Every finding on record at Lacombe Nursing Centre

Based on observations, interviews, and record reviews, the facility failed to provide maintenance services necessary to maintain a sanitary, orderly, and comfortable interior by failing to ensure:Halls A, B, and C ceiling tiles were maintained in good repair; andRoom BB was maintained safely, sanitarily, and in good repair.Findings: 1. On 06/22/2026 at 9:00 a.m., a tour of the facility was conducted with the following observations made: Hall A - There were multiple ceiling tiles with a brown and yellow discolored substance. The entrance of Hall A air conditioning vent located in close proximity to the nurses' station was observed to have active condensation with multiple black spots with yellow, brown, grey and black discoloration to the ceiling tile. The air conditioning vent cover was covered in a black substance. Hall B - There were numerous ceiling tiles with a brown and yellow discolored substance ranging in various sizes. The common/day room area of Hall B had multiple ceiling tiles with a brown, yellow and grey-black discoloration. Hall C - There were multiple ceiling tiles with a brown and yellow discolored substance. Additional observations were conducted of Hall A, Hall B, and Hall C on 06/23/2026 at 9:00 a.m. and 06/24/2026 at 9:00 a.m. which revealed the same observations listed above. On 06/24/2026 at 9:10 a.m., an observation was made of Hall A, Hall B, and Hall C with S10MS. He stated the brown and yellow discolored ceiling tiles were caused from either leaking condensation from air conditioning duct work or pin holes in the roof of the building. He stated these tiles didn't need to be changed and only needed a coating of paint primer. He stated the ceiling tiles that appeared to be grey and black in discoloration appeared to be mildew and needed to be changed immediately. 2.Resident #11Review of Resident #11's clinical record revealed an admission date of 06/04/2026, and Resident #11 resided in Room BB Review of Resident #11's admission MDS with an ARD of 06/11/2026 revealed, in part, the resident was assessed by the facility to have a BIMS of 15, which indicated he was cognitively intact. Resident #57Review of Resident #57's clinical record revealed an admission date of 05/18/2026, and Resident #57 resided in Room BB. Review of Resident #57's admission MDS with an ARD of 05/25/2026 revealed, in part, the resident was assessed by the facility to have a BIMS of 15, which indicated he was cognitively intact. Review of the facility's Maintenance Log dated May 2026 to current revealed the following:05/28/2026: Location: Room BB -AC leaking;06/06/2026: Location: Room BB -AC leaking; and06/13/2026: Location: Room BB - AC unit is leaking water on the floor. On 06/23/2026 at 8:50 a.m., observations were conducted of Room BB, which revealed the following:There was a grey wash basin underneath the air conditioning unit with water leaking into the basin. There was a small amount of water on the floor next to the basin at the foot of Resident #57's bed; electrical outlet in which the air conditioning unit was plugged into was off centered exposing interior wall, with staining of brown substance on the wall; Resident #11 and Resident #57's bathroom wall to the left of the sink had areas of bulged out paint. On 06/24/2026 at 8:50 a.m., additional observations were conducted of Hall B/Room BB environment. The gray wash basin underneath the air conditioning unit was 1/4 full of water due to continued leaking of air conditioning unit. All other aforementioned findings remained unchanged. On 06/24/2026 at 8:55 a.m., an interview was conducted with Resident #11 and Resident #57. Resident #11 and Resident #57 stated the air conditioning unit had been leaking since their admission. Resident #11 and Resident #57 stated maintenance attempted to fix the air conditioning unit, but everything they had attempted at this point had not resolved the issue. Resident #57 stated water was leaking all over the floor so his daughter had to put the grey wash basin underneath the air conditioning unit to collect dripping water. Resident #57 stated he would like to have the air conditioning unit fixed so his daughter would not have to keep emptying out the wash basin. On 06/24/2026 at 9:00 a.m., an interview was conducted with S10MS. He stated the air conditioning unit in Room BB had been serviced numerous times due to the drain hole becoming clogged with algae. He stated this was a common issue with all units within the facility. He stated the only fix for this was to drill the drain plug area to help facilitate better drainage. He confirmed this had not been done at this time and should have been to alleviate recurrent, ongoing issues with the leaking window unit into the interior of the building. On 06/24/2026 at 9:45 a.m., observations with an interview was conducted with S1ADM of the above findings. S1ADM confirmed the ceiling tiles on Hall A, Hall B, and Hall C needed to be replaced to prevent the growth of mildew or mold from visible water damage. S1ADM stated he was unaware of any ongoing issues of Resident #11 and Resident #57's leaking air conditioner. S1ADM stated he would expect his maintenance staff to repair any issues in full repair to resolve the issue and to not patch or apply band aids to any repairs within facility. S1ADM confirmed the facility should always be maintained in a sanitary, homelike environment and of good repair.

Based on observations, interviews, and record reviews, the facility failed to ensure residents' call lights were within reach for 2 (#8 and #76) of 2 residents reviewed for accommodation of needs. Findings: Review of the facility's undated policy titled Call Light, revealed the following, in part: Objective: Call-Light is to be placed within reach of resident when in the room at all times. Resident #8 Review of Resident #8's Clinical Record revealed she was admitted to the facility on [DATE] with a diagnosis of Acute on Chronic Diastolic (Congestive) Heart Failure. Review of Resident #8's Quarterly MDS with an ARD of 03/19/2026 revealed she had a BIMS of 7, which indicated she was severely cognitively impaired. Further review revealed she could make her needs known. Review of Resident #8's current Care Plan revealed she required assistance with ADL care and had potential for falls. Further review revealed interventions to keep the call light within reach. On 06/22/2026 at 11:15 a.m., an observation was made of Resident #8 in her room lying in her bed. Resident #8's call light was, clipped to the curtain which was pushed toward the back wall, and out of her reach. On 06/22/2026 at 11:16 a.m., an interview was conducted with Resident #8. She stated she used the call light to call staff when she needed assistance. She stated her room was too cold, she spilled tea and needed a towel, her stomach was cramping, and she needed to be changed. She stated she could not find her call light. She stated S11CNA changed her recently. She stated most of the time, the call light was not within reach for her to use and call for assistance. On 06/22/2026 at 4:13 p.m., an observation was made of Resident #8 lying in bed sleeping. Her call light was clipped to the outer edge of the bed and out of her reach. There was signage on the wall stating Please call don't fall call for assistance, with a picture of a call light. On 06/23/2026 at 8:15 a.m., an observation was made of Resident #8 in her room lying in her bed. Her call light was clipped to the outer edge of the bed and out of her reach. On 06/23/2026 at 8:16 a.m., an interview was conducted with Resident #8. She stated she did not know where her call light was located. After she looked around in her bed, she stated she could not find it. On 06/23/2026 at 12:14 p.m., an interview was conducted with S11CNA. S11CNA stated Resident #8 was not able to get out of bed on her own and received assistance from staff for all ADL care. S11CNA stated Resident #8 used the call light, without difficulty, if she needed assistance in between staff rounds. On 06/23/2026 at 12:27 p.m., an observation and interview was conducted with S11CNA in Resident #8's room. S11CNA confirmed the call light was clipped to the right outer edge of the bed and was not within reach for the resident. S11CNA confirmed every time she entered a residents' room she should have placed the call light within reach and she did not. Resident #76Review of Resident #76's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included Unspecified Dementia, Contracture of Muscle, Left Lower Leg, Contracture, Left Knee, Dysphagia, Hemiplegia and Hemiparesis following Non traumatic Intracerebral Hemorrhage affecting left non-dominant side. Review of Resident #76's Quarterly MDS with an ARD of 03/19/2026, revealed a BIMS score of 08, which indicated she was moderately cognitively impaired. Review of Resident #76's current Care Plan revealed she was bed and geriatric chair bound, required support and comfort related to left sided hemiplegia, incontinent of bowel and bladder, and required mechanical lift for transfers. Further review revealed interventions included to ensure the resident's call light was within reach and encourage the resident to use it for assistance as needed. On 06/22/2026 at 9:47 a.m., an observation was made of Resident #76 revealed her call light was clipped to the right side of her mattress and not within her reach. On 06/22/2026 at 9:49 a.m., an interview and observation was conducted with Resident #76. She attempted to reach the call light to call for assistance and stated she was unable to reach the call light. On 06/23/2026 at 8:05 a.m., an observation of Resident #76's call light was made. Her call light was attached to the outer edge of the mattress at the level of her head and not within her reach. On 06/23/2026 at 8:06 a.m., an observation was made of Resident #76. Resident #76 attempted to reach for the call light and admitted she could not reach or find her call light. On 06/23/2026 at 8:07 a.m., an interview was conducted with S8CNASUP. S8CNASUP stated all call lights were to be within residents' reach at all times. After viewing where Resident #76's call light was located, S8CNASUP confirmed Resident #76's call light was not within reach. On 06/24/2026 at 8:10 a.m., an observation was made of Resident #76. Resident #76's call light was located hanging under her bed, not within her reach. On 06/24/2026 8:49 a.m., an interview was conducted with S3ADON in Resident #76's room. S3ADON confirmed Resident #76's call light was hanging under her bed and not within Resident #76's reach. S3ADON further confirmed all call lights should have been within residents' reach at all times and were not.

Based on interviews and record reviews, the facility failed to ensure residents or resident representatives understood the arbitration agreement signed on admission for 3 (#11, #15, and #17) of 3 residents reviewed for arbitration.Findings:Resident #11Review of Resident #11's clinical record revealed he was admitted to the facility on [DATE].Review of Resident #11's admission packet dated 06/03/2026 revealed an arbitration agreement signed by Resident #11's RP.An interview was conducted on 06/23/2026 at 10:12 a.m. with Resident #11's RP. She stated she recalled signing Resident #11's admission documents. She stated S7AC told her where to sign, but she was not educated on what an arbitration agreement was. She stated she would not have signed this arbitration agreement if she would have been educated on what it meant. Resident #15Review of Resident #15's clinical record revealed she was admitted to the facility on [DATE].Review of Resident #15's admission MDS with ARD of 06/09/2026 revealed a BIMS of 15 which indicated she was cognitively intact.Review of Resident #15's admission packet dated 05/27/2026 revealed an arbitration agreement signed by Resident #15. An interview was conducted on 06/23/2026 at 9:40 a.m. with Resident #15. She stated she was not educated by the facility on what an arbitration agreement was prior to signing the admission documents.Resident #17Review of Resident #17's clinical record revealed he was admitted to the facility on [DATE].Review of Resident #17's admission packet dated 06/10/2026 revealed an arbitration agreement signed by Resident #17's RP.An interview was conducted on 06/23/2026 at 12:30 p.m. with Resident #17's RP. She stated she recalled signing Resident #17's admission documents. She stated S7AC told her where to sign but she was not educated on what an arbitration agreement was.An interview was conducted on 06/23/2026 at 9:20 a.m. with S7AC. She reviewed Resident #11, #15, and #17's signed admission packets. She confirmed all 3 residents' admission packets included a signed arbitration agreement. She confirmed the residents or their RPs had not been educated on what an arbitration agreement was. She stated she was responsible for educating the residents and RPs on arbitration agreements upon admission. She stated she should have educated them on what an arbitration agreement was and did not.An interview was conducted on 06/23/2026 at 9:28 a.m. with S1ADM. He stated the staff member getting an admission packet signed had the responsibility to educate residents and RPs on arbitration agreements.

Based on record review, observations, and interviews, the facility failed to ensure a resident fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding by failing to ensure enteral water flushes were administered per Physician's Orders for 1 (#49) of 1 resident reviewed for enteral feedings.Findings: Review of the facility's undated policy titled Gastric Tube Feeding, Continuous revealed in part, the following:7. Key Points - Rate prescribed by physician.Review of Resident #49's clinical record revealed he was admitted to the facility on [DATE] with diagnoses, which included Gastrostomy Status.Review of Resident #49's current Physician Orders revealed, in part, the following:Enteral Feed Order - Continuous enteral feeding with 275 mL water flush every 4 hours. Start date: 06/18/2025.On 06/22/2026 at 9:03 a.m., an observation was made of Resident #49's enteral feeding pump with water flushes infusing at 200 mLs every 4 hours. On 06/22/2026 at 9:03 a.m., an observation was made of Resident #49's enteral feeding pump with S8LPN. S8LPN confirmed Resident #49's water flushes were infusing at 200 mLs every 4 hours. On 06/22/2026 at 12:45 p.m., an observation was made of Resident #49's enteral feeding pump with water flushes infusing at 200 mLs every 4 hours. On 06/22/2026 at 3:40 p.m., an observation and interview was conducted with S8LPN. She observed Resident #49's enteral feeding pump with water flushes infusing at 200 mLs every 4 hours. S8LPN reviewed Resident #49's current Physician's Orders and confirmed water flush infusion rate should have been infusing at 275 mLs every 4 hours and was not. On 06/24/2026 at 11:45 a.m., an interview was conducted with S2DON. S2DON reviewed Resident #49's current Physician's Orders and confirmed enteral water flushes should have been infusing at 275 mLs every 4 hours. She stated she expected water flushes to be infused at the ordered rate.

Based on observation, interviews, and record review, the facility failed to ensure that drugs were stored and labeled properly in accordance with current accepted professional principles. The facility failed to ensure insulin pens containing multiple doses of insulin were clearly labeled with a puncture date for 1 (#67) of 2 residents observed during insulin administration.Findings:Review of the facility's policy titled Insulin Policy dated 11/02/2023 revealed in part, the following:Insulin pens will be dated when first punctured. Puncture date will be written on the labels already attached to insulin pens.An observation was made on 06/22/2026 at 11:39 a.m. of S5LPN during insulin administration for Resident #67. Observed 1 opened, partially filled Humalog insulin pen for Resident #67, without a puncture date.An interview was conducted on 06/22/2026 at 11:40 a.m. with S5LPN. S5LPN confirmed the Humalog insulin pen for Resident #67 was opened and partially used. S5LPN stated it was nurses' responsibility to label all insulin pens with a puncture date. S5LPN confirmed the insulin pen was undated and should have had a puncture date on it.An interview was conducted on 06/23/2026 at 3:00 p.m. with S2DON. S2DON stated she expected nursing staff to date insulin pens with the puncture date.

Based on observation and interviews, the facility failed to ensure garbage and waste were properly contained in the outdoor trash dumpster. This deficient practice had the potential to affect the 73 residents currently residing in the facility.Findings:Review of the facility's policy titled Waste Management dated 11/2022, revealed in part, the following:Policy: The facility will dispose of non-medical waste in a clean manner.3. Waste is properly contained in dumpsters with lids or otherwise covered.4. Areas used for garbage disposal are maintained to prevent pests.An observation was made on 06/22/2026 at 1:34 p.m. of garbage dumpster area outside of the facility. Observed in part, the following, on the ground outside of the garbage dumpster:6 filled, white garbage bags;8 empty, saturated cardboard boxes;5 open, disposable food boxes with food contents remaining;3 filled, large black garbage bags; andlarge amount of scattered trash items. An interview was conducted on 06/22/2026 at 1:39 p.m. with S4FSD. She observed the garbage dumpster area, and stated the amount of garbage located on the ground was unacceptable. She stated if the garbage dumpster was full, all staff should utilize a large grey bin for garbage overflow. She stated garbage should not be located on the ground.An interview was conducted on 06/22/2026 at 1:40 p.m. with S6MT. He stated maintenance makes rounds to ensure all garbage is picked up. He stated garbage should not be located on the ground.An interview was conducted on 06/22/2026 at 1:45 p.m. with S1ADM. He stated maintenance makes rounds to ensure all garbage is picked up. He stated staff should not be placing garbage on the ground.

Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections by failing to ensure:1. Nursing staff sanitized insulin pen rubber seal prior to extracting insulin for 2 (#30 and #67) of 2 residents observed for insulin administration.2. Nursing staff disinfected the glucometer between resident use for 1 (#67) of 2 residents observed during blood glucose monitoring.Findings:Review of Novolog and Humalog Insulin Pen Manufacturer's Inserts revealed in part, the following:Step 2: Wipe the pen tip rubber seal with an alcohol swab. Then apply new needle.Review of the facility's untitled and undated policy, revealed in part, the following:Disinfect the glucometer between each patient to prevent infection.1.Resident #30 Review of Resident #30's Clinical Record revealed the resident was admitted to the facility on [DATE].Review of Resident #30's current Physician's Orders revealed in part, the following:Novolog Insulin 100 unit/mL subcutaneously before meals and at bedtime per sliding scale.An observation was made on 06/22/2026 at 11:29 a.m. of S5LPN administering Novolog Insulin 100 unit/mL to Resident #30. S5LPN applied the insulin pen needle without sanitizing the insulin pen rubber seal. S5LPN administered the insulin.Resident #67Review of Resident #67's Clinical Record revealed the resident was admitted to the facility on [DATE].Review of Resident #67's current Physician's Orders revealed in part, the following:Humalog Insulin 100 unit/mL subcutaneously before meals and at bedtime per sliding scale.An observation was made on 06/22/2026 at 11:40 a.m. of S5LPN administering Humalog Insulin 100 unit/mL to Resident #67. S5LPN applied the insulin pen needle without sanitizing the insulin pen rubber seal. S5LPN administered the insulin.2.An observation was made on 06/22/2026 at 11:27 a.m. of S5LPN performing a blood glucose check on Resident #30. S5LPN then placed the glucometer on the top of the medication cart without using disinfectant. Observed the glucometer remain on the top of the medication cart without being disinfected.An observation was made on 06/22/2026 at 11:39 a.m. of S5LPN removing the glucometer from the top of the medication cart, without disinfecting the glucometer, and perform a blood glucose check on Resident #67. S5LPN then placed the glucometer on the top of the medication cart without using disinfectant.An interview was conducted on 06/22/2026 at 11:40 a.m. with S5LPN. S5LPN confirmed she did not clean the glucometer with a disinfectant between resident use for Resident #30 and Resident #67 and should have. S5LPN confirmed she did not sanitize the insulin pen rubber seal prior to applying the insulin pen needle before Resident #30 and Resident #67's insulin administration and should have.An interview was conducted on 06/23/2026 at 3:00 p.m. with S2DON. S2DON stated she expected nursing staff to disinfect the glucometer with the appropriate disinfectant wipes between resident use. S2DON stated she did not expect nursing staff to sanitize the insulin pen rubber seal prior to applying the insulin pen needle.

Based on record review and interviews, the facility failed to maintain complete and accurate records in accordance with accepted professional standards and practices for 4 (#3, #6, #19, and #32) of 19 sampled residents reviewed for accurate documentation. The facility failed to ensure the following: 1. Resident #3's medication administration and wound care treatment administration were accurately documented; 2. Resident #6's Percutaneous Endoscopic Gastrostomy (PEG) site care was accurately documented; 3. Resident #19's medication administration and wound care treatment administration was accurately documented; and4. Resident #32's suprapubic catheter care was accurately documented. 1.Resident #3Review of Resident #3’s clinical record revealed he was admitted to the facility on [DATE] with diagnoses, which included Diabetes Mellitus II (DM), Acquired Absence of Left Great Toe, Non-Pressure Chronic Ulcer of Right Ankle, Acquired Absence of Other Left Toe, Cerebral Infarction Due to Embolism of Cerebral Artery, Acquired Absence of Limb, and Chronic Osteomyelitis with Draining Sinus. A review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/10/2025 revealed Resident #3 had a Brief Interview for Mental Status (BIMS) of 15, which indicated she was cognitively intact. Review of Resident 3’s current Physician Orders revealed the following wound care orders, in part: DM wound right lateral ankle, clean with wound cleanser, pat dry with 4x4, apply betadine, pad, gauze wrap, elastic bandage dressing and secured with tape until resolved;DM wound to right 4th toe lateral, clean with wound cleanser, pat dry with 4x4, apply betadine, alginate between 4th and 5th toe, cover with pad, gauze wrap, elastic dressing and secure with tape until resolved;DM wound to right foot lateral, clean with wound cleanser, pat dry with 4x4, apply betadine, pad, gauze wrap, elastic dressing and secured with tape until resolved; andDM wound to right heel, clean with wound cleanser, pat dry with 4x4, apply betadine, pad, gauze wrap, elastic dressing and secured with tape. Review of Resident #3’s Treatment Administration Records (TAR) dated July 2025 revealed the aforementioned wound care treatment orders were not initialed as completed from 07/04/2025 through 07/11/2025 at 16:00, 07/15/2025 through 07/25/2025 at 16:00, and 07/28/2025 at 16:00. Review of Resident #3’s Medication Administration Records (MAR) dated July 2025 revealed the following medications were not initialed as completed on the following dates/times, in part:Novolog flex pen subcutaneous solution pen injector 100 unit/milliliters (ML) inject as per sliding scale on 07/26/2025 at 16:00 and 20:00, 07/27/2025 at 16:00 and 20:00;Observe for signs and symptoms of abnormal bleeding/bruising on the 07/26/2025 and 07/27/2025 evening shift;Pain monitoring on 07/27/2025 evening shift;Protein oral liquid 30 ML by mouth (PO) Twice a Day (BID) on 07/27/2025 at 16:30;Sotalol hydrochloride oral tablet 80 milligram (MG) give 1 tablet PO BID on 07/26/2025 and 07/27/2025 at 20:00;Vitamin C oral tablet 500 mg PO BID on 07/27/2025 at 20:00;Novolog flex pen subcutaneous (SC) solution pen injector 100 unit/ml inject 4 unit SC BID on 07/27/2025 at 16:00.Pregabalin oral capsule 150 mg give 1 capsule PO every 12 hours on 07/27/2025 at 20:00;Apixaban oral tab 5 mg PO BID on 07/27/2025 at 20:00;Atorvastatin calcium oral tablet give 1 tablet PO at bedtime on 07/27/2025 at 20:00;Fenofibrate Oral Tablet 145 mg give 1 tablet PO at bedtime on 07/27/2025 at 20:00; andMiralax oral powder 17 gram/scoop give 1 scoop PO one time a day on 07/27/2025 at 20:00. On 07/28/2025 at 1:43 p.m., an interview was conducted with Resident #3. She stated the nurses had not missed any wound care treatments since her admission to the facility. On 07/30/2025 at 1:09 p.m., an interview was conducted via telephone with S12LPN. She confirmed she worked the evening shift from 3:00 p.m. to 11:00 p.m. on 07/26/2025 and 07/27/2025 and completed medication administration for all of Resident #3’s medications. She further confirmed if the box was blank on the MAR next a medication, then medication administration was not accurately documented and should have been. On 07/30/2025 at 2:20 p.m., an interview was conducted with S2DON. She stated she expected the wound care nurse to accurately document each resident’s wound care treatment administration on the TAR and medication administration on the MAR. After review of Resident #3’s TAR and MAR dated July 2025, and S2DON confirmed the aforementioned wound care treatments and medication administration dates/ times were not accurately documented and should have been. 2.Resident #6Review of Resident #6’s clinical record revealed he was admitted to the facility on [DATE] with diagnoses, which included Gastrostomy Status and Mild Protein-calorie Malnutrition. Review of Resident #6’s current Physician Orders revealed the following, in part: PEG site: Clean with wound cleanser, pat dry, and cover with a drain sponge every day shift. Review of Resident #6’s TAR dated July 2025 revealed PEG site care was not documented as complete on 07/05/2025, 07/06/2025, 07/19/2025, and 07/20/2025. On 07/30/2025 at 12:40 p.m., an interview was conducted with S11LPN. She stated she worked and performed Resident #6’s PEG site care on 07/05/2025, 07/06/2025, 07/19/2025, and 07/20/2025. She confirmed if there was a blank box on the TAR for those dates, then treatment administration was not accurately documented. On 07/30/2025 at 2:17 p.m., an interview was conducted with S2DON. She stated S11LPN was responsible for Resident #6’s PEG site care and documentation on the aforementioned dates/times. S2DON reviewed Resident #6’s TAR dated July 2025 and confirmed incomplete documentation of PEG site care. S2DON further confirmed all PEG site care should be accurately documented upon completion. 3.Resident #19Review of Resident #19’s clinical record revealed he was admitted to the facility on [DATE] with diagnoses, which included Pain in Right Knee, Hypertensive Emergency, End Stage Renal Disease and DM. Review of Resident #19’s TAR dated July 2025 revealed the following wound care treatment orders were not initialed as completed, in part:Monitor surgical areas/sutures on right knee, cleanse and keep open to air every day shift for skin healing on 07/19/2025 and 07/20/2025. Review of Resident #19’s MAR dated July 2025 revealed the following medications were not initialed as completed on the following dates/ times, in part:Novolog flexpen subcutaneous solution pen injector 100 unit/ml inject as per sliding scale on 07/27/2025 at 1600 and 2000;Right upper arm midline to be checked every shift for increased redness, heat, signs of infiltration, or drainage on 07/27/2025 evening shift;Vitamin C oral tablet 500 mg give 1 tablet PO BID on 07/27/2025 at 20:00;Haloperidol oral tablet 1 mg give 1 tablet PO BID on 07/27/2025 at 20:00;Protein oral liquid give 30 ml PO BID on 07/27/2025 at 20:00;Carvedilol oral tablet 6.25mg give 1 tablet PO BID on 07/27/2025 at 20:00;Zinc sulfate oral capsule 220 mg give 1 capsule PO at bedtime on 07/27/2025 at 20:00;Normal Saline flush intravenous solution use 1 syringe intravenously in the evening to maintain midline patency on 07/27/2025 at 20:00;Ceftriaxone sodium injection solution reconstituted 1 gram use 1 gram intravenously at bedtime for anti-infective on 07/27/2025 at 20:00;Atorvastatin Calcium Oral Tablet 20 mg give 1 tablet PO at bedtime on 07/27/2025 at 20:00; andTizanidine hcl oral tablet 2 mg give 1 tablet PO at bedtime on 07/27/2025 at 20:00. On 07/30/2025 at 12:40 p.m., an interview was conducted with S11LPN. She confirmed she worked and performed Resident #19’s wound care on 07/19/2025 and 07/20/2025. S11LPN confirmed if the box was a blank on the TAR for those dates, then treatment administration was not accurately documented. On 07/30/2025 at 1:09 p.m., an interview was conducted with S12LPN. She confirmed she worked the evening shift from 3:00 p.m. to 11:00 p.m. on 07/26/2025 and 07/27/2025 and completed medication administration for all of Resident #19’s medications. She further confirmed if the box is blank on the MAR next to the medications, then medication administration was not accurately documented and should have been. On 07/30/2025 at 2:20 p.m., an interview was conducted with S2DON. She stated she expected the wound care nurse to accurately document each residents’ wound care treatment administration on the TAR and medication administration on the MAR. After review of Resident #19’s TAR and MAR dated July 2025, S2DON confirmed the aforementioned wound care treatments and medication administration dates/ times were not accurately documented and should have been. 4. Resident #32 Review of Resident #32's clinical record revealed she was admitted to the facility on [DATE] with diagnoses, which included Acute Kidney Failure and Neuromuscular Dysfunction of Bladder. Review of Resident #32’s current Physician Orders revealed the following, in part: Suprapubic Catheter: Clean with wound cleanser, pat dry, paint with betadine and cover with a drain sponge every day shift. Review of Resident #32’s TAR dated July 2025 revealed Suprapubic Catheter care treatment was not documented as complete on 07/05/2025, 07/06/2025, 07/19/2025, and 07/20/2025. On 07/30/2025 at 12:40 p.m., an interview was conducted with S11LPN. She stated she worked and performed Resident #32’s suprapubic catheter care on 07/05/2025, 07/06/2025, 07/19/2025, and 07/20/2025. She confirmed if there was a blank box on the TAR for those dates, then treatment administration was not accurately documented. On 07/30/2025 at 2:17 p.m., an interview was conducted with S2DON. She stated S11LPN was responsible for Resident #32’s suprapubic catheter care and documentation on the aforementioned dates/times. S2DON reviewed Resident #6’s TAR dated July 2025 and confirmed incomplete documentation of suprapubic catheter care. S2DON further confirmed all suprapubic catheter care should be accurately documented upon completion.

Based on observations and interviews, the facility failed to store and prepare food under sanitary conditions by failing to ensure the food was properly stored and labeled in the facility's kitchen. This deficient practice had the potential to affect all of the 69 facility residents who were served from the facility's kitchen. Review of facility's undated policy titled, How to Store Under Sanitary Conditions revealed in part:1. For dry storage-All items must be in a container with a lid or in a labeled zip lock bag. All items must be labeled with what it is, the date it was opened and the initial of the person who placed it in there. On 07/28/2025 at 8:27 a.m., an observation was made of the kitchen food preparation area with S5CK. The observation revealed and S5CK confirmed the following items were found to be open and undated.1 - 20 ounce package of whole wheat sliced bread; and1 - 24 ounce package of dinner rolls.On 07/28/2025 at 8:32 a.m., an observation was made of the dry storage area with S5CK. The observation revealed and S5CK confirmed the following items were found to be open and undated.1 - 26 ounce package of instant mashed potatoes;1 - 5 pound package of macaroni noodles; and1 - 5 pound package of instant sliced potatoes. On 07/28/2025 at 8:45 a.m., an observation was made of the walk in cooler with S5CK. The observation revealed and S5CK confirmed the following items were open and undated. 1 - 2 quart pitcher of red punch and 1 - 5 pound container of chicken salad. On 07/28/2025 at 10:10 a.m., an interview was conducted with S4FSD. S4SFD stated she was responsible for the staff and the meals prepared in the facility's kitchen/dietary department. S4SFD observed the above observations. S4SFD confirmed all items should be labelled with the open date once opened.

Based on record reviews and interviews, the facility failed to ensure all medical records regarding the resident's code status consistently reflected the resident's wishes for 2 (#4 and #66) of 25 residents reviewed in the initial screening for advanced directives. Review of the facility’s undated policy titled, “LaPOST”, revealed the following, in part:Procedure6. Place the original LaPOST form in a prominent and appropriate place in the medical record. Do not document code status in the electronic record. Resident #4Review of Resident #4’s clinical record revealed he was admitted to the facility on [DATE]. Review of Resident #4's current Physician Orders revealed the following, in part:Order date: [DATE]-Full Code Status. Review of Resident #4's hard, physical chart revealed a Louisiana Physician Orders for Scope of Treatment (LaPOST) dated [DATE]. The LaPOST revealed Resident #4’s Health Care Representative checked DNR/Do Not Attempt Resuscitation. Resident #66 Review of Resident #66’s clinical record revealed he was admitted to the facility on [DATE]. Review of Resident #66’s electronic medical record revealed a LaPOST dated [DATE]. The LaPOST revealed Resident #66’s Health Care Representative checked CPR/Attempt Resuscitation. Further review of Resident #66’s electronic medical record revealed no other LaPOST documents. Review of Resident #66’s hard, physical chart revealed a LaPOST dated [DATE]. The LaPOST revealed Resident #66 checked DNR/Do Not Attempt Resuscitation. On [DATE] at 12:58 p.m., an interview was conducted with S6LPN. She stated she was assigned to Resident’s #66 and #4. She stated Resident #66 was a full code but recently changed to a DNR. She stated the facility’s process was to look directly in the resident's hard, physical chart for code status and not in the resident’s electronic medical record. On [DATE] at 1:05 p.m., an interview was conducted with S2DON. She stated the facility’s process for checking a resident’s code status was to look directly in the resident’s hard, physical chart. She stated she went through all residents’ charts and deleted the code status orders to eliminate confusion. She was made aware of the findings above. She stated she did not realize LaPOST forms were scanned into some of the resident’s residents’ charts. She confirmed if a resident’s code status was found in two different places, the code statuses should match.

Based on interviews, video observation, and record review, the facility failed to protect the resident's right to be free from physical abuse for 1 (#4) of 24 sampled residents reviewed for abuse. The facility failed to ensure Resident #4 was free from physical abuse by Resident #50.Review of the facility's policy dated 2025 and titled, Policy for Prohibition of Abuse revealed in part, the following:Each resident has the right to be free from abuse.Resident #4Review of Resident #4's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Parkinson's Disease, Depression, and Mild Intellectual Disabilities.Review of Resident #4's Quarterly MDS with an ARD of 06/05/2025 revealed a BIMS of 11, which indicated he was moderately cognitively impaired.Review of Resident #4's July 2025 Progress Notes revealed in part, the following:On 07/13/2025 S9RN wrote, Resident #4 wheeled himself into nurse's station and stated to S9RN, Resident #50 just punched me in my face. S9RN asked Resident #4 why the other Resident #50 would have punched him in the face, and he stated, I don't know. I was just down there sitting next to her and she told me to go away and I didn't, and she punched me. Once S9RN completed assessment of Resident #4, S9RN, entered day room, where incident occurred, to ask Resident #50 if she had in fact hit resident. Resident #50 responded Yeah, I sure did. But I didn't hit him hard. Notified S10WS of incident. S1ADM was then notified.Review of Resident #4's current Care Plan revealed in part, the following:On 07/13/2025, Resident #4 reported Resident #50 hit him in the face because he sat next to her and did not move when she asked him to.Resident #50 Review of Resident #50's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included Depression and Anxiety.Review of Resident #50's Annual MDS with an ARD of 06/20/2025 revealed a BIMS of 10, which indicated she was moderately cognitively impaired.Review of Resident #50's July 2025 Progress Notes revealed in part, the following:On 07/13/2025 S13LPN wrote, Resident #4 stated Resident #50 punched him in the face. S13LPN completed assessment of Resident #4, entered day room, where incident occurred, and asked Resident #50 if she hit Resident #4. Resident #50 responded Yeah, I sure did. But I didn't hit him hard. Notified S10WS of incident. S1ADM was then notified. On 07/29/2025 at 8:05 a.m., review of the facility's incident log dated July 2025 revealed in part, the following:Physical Aggression Received Incidents:07/13/2025 at 2:00 p.m.-Resident #4Physical Aggression Initiated Incidents:07/13/2025 at 2:00 p.m. - Resident #50On 07/29/2025 at 8:05 a.m., review of the facility's incident report dated 07/13/2025 revealed in part, the following:Incident Location: Activity RoomPerson Preparing Report: S9RNIncident Description:Resident #4 wheeled himself into the nurse's station and stated to S9RN, Resident #50 just punched me in my face. S9RN asked Resident #4 why Resident #50 punched him in the face, and he stated he didn't know. Resident #4 stated he was sitting down next to Resident #50, she told him to go away and he didn't, and then she punched him.Immediate Action Taken:S9RN immediately assessed Resident #4. After assessing Resident #4 S9RN entered the day room, where the incident occurred. S9RN asked Resident #50 if she hit Resident #4 and she responded, Yeah, I sure did. But I didn't hit him hard. S9RN notified S10WS of the incident. S1ADM was then notified by S10WS. Review of Resident #50's current Care Plan revealed on 07/13/2025, Resident #50 became angry and hit another resident when he did not do what she asked him to do and said something inappropriate to her. Resident #50 has the potential to be physically aggressive, related to poor impulse control.An interview was conducted on 07/29/2025 at 9:20 a.m. with Resident #50. She was alert and oriented to person, place, time, and situation. Resident #50 stated around 2 weeks ago, she punched Resident #4 in the face with a closed fist in the activity room. She stated Resident #4 came to her table and began speaking to her in a sexually inappropriate manner. Resident #50 stated she told Resident #4 multiple times to leave her alone and he did not. She stated she then punched Resident #4 in the face with a closed fist. Resident #50 stated she meant to punch him and would do it again if he bothers me. She stated after the incident, S1ADM asked her what happened. Resident #50 stated she told S1ADM that she punched Resident #4 in the face when he spoke to her in a sexually inappropriate manner in the activity room.An interview was conducted on 07/29/2025 at 9:30 a.m. with Resident #4. He was alert and oriented to person, place, time, and situation. He stated around 2 weeks ago, Resident #50 punched him in the face with a closed fist in the activity room. He stated it hurt a little. He stated after the incident, S1ADM asked him what happened. He stated he told S1ADM Resident #50 punched him in the face when he was trying to talk to her in the activity room.An interview and video camera footage observation was conducted on 07/29/2025 at 11:00 a.m. with S1ADM. Review of the video camera footage with S1ADM dated 07/13/2025 at 1:49 p.m. revealed Resident #4 and Resident #50 can be seen at a table together in the activity room. Resident #50 hit Resident #4 in the head with her hand. Resident #50 then placed her head in her hands while looking down at the table.An interview was conducted on 07/29/2025 at 2:15 p.m. with S2DON. She stated she was aware of the incident on 07/13/2025 between Resident #4 and Resident #50 and stated it was not willful abuse.An interview was conducted on 07/29/2025 at 3:03 p.m. with S9RN. She stated Resident #4 and Resident #50 are alert, oriented, and able to make their needs known. She stated on 07/13/2025, Resident #4 told her Resident #50 punched me in the face. She stated Resident #50 told her Yes I sure did hit him, but I didn't hit him hard. I'll do it again if I have to. She stated Resident #50 told her she was not sorry for hitting Resident #4. She stated she immediately notified S10WS, who then notified S1ADM. She stated Resident #50 punching Resident #4 was physical abuse.An interview was conducted on 07/30/2025 at 11:57 a.m. with S10WS. She stated Resident #4 and Resident #50 are alert, oriented, and able to make their needs known. She stated on 07/13/2025, S9RN notified her Resident #50 punched Resident #4 in the face. She stated this was not abuse because Resident #50 is a b***h. She stated she immediately notified S1ADM of the incident.An interview was conducted on 07/29/2025 at 11:00 a.m. with S1ADM. He stated he was notified on 07/13/2025 by S10WS that Resident #4 was punched in the face by Resident #50 in the activity room. He stated he did not believe this incident was abuse because it was not willful.

Based on interviews and record reviews, the facility failed to ensure allegations of physical abuse were reported to the State Agency in the required timeframe for 1 (#4) of 24 sampled residents reviewed for abuse.Review of the facility's policy dated 02/2025 and titled, Policy for Prohibition of Abuse revealed in part, the following:Reporting:1. Report incidents to the state agency as required.Internal Reporting Timelines:Abuse: Immediately.Resident #4Review of Resident #4's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Parkinson's Disease, Depression, and Mild Intellectual Disabilities.Review of Resident #4's Quarterly MDS with an ARD of 06/05/2025 revealed a BIMS of 11, which indicated he was moderately cognitively impaired.Review of Resident #4's July 2025 Progress Notes revealed in part, the following:On 07/13/2025 S9RN wrote, Resident #4 wheeled himself into nurse's station and stated to S9RN, Resident #50 just punched me in my face. Once S9RN completed assessment of Resident #4, S9RN, entered day room, where incident occurred, to ask Resident #50 if she had in fact hit resident. Resident #50 responded Yeah, I sure did. But I didn't hit him hard. Notified S10WS of incident. S1ADM was then notified.Resident #50 Review of Resident #50's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included Depression and Anxiety.Review of Resident #50's Annual MDS with an ARD of 06/20/2025 revealed a BIMS of 10, which indicated she was moderately cognitively impaired.Review of Resident #50's July 2025 Progress Notes revealed in part, the following:On 07/13/2025 S13LPN wrote, Resident #4 stated Resident #50 punched him in the face. Notified S10WS of incident. S1ADM was then notified. On 07/29/2025 at 8:05 a.m., review of the facility's incident log dated July 2025 revealed in part, the following:Physical Aggression Received Incidents:07/13/2025 at 2:00 p.m.-Resident #4Physical Aggression Initiated Incidents:07/13/2025 at 2:00 p.m. - Resident #50On 07/29/2025 at 8:05 a.m., review of the facility's incident report dated 07/13/2025 revealed in part, the following:Incident Location: Activity RoomPerson Preparing Report: S9RNIncident Description:Resident #4 stated he was sitting down next to Resident #50, she told him to go away and he didn't, and then she punched him.Immediate Action Taken:S9RN notified S10WS of the incident. S1ADM was then notified by S10WS. An interview was conducted on 07/29/2025 at 9:20 a.m. with Resident #50. She was alert and oriented to person, place, time, and situation. Resident #50 stated around 2 weeks ago, she punched Resident #4 in the face with a closed fist in the activity room. She stated after the incident, S1ADM asked her what happened. Resident #50 stated she told S1ADM that she punched Resident #4 in the face when he spoke to her in a sexually inappropriate manner in the activity room.An interview was conducted on 07/29/2025 at 9:30 a.m. with Resident #4. He was alert and oriented to person, place, time, and situation. He stated around 2 weeks ago, Resident #50 punched him in the face with a closed fist in the activity room. He stated after the incident, S1ADM asked him what happened. He stated he told S1ADM Resident #50 punched him in the face when he was trying to talk to her in the activity room.An interview was conducted on 07/29/2025 at 3:03 p.m. with S9RN. She stated Resident #4 and Resident #50 are alert, oriented, and able to make their needs known. She stated on 07/13/2025, Resident #4 told her Resident #50 punched me in the face. She stated she immediately notified S10WS, who then notified S1ADM. She stated Resident #50 punching Resident #4 was physical abuse.An interview was conducted on 07/30/2025 at 11:57 a.m. with S10WS. She stated Resident #4 and Resident #50 are alert, oriented, and able to make their needs known. She stated on 07/13/2025, S9RN notified her Resident #50 punched Resident #4 in the face. She stated she immediately notified S1ADM of the incident.An interview was conducted on 07/29/2025 at 11:00 a.m. with S1ADM. He stated he was notified on 07/13/2025 by S10WS that Resident #4 was punched in the face by Resident #50 in the activity room. He stated he did not believe this incident was abuse because it was not willful therefore it was not reported to the state agency.

Based on interviews and record reviews, the facility failed to ensure a resident with an identified mental health diagnosis was referred for a Preadmission Screening and Resident Review (PASRR) Level II evaluation as required for 1 (#2) of 3 (#2, #9, and #47) residents reviewed for PASRR.Review of Resident #2's clinical record revealed he was admitted to the facility on [DATE] with diagnoses which included Major Depressive Disorder. Further review revealed he was diagnosed with Adjustment Disorder on 10/26/2019 and Schizophrenia on 12/23/2019. Review of Resident #2's Level 1 PASRR dated 09/24/2019 revealed Section III: Mental Illness, did not have Adjustment Disorder or Schizophrenia selected as a diagnosis. On 07/30/2025 at 9:30 a.m., an interview was conducted with S7SSD. She stated she was responsible for resubmitting resident review forms to the Office of Behavioral Health (OBH) if a new mental health diagnosis was acquired. She reviewed Resident #2's Level 1 PASSR dated 09/24/2019 and confirmed a mental diagnosis of Major Depressive Disorder was checked. She reviewed Resident #2's current diagnoses list and confirmed he received a diagnosis of Adjustment Disorder on 10/26/2019 and Schizophrenia on 12/23/2019. She confirmed a resident review form should have been resubmitted to OBH for Level II evaluation after the new mental health diagnoses and was not.

Based on observations, interviews, and record review, the facility failed to provide necessary care and services for the provision of respiratory care in accordance with professional standards of practice. The facility failed to ensure a resident's oxygen was administered at the physician ordered rate for 1 of 1 (#10) residents reviewed for respiratory care.Review of Resident #10's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included Senile Degeneration of the Brain.Review of Resident #10's current Physician Orders revealed the following, in part:Start date 05/12/2025 - Oxygen at 3L per nasal cannula continuous every shift.An observation was made on 07/28/2025 at 12:02 p.m. of Resident #10 in her room wearing oxygen per nasal cannula at 2.5L.An observation was made on 07/29/2025 at 9:00 a.m. of Resident #10 in her wearing oxygen per nasal cannula at 2.5L.An interview was conducted on 07/29/2025 at 9:02 a.m. with S8LPN. S8LPN confirmed Resident #10 had an order for oxygen per nasal cannula continuous at 3L. S8LPN confirmed Resident #10's oxygen was set at 2.5L and should have been at 3L.An interview was conducted on 07/29/2025 at 9:13 a.m. with S3ADON. She confirmed all residents' oxygen should be administered at the ordered rate.An interview was conducted on 07/30/2025 at 10:10 a.m. with S2DON. She confirmed all residents' oxygen should be administered at the ordered rate.

Based on observations and interview, the facility failed to post the name, address, and telephone numbers of the Office of the State Long-Term Care Ombudsman program, in a form and manner accessible and understandable to residents and resident representatives. This deficient practice had the potential to affect any of the 71 residents residing in the facility.On 07/28/2025 at 9:45 a.m., an observation of the facility revealed no posting/signage of the required Office of the State Long-Term Care Ombudsman Program names, addresses, and telephone numbers. On 07/28/2025 at 9:50 a.m. an observation was made throughout the facility with S3ADON. S3ADON confirmed there was no information regarding the Office of the State Long-Term Care Ombudsman Program posted in the facility.

Based on interviews and record review, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 1 (#3) of 3 (#1, #2, and #3) sampled residents. The facility failed to ensure Resident #3 was coded correctly for falls. Findings: Review of Resident #3's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included Age Related Osteoporosis and Unspecified Disorder of Adult Personality and Behavior. Further review revealed Resident #3 had a diagnosis of Displaced Intertrochanteric Fracture of Right Femur on 12/16/2024. Review of Resident #3's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/23/2024 revealed Section J1700: Fall History was blank. An interview was conducted on 01/29/2025 at 1:10 p.m. with S3RN. She stated she was responsible for completing resident MDS assessments. She reviewed Resident #3's Incident Report dated 12/11/2024. She stated Resident #3 was admitted to the hospital and returned on 12/16/2024 with a diagnosis of Displaced Intertrochanteric Fracture of Right Femur. She reviewed Resident #3's Quarterly MDS with an ARD of 12/23/2024 and stated Section J1700 was not coded for falls. An interview was conducted on 01/29/2025 at 1:47 p.m. with S2DON. She reviewed the aforementioned findings and confirmed Resident #3's MDS assessment was not coded for falls and should have been.

Based on record review and interviews, the facility failed to ensure a resident's plan of care was revised by failing to update fall interventions after each fall for 1 (#3) of 3 (#1, #2, and #3) residents reviewed for falls. Findings: Review of the facility's policy titled, Fall Policy and Procedure, and dated 01/10/2017, revealed in part, the following: 6. The fall care plan shall be updated after a fall and is to include any interventions. Treatment/Management: 1. Based on the assessment, the staff will identify pertinent interventions to try to prevent subsequent falls and to mitigate risks of serious injuries associated with falls. Review of Resident #3's Clinical Record revealed she was admitted to the facility on [DATE], with diagnoses which included Age Related Osteoporosis. Review of the facility's Incident Report dated 12/08/2024 revealed, in part the following: Resident #3 had an unwitnessed fall in the day room. Review of Resident #3's Nurse's Note dated 12/08/2024 revealed, in part, the following: Nurse was flagged down by another resident to the dayroom. She notified staff that resident had fallen. Resident was seen lying on her left side with her head on the floor. Resident unable to explain what happened and how she fell . Review of Resident #3's Care Plan revealed it was not revised to include interventions to address Resident #3's fall on 12/08/2024. An interview was conducted on 01/28/2025 at 1:10 p.m. with S3RN. S3RN stated she was responsible for updating Resident #3's Care Plan. S3RN reviewed Resident #3's Care Plan. S3RN stated after Resident #3's fall on 12/08/2024, the only intervention added to the care plan was to send Resident #3 to the local hospital for evaluation. An interview was conducted on 01/28/2025 at 1:47 p.m. with S2DON. S2DON stated S3RN was responsible for updating Resident #3's Care Plan. S2DON reviewed Resident #3's Care Plan. S2DON stated after Resident #3's fall on 12/08/2024, bright signs were placed throughout the resident's room to remind the resident to ask for assistance. S2DON stated the Care Plan should have been revised to reflect the intervention.

47191 Based on observation, interviews, and record review, the facility failed to provide necessary care and services for the provision of respiratory care in accordance with professional standards. The facility failed to ensure oxygen tubing and humidifier bottle were properly labeled for 4 (#11, #43, #62, and #64) of 4 (#11, #43, #62, and #64) residents reviewed for oxygen therapy. Findings: Review of the facility's policy dated 12/09/2026 and titled, Changing of Oxygen Tubing, Humidifiers, and Nebulizer Tubing and Mask/Pipes revealed the following, in part: Nurses working the 11:00 p.m.-7:00 a.m. shift shall change the tubing, humidifier, and nebulizer sets every Sunday night for those residents who use the equipment continually. These items should be dated on day of exchange. Resident #11 Review of the clinical record for Resident #11 revealed she was admitted to the facility on [DATE] and had a diagnosis of Heart Failure. Review of the current Physicians Orders for Resident #11 revealed the following, in part: Start date: 06/03/2024 May use 2-4 liters via nasal cannula PRN for SOB. On 08/19/2024 at 8:55 a.m., an observation was made of Resident #11wearing oxygen via nasal cannula. There was no date observed on the oxygen tubing indicating when changed. On 08/19/2024 at 9:25 a.m., an observation was made of Resident #11's oxygen tubing with S6RN. She confirmed the oxygen tubing was not labeled with the date last changed. She stated per facility policy, oxygen tubing was to be changed every Sunday by night shift nursing staff and dated when changed. Resident #43 Review of the clinical record for Resident #43 revealed he was admitted to the facility on [DATE] and had diagnoses which included Chronic Obstructive Pulmonary Disease and Acute Respiratory Failure. Review of the current Physicians Orders for Resident #43 revealed the following, in part: Start date: 06/03/2024 Oxygen at 2 liters per nasal cannula or mask PRN every shift for COPD. On 08/19/2024 at 8:55 a.m., an observation was made of Resident #43wearing oxygen via nasal cannula. There was no date observed on the oxygen tubing or humidifier bottle indicating when changed. Resident #62 Review of the clinical record for Resident #62 revealed he was admitted to the facility on [DATE] and had diagnoses which included Chronic Obstructive Pulmonary Disease and Congestive Heart Failure. Review of the current Physicians Orders for Resident #62 revealed the following, in part: Start date: 06/03/2024 Oxygen at 4-5 L per minute as needed for SOB. On 08/19/2024 at 8:48 a.m., an observation was made of Resident #62 wearing oxygen via nasal cannula. There was no date observed on the oxygen tubing or humidifier bottle indicating when changed. Resident #64 Review of the clinical record for Resident #64 revealed she was admitted to the facility on [DATE] and had diagnoses which included Chronic Obstructive Pulmonary Disease and Chronic Respiratory Failure with Hypoxia. Review of the current Physicians Orders for Resident #64 revealed the following, in part: Start date: 06/07/2024 Oxygen at 3 LPM continuous. Start date: 06/09/2024 Oxygen: NC/Mask and Humidifier change every Sunday night shift. On 08/19/2024 at 9:00 a.m., an observation was made of Resident #64 wearing oxygen via nasal cannula. There was no date observed on the oxygen tubing indicating when changed. On 08/19/2024 at 9:20 a.m., an observation was made of Resident #43, #62, and #64's oxygen tubing with S3LPN. She observed the above resident's oxygen tubing and humidifiers and confirmed they were not labeled with the date last changed. She stated all resident's oxygen tubing and humidifiers should be changed every Sunday on night shift and should be labeled with the date changed. On 08/20/2024 at 1:00 p.m., an interview was conducted with S2DON. She was made aware of the observations regarding the aforementioned resident's oxygen tubing and humidifiers. She stated the facility's policy was for the nurse working Sunday night to change and date oxygen tubing or humidifiers. She confirmed all oxygen tubing or humidifier bottles should be labeled with the date it was changed.

Based on observations, interviews, and policy review, the facility failed to store, prepare, and distribute foods under sanitary conditions. The facility failed to ensure food and dietary supplements used for resident consumption was not expired. There were 35 facility residents who were provided dietary supplements from the facility's kitchen and nursing stations. Findings: Review of Facility's Policy dated [DATE] titled Food Receiving and Storage revealed the following, in part: Policy Statement: Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation: 8. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). 14. Food items and snacks kept on the nursing units must be maintained as indicated below: a. All food items to be kept at or below 41 degrees Fahrenheit must be placed in the refrigerator located at the nurse's station and labeled with a use by date. d. Beverages must be dated when opened and discarded after twenty-four (24) hours. An observation was made of Med Storage Room B and the nursing station's refrigerator on [DATE] at 1:00 p.m. with S2DON, who confirmed the following: 4- 32 oz. No Sugar Added Vanilla supplements opened, with expiration dates [DATE]; 3- 32 oz. No Sugar Added Vanilla supplements, with expiration date [DATE]; and, 1- 8 oz. 1% milk with expiration date [DATE]. An interview was conducted with S2DON on [DATE] at 1:15 p.m. S2DON confirmed the facility failed to store food and dietary supplements properly. S2DON confirmed she would expect all food products and supplements to be used by the expiration date and any opened supplements should have been discarded after 24 hours and were not. An observation was made of Med Cart C on [DATE] at 1:20 p.m. with S3LPN, which revealed the following: ,d+[DATE] oz. No Sugar Added Vanilla supplement opened, with expiration date of [DATE]. An interview was conducted with S3LPN on [DATE] at 1:22 p.m. S3LPN confirmed the above observation, and stated the expired supplement available for residents' consumption should have been discarded and was not. An interview was conducted with S1ADM on [DATE] at 2:10 p.m. Observations conducted on [DATE] of Med Cart C and Med Storage Room B and the nurse's station refrigerator were discussed. S1ADM confirmed food and dietary supplements available for resident consumption should be discarded prior to the expiration date or within 24 hours after the open date and were not.

Based on observations, record review and interviews, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice by failing to ensure device site care orders were obtained for 1 (#56) of 3 (#25, #39, and #56) residents reviewed for indwelling devices. Findings: Review of the facility's policy dated 12/03/2009 titled Peripherally Inserted Central Catheter and Midline revealed the following, in part: Purpose: The purpose of this guideline is to provide information on the best practices related to preventing complications with peripherally inserted central catheter lines: routine care and dressing changes, medication infusion, maintaining patency. Routine care & dressing: 4. If peripherally inserted central catheter line dressing is not found to be torn, loose, damp, soiled, or raised, the insertion site dressing should be routinely changed every 7 days to decrease incidence of infection. This is a sterile dressing change task and should be done by a registered nurse. Review of Resident #56's clinical record revealed she was admitted to the facility on [DATE] with diagnoses which included Dementia, Severe Sepsis without Septic Shock, Bacteremia and Urinary Tract Infection. Review of Resident #56's Nurses Notes dated August 2024 revealed the resident had a midline catheter placed on 08/09/2024. Further review revealed no documentation of site monitoring or dressing changes to the midline catheter site. Review of Resident #56's Physician's Orders dated August 2024 revealed no orders for midline catheter dressing changes or site monitoring. Review of Resident #56's Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated August 2024 revealed no documentation site monitoring or dressing changes had been performed to the resident's Midline catheter. On 08/20/2024 at 12:55 p.m., an observation was made of Resident #56 midline catheter. The date on the dressing was illegible. On 08/20/2024 at 2:49 p.m., an observation was made with S2DON of Resident #56's midline catheter dressing. She stated the date labeled on the dressing was illegible. She confirmed facility policy was to perform site dressing change every seven days and the dressing was overdue to be changed. On 08/21/2024 at 10:10 a.m., an interview was conducted with S7LPN. She stated she worked on 08/09/2024 when Resident #56's midline catheter was placed. S7LPN confirmed she did not obtain an order to initiate the ongoing site monitoring or care of the midline catheter and should have. On 08/20/2024 at 2:49 p.m., an interview was conducted with S2DON. She reviewed Resident #56's Physician's Orders, Medication Administration Record (MAR), Treatment Administration Record (TAR), and Nurses' Notes and confirmed there was no documentation in the clinical record to show midline catheter care had been initiated to ensure ongoing site monitoring and site care. She stated it was the floor nurses responsibility to obtain and initiate orders to monitor the midline catheter site. She confirmed midline catheter care orders should have been obtained and were not.