Every finding on record at Luling Living Center

Based on observation, interviews, and record reviews, the facility failed to ensure licensed nursing staff provided basic life support, including cardiopulmonary resuscitation [(CPR) chest compressions and rescue breaths to maintain blood flow and oxygen to vital organs], in accordance with the resident's physician orders and American Heart Association for 1 (Resident #54) of 1 sampled residents reviewed who had expired in the facility in a total sample of 19 residents. This deficient practice resulted in an Immediate Jeopardy situation on [DATE] at 12:49PM when Resident #54 was found unresponsive, without a pulse and not breathing by S4Licensed Practical Nurse (LPN) and S5LPN The Immediate Jeopardy situation continued on [DATE] at 1:19PM when Resident #54 was pronounced deceased by his hospice nurse after no life-saving measures were being implemented upon Resident #54's hospice nurse's arrival, despite a physician order for full code status. The Immediate Jeopardy further continued on [DATE] at 1:20PM when licensed nursing staff continued to provide care to residents without being re-educated on verifying residents' code status, initiating and continuing CPR to a resident until advanced medical providers arrived, placing other residents at risk for the same failure to provide CPR in accordance with physician orders. S1Administrator was notified of the Immediate Jeopardy situation on [DATE] at 5:33PM. This systemic failure had the likelihood to cause more than minimal harm to all 51 residents residing in the facility on [DATE], placing them at risk for care not provided in accordance with their code status and advance directives. Findings:Review of the facility's undated CPR policy and procedure revealed, in part, staff should provide basic life support, including CPR, to a resident requiring emergency care, prior to the arrival of emergency personnel, according to the resident's Physician's Orders and/or advance directives. Review of the [DATE] American Heart Association Basic Life Support Algorithm: A Step-by-Step Guide revealed, in part, the most critical part of basic life support was high-quality CPR. Further review revealed CPR should continue until advanced medical providers arrived or the patient presents signs of life. Review of Resident #54's Louisiana Physician Orders for Scope of Treatment dated [DATE] revealed, in part, if Resident #54 was unresponsive, pulseless and was not breathing and CPR was to be performed. Further review revealed the form was signed and dated by Resident #54's responsible party on [DATE] and the physician on [DATE]. Review of Resident #54's February 2026 Physician's Orders revealed, in part, an order dated [DATE] for Resident #54 to have a full code status (a code status where chest compressions and rescue breaths were to be provided in the event the resident was unresponsive, pulseless, or not breathing). Review of Resident #54's Hospice Certification and Plan of Care dated [DATE] revealed, in part, Resident #54 had diagnoses which included, in part, hypertensive heart and chronic kidney disease with heart failure and stage 5 chronic kidney disease (a condition where high blood pressure affects the heart and the kidneys at the same time, leading to failure in both systems) and chronic obstructive pulmonary disease (a progressive lung disease that restricts airflow). Further review revealed Resident #54's advanced directive was to be a full code status. Review of Resident #54's comprehensive care plan dated [DATE] revealed, in part, Resident #54's advanced directive was to be a full code status. Review of Resident #54's health status note dated [DATE] at 2:34PM and documented by S4LPN revealed, in part, S4LPN was summoned to Resident #54's room and found Resident #54 unresponsive and not breathing. Further review revealed S4LPN attempted CPR but was unsuccessful. Further review revealed Resident #54's time of death was pronounced at 1:19PM by Resident #54's hospice nurse. Review of the facility's surveillance footage from [DATE] revealed, in part, the incident began at 12:47PM, when S18Certified Nursing Assistant (CNA) was observed exiting Resident #54's room and quickly walking towards S10CNA Supervisor's location. Further review revealed S10CNA Supervisor and S18CNA quickly walked back to Resident #54's room. Further review revealed S10CNA Supervisor then exited Resident #54's room and gestured for other staff to come to Resident #54's room. Further review of the facility's surveillance footage revealed S4LPN and S5LPN entered Resident #54's room at 12:49PM. S5LPN was observed exiting, entering, and then exiting Resident #54's room for a final time at 12:50PM. S4LPN was observed exiting Resident #54's room at 12:51PM. Further review of the facility's surveillance footage revealed from 12:47PM through 1:15PM multiple staff were observed entering Resident #54's room and none of the facility staff were observed to have brought cardiopulmonary emergency equipment, such as a backboard, Ambu bag (manual resuscitation bag/ventilation device) or crash cart into Resident #54's room. Further review revealed Resident #54's hospice nurse entered Resident #54's room at 1:15PM. In a telephone interview on [DATE] at 10:41AM, Resident #54's hospice nurse indicated she was notified by the facility on [DATE] sometime after 1:00PM that Resident #54 had expired. Resident #54's hospice nurse further indicated upon arrival, Resident #54 was in bed with a sheet covering his head and no life-saving measures were being implemented by the facility's staff. Resident #54's hospice nurse further indicated Resident #54 had no vital signs (measurements of basic body functions that signify life) and pronounced Resident #54 deceased at 1:19PM. Resident #54's hospice nurse further indicated she had been informed the facility's nursing staff had provided CPR to Resident #54 and stopped. Resident #54's hospice nurse further indicated she did not instruct the facility's nursing staff to stop CPR and expected CPR to continue until emergency medical services staff or a physician directed otherwise. In an interview on [DATE] at 11:24AM, S5LPN indicated she assisted S4LPN at the time of Resident #54's death on [DATE]. S5LPN further indicated she and S4LPN were called to Resident #54's room by S10CNA Supervisor and Resident #54 was found in bed, unresponsive and not breathing. S5LPN further indicated when she assessed Resident #54 he was found to have no pulse, was still warm to the touch with no observable signs of prolonged death. S5LPN further indicated Resident #54's code status was not discussed and she assumed, because Resident #54 had hospice services, that Resident #54's code status was do not resuscitate [(DNR) a code status where chest compressions and rescue breaths where not provided to maintain blood flow and oxygen to vital organs). S5LPN further indicated on [DATE] she was not aware Resident #54's code status was full code and she had not observed anyone implementing CPR to Resident #54. In an interview on [DATE] at 11:55AM, Resident #54's responsible party indicated she had been reluctant to initiate hospice services; however, she had not requested or agreed to a change in Resident #54's code status. Resident #54's responsible party further indicated she expected Resident #54 to remain a full code and to receive all life-saving interventions, including CPR, in the event of an emergency. In an interview on [DATE] at 12:53PM, S2Director of Nursing (DON) indicated on [DATE] S4LPN came to her office and notified her that Resident #54 had expired. S2DON further indicated S4LPN then informed her that she (S4LPN) had thought Resident #54's code status was DNR, but Resident #54's code status was actually full code. S2DNR further indicated S4LPN then indicated to her that she had not yet implemented CPR. S2DON indicated she then instructed S4LPN to go back to Resident #54's room and initiate CPR on Resident #54. S2DON indicated S4LPN should have been aware of Resident #54's cull code status. The facility was unable to provide evidence S4LPN or any of the facility's licensed nursing staff immediately verified and/or implemented Resident 54's code status and/or ensured Resident #54 received continuous CPR from when Resident #54 was found not breathing and with no pulse on [DATE] at 12:49PM, until his official time of death on [DATE] at 1:19PM. In an interview on [DATE] at 1:17PM, S1Administrator indicated on [DATE] S4LPN should have provided continuous CPR to Resident #54 until emergency medical services arrived and took responsibility for Resident #54's resuscitation efforts. The Immediate Jeopardy situation was removed on [DATE] at 3:24PM, after it was verified through observations, interviews, and record reviews, the facility implemented an acceptable Plan of Removal, prior to the survey exit. A Plan of removal was accepted on [DATE] at 3:24PM which included the following actions to correct the deficient practice: 1. Resident #54 expired on [DATE]. S4LPN last day worked was on [DATE] and was terminated on [DATE] for excessive absences. S5LPN was in-serviced on [DATE] on checking Code Status in the Electronic Medication Administration Record (EMAR) and proper procedures for CPR. 2. All 51 Residents have the potential to be affected. All active Residents' EMAR's were reviewed to make sure code status was posted. 25 Residents have a DNR status. All nurses for each shift were in-serviced on [DATE] and prior to shift on [DATE] for checking code status in the EMAR and proper procedures for CPR. 3. On [DATE] the Facility implemented a policy to train all nurses on checking code status in the EMAR and proper procedures for CPR prior to working on the floor to ensure the likelihood for serious harm to any resident no longer exists. All new hire nurses will be trained on checking code status and proper procedures for CPR prior to working on the floor to ensure the likelihood for serious harm to any resident no longer exists. The code status binder and the red dot stickers have been removed and are no longer in use. A resident's code status must be checked in the EMAR. 4. Starting on [DATE] the DON will monitor weekly for proper training to all nurses and to make sure training is completed prior to working on the floor. DON will audit training documents prior to scheduling nurses to the floor on a weekly basis and before all new hires. The DON will not schedule any nurse who was not completed training. The facility asserted that as of [DATE] at 3:24PM the likelihood of serious harm to any resident no longer existed.

I.Based on observations, record reviews, and interviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical well-being of each resident by failing to implement and maintain an adequate system to ensure administrative staff identified deficient practices, implemented corrective actions, and ensured licensed nursing staff were trained and competent in verifying residents' code status, initiating and continuing CPR until emergency medical services arrived.This deficient practice was identified for 1 (Resident #54) of 1 sampled residents reviewed who had expired in the facility in a total sample of 19 residents.This deficient practice resulted in an Immediate Jeopardy situation on [DATE] at 12:49PM when Resident #54 was found unresponsive, without a pulse, and not breathing, and licensed nursing staff failed to ensure CPR was initiated and continuously provided in accordance with the resident's physician's orders for full code status. On [DATE] at 1:19PM when Resident #54 was pronounced deceased by Resident #54's hospice nurse after no life-saving measures were being implemented upon arrival, despite a physician's order for full code status. The Immediate Jeopardy continued as facility administration failed to identify the deficient practice, failed to implement immediate corrective actions, failed to ensure licensed nursing staff were re-educated and competent in verifying code status, and initiating and continuing CPR until emergency medical services arrived.S1Administrator was notified of the Immediate Jeopardy situation on [DATE] at 5:33PM. This systemic failure had the likelihood to cause more than minimal harm to all 51 residents residing in the facility on [DATE], placing them at risk for care not provided in accordance with their code status and advance directives.Findings:Cross Reference F678 In an interview on [DATE] at 12:53PM, S2Director of Nursing (DON) indicated she had not identified the above mentioned incident as deficient practice on [DATE] when S4LPN did not accurately determine Resident #54's code status, and did not continuously provide CPR to Resident #54 until emergency medical services arrived and took responsibility. S2DON further indicated she had not realized the magnitude of the above deficient practice until it was brought to her attention today. S2DON further indicated the facility did not provide additional education to the facility's nursing staff on verifying a resident's code status and/or continuing CPR once it was started until emergency medical services arrived and took responsibility of resuscitation efforts, and should have. In an interview on [DATE] at 1:17PM, S1Administrator indicated when S2DON discovered S4LPN did not properly determine Resident #54's code status and did not continuously provide CPR to Resident #54 until emergency medical services arrived, S2DON and/or facility's administrative staff should have completed a review of the above mentioned incident to determine the root cause of the deficient practice. S1Administrator further indicated S2DON and/or the facility's administrative staff should have provided re-education to the facility's nursing staff on the facility's CPR policy and procedure. A Plan of Removal was accepted on [DATE] at 3:24PM which included the following actions to correct the deficient practice: 1. Resident #54 expired on [DATE]. S4LPN last day worked was on [DATE] and was terminated on [DATE] for excessive absences. S5LPN was in-serviced on [DATE] on checking a residents Code Status in the Electronic Medication Administration Record (EMAR) and proper procedures for CPR. 2. All 51 Residents have the potential to be affected. All active Residents' EMAR were reviewed to make sure Code Status was posted. 25 Residents have a Do Not Resuscitate (DNR) status. All nurses for each shift were in-serviced on [DATE] and prior to shift on [DATE] for checking Code Status in the EMAR and proper procedures for CPR. 3. On [DATE] the facility updated the policy and procedure for Review of Resident Deaths and the Death Review form was implemented for the DON and/or Quality Nurse to complete the Death Review form and immediately initiate any changes necessary to ensure the likelihood that serious harm to any resident no longer exits. All residents' deaths must be reviewed within 5 business days by the DON or designee. Deaths identified as unexpected or high-risk must be reviewed within 48 hours. The case must be presented to the Quality Assurance Performance Improvement (QAPI) Committee the next scheduled meeting. On [DATE] the Administrator consulted with the on the Policy and Procedure for Review of Resident Deaths, how to fill out the Death Review form and the actions to take place if there are any discrepancies noted on the Death Review form, on training the nurses to look up code status in the Electronic Medication Administration Record, and the proper procedure for CPR. 4. The QAPI Team will review that the DON is reviewing completed Death Review forms and that the DON is following through with any discrepancies. The Quality Assurance Performance Improvement Team will monitor weekly for 3 months and quarterly, thereafter. The Quality Assurance Performance Improvement team will review all Death Review forms weekly for the next 3 months and quarterly, thereafter. The facility asserted that as of [DATE] at 3:24PM the likelihood of serious harm to any resident no longer existed. II. Based on observations, record reviews, and interviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently by failing to have an adequate system in place to ensure administrative staff made licensed nursing staff aware of their assigned responsibilities in the absence of a Treatment Nurse for 3 (Resident #7, Resident #16, Resident #44) of 3 sampled residents investigated for pressure ulcers. Findings: Cross Reference F686 Review of the undated DON's job description revealed, in part, the DON provided direction to the nursing staff and coordinated health services. Further review revealed the DON must organize and oversee all nursing operations in the facility. Review of the undated Registered Nurse (RN) Supervisor job description revealed, in part, the RN Supervisor would monitor elements of patient care. Further review revealed the RN Supervisor will report any concerns to the DON. Review of the undated Floor Nurse/LPN job description revealed, in part, the LPN would initiate the orders of physicians involved in the care of the resident and carry out any treatments and procedures outlined in the patient's plan. Review of the facility's Wound Care Protocol, dated 2026, revealed, in part, residents with wounds would have wound care provided to them as ordered by the physician. Resident #7 In an interview on [DATE] at 11:05AM, S3Treatment Nurse indicated the weekend nurse(s) should have performed Resident #7's wound care if a Treatment Nurse was not present. In a telephone interview on [DATE] at 8:55AM, S6LP indicated she was Resident #7's nurse on [DATE]. S6LPN indicated she did not provide Resident #7's sacral wound care as ordered by the physician. S6LPN indicated she was not aware she was responsible to complete wound care on her assigned residents. In a telephone interview on [DATE] at 9:01AM, S7LPN indicated she was Resident #7's nurse on [DATE]. S7LPN further indicated she did not provide wound care to Resident #7's Stage IV sacral pressure ulcer on [DATE], because she was not informed that she had to perform wound care on her assigned residents. In an interview on [DATE] at 11:18AM, S2DON indicated the facility did not have an assigned Treatment Nurse for [DATE] and [DATE]. S2DON indicated on [DATE] and [DATE] it was the responsibility of S9Registered Nurse (RN) Supervisor to remind the floor nurses to complete wound care in the absence of an assigned Treatment Nurse. S2DON also indicated she provided S9RN Supervisor with a list of responsibilities which included reminding the floor nurses to complete wound care due to not having a Treatment Nurse. S2DON indicated S9RN Supervisor was responsible to ensure wound care was provided as ordered. In a telephone interview on [DATE] at 11:53AM, S9RN Supervisor indicated S2DON had provided her with a list of responsibilities for the dates of [DATE] and [DATE]. S9RN Supervisor further indicated it was an understood responsibility that the floor nurses were responsible for wound care in the absence of a Treatment Nurse. Review of the communication sheet provided to S9RN Supervisor dated [DATE] revealed, in part, nurses need to remember to do wound care on weekends and sign the Treatment Administration Record off when we do not have a Treatment Nurse. Further review revealed the RN Supervisor was to remind them of this responsibility. In an interview on [DATE] at 2:10PM, S1Administrator indicated wound care treatments should have been provided as ordered by the physician. Resident #16 In a phone interview on [DATE] at 4:28PM, S14LPN indicated she was not aware she was responsible to provide wound care to Resident #16 on [DATE] and [DATE]. In an interview on [DATE] at 11:53AM, S9RN Supervisor indicated it was the responsibility of the residents' assigned nurse to provide wound care to the residents' wounds, as ordered by the physicians on [DATE] and [DATE]. Resident #44 In an interview on [DATE] at 4:40PM, S6LPNindicated she did not perform Resident #44's Stage III right heel pressure ulcer wound care as ordered by Resident #44's physician on [DATE] and [DATE], and should have. In an interview on [DATE] at 4:54PM, S7LPN indicated she was not aware that she was responsible for providing daily wound care treatment to Resident #44's Stage III right heel pressure ulcer. S7LPN further indicated she did not provide wound care to Resident #44's right heel pressure ulcer on [DATE] and [DATE] as ordered by the physician, and should have.

Based on observations, interviews, and record reviews, the facility failed to provide pressure ulcer treatments as ordered by the physician for 3 (Resident #7, Resident #16, Resident #44) of 3 sampled residents investigated for pressure ulcers. Findings:Review of the facility's Wound Care Protocol, dated 2026, revealed, in part, residents with wounds will have wound care provided to them as ordered by the physician. Resident #7 Review of Resident #7's March 2026 Physician's Orders revealed, in part, cleanse sacral pressure ulcer with wound cleanser, pat dry, loosely fill cavity with gauze soaked in Dakin's solution (an antiseptic used to clean infected skin and tissues, treat wounds, and manage odors), apply Santyl ointment (a prescription medicine used to remove dead tissue from chronic skin ulcers to promote healing), followed by calcium alginate (a highly absorptive fiber commonly used in specialized wound dressings), cover with silicone foam border or equivalent dressing, change dressing daily and as needed. Review of Resident #7's Care Plan Report revised on 03/11/2026 revealed, in part, Resident #7 had a Stage IV sacral pressure ulcer. Further review revealed a documented intervention to administer wound care treatments as ordered. On 03/23/2026 at 11:05AM, S3Treatment Nurse and the surveyor observed Resident #7's sacral dressing. Further observation revealed the date written on Resident #7's sacral wound dressing was 03/20/2026. In an interview on 03/23/2026 at 11:05AM, S3Treatment Nurse indicated Resident #7 had a physician's order for daily wound care for her sacral pressure ulcer. S3Treatment Nurse indicated Resident #7's dressing dated 03/20/2026 was the dressing she had applied on 03/20/2026. S3Treatment Nurse further indicated Resident #7 should have received wound care as ordered by the physician on 03/21/2026 and 03/22/2026, and did not. S3Treatment Nurse indicated the weekend staff nurse assigned to Resident #7, should have performed wound care on Resident #7 as ordered. Review of Resident #7's March 2026 Treatment Administration Record revealed, in part, no documented evidence Resident #7's Stage IV sacral pressure ulcer wound care was provided on 03/21/2026 and 03/22/2026. In a telephone interview on 03/24/2026 at 8:55AM, S6Licensed Practical Nurse indicated she was Resident #7's assigned nurse on 03/21/2026. S6Licensed Practical Nurse indicated she did not provide Resident #7's sacral wound care as ordered by Resident #7's physician. In a telephone interview on 03/24/2026 at 9:01AM, S7Licensed Practical Nurse indicated she was Resident #7's assigned nurse on 03/22/2026. S7Licensed Practical Nurse indicated she did not provide Resident #7's sacral wound care as ordered by Resident #7's physician. In an interview on 03/23/2026 at 11:18AM, S2Director of Nursing indicated Resident #7's sacral pressure ulcer wound care should have been completed daily as ordered by Resident #7's physician. Resident #16 Review of Resident #16's electronic medical record revealed, in part, Resident #16 had a diagnosis of a Stage II sacral pressure ulcer. Review of Resident #16's Physician's Orders dated 02/18/2026 revealed, in part, cleanse sacral pressure ulcer with wound cleaner, pat dry, apply Santyl ointment to wound bed, followed by calcium alginate, apply Collagenase ointment (ointment to remove dead tissue from skin ulcers) to sacral wound every day shift, cover with silicone foam border or equivalent dressing, and to change dressing daily and as needed if soiled or dislodged. Review of Resident #16's Care Plan Report revealed, in part, Resident #16 had a Stage II sacral pressure ulcer. Further review revealed a documented intervention to administer daily wound care treatment to Resident #16's Stage II sacral pressure ulcer as ordered. Review of Resident #16's Treatment Administration Record for March 2026 revealed, in part, daily wound care to Stage II sacral pressure ulcer was not completed on 03/21/2026 and 03/22/2026. On 03/23/2026 at 11:34AM, S3Treatment Nurse and the surveyor observed Resident #16's sacral dressing. Further observation revealed the date written on Resident #16's sacral wound dressing was 03/20/2026. In an interview on 03/23/2026 at 11:35AM, S3Treatment Nurse indicated Resident #16 should have received daily wound care as ordered by the physician. In an interview on 03/24/2026 at 3:00PM, S2Director of Nursing indicated Resident #16's daily Stage II sacral pressure ulcer wound care should have received daily wound care as ordered by the physician. In a phone interview on 03/24/2026 at 4:28PM, S14Licensed Practical Nurse indicated she did not provide wound care on 03/21/2026 and 03/22/2026 to Resident #16's sacral pressure ulcer as ordered by the physician, and should have. In an interview on 03/25/2026 at 10:00AM, S11Contracted Wound Care Nurse Practitioner indicated Resident #16's sacral pressure ulcer wound care should have been performed daily as ordered by Resident #16's physician. In an interview on 03/25/2026 at 11:53AM, S9Registered Nurse Supervisor indicated the assigned nurse should have provided wound care to the residents as ordered by their physicians. Resident #44 Review of Resident #44's March 2026 Physician's orders revealed, in part, cleanse right heel pressure injury/ulcer with wound cleanser, pat dry, apply Santyl ointment to wound bed, cover with silicone foam border or equivalent dressing, change dressing daily and as needed, Collagenase ointment to right heel every day shift for pressure injury/ulcer. Review of Resident #44's Care Plan Report revised on 02/23/2026 revealed, in part, Resident #44 had a Stage III right heel pressure ulcer with an intervention to administer treatment as ordered. Review of Resident #44's March 2026 Treatment Administration Record revealed, in part, wound care to Resident #44's right heel was not completed on 03/21/2026 and 03/22/2026. Observation on 03/23/2026 at 9:42AM revealed Resident #44's dressing to right heel was dated 03/20/2026. In an interview on 03/23/2026 at 11:18AM, S2Director of Nursing indicated Resident #44's wound care to the Stage III right heel pressure ulcer wound should have been completed daily as ordered by Resident #44's physician. In an interview on 03/23/2026 at 1:01PM, S3Treatment Nurse confirmed Resident #44's dressing on his right heel had a date of 03/20/2026. S3Treatment Nurse confirmed Resident #44 did not receive wound care to the right heel wound care as ordered by Resident #44's physician. In an interview on 03/24/2026 at 4:40PM, S6Licensed Practical Nurse indicated she did not perform Resident #44's Stage III right heel pressure ulcer wound care as ordered by Resident #44's physician on 03/21/2026 and 03/22/2026, and should have. In an interview on 03/24/2026 at 4:54PM, S7Licensed Practical Nurse indicated she did not perform Resident #44's Stage III right heel pressure ulcer wound care as ordered by Resident #44's physician on 03/21/2026 and 03/22/2026, and should have. In an interview on 03/25/2026 at 11:10AM, S11Contracted Wound Care Nurse Practitioner indicated Resident #44's should have had wound care performed daily to the Stage III right heel pressure ulcer as ordered by Resident #44's physician.

Based on interviews and record review, the facility failed to maintain complete and accurate medical records for 6 residents (Residents #2, #7, #16, #27, #44, #47) of 6 sampled residents reviewed for accurate documentation. Findings:Review of the facility's Medical Records policy and procedure, last revised 09/02/2025, revealed, in part, the facility should maintain medical records on each resident that are complete and accurately documented. Review of the facility's Charting and Documentation policy and procedure revealed, in part, all observations, medications administered, and services performed must be documented in the resident's clinical record. Resident #2 Review of Resident #2's March 2026 physician orders revealed, in part: Mirtazapine 15 milligrams (medication used to treat major depressive disorder); Seroquel 25 milligrams (medication used to treat insomnia); Artificial Tears ophthalmic solution (used to treat dry eyes); and, Systane ophthalmic solution (used to treat dry eyes) were ordered to be administered on 03/19/2026 at 9:00PM. Review Resident #2's March 2026 Medication Administration Record revealed the above mentioned medications were not documented as administered on 03/19/2026 at 9:00PM. In an interview conducted on 03/24/2026 at 10:15AM, S2Director of Nursing indicated the above mentioned medications should have been documented as administered as ordered; therefore, the facility was unable to verify the above mentioned medications were administered as ordered. Resident #7 Review of Resident #7's March 2026 physician orders revealed wound care to a sacral pressure ulcer (treatment used to promote healing and prevent infection), use of a low air loss mattress (device used to reduce pressure and prevent skin breakdown), and pain assessments prior to wound care (assessment used to evaluate pain and ensure appropriate treatment) were ordered daily. Review of Resident #7's March 2026 Treatment Administration Record (TAR) revealed wound care was not documented as provided on 03/07/2026, 03/08/2026, and 03/14/2026. The low air loss mattress and pain assessments were not documented as provided on 03/07/2026, 03/08/2026, 03/14/2026, 03/21/2026, and 03/22/2026. Review of Resident #7's Care Plan revised on 06/05/2025 revealed, in part, Resident #7 had an Activities of Daily Living self-care performance deficit and required assistance for bed mobility, toileting, and transfers. Review of Resident #7's Activities of Daily Living documentation for 03/12/2026 through 03/23/2026 revealed bed mobility, toileting, and transfers were not documented as provided on 03/15/2026, 03/16/2026, 03/19/2026, and 03/22/2026. In an interview conducted on 03/24/2026 at 11:05AM, S11Contracted Wound Care Nurse indicated the above mentioned treatments and pain assessments should have been documented as provided as ordered; therefore, the facility was unable to verify treatments and services were provided as ordered. Resident #16 Review of Resident #16's Activities of Daily Living documentation for March 2026 revealed, in part, Resident #16 had an Activities of Daily Living self-care performance deficit and required total assistance from staff for bed mobility. Review of Resident #16's Activities of Daily Living documentation for 03/11/2026 to 03/23/2026 revealed, in part assistance with bed mobility was not documented as provided on all shifts for 03/12/2026, 03/13/2026, 03/15/2026, 03/16/2026, 03/17/2026, 03/18/2026, on the morning on 03/20/2026, day and evening of 03/21/2026, day and evening of 03/22/2026, and day shift of 03/23/2026. In an interview on 03/24/2026 at 3:03PM, S10Certified Nursing Assistant Supervisor indicated the above documented dates did not include documentation for bed mobility, and should have. In an interview on 03/24/20265 at 3:00PM, S2Director of Nursing indicated Certified Nursing Assistant staff should have documented Resident #16's bed mobility, transfers, and toileting. Resident #27 Review of Resident #27's physician orders revealed: Atorvastatin calcium 40 milligrams (medication used to lower cholesterol); Hydrocortisone acetate 25 milligrams rectal suppository (medication used to treat rectal inflammation/irritation); Melatonin 10 milligrams (medication used to treat insomnia); Trazodone HCl 150 milligrams (medication used to treat depression); Xarelto 20 milligrams (medication used to prevent blood clots); and, Buspirone HCl 15 milligrams (medication used to treat anxiety) were ordered to be administered on 03/03/2026 and 03/19/2026 at 9:00PM. Review of Resident #27's March 2026 Medication Administration Record revealed the above mentioned medications were not documented as administered on those dates and times. In interview conducted on 03/25/2026 at 10:10AM, S2Director of Nursing indicated the above mentioned medications should have been documented as administered as ordered; therefore, the facility was unable to verify Resident #27's medications were administered as ordered. Resident #44 Review of Resident #44's March 2026 physician orders revealed a wound care treatment order for a pressure ulcer to the right heel (treatment used to promote wound healing and prevent infection); the use of a low air loss mattress (device used to reduce pressure and prevent further skin breakdown); pain assessments prior to wound care (assessment used to evaluate pain and guide treatment); and, staff assistance with Activities of Daily Living, including bed mobility, toileting, and transfers (services used to maintain safety and functional status). Review of Resident #44's Care Plan revised on 02/23/2026 revealed, in part, Resident #44 had an Activities of Daily Living Self-care performance deficit and required assistance for bathing/showering, dressing, eating, personal hygiene. Review of Resident #44's March 2026 Treatment Administration Record and Activities of Daily Living documentation revealed the treatments and services were not documented as provided on 03/01/2026, 03/07/2026, 03/08/2026, 03/14/2026, 03/21/2026, and 03/22/2026. Review of Resident #44's March 2026 Activities of Daily Living documentation revealed Resident #44's Activities of Daily Living were not documented as completed on 03/01/2026, 03/05/2026, 03/102026, 03/11/2026, 03/14/2026, 03/16/2026, 03/19/2026, 03/22/2026, and 03/23/2026. In an interview on 03/24/26 at 1:40PM, S10Certiifed Nursing Assistant Supervisor indicated the above documented dates did not include documentation Resident #44 received assistance with bed mobility, transferring, and toileting, and should have. S10Certified Nursing Assistant Supervisor further indicated S2Director of Nursing was responsible to complete audits of the Activities of Daily of Living charting. In an interview on 03/24/2026 at 1:46PM, S2Director of Nursing indicated the above documented dates did not include documentation Resident #44 received assistance with the above mentioned Activities of Daily Living and should have. S2Director of Nursing further indicated S10Certified Nursing Assistant Supervisor was responsible to complete audits of the Activities of Daily Living charting. S2Director of Nursing indicated Resident #44's March 2026 Treatment Administration Record did not have documentation treatments were documented as being completed, and should have. In an interview on 03/24/26 at 2:10PM, S1Administrator indicated S10Certified Nursing Assistant Supervisor should have performed audits on the Activities of Daily Living documentation. Resident #47 Review of Resident #47's March 2026 physician orders revealed, in part: Gabapentin 300 milligrams (medication used to treat nerve pain); Latanoprost ophthalmic solution 0.005% (medication used to treat glaucoma); Melatonin 3 milligrams (medication used to treat insomnia); Sertraline HCl 25 milligrams (medication used to treat depression); and Amoxicillin-clavulanate 875-125 milligrams (medication used to treat infection) were ordered to be administered on 03/19/2026 at 9:00PM. Review of Resident #47's March 2026 Medication Administration Record revealed the above mentioned medications were not documented as administered on that date and time. In an interview conducted on 03/25/2026 at 11:35AM, S2Director of Nursing indicated the above mentioned medications should have been documented as administered as ordered; therefore, the facility was unable to verify the medications were administered as ordered.

Based on interviews and record review, the facility failed to ensure medications were administered as ordered by the physician for 1 (Resident #47) of 2 sampled residents reviewed, in accordance with professional standards of nursing practice. Findings:In accordance with the Louisiana Nurse Practice Act (La. R.S. 37:913), nursing practice includes executing medical regimens prescribed by a licensed physician or authorized prescriber; therefore, medications must be administered as ordered. Review of the facility's policy titled Physician Orders Policy and Procedure, revised 09/12/2025, revealed Licensed Practical Nurses are required to follow physician orders as prescribed. Review of Resident #47's physician orders dated January 2026 through March 2026 revealed, in part, the following:An order dated 01/19/2026 for Simethicone 80 mg tablet (used to relieve symptoms caused by excess gas in the digestive tract), administer 1 tablet by mouth twice daily at 8:00AM and 5:00PM for 14 days;An order dated 02/10/2026 for Pataday ophthalmic solution 0.2% (used to treat allergic conjunctivitis), instill one drop in both eyes daily at 9:00AM;An order dated 03/01/2026 for Gabapentin 300 mg capsule (used to treat nerve pain), administer 1 capsule by mouth daily at 9:00PM;An order dated 03/01/2026 for Meloxicam 15 mg tablet (used to relieve pain and inflammation), administer 1 tablet by mouth daily at 9:00AM; and,An order dated 04/25/2026 for Sertraline HCl 25 mg tablet (used to treat depression), administer 1 tablet by mouth daily at 9:00PM. Review of Resident #47's January 2026 Medication Administration Record (MAR) revealed:Simethicone 80 mg was not administered on 01/21/2026 at 8:00AM, 01/23/2026 at 8:00AM, and 01/24/2026 at 5:00PM and the MAR was blank with no documented reason;Gabapentin 300 mg was not administered on 01/21/2026 at 9:00PM and the MAR was blank with no documented reason;Meloxicam 15 mg was not administered on 01/21/2026 at 9:00AM and the MAR was blank with no documented reason;Sertraline HCl 25 mg was not administered on 01/21/2026 at 9:00PM and the MAR was blank with no documented reason. Review of Resident #47's March 2026 MAR revealed Pataday ophthalmic solution 0.2% was not administered on 03/10/2026 at 9:00AM and 03/12/2026 at 9:00AM and the MAR was blank with no documented reason. In an interview on 03/25/2026 at 10:32AM, S13Licensed Practical Nurse indicated she believed the Pataday ophthalmic solution was out of stock; however, she further indicated she did not verify the location of available medication and did not administer the medication as ordered. In an interview on 03/25/2026 at 3:00PM, S2Director of Nursing (DON) indicated Simethicone and Pataday ophthalmic solution were stocked with the facility's over-the-counter medications and available for use. In an interview on 03/25/2026 at 4:26PM, S16Registered Nurse indicated non-over-the-counter medications were delivered weekly from the pharmacy and verified the above-mentioned medications were available for administration. In an interview on 03/25/2026 at 4:30PM, S2DON indicated the above-mentioned medications were available for use, should have been administered as ordered, and were not.

Based on interviews and record reviews, the facility failed to ensure a resident received dental services as required for 1 (Resident #47) of 1 sampled residents investigated for dental services. Findings:Review of the facility's Dental Services policy and procedure, last revised 08/2006, revealed, in part, social services personnel will be responsible for assisting the resident in making dental appointments and transportation arrangements as necessary. Review of Resident #47's physician's progress noted dated 01/29/2026 revealed, in part, Resident #47 was seen by the facility's contracted dental company with a chief complaint of a lower left broken tooth. Further review revealed the contracted dental company's plan to address Resident #47's broken tooth was a #18 Distolingual (DL) Silver Modified Atraumatic Restorative Technique (SMART) filling (a minimally invasive filling technique that was to be used to completed a filling to the back and tongue area of Resident #47's permanent lower left second molar). Review of Resident #47's medical records revealed Resident #47's dentist sent an email correspondence dated 02/17/2026 at 2:20PM to S15Social Services Director requesting the completion of a triage form for Resident #47 to be seen by the dentist. In an interview on 03/23/2026 at 10:26AM, Resident #47 indicated she had a broken tooth that occurred during a contracted dental cleaning procedure in the facility. Resident #47 further indicated the facility's contracted dental hygienist indicated to her (Resident #47) the tooth would have to be filled on a follow-up appointment. Resident #47 indicated she never had a follow-up appointment with the facility's contracted dental company to have the broken tooth addressed. In an interview on 03/25/2026 at 10:19AM, S15Social Services Director indicated Resident #47 had complained of dental pain on 02/13/2026. S15Social Services emailed the contracted dentist on 02/13/2026 and on 02/17/2026 the contracted dentist requested that S15Social Services Director complete a triage form. S15Social Services indicated she did not complete Resident #47's dental triage form until 03/23/2026, which resulted in Resident #47 not to be seen by the contracted dentist during the 02/23/2026 dental visit. In an interview on 03/25/2026 at 4:30PM, S2Director of Nursing indicated the triage form should have been sent to the contracted dental company by S15Social Services Director prior to 03/23/2026.

Based on observations, interviews, and record review the provider failed to ensure staff administered a resident's hydration through an enteral tube (a tube inserted directly into the stomach) per a Physician's Order for 1 (Resident #4) of 1 sampled residents investigated for enteral tube hydration. Findings:Review of Resident #4's 03/17/2026 Physician's Order revealed, in part, to administer Resident #4 Diabetisource ( a type of enteral feeding [a liquid nutritional supplement delivered directly into the stomach through an enteral tube]) at a rate of 45 milliliters an hour with a flush of 200 milliliters (ml) of water every hour. Observation on 03/23/2026 at 9:15AM revealed Resident #4's enteral feeding pump was set to administer Resident #4 Diabetisource at 45 ml an hour continuously with a water flush at 150 ml every 4 hours. Observation on 03/24/2026 at 10:24AM revealed Resident #4's enteral feeding pump was set to administer Resident #4 Diabetisource at 45 ml an hour continuously with a water flush at 150 ml every 4 hours. In an interview on 03/24/2026 at 5:35PM, S8Licensed Practical Nurse (LPN) confirmed Resident #4's enteral feeding pump was programed to administer Resident #4 a flush of 150 ml of water every 4 hours. S8LPN further confirmed Resident #4's active Physician's Order was to administer Resident #4 a flush of 200 ml of water an hour with her continues enteral feeding. In an interview on 03/24/2026 at 5:43PM, S2Director of Nursing (DON) indicated Resident #4's enteral feeding pump was not programmed to administer a water flush at a rate of 200 ml an hour, as ordered by the physician; and it should have been administered as ordered.

Based on interviews and record reviews, the facility failed to coordinate hospice care and obtain required information from the resident's hospice agency.This deficient practice was identified for 1 (Resident #23) of 1 sampled residents investigated for hospice services. Findings:Review of Resident #23's electronic medical record revealed Resident #23 had an initial admission date of 08/18/2025, and was admitted for hospice services on 02/24/2026. Review of the facility's Hospice Program policy and procedure revised, August 2006 revealed, in part, when a resident participated in the hospice program, a coordinated plan of care between the facility, hospice agency, and resident/family will be developed and would include directives for managing pain and other uncomfortable symptoms. Further review revealed on the day of admission, the facility's nurse must obtain admission orders and a binder from the hospice nurse. On 03/23/2026 at 8:55AM this surveyor requested Resident #23's hospice binder from S1Director of Nurse. On 03/24/2026 at 9:00AM this surveyor requested Resident #23's hospice binder from S17Licensed Practical Nurse. In an interview on 03/24/2026 at 9:00AM, S17Licensed Practical Nurse indicated the facility did not have a hospice binder for Resident #23, and should have. In an interview on 03/24/2026 at 9:17AM, the Resident #23's hospice agency's medical records representative indicated it is the hospice agency policy and procedure to create a hospice binder which contained the required documentation needed to coordinate hospice care for the resident. Resident #23's hospice agency's medical records representative further indicated Resident #23's hospice binder should be brought to the facility by the resident's hospice nurse. In an interview on 03/24/2026 at 9:55AM, S2Director of Nursing indicated Resident #23 did not have a hospice binder which contained the required documentation needed to coordinate hospice care for Resident #23 In a phone interview on 03/24/2026 at 10:21AM, Resident #23's hospice agency case manager indicated the facility did not have a hospice binder which contained the required documentation needed to coordinate hospice care for Resident #23. In an interview on 03/24/2026 at 11:20AM, S1Administrator indicated the facility did not have Resident #23's hospice binder, and should have had a hospice binder available at the facility.

Based on observation, interviews and record reviews, the facility failed to ensure a resident's medical record was accurately documented for 2 (Resident #1, Resident #2) of 3 (Resident #1, Resident #2, Resident #3) sampled residents investigated for accurate medical record documentation. Findings:Review of the facility's undated Floor Nurse/Licensed Practical Nurse (LPN) job description revealed, in part, the LPN must accurately document the care they provide for a patient. Resident #1Review of Resident #1's August 2025 physician's orders revealed, in part, an order for suprapubic catheter (a tube inserted directly into the bladder through an incision in the lower abdomen) care to be performed every shift. Review of Resident #1's August 2025 electronic Medication Administration Record (eMAR) revealed, in part, S7LPN documented on 08/25/2025 Resident #1's catheter care was completed. In an interview on 08/25/2025 at 1:52PM, S7LPN indicated she was the nurse assigned to Resident #1. S7LPN further indicated she did not perform Resident #1's catheter care during her shift as ordered. Resident #2Review of Resident #2's August 2025 physician's orders revealed, in part, an order for suprapubic catheter care to be performed every shift. Further review revealed an order for a pressure relieving cushion to be in placed on Resident #2's wheelchair to prevent skin breakdown every shift. Review of Resident #2's Minimum Data Set with an Assessment Reference Date of 06/11/2025 revealed, in part, Resident #2 had a Brief Interview for Mental Status (BIMS) summary score of 15, which indicated Resident #2 was cognitively intact. Review of Resident #2's August eMAR revealed, in part, S6LPN documented she performed catheter care on Resident #2's suprapubic catheter on the following 6:00AM to 2:00PM shifts:- 08/01/2025;- 08/04/2025 through 08/08/2025; - 08/11/2025 through 08/15/2025;- 08/18/2025;- 08/22/2025;- 08/25/2025; and,- 08/26/2025.Further review revealed the following nurses documented a pressure relieving cushion was in place on Resident #2's wheelchair on the following 6:00AM to 2:00PM shifts:- S6LPN on 08/01/2025;- S9LPN on 08/02/2025 and 08/03/2025;- S6LPN on 08/04/2025 through 08/08/2025;- S9LPN on 08/09/2025 and 08/10/2025;- S6LPN on 08/11/2025 through 08/15/2025;- S9LPN on 08/16/2025 and 08/17/2025;- S6LPN on 08/18/2025 and 08/19/2025;- S7LPN on 08/20/2025 and 08/21/2025;- S6LPN on 08/22/2025;- S6LPN on 08/23/2025 and 08/24/2025; and,- S9LPN on 08/25/2025 and 08/26/2025. Observation on 08/25/2025 at 11:30AM revealed Resident #2 was sitting in his wheelchair without a pressure relieving cushion in place. In an interview on 08/26/2025 at 12:45PM, Resident #2 indicated he has not had a pressure relieving cushion on his wheelchair in months. In an interview on 08/26/2025 at 12:50PM, S6LPN indicated she documented on Resident #2's eMAR that catheter care had been performed, even though she had not performed Resident #2's catheter care. S6LPN further indicated she did not check to see if Resident #2 had a pressure relieving cushion in place, but S6LPN documented in Resident #2's eMAR that Resident #2's pressure relieving cushion was in place and should not have. In an interview on 08/27/2025 at 12:45PM, S2Director of Nursing confirmed the above mentioned documentation in Resident #2's eMAR was inaccurate and should not have been. In an interview on 08/27/2025 at 1:20PM, S1Administrator was presented with the above mentioned findings and offered no further explanation to dispute the above mentioned deficient practice.

Based on record reviews and interviews, the facility failed to ensure direct care staff were provided effective communication training for 5 (S10Certified Nursing Assistant [CNA], S13CNA, S14CNA, S15CNA, S16CNA) of 5 (S10CNA, S13CNA, S14CNA, S15CNA, S16CNA) sampled direct care staff investigated for training requirements. Findings:Review of S10CNA's personnel record revealed, in part, S10CNA had a date of hire of 04/01/2025. Further review revealed S10CNA did not receive effective communication training as required. Review of S13CNA's personnel record revealed, in part, S13CNA had a date of hire of 02/25/2025. Further review revealed S13CNA did not receive effective communication training as required. Review of S14CNA's personnel record revealed, in part, S14CNA had a date of hire of 03/03/2025. Further review revealed S14CNA did not receive effective communication training as required. Review of S15CNA's personnel record revealed, in part, S15CNA had a date of hire of 07/15/2025. Further review revealed S15CNA did not receive effective communication training as required. Review of S16CNA's personnel record revealed, in part, S16CNA had a date of hire of 04/10/2025. Further review revealed S16CNA did not receive effective communication training as required. In an interview on 08/26/2025 at 11:45AM, S3CNA Supervisor indicated she was responsible for providing training for new hire orientation and in-services to staff. S3CNA Supervisor further indicated effective communication training was not included in orientation training or in-services. In an interview on 08/27/2025 at 12:45PM, S2Director of Nursing confirmed S10CNA, S13CNA, S14CNA, S15CNA, and S16CNA did not have effective communication training.

Based on observations, interviews, and record reviews, the facility failed to ensure:1. A resident's indwelling catheter tubing and bag were changed as needed (Resident #1); 2. Residents with an indwelling urinary catheter received catheter care as ordered (Resident #1, Resident #2); and,3. A resident's urinary catheter order was completed (Resident #2).This deficient practice was identified for 2 (Resident #1, Resident #2) of 2 (Resident #1, Resident #2) sampled residents investigated for urinary catheter care and Urinary Tract Infections (UTI). Findings: Review of the facility's Indwelling Catheter policy and procedure, revised on 09/23/2024, revealed, in part, catheter care shall be provided every shift for residents with an indwelling catheter. Review of the facility's undated Floor Nurse/Licensed Practical Nurse (LPN) Job Description, revealed, in part, the LPN shall initiate the orders of physician's and carry out any treatment and procedures outlined in the patient's plan. Resident #1Review of Resident #1's August 2025 physician's orders revealed, in part, an order for a suprapubic catheter (a tube inserted directly into the bladder through an incision in the lower abdomen). Further review revealed an order to change Resident #1's catheter drainage bag and tubing every month and as needed. Further review also revealed an order to provide suprapubic catheter care every shift. Observation on 08/25/2025 at 1:30PM revealed Resident #1's suprapubic catheter tubing and collection bag contained cloudy urine with sediment and a thick white substance which adhered to the inside wall of the tubing. Observation on 08/26/2025 at 11:30AM revealed Resident #1's suprapubic catheter tubing and collection bag contained cloudy urine with sediment and a thick white substance which adhered to the inside wall of the tubing. Observation on 08/27/2025 at 12:30PM revealed Resident #1's suprapubic catheter tubing and collection bag contained cloudy urine with sediment and a thick white substance which adhered to the inside wall of the tubing. In an interview on 08/25/2025 at 1:45PM, S10Certified Nursing Assistant (CNA) indicated she was the CNA assigned to Resident #1. S10CNA further indicated she did not perform catheter care every shift on Resident #1. S10CNA further indicated she thought it was the nurse's responsibility to perform catheter care on residents with a suprapubic catheter. In an interview on 08/25/2025 at 1:52PM, S7LPN indicated she was the nurse assigned to Resident #1. S7LPN further indicated she did not perform Resident #1's catheter care during the 6:00AM to 2:00PM shift as ordered. In an interview on 08/27/2025 at 12:45PM, S2Director of Nursing (DON) confirmed Resident #1's suprapubic catheter tubing had sediment and a think white substance throughout the drainage tubing. S2DON further indicated that Resident #1's catheter bag and tubing should have been changed out when the sediment and thick white substance were first observed and the date written on the collection bag. S2DON further indicated that Resident #1's catheter care should have been performed every shift as ordered. In an interview on 08/27/2025 at 1:20PM, S1Administrator was presented with the above mentioned findings and offered no further explanation to dispute the above mentioned deficient practice. Resident #2Review of Resident #2's August 2025 physician's orders revealed, in part, an order for Resident #2 to receive catheter care to Resident #2's suprapubic catheter every shift. Further review revealed an order for Resident #2's suprapubic catheter anchor (a device that securely attaches the catheter tubing to the resident's upper leg) to be changed out weekly. Review of Resident #2's Minimum Data Set with an Assessment Reference Date of 06/11/2025 revealed, in part, Resident #2 had a Brief Interview for Mental Status (BIMS) summary score of 15, which indicated Resident #2 was cognitively intact. Review of Resident #2's July 2025 and August 2025 electronic Treatment Administration Record (eTAR) revealed, in part, no documentation Resident #2's urinary catheter anchor was applied and/or changed to secure Resident #2's suprapubic catheter tubing as ordered weekly in July 2025 nor August 2025. Observation on 08/25/2025 at 11:30AM revealed Resident #2's suprapubic catheter did not have an anchoring device as ordered, and Resident #2's suprapubic catheter was not secured to Resident #2's body. Further observation revealed Resident #2's catheter tubing had a dried drainage on it near the insertion site. In an interview on 08/26/2025 at 11:30AM, S9CNA indicated she did not perform suprapubic catheter care on Resident #2. S9CNA further indicated Resident #2's nurse was responsible to perform catheter care. Observation on 08/26/2025 at 12:40PM revealed Resident #2's suprapubic catheter did not have an anchoring device as ordered, and Resident #2's suprapubic catheter was not secured to Resident #2's body. Further observation revealed Resident #2's catheter tubing had a dried drainage on it near the insertion site. In an interview on 08/26/2025 at 12:45PM, Resident #2 indicated catheter care was not performed every day. Resident #2 further indicated that he had not received catheter care today (08/26/2025) or yesterday (08/25/2025). In an interview on 08/26/2025 at 12:50PM, S6LPN indicated catheter care was only done on the night shift. S6LPN further indicated she had not performed catheter care on Resident #2 during the day shift. S6LPN further indicated she did not know catheter care was ordered every shift. Observation on 08/27/2025 at 11:00AM revealed Resident #2's suprapubic catheter did not have an anchoring device as ordered, and Resident #2's suprapubic catheter was not secured to Resident #2's body. Further observation revealed Resident #2's catheter tubing had a dried drainage on it near the insertion site. In an interview on 08/27/2025 at 11:30AM, Resident #2 indicated nobody came to clean his catheter or the insertion site yesterday (08/26/2025). Resident #2 further indicated he had not had a catheter anchoring device placed in months. In an interview on 08/27/2025 at 12:45PM, S2DON confirmed Resident #2's catheter care should have been performed every shift as ordered. S2DON further confirmed Resident #2 did not have a catheter anchoring device as ordered and should have. In an interview on 08/27/2025 at 1:20PM, S1Administrator was presented with the above mentioned findings and offered no further explanation to dispute the above mentioned deficient practice.

Based on record reviews and interviews, the facility failed to ensure direct care staff were provided Quality Assurance and Performance Improvement (QAPI) training for 5 (S10Certified Nursing Assistant [CNA], S13CNA, S14CNA, S15CNA, S16CNA) of 5 (S10CNA, S13CNA, S14CNA, S15CNA, S16CNA) sampled direct care staff investigated for training requirements. Findings:Review of S10CNA's personnel record revealed, in part, S10CNA had a date of hire of 04/01/2025. Further review revealed S10CNA did not receive QAPI training as required. Review of S13CNA's personnel record revealed, in part, S13CNA had a date of hire of 02/25/2025. Further review revealed S13CNA did not receive QAPI training as required. Review of S14CNA's personnel record revealed, in part, S14CNA had a date of hire of 03/03/2025. Further review revealed S14CNA did not receive QAPI training as required. Review of S15CNA's personnel record revealed, in part, S15CNA had a date of hire of 07/15/2025. Further review revealed S15CNA did not receive QAPI training as required. Review of S16CNA's personnel record revealed, in part, S16CNA had a date of hire of 04/10/2025. Further review revealed S16CNA did not receive QAPI training as required. In an interview on 08/26/2025 at 11:45AM, S3CNA Supervisor indicated she was responsible for providing training for new hire orientation and in-services to staff. S3CNA Supervisor further indicated QAPI training was not included in orientation training or in-services. In an interview on 08/27/2025 at 12:45PM, S2Director of Nursing confirmed S10CNA, S13CNA, S14CNA, S15CNA, and S16CNA did not receive QAPI training.

Based on observations, interviews, and record reviews, the facility failed to ensure staff wore proper personal protective equipment (PPE) and completed hand hygiene while performing incontinence and/or wound care for residents on Enhanced Barrier Precautions (EBP) for 2 (Resident #1, Resident #3) of 2 (Resident #1, Resident #3) sampled residents observed for incontinence and/or wound care. Findings: Review of the facility's undated Enhanced Barrier Protection policy and procedure, revealed, in part, EBP consisted of, at a minimum, gloves and gown. Further review revealed EBP was indicated for residents with indwelling devices. Review of the facility's Handwashing/Hand Hygiene policy and procedure, revised 12/2009, revealed, in part, all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Further review revealed, employees must wash their hands with soap and water or sanitize using alcohol based hand sanitizer after handling soiled or used linens, dressings, catheters, and urinals, after removing gloves, before moving from a contaminated body site to a clean body site during resident care, and before and after direct resident contact. Resident #1 Review of the Centers for Disease Control and Prevention (CDC)'s October 2022 Guidelines for Hand Hygiene in Health-Care Settings revealed, in part, staff should decontaminate their hands if moving from a contaminated body site to a clean body site during patient care. Review of Resident #1's August 2025 physician's orders revealed, in part, an order for EBP: gown and gloves to be worn during high contact resident care activities such as dressing, hygiene, toileting, chronic wound care, and urinary catheter care every shift. Observation of Resident #1's door on 08/25/2025 at 1:15PM revealed a sign for EBP which indicated gloves and gown shall be worn for resident activity involving changing briefs and hygiene. Further observation of the EBP sign revealed everyone must clean their hands including before entering and when leaving the room. Observation on 08/25/2025 at 1:17PM revealed S10Certified Nursing Assistant (CNA) and S11CNA entered Resident #1's room to perform incontinence care. S10CNA and S11CNA had direct resident contact during incontinence care, without wearing gowns. S10CNA removed Resident #1's soiled diaper, and wiped Resident #1's buttocks and perineal area. S10CNA then reached her gloved hand into a container of Resident #1's barrier cream and applied the cream to Resident #1's buttocks without changing her gloves and performing hand hygiene. S10CNA then changed her gloves without performing hand hygiene and placed a clean brief on Resident #1. S10CNA, without a gown, emptied Resident #1's urine catheter drainage bag. S10CNA and S11CNA removed their gloves, did not perform hand hygiene, and exited Resident #1's room. S10CNA exited Resident #1's room carrying a bag of dirty trash from Resident #1's incontinence care. Further observation revealed S10CNA walked down the hallway and threw the bag of dirty trash into the soiled trash room and did not perform hand hygiene. Further observation revealed S11CNA entered Resident R4's room, took Resident R4's water cup, filled it with ice from the ice machine and then returned it to Resident R4 without performing hand hygiene after assisting with Resident #1's incontinence care. In an interview on 08/25/2025 at 1:45PM, S10CNA indicated Resident #1 was on EBP. S10CNA further indicated she and S11CNA did not wear a gown during incontinence care, did not change her gloves and perform hand hygiene after removing Resident #1's soiled diaper, did not perform hand hygiene before leaving Resident #1's room and should have. In an interview on 08/27/2025 at 11:55AM, S4Infection Preventionist (IP) indicated residents with indwelling devices should be on EBP. S4IP further indicated staff who performed incontinence care should have worn gloves and a gown, and should have changed their gloves and performed hand hygiene when they moved from a contaminated body site to a clean body site during resident care and prior to leaving resident's room. In an interview on 08/27/2025 at 12:45PM, S2Director of Nursing (DON) confirmed S10CNA and S11CNA should have worn a gown when they performed Resident #1's incontinence care. S2DON further indicated S10CNA should have performed hand hygiene when she moved from a contaminated body area to a clean body area, and S10CNA and S11CNA should have performed hand hygiene before they exited Resident #1's room. S2DON further indicated S11CNA should not have entered another resident's room without performing hand hygiene. In an interview on 08/27/2025 at 1:20PM, S1Administrator was presented with the above mentioned findings and offered no further explanation to dispute the above mentioned deficient practice. Resident #3Review of Resident #3's medical record revealed, in part, Resident #3 had an ileostomy (a surgical opening in the lower abdomen that allows stool to completely bypass the large intestine and rectum and collect into an external pouch). Observation of Resident #3's door on 08/25/2025 at 12:30PM revealed a sign for EBP which indicated gloves and gown shall be worn for any resident activity involving wound care and/or dressings. Observation on 08/26/2025 at 10:09AM revealed S8Licensed Practical Nurse (LPN) entered Resident #3's room to secure Resident #3's ostomy dressing and did not wear a gown. Further observation revealed S8LPN completed Resident #3's dressing securement without a gown. In an interview on 08/26/2025 at 10:11AM, S8LPN indicated Resident #3 was on EBP. S8LPN confirmed she provided wound care for Resident #3's ostomy site and did not wear a gown. S8LPN further indicated a gown was not needed when wound care was performed on Residents who were on EBP. In an interview on 08/27/2025 at 11:55AM, S4IP indicated residents with indwelling devices should be on EBP. S4IP further indicated the securement of an ostomy dressing was considered wound care and staff should have worn gloves and a gown for a resident on EBP. In an interview on 08/27/2025 at 12:45PM, S2DON confirmed the securement of an ostomy dressing was considered wound care, and S8LPN should have worn a gown while she secured Resident #3's ostomy dressing. In an interview on 08/27/2025 at 1:20PM, S1Administrator was presented with the above mentioned findings and offered no further explanation to dispute the above mentioned deficient practice.

Based on interview and record review, the facility failed to ensure the facility assessment included active involvement from direct care staff, residents, and residents' representatives in its development and the current number of residents in the facility at the time of the assessment. Findings:Review of the facility's facility assessment dated [DATE] revealed, in part, direct care staff, including a Registered Nurse (RN), Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA), a resident and resident representatives were not included in the development of the facility's assessment. Further review revealed the average daily census was not documented. In an interview on 08/27/2025 at 1:20PM, S1Administrator confirmed the facility assessment was not developed with direct care staff, including a RN, a LPN, and a CNA, a resident and resident representatives. S1Administrator further indicated he could offer no further explanation as to why an accurate census was not included in the facility's facility assessment dated [DATE].

Based on observations and interviews, the facility failed to post the required nurse staffing information at the beginning of each shift daily for 3 (08/25/2025, 08/26/2025, 08/27/2025) of 3 (08/25/2025, 08/26/2025, 08/27/2025) days observed for nurse staffing information. Findings:Observation on 08/25/2025 at 10:30AM revealed the facility's posted nurse staffing information dated 08/25/2025 did not include the facility's daily census or the actual hours worked by Registered Nurses (RN), Licensed Practical Nurses (LPN), and Certified Nursing Assistants (CNA). Observation on 08/26/2025 at 9:47AM revealed the facility's posted nurse staffing information dated 08/26/2025 did not include the facility's daily census or the actual hours worked by RNs, LPNs, and CNAs. Observation on 08/27/2025 at 11:51AM revealed the facility's posted nurse staffing information dated 08/27/2025 did not include the facility's daily census or the actual hours worked by RNs, LPNs, and CNAs. In an interview on 08/27/2025 at 12:45PM, S2Director of Nursing confirmed the above mentioned staffing reports did not contain the facility's daily census or the actual hours worked by RNs, LPNs, and CNAs. In an interview on 08/27/2025 at 1:20PM, S1Administrator was presented with the above mentioned findings and offered no further explanation to dispute the above mentioned deficient practice.

Based on interviews, the facility failed to ensure that the individual designated as the Infection Preventionist had completed specialized infection prevention and control training. Findings: In an interview on 03/03/2025 at 10:15AM, S1Administrator indicated S3Infection Control/Licensed Practical Nurse (LPN) was the facility's designated Infection Preventionist. S1Administrator further indicated S3Infection Control/LPN did not have an Infection Preventionist certificate or specialized infection prevention and control training. In an interview on 03/10/2025 at 2:30PM, S3Infection Control/LPN indicated she had not completed any specialized infection prevention and control training.