the facility's Hand Washing Policy and Procedure revealed, in part, 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel and residents. 6. Wash hands with soap (antimicrobial or non-antimicrobial) and water when hands are visible soiled. 7. Use an alcohol-based hand rub; or, alternatively, soap and water for the following situations: Before and after direct contact with residents; Before and after handling an invasive device (e.g., urinary catheters); Before moving from a contaminated body site to a clean body site during resident care; After contact with residents intact skin; After contact with blood or body fluids; After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; and after removing gloves. 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Review of the facility's Catheter Care, Urinary Policy and Procedure revealed, in part, Infection Control 1. Use standard precautions when handling or manipulating drainage system. 2. Maintain clean technique when handling or manipulating the catheter, tubing or drainage bag. Review of the facility's Wound Care Policy and Procedure revealed, in part, Wear gloves for holding gauze to catch irrigation solutions that are poured directly over the wound; Wash tissue around the wound that is usually covered by the dressing, tape or gauze with wound cleanser or normal saline; Apply treatments as indicated; Discard disposable items; Remove disposable gloves; and Wash and dry your hands thoroughly. Review of Resident #1's MDS (Minimum Data Sheet) with ARD (Assessment Reference Date dated 07/24/2023 revealed, in part: Sections C - Cognitive Patterns- Brief Interview for Mental Status (BIMS) Score of 15 which indicates he was cognitively intact; and Section GG-Functional Abilities- Toileting/Hygiene- partial to moderate assistance. Review of Resident #1's Care Plan revealed, in part, Resident #1 required assistance with Activities of Daily Living (ADL's) related to decreased mobility related to a right below the knee amputation and incontinence. Observation of incontinence care on 08/07/2023 at 1:22 p.m., revealed S6Certified Nursing Assistant (S6CNA) and S5Cetified Nursing Assistant Supervisor (S5CNA Supervisor) entered Resident #1's room and both donned gloves retrieved from their shirt pockets without performing hand hygiene before assisting Resident #1 with incontinence care. S5CNA Supervisor then removed a feces soiled bed spread from Resident #1's bed then turned the door handle to Resident #1's room with soiled gloves on. S5CNA supervisor returned to Resident #1's room closed door with ungloved hands, without performing hand hygiene and donned gloves from her shirt pocket. S5CNA Supervisor removed Resident #1's incontinence brief. Further observation revealed S6CNA wiped feces from Resident #1's perineal area and turned Resident #1 while S5CNA Supervisor wiped Resident #1's buttocks. S5CNA Supervisor then removed remaining soiled linen from the bed; opened the door to Resident #1's room with gloves on; and returned to the room; and removed gloves without performing hand hygiene. S5CNA donned gloves retrieved from her pocket and applied a clean incontinence brief to Resident #1. S6CNA picked up the urinary catheter bag and tubing with soiled gloves then placed the catheter bag on the bed rail. Further observation revealed S6CNA applied a gown to Resident #1, and moved Resident #1's bedside table with personal belongings closer to Resident #1 with soiled gloves on. Further observation revealed S6CNA removed her soiled gloves, and both S6CNA and S5CNA Supervisor exited Resident #1's room without performing hand hygiene. In an interview on 08/07/2023 at 1:39 p.m., S6CNA acknowledged she did not perform hand hygiene prior to or after performing incontinence care for Resident #1. S6CNA acknowledged she should have performed hand hygiene and applied clean gloves before and after incontinence care and touching Resident #1's catheter bag, tubing, and personal belongings. S6CNA stated there isn't any hand sanitizer in Resident #1's room. S6CNA acknowledged soap and water is available in Resident #1's bathroom. In an interview on 08/07/2023 at 1:41 p.m., S5CNA Supervisor acknowledged she did not perform hand hygiene prior to applying gloves and performing Perineal Care to Resident #1. S5CNA Supervisor acknowledged she should have performed hand hygiene after providing incontinence care for Resident #1 and touching multiple surfaces in his room. In an interview on 08/09/2023 at 1:08 p.m., S2Director of Nursing (S2DON) acknowledged S5CNA Supervisor and S6CNA should have performed hand hygiene before and after providing incontinence care to Resident#1. In an interview and observation on 08/08/2023 at 1:15 p.m., S4Licensed Practical Nurse (S4LPN) entered Resident #1's room and washed her hands with soap and water, then she picked up the bed remote adjusted Resident #1's bed removed his incontinence brief, did not perform hand hygiene donned gloves, and provided urinary catheter care to Resident #1. S4LPN acknowledged she picked up the remote to adjust Resident #1's bed, removed his incontinence brief and did not perform hand hygiene before proceeding with catheter care for Resident #1. In an interview on 08/09/2023 at 1:08 p.m., S2Director of Nursing (S2DON) acknowledged S4LPN should have performed hand hygiene before performing catheter care for Resident #1. 2. Review of Resident #R6's record revealed diagnosis, in part, Traumatic spinal cord injury and Quadriplegia. Review of the MDS (Minimum Data Sheet) with ARD (Assessment Reference Data) dated 06/06/2023 revealed, in part, Section C- Cognitive Patterns- Brief Interview for Mental Status (BIMS) 15 which indicates cognitively intact. Section M-Skin conditions- Pressure Ulcer/Injury and Resident # R6 has 1+ unhealed pressure ulcers. Review of Resident #R6's wound care note dated 08/08/2023 revealed Resident #R6 was sent out to a local hospital emergency department (ER) for left gluteal wound deterioration. Observation on 08/08/2023 at 9:09 a.m. of Resident #R6's wound care revealed S3Wound Care Nurse removed gauze soaked with wound cleanser from a container, then cleaned pressure ulcer to sacral area and discarded the soiled gauze without performing hand hygiene. S3Wound Care Nurse then removed another gauze from the container and cleaned another pressure ulcer to left gluteal. In an interview on 08/08/2023 at 12:03 p.m., S3Wound Care Nurse acknowledged she cleaned the Resident #R6's sacral pressure ulcer then his left gluteal pressure ulcer without changing gloves or performing hand hygiene. S3Wound Care Nurse acknowledged she probably should have changed gloves and performed hand hygiene after cleaning Resident #R6's sacral pressure ulcer before she cleaned his left gluteal pressure ulcer. S3Wound Care Nurse stated she thought it was okay to clean both pressure ulcers without changing gloves and performing hand hygiene because both wounds were under the same dressing. In an interview on 08/09/2023 at 1:08 p.m., S2Director of Nursing (S2DON) stated it was okay for S3Wound Care Nurse to clean a wound located in Resident #R6's sacral area, not perform hand hygiene, or remove gloves, then proceed to clean left gluteal pressure ulcer with same gloves on because both pressure ulcers are under the same dressing. S2DON acknowledged the facility does not have a policy on cleaning two separate pressure ulcers with the same gloves and not performing hand hygiene.

Based on record review, observations, and interviews the facility failed to ensure staff changed gloves and performed hand hygiene during incontinence care for 2 (Resident #68 and Resident #112) of 2 (Resident #68 and Resident #112) sampled residents observed for incontinence care in a total sample of 25. Findings: Review of the facility's Perineal Care Policy revealed, in part, the purpose of the procedure was to provide cleanliness and to prevent infections. Further review revealed, in part, after washing and drying the perineal area staff should remove gloves and discard, wash and dry your hands thoroughly, then reposition bed covers and make the resident comfortable. Resident #68 Observation of peri-care on Resident #68 at 1:00 p.m., S10CNA (Certified Nursing Assistant), entered the room with the needed supplies to change an adult brief. She put gloves on without washing her hands and/or without using alcohol gel, and removed Resident #68's brief and proceeded to use wet wipes to clean resident's peri-area. After cleaning the resident, S10CNA grabbed a jar of Vaseline from the bedside table with the same gloved hands, and dipped the first 2 gloved fingers of her right hand into the Vaseline jar. S10CNA then applied the Vaseline to the resident's buttocks utilizing the same gloves. From there she changed the resident's fitted sheet and placed a new pad under resident and an adult brief on Resident #68 while wearing the same gloves. Resident #68 then asked S10CNA to apply more Vaseline to his buttocks, and S10CNA proceeded to apply more Vaseline with the same gloved hands and the same technique. S10CNA proceeded to empty Resident #68's urinal into the toilet. She returned to the room and grabbed the clean flat sheet and proceeded to cover the resident without changing her gloves. She then finished removing the dirty bedding from the bed and placed the dirty bedding on the floor. S10CNA then finished applying the fitted sheet to the bed. She grabbed the garbage bag, opened the door, walked down the hall with the garbage bag in her gloved hand. In an interview on 03/21/2023 at 1:12 p.m., S10CNA verified she should have changed gloves before she put her hand into the Vaseline jar before she applied it to Resident #68's buttocks and before she began putting clean linen on the bed. In an interview on 03/23/2023 at 10:50am S2DON (Director of Nursing) stated S10CNA should have changed her gloves before she dipped her fingers into the Vaseline jar and after she provided peri-care. Resident #112 Review of Resident #112's Minimum Data Set with an Assessment Review Date of 12/08/2022 revealed, in part Resident #112 required extensive assistance from staff for toileting and was always incontinent of bowel and bladder. Observation on 03/22/2023 at 12:03 p.m., revealed, in part, S9CNA (Certified Nursing Assistant) entered the room with a single pair of gloves and applied the gloves. Further observation revealed S9CNA opened Resident #112's diaper and provided incontinence care after a bowel movement. Further observation revealed S9CNA did not remove her gloves after providing incontinence care and placed a new diaper on Resident #112, then removed Resident #112's soiled shirt and placed a new shirt on Resident #112, pulled up Resident #112's blanket, and grabbed the bed control remote to raise the head of the bed. In an interview on 03/22/2023 at 12:19 p.m., S9CNA acknowledged she should have performed hand hygiene and changed gloves when moving from dirty to clean when providing incontinence care. In an interview on 03/22/2023 at 2:10 p.m., S2DON (Director of Nursing) stated S9CNA should have completed hand hygiene and changed her gloves after cleaning Resident #112's incontinent episode and prior to touching clean areas, personal belongings, and equipment.

Based on observations, record review, and interviews the facility failed to ensure: 1. Expired medications were not available for administration to residents for 1 of 4 Carts (Medication Cart A) reviewed for medication storage; and, 2. Nurses sign off on the Controlled Drugs-Count Record at the beginning and end of each shift for 2 of 3 floors (Floor W and Floor X) reviewed for controlled substance reconciliation. This deficient practice had the potential to affect 1 of the 16 residents who resided on the Floor W of the facility. Findings: Observation on 03/22/2023 at 11:20 a.m. revealed Medication Cart A contained 1 tube of Hemorrhoidal Cream with an expiration date of 01/2023. In an interview on 03/22/2023 at 11:32 a.m., S4Licensed Practical Nurse (LPN) nurse for Floor W stated the nurses are responsible to ensure there are no expired medications available for resident use and confirmed the above documented medication was expired. Review of Floor W's Controlled Drugs - Count Record revealed missing nurses' signatures for witnessing the narcotic counts on the following dates: 02/17/2023, 02/23/2023, 02/24/2023, 02/ 25/2023, 02/28/2023, 03/02/2023, 03/03/2023, 03/09/2023, 03/11/2023, 03/19/2023, 03/21/2023, 2023, 03/22/2023. Review of Floor X's Controlled Drugs - Count Record revealed missing nurses' signatures for witnessing narcotic counts on the following dates: 01/03/2023, 01/12/ 2023, 01/17/2023, 01/22/2023, 01/24/2023, 01/25/2023, 01/28/2023, 01/29/2023, 01/30/2023, and 01/31/2023. In an interview on 03/22/2023 at 11:20 a.m., S4LPN stated the nurses are responsible for counting and signing the Controlled Drug- Count Record with the oncoming nurse and off going nurse for each shift. In an interview on 03/22/2023 at 11:32 a.m., S6LPN stated the nurses are responsible for counting and signing the Controlled Drug- Count Record with the oncoming nurse and off going nurse for each shift. In an interview on 03/22/2023 at 12:10 p.m., S2Director of Nursing (DON) stated the nurses are responsible for checking for expired medications and nurses are responsible for counting and signing the Narcotic Controlled Count Sheet for all shifts with oncoming and off-going nurse for each shift worked.

Based on observations, interviews, and record reviews the facility failed to ensure a resident, dependent on staff for nail care, received assistance to keep finger nails trimmed for 1 (Resident #112) of 2 sampled residents (Resident #112 and #34) reviewed for activities of daily living (ADLs) in a total sample of 25. Findings: Review of Resident #112's Minimum Data Set with an Assessment Review Date of 12/08/2022 revealed, in part, Resident #112 had a primary diagnosis of Hemiplegia (weakness on one side of the body) affecting his right dominant side. Further review of Resident #112's MDS revealed Resident #112 was not cognitively intact, and required extensive assistance from staff with personal hygiene. Observation on 03/20/2023 at 11:00 a.m. revealed, in part, Resident #112's finger nails extended beyond the tips of his fingers on both hands. Observation on 03/23/2023 at 9:25 a.m. revealed, in part, Residents #112's finger nails extended beyond the tips of his fingers on both hands and multiple nails displayed sharp pointed corners. Observation on 03/23/2023 at 10:15 a.m. of Resident #112's finger nails with S2DON (Director of Nursing) present revealed Resident #112's finger nails extended beyond the tips of his fingers and multiple nails had sharp pointed corners. In an interview on 03/23/2023 at 10:15 a.m., S2DON stated the CNA's (Certified Nursing Assistants) were responsible for trimming Resident #112's nails. S2DON also indicated Resident #112's finger nails on both hands were too long, had sharp corners, and needed to be trimmed.

Based on record review and interviews, the facility failed to ensure the resident's code status was accurate in the resident's plan of care. This deficient practice was identified for 1 (Resident #13) of 25 sampled residents reviewed for accurate code status. Findings: Review of Resident #13's record revealed an admitted [DATE]. Review of Resident #13's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of [DATE] revealed, in part, Resident #13 had a BIMS (Brief Interview for Mental Status) of 14 (Score of ,d+[DATE] indicated resident was cognitively intact). Review for Resident #13 [DATE] Physician's Orders revealed a DNR (Do Not Resuscitate) order dated [DATE]. Review of Resident #13's Louisiana Physician Order for Scope of Treatment (LaPost) dated [DATE], revealed an order by the physician for a Full Code (indicated cardiopulmonary resuscitation should be provided). In an interview on [DATE] at 9:55 a.m., S2DON (Director of Nursing) stated a resident's code status would be taken from the LaPost, if they have one, upon admit. S2DON further stated if there was no LaPost then the SSW would get a LaPost signed by the doctor. In an interview on [DATE] at 10:00 a.m., S3ADON (Assistant Director of Nursing) stated if she needed to find the code status of a resident she would look in the electronic record first, if she did not see it on there, she would then go to the hard chart. In an interview on [DATE] at 10:30 a.m., S7SSW (Social Service Worker) confirmed Resident #13 had a LaPost in the hard chart which indicated Full Code status and that the [DATE] Physician's Orders indicated a DNR status. In an interview on [DATE] at 10:35 a.m., S3ADON (Assistant Director of Nursing) stated in the event Resident #13 needed Cardiopulmonary Resuscitation (CPR), she would not perform CPR because the electronic orders indicated Resident #13 was a DNR. In an interview on [DATE] at 10:40 a.m., S7SSW stated he handled the LaPost by getting them signed by the doctor and then he placed the signed LaPost into the resident's chart. When asked who put the code status orders into the computers, he stated he did not know. When asked if he notified the nurse of the change in Resident #13's Code Status, he stated he did not know he needed to do that. In an interview on [DATE] at 10:45 a.m., S2DON stated the process to have a LaPost order put into the computer correctly was as follows: S7SSW would have the LaPost signed by the physician then S7SSW should notify the nurses before he placed the LaPost into the chart. She further stated S7SSW would forget at times to let the nurses know he had received a LaPost. In an interview on [DATE] at 11:30 a.m., Resident #13 stated she wanted CPR to be performed, if needed. In an interview on [DATE] at 2:30 p.m., S1Administrator confirmed Resident #13 had an advanced directive which indicated Resident #13 was a DNR and a LaPost which indicated she was a Full Code. S1Administrator further confirmed the LaPost was signed by Resident #13's primary physician on [DATE].

Based on observation, record review, and interview the facility failed to develop a person-centered comprehensive care plan for 1 resident (Resident #322) in a total sample of 11 with percutaneous endoscopic gastrostomy (PEG) tube as documented on the facility's Resident Census and Conditions of Residents CMS Form-672. Findings: Review of Resident #322's care plan revealed a plan of care was not developed related to Resident #322's PEG tube. Review of Resident #322's physician orders dated March 2023 revealed, in part, no orders or interventions for the PEG tube. In an interview on 03/21/2023 at 11:08 a.m., S3Assiant Director of Nursing (ADON) stated Resident #322 did not have a PEG tube. Observation on 03/21/2023 at 11:39 a.m., revealed Resident #322 sitting in a wheelchair with a PEG tubing exposed from under shirt. In an interview on 03/22/2023 at 10:52 a.m., Resident #322 stated he had a feeding tube but did not receive medications or nutrition through the tube. In an interview on 03/22/2023 at 12:30 p.m., S5Minimum Data Set Nurse (MDS) stated Resident #322 did not have any care plan interventions for the PEG tube. In an interview on 03/22/2023 at 12:45 p.m., S2Director of Nursing (DON) confirmed Resident #322 should have had a care plan for the PEG tube.