Every finding on record at Ouachita Healthcare and Rehabilitation Center

Based on interview and record reviews, the facility failed to ensure it notified the resident's representative of a significant change in the resident's physical, mental, or psychosocial status by failing to notify the responsible party of significant changes for 2 (#1, #2) of 3 sampled residents.Findings: Review of the facility Change in Condition Policy and Procedure, effective date 08/27/2018, revealed it defined an acute change in condition as a sudden, clinically important deviation from a resident's baseline in areas such as physical, cognitive, behavioral, functional, etc. The policy read in part, The resident and or the resident's representative will also be notified and documented in the electronic medical record and on physician order as appropriate. Resident #1 Record review revealed Resident #1 was admitted to the facility on [DATE] diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, unspecified dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, history of UTI, overactive bladder unspecified, chronic kidney disease stage3B, primary insomnia, unspecified glaucoma, primary generalized (osteo)arthritis, cognitive communication deficit, type 2 diabetes mellitus with diabetic polyneuropathy, dysphagia oral phase, leiomyoma of uterus, bladder neck obstruction, essential (primary) hypertension, depression, and chronic obstructive pulmonary disease. Review of the Quarterly MDS assessment dated [DATE] revealed a BIMS score of 11 which indicated moderate cognitive impairment. Further review revealed Resident #1 had a urine lab result date 05/13/2026 indicating the resident had a UTI. Resident #1 had a Urine culture and sensitivity dated 05/14/2026 which indicated the resident had a UTI caused by a bacteria (Klebsiella pneumoniae) that was susceptible to Ceftriaxone (antibiotic). Review of May 2026 Physician Orders revealed an order dated 05/18/2026 Ceftriaxone Sodium solution reconstitute 1 gm Administer 1 gm intravenously every 24 hours for 7 days for UTI. On 06/15/2026 at 10:05 a.m. a telephone interview with Resident #1's responsible party revealed she was not notified of Resident #1 had a UTI with hallucinations and that she was receiving IV antibiotics to treat the UTI until 05/23/2026 when S5LPN called her to inform her Resident #1's IV had infiltrated. On 06/16/2026 at 12:16 p.m. an interview with S4LPN revealed Resident #1 was ordered a UA and culture and sensitivity due to her having some hallucinations. S4LPN reported he received an order on 05/18/2026 for Ceftriaxone Sodium solution reconstitute 1 gm Administer 1 gm intravenously every 24 hours for 7 days for UTI. S4LPN confirmed he did not notify Resident #1's responsible party about her having hallucinations, UTI, or the new order for the intravenous antibiotic to treat her UTI. Review of the progress notes revealed there was no documentation the responsible party was notified in the change of Resident #1's condition. On 06/15/2026 at 1:30 p.m. an interview with S3DON confirmed S4LPN should have notified Resident #1's responsible party about her hallucinations, UTI, and the new order for the intravenous antibiotic to treat her UTI. Resident #2 Review of the medical record revealed Resident #2 had an admission date of 3/18/2026 with diagnoses which included dementia, anxiety and major depression. Review of the 03/18/2026 significant change MDS assessment revealed the resident had a BIMS score of 8 which indicated moderate cognitive impairment. Review of the medical record revealed Resident #2 had a urine lab result dated 06/01/2026 indicating the resident had a UTI. Review of the June 2026 physician orders revealed Resident #2 was started on the antibiotic Augmentin for the treatment of a UTI. Review of the progress notes revealed there was no documentation the responsible party was notified in the change of condition. On 06/15/2026 at 11:40 a.m., interview with the responsible party of Resident #2 revealed he was not notified that Resident #2 developed a UTI. On 06/16/2026 at 9:50 a.m., interview with S2Assistant Administrator confirmed there was no documentation that the responsible party was notified when Resident #2 developed a UTI.

Based on observations, record reviews, and interviews, the facility failed to ensure respiratory care was provided in accordance with professional standards of practice for 3 (#36, #84 and #169) of 5 residents reviewed for respiratory care. The facility failed to:1) Change oxygen tubing, and humidified water bottles per the policy for 2 (#36, #84), and2) ensure the BiPAP nasal prongs were stored properly when not in use for Resident #169.Findings:Review of the facility's Oxygen Concentrator Cleaning Policy and Procedure dated 11/16/2014 Purpose: To Keep Oxygen concentrator and equipment clean. Policy: Resident's Oxygen concentrator will be kept clean when in resident room. Procedure: 1. All Surfaces areas of the machine will be cleaned with disinfectant wipe or spray when needed. 2. Store Oxygen tubing, cannula, and mask in a plastic bag when not in use. 3. Oxygen tubing, cannula, and mask to be changed out weekly and as needed. 4. Oxygen concentrator filter to be cleaned and or changed out weekly and as needed. Resident #36 Record review revealed Resident #36 was admitted to the facility on [DATE] with diagnoses including unspecified sequelae of cerebral infarction; acute and chronic respiratory failure with hypoxia; chronic obstructive pulmonary disease, unspecified; weakness; and shortness of breath. Review of Resident #36's quarterly MDS assessment dated [DATE] revealed Resident #36 had a BIMS score of 15, indicating Resident #36 was cognitively intact. Further review of the MDS assessment revealed Resident #36 was on oxygen therapy. Review of Resident #36's active physician's orders revealed an order for oxygen to be administered at 2 liters per nasal cannula continuously. Further review of the active physician's orders also revealed an order to change the oxygen tubing and humidifier every Monday on the night shift. On 04/13/2026 at 7:05 a.m., Resident #36 was observed lying in bed with nasal cannula in place administering oxygen at a rate of 2 liters per minute. Further review of Resident #36's oxygen concentrator revealed the humidifier water bottle was empty and dated 03/03/2026. On 04/14/2026 at 4:00 p.m., S2DON informed of finding of Resident #36's oxygen humidifier empty and dated 03/03/2026 when surveyor made observation on 04/13/2026. Resident 84 Review of the medical record for Resident #84 revealed an admit date of 06/29/2022. Resident #89 had diagnoses that included obstructive sleep apnea, chronic respiratory failure with hypoxia, shortness of breath, congestive heart failure, and COPD. Review of Resident #89's April 2026 physician orders revealed an order dated 07/01/2024 for oxygen: tubing and humidifier change every week on Monday night shift and as needed. Review of the care plan for Resident #84 revealed the resident had COPD and chronic respiratory failure. Further review revealed she required oxygen continuously and humidified via nasal prongs at 4 liters. Observation on 04/13/2026 at 5:24 a.m. of Resident #84 revealed she had oxygen at 4 liters per nasal cannula. The oxygen tubing was undated and the date on the humidifier was 03/31/2026. On 04/15/2026 at 4:00 p.m. S2DON confirmed Resident #84's oxygen tubing and humidifier were not changed in a timely manner. Resident 169 Review of the medical record for Resident #169 revealed an admit date of 04/02/2026. Resident #169 had diagnoses that included dementia, disorders of the lung, interstitial pulmonary disease, pleural effusion and shortness of breath. Review of the April 2026 physician orders revealed an order dated 02/25/2026 for oxygen- BiPAP to be used at bedtime. Review of the care plan for Resident #169 revealed the resident had chronic lung disorder/interstitial pulmonary disease and sleep apnea and to use oxygen via nasal prongs at 2 liters every hour of sleep. Observation on 04/13/2026 at 10:00 a.m. of Resident #169 revealed the BiPAP was not in use, and the nasal prongs were not stored in a bag. On 04/15/2026 at 11:20 a.m. S2DON confirmed the BiPAP nasal prongs should be stored in a bag when not in use.

Based on observations and interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards. According to S2DON the facility provided meals from the kitchen to 159 residents.Findings: On 04/13/2026 at 5:20 a.m. an initial observation of the kitchen revealed the following:The storage pantry contained a large bottle of browning serving sauce that had spills and splatters on the outside of the bottle, and a bag of miniature marshmallows was open to air and did not contain an open date.The freezer revealed a bag of meat pies was open to air and was not sealed properly.The refrigerator revealed a large ziplock bag of cheese was open to air, and an opened bag of turkey was open to air and not sealed properly.Two large fryers contained grease buildup on the inside compartments and on the outside of the fryers. On 04/13/2026 at 5:40 a.m. interview with S5Assistant Dietary Manager confirmed the above issues in the kitchen. On 04/14/2026 at 9:20 a.m. S6Dietary Manager was notified of the issues observed in the kitchen.

Based on observations, record reviews and interviews, the facility failed to maintain and establish an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (#9 and #13) of 2 residents reviewed for infection control, by having staff not utilize appropriate PPE while caring for residents on EBP.Findings:Review of the facility's Enhanced Barrier Precautions Policy and Procedure dated 04/01/2024 revealed the following in part: Enhanced Barrier Precautions refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. 4. For residents for who EBP are indicated, EBP is employed when performing the following high-contact resident care activities: c. Transferring g. Device care or use (Central line, urinary catheter, feeding tube, tracheostomy) Resident 9 Review of the medical record for Resident #9 revealed an admission date of 06/23/2025. Resident #9 had diagnoses that included Parkinson's disease, retention of urine, malignant neuroendocrine tumors and benign neoplasm of prostate. Review of the April 2026 physician orders revealed an order dated 01/16/2025 for EBP: utilize gown and gloves during high -contact care activities for residents with chronic wounds or indwelling medical devices. Further review of the orders revealed an order dated 01/20/2025 for a urinary catheter. Review of the significant change MDS assessment dated [DATE] revealed Resident #9 had a BIMS score of 11 which indicated Resident #9 had moderate cognitive impairment with daily decision making. Further review of the MDS assessment revealed Resident #9 had an indwelling urinary catheter. Review of care plan revealed Resident #9 had an indwelling catheter related to urine retention. On 04/13/2026 at 5:55 a.m. observation of the outside of Resident #9's door revealed signage to indicate EBP. At this time, S7CNA entered Resident #9's room, donned gloves and emptied the urinary catheter bag but failed to don a gown. On 04/13/2026 at 6:00 a.m. interview with S7CNA revealed she was not sure when to wear a gown with residents that were on EBP. On 04/14/2026 at 4:10 p.m. S2DON confirmed Resident #9 was on EBP related to a urinary catheter and S7CNA should have worn gloves and a gown when emptying resident #9's urinary catheter bag. Resident #13 Review of the record for Resident #13 revealed an admission date of 02/12/2026 with diagnoses that included multiple sclerosis, type 2 diabetes mellitus, protein calorie malnutrition, pressure ulcer sacral region stage 4, dysphagia following CVA, neuromuscular dysfunction of bladder, and hypertension. Review of the comprehensive MDS assessment dated [DATE] revealed a BIMS score of 9 which indicated Resident #13 had moderate cognitive impairment with daily decision making. Further review of the MDS assessment revealed Resident #13 had an indwelling catheter and an unhealed pressure ulcer. On 04/14/2026 at 9:09 a.m., observation revealed EBP signage posted on Resident #13's door. Further observation revealed Resident #13 had an indwelling urinary catheter and a left arm midline IV access. At this time, S8CNA and S9CNA were observed transferring Resident #13 wearing gloves without a gown. On 04/14/2026 at 9:20 a.m., S8CNA and S9CNA confirmed in an interview that EBP precautions were not implemented appropriately due to the failure to don a gown when Resident #13 was transferred. On 04/14/2026 at 9:59 a.m., S2DON was informed of findings and did not disagree that gowns should have been donned during the transfer of Resident #13.

Based on record review and interviews, the facility failed to develop a comprehensive care plan related to the need for counseling and mental health services for 1 (#3) of 2 residents reviewed for PASARR. Findings: On 04/13/2026 at 8:38 a.m., an interview with Resident #3 revealed she said she has Post Traumatic Stress Disorder related to an incident that occurred when she was eight years old. Resident #3 further said that she goes to her counselor about every 3 weeks and to a mental health clinic.On 04/14/2026 review of the record for Resident #3 revealed diagnoses, in part, of anxiety disorder, personality disorders, depression, post-traumatic stress disorder and bi-polar disorder.Review of the social history and assessment dated [DATE] revealed Resident #3 was alert and oriented. Resident #3 scored 14 on BIMS indicating resident is cognitively intact.On 04/14/2026 at 11:32 a.m., an interview with S4Social Service Specialist revealed Resident #3 was recently admitted to the facility from another nursing home. She said Resident #3 is going to a counselor and to a mental health clinic.On 04/14/2026 at 11:46 a.m., review of the care plan revealed no documentation of Resident #3's mental health needs and that Resident #3 was attending counseling and a mental health clinic.On 04/14/2026 at 1:30 p.m., an interview with S2DON confirmed there was no care plan developed for counseling and mental health services for Resident #3.

Based on observations and interviews, the facility failed to maintain a safe, clean, comfortable and homelike environment for 1 (#106) of 1 sampled resident reviewed for environmental concerns. The facility failed to ensure that residents' wheelchairs were clean and maintained in good repair. Findings:Review of Resident #106's record revealed an admit date of 08/02/2024 with diagnoses including bilateral primary osteoarthritis of hip, muscle wasting and atrophy, unspecified lower leg weakness, and spondylosis of the lumbar region. Review of the quarterly MDS assessment dated [DATE] documented Resident #106 utilized a wheelchair for mobility.On 04/13/2026 at 9:28 a.m., 04/14/2026 at 8:55 a.m., and 04/15/2026 at 8:00 a.m. observations of Resident #106's wheelchair revealed the wheelchair arm padding to be cracked and torn with foam exposed. Further observations revealed Resident #106's wheelchair frame revealed dirt and debris on the wheelchair frame.On 04/15/2026 at 12:40 p.m., an observation and interview conducted with S2DON confirmed Resident #106's wheelchair armrest was cracked, torn, and in need of replacement. Further observation and interview with S2DON confirmed Resident #106's wheelchair frame had dirt and debris on it and needed to be cleaned.

Based on observation and interview, the facility failed to maintain an effective pest control program so that the facility is free of pests by having ants in the dry pantry area. This failed practice had the potential to affect the 168 residents receiving meals from the kitchen. Findings: On 03/09/2025 at 7:45 a.m., an observation of the dry food storage area of the kitchen revealed there were small black ants on the large containers of grits and sugar. At this time, S5Cook confirmed there were little black ants and they had been having issues with them.

Based on observation and interview the facility failed to ensure mechanical equipment was in safe operating condition by having the manual can opener with metal shavings. There were 168 diets served from the kitchen. Findings: On 03/09/2025 at 8:00 a.m., an observation of the large mechanical can opener revealed there was a buildup of metal shavings. At that time an interview with S5Cook confirmed the metal shavings on the can opener.

Based on observation and interview the facility failed to store and distribute and serve food in accordance with professional standards for food service safety. There were 168 diets served from the kitchen. Findings: On 03/09/2025 at 8:06 a.m. observation of the reach in freezer revealed a personal drink was inside. Interview with S4Dietary confirmed the staff personal drink should not be in the refrigerator. At 8:10 a.m., observation of the walk in refrigerator revealed there was a pan of pureed rib meat that was not fully covered, and was not dated, there was also a pan of taco soup with a date of 02/27/2025 that should not have been available for resident consumption. At the time of the observation, S5Cook confirmed the items in the walk in refrigerator. At 8:20 a.m., observation of 2 large containers of powdered mashed potatoes revealed the scoop and handle were laying inside the powdered potatoes. Interview again with S5Cook confirmed the scoop and handles should not be stored inside the mashed potato bins. Further observation of the kitchen environment revealed the bowl, divided plates, regular plates, and insulated covers were stored facing in the upright position and not inverted. At that time S3Dietary Manager was notified of the dishes that were being stored in the upright position. At 11:00 a.m. observation of the lunch meat revealed S3Dietary Manager and S18Assistant Dietary Manager were picking up the cornbread with gloved hands after touching other items such as spoon handles, desserts, and drinks. Further observation revealed the residents who received the alternate meal choice of a chicken salad sandwich also received chips. Observation revealed when dietary staff handed S3Dietary Manager the bag of chip it fell on the floor. S3Dietary Manager picked up the bag of chips and handed it to S5Cook who then reached into the bag with the same hands that touched the outside of the bag that had fallen on the floor and got chips out of the bag. S5Cook continued to serve the lunch meal without changing her gloves. Further observation revealed S3Dietary Manager did not change her gloves after picking up the bag off the floor and continued to touch the bread to make chicken salad sandwiches and serve cornbread. On 03/10/2025 at 10:30 a.m., an interview with S5Cook while pureeing food revealed the menu for the lunch meal was beans, rice, spinach, ham, cornbread and dessert. S5Cook said she pureed the rice and beans together, pureed the ham with some broth and pureed the spinach with some broth. At 11:40 a.m. observation of the lunch meal revealed the cornbread again was served with gloved hands after touching other trays, plates, glasses and dessert bowls. Further observation revealed S19Dietary was observed using her gloved hand to take the dessert out of regular serving bowl and place into a styrofoam container for 2 isolation residents. S19Dietary was then noted to spill chocolate milk on the tray that contained pre-prepared milk, she then picked up a towel to wipe up the spill and then continued to serve the cornbread without changing her gloves and touching the cornbread with the same gloves she touched the towel with. At 12:30 p.m. observation of the food prep sink revealed there were three 10 pound tubes of hamburger meat thawing in standing water without out cold water running over the meat. On 03/10/2025 at 3:00 p.m. S3Dietary Manager was notified of the findings.

Based on record review, observation, and interview the facility failed to ensure the menus were followed for 7 of 7 (#5, #39, #63, #72,# 80,#104, and # 127) pureed diets by not serving pureed cornbread as per the menu. Findings: On 03/09/2025 review of the lunch menu for the pureed diets revealed they were supposed to receive a dinner roll but facility substituted cornbread on the menu. Further review of the menu for the pureed diets revealed they were supposed to be served pureed cornbread. On 03/09/2025 at 11:00 a.m., observation of the lunch meal revealed residents #5, #39, #63, #72, #80, #104, and #127 did not receive the pureed cornbread. On 03/10/2025 review of the lunch menu for the pureed diets revealed they were supposed to receive pureed cornbread with their meal. On 03/10/2025 at 11:00 a.m., observation again of the lunch meal revealed residents #5, #39, #63, #72, #80, #104, and #127 did not receive the pureed cornbread. On 03/10/2025 at 3:00 p.m., an interview with S3Dietary Manager agreed the pureed diets were not served cornbread.

Based on record review, observations and interviews, 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 was administered as ordered by the physician for 2 (#48, #138) of 3 (#29, #48, #138) residents reviewed for oxygen therapy. Findings: Review of the Oxygen Administration Policy and Procedure revised 11/16/2024 revealed the following in part: Policy: Oxygen Administration will be performed as ordered by the physician. Procedure: 1. Check physician's order for liter flow and method of administration. 5. e. Set the flow meter to the rate ordered by the physician. 6. Nasal Cannula: connect tubing to humidifier outlet and adjust liter flow as ordered. Place prongs of cannula in the resident's nares. Addjust elastic loosely around head, above the ears. If cannula does not have elastic adjustment, lop the plastic around the ears and under the chin. Adjust the plastic slide to hold cannula in place. Resident #138 Review of the medical record revealed sample resident #138 was admitted to the facility on [DATE] with diagnosis that included subdural hemorrhage, insomnia, abnormal weight loss, depression, abnormalities of gait and mobility, muscle wasting, chronic atrial fibrillation, left artificial hip joint, hypertension, cardiomegaly, and altered mental status. Review of the quarterly Minimum Data Set assessment (MDS) dated [DATE] revealed the resident has a Brief Interview for Mental Status (BIMS) score of 12 which indicates the resident is cognitively aware and able to make daily decisions. Further review revealed the resident is dependent on staff with activities of daily living. Review of the health conditions revealed the resident has shortness of breath or trouble breathing with exertion and wears oxygen. Review of the March 2025 physician's orders revealed sample resident #138 has an order dated 07/12/2024 for continous oxygen at 3 liters per nasal cannula. Observation on 03/10/2025 at 9:20 a.m. and 03/11/2025 at 1:30 p.m. revealed sample resident #138 was sitting up in bed with oxygen per nasal cannula in place. Observation of the oxygen concentrator at both times revealed the oxygen set at 2 liters. Interview on 03/11/2025 at 2:00 p.m. with S9Licensed Practical Nurse (LPN), confirmed the resident's oxygen concentrator was set at 2 liters per nasal canula and the physician's order was to be at 3 liters per nasal canula. The nurse changed the oxygen concentrator to 3 liters per nasal canula at this time. Interview on 03/11/2025 at 4:00 p.m. with S2Director of Nurses (DON) confirmed resident #138's oxygen was ordered for 3 liters per nasal canula. 43405 Resident #48 Review of resident #48's record revealed an admitted [DATE] with diagnoses including other speech and language deficits following other cerebrovascular disease, personal history of pulmonary embolism, hemiplegia and hemiparesis following other cerebrovascular disease affecting left non dominant side, dyspnea, shortness of breath, and chronic obstructive pulmonary disease. Review of resident #48's March 2025 Physician's Orders revealed an order dated 07/01/2024 for oxygen at 2 liters per minute per nasal cannula continuous. Review of resident #48's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 14 indicating cognitvely intact. Further review revealed oxygen therapy marked on the MDS. Review of resident #48's current careplan revealed resident has oxygen therapy related to respiratory illness and intervention included oxygen via nasal prongs at 2 Liters continually humidified. Observations on 03/09/2025 at 10:30 a.m. and 03/11/2025 at 8:00 a.m. of resident #48 revealed resident's oxygen concentrator was set at 3.5 liters per minute. An interview on 03/11/2025 at 8:00 a.m. with resident #48 revealed she wears her oxygen all the time, and her oxygen should be set at 2 liters per minute. Resident #48 reported she does not adjust her oxygen settings. An interview on 03/11/2025 at 8:05 a.m. with S17LPN confirmed that resident #48 has an order for oxygen at 2 liters per minute per nasal cannula continuously. S17LPN confirmed during observation of resident #48 that her oxygen was set at 3.5 liters per minute, changed oxygen settings to 2 liters per minute. An interview on 03/11/2025 at 8:25 a.m. with S2DON confirmed that resident #48's oxygen should be set at 2 liters per minute per nasal cannula.

Based on observations and interviews, the facility failed to provided a resident who is unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 2 (#14,#63) of 3 (#14,#25,#63) residents reviewed for ADL (Activities of Daily Living), by failing to ensure residents #14 and #63 received assistance with personal hygiene. Findings: Resident #14 Review of resident #14's medical record revealed that he was admitted to the facility on [DATE] with diagnoses including Parkinson's disease. Review of the quarterly minimum data set assessment dated [DATE] revealed resident #14 had a brief interview for mental status score of 12, which indicated that he had moderate cognitive impairment with daily decision making skills. Further review revealed resident #14 required partial to moderate assistance with personal hygiene that included shaving. Review of resident #14's record revealed he was care planned for having an activities of daily living self-care performance deficit related to the disease process Parkinson's and impaired balance. The documented approaches included that resident #14 required one staff assistance with personal hygiene. On 03/09/2025 at 8:17 a.m., an observation revealed resident #14 lying in bed resting. Further observation revealed the resident's eyebrows were long and untrimmed. Attempted an interview with resident #14, but he could not answer the questions appropriately. On 03/10/2025 at 8:03 a.m., S8ADON (Assistant Director of Nursing) was notified of the observation of resident #14 having long, untrimmed eyebrow hair to both eyebrows. On 03/10/2025 at 8:15 a.m., an observation of resident #14 and interview with S8ADON confirmed that resident #14's eyebrows needed to be trimmed. On 03/11/2025 at 3:45 p.m., S2Director of Nursing was notified of the observation of resident #14 having long and untrimmed eyebrows. On 03/11/2025 at 3:55 p.m., S1Administrator was notified of the above findings. Resident #63 Review of resident #63's medical record revealed she was admitted to the facility on [DATE] with diagnoses including, hemiplegia and hemiparesis following other cerebrovascular disease affecting right dominant side, weakness, and dementia. Review of the significant change in status Minimum Data Set (MDS) assessment dated [DATE] revealed resident #63 had a brief interview for mental status score of 03, which indicated that she had severe cognitive impairment with daily decision making skills. Further review of the MDS revealed that resident #63 had an impairment to one side of the upper extremity, she had a self-care deficit, and was dependent upon staff with personal hygiene that included shaving. Review of resident #63's medical record revealed the resident was care planned as she required staff assistance with activities of daily living care related to cardiovascular vascular accident with right sided hemiplegia and osteoarthritis. The documented approaches included in part, assist the resident with hygiene and grooming tasks. On 03/09/2025 at 8:02 a.m., an observation revealed resident #63 in bed, resting. Further observation revealed a large amount of long, untrimmed hair on resident #63's chin. On 03/10/2025 at 8:08 a.m., S8ADON was notified of the observation of resident #63 having long and untrimmed chin hair. On 03/10/2025 at 8:11 a.m., an observation of resident #63 and an interview with S8ADON confirmed that resident #63's chin hair needed to be trimmed. On 03/11/2025 at 10:41 a.m., S2Director of Nursing was notified of the observation of resident #63. On 03/11/2025 at 3:55 p.m., S1Administrator was notified of the above findings.

Based on observation, record review and interview the facility failed to ensure resident personal privacy was maintained during care for 1 (#102) of 1 residents observed exposed to the hallway during care. Findings: On 03/09/2025 at 1:45 p.m., observation from the hallway into resident #102's room revealed resident #102 was lying on the bed with no sheets covering her. Further observation revealed resident #102 was lying in the bed with her brief exposed to the hallway. On 03/09/2025 at 1:47 p.m., an interview with S6Certified Nurse Aide (CNA) and S7CNA revealed when S7CNA left out of the room the door must have swung back open when they went to get a gown for the resident. S6CNA and S7CNA agreed the door was open to the hallway and resident #102 was lying on the bed with no sheets covering her and her brief was exposed to the hallway, not maintaining the resident's privacy. Review of the record for resident #102 revealed diagnoses of cerebral infarction, psychotic disorders with delusions, chronic respiratory failure with hypercapnia, major depressive disorder with psychotic symptoms, and vascular dementia with behavioral disturbances. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #102 had a Brief Interview for Mental Status (BIMS) of 15 indicating the resident was cognitively intact. Further review of the MDS revealed resident #102 was always incontinent of bladder and bowel and was dependent on staff for all activities of daily living. On 03/11/25 at 1:45 p.m., an interview with resident #102 revealed she did not like when the staff came into her room to change her and left the door open, causing her to be exposed in her room with a brief on. On 03/11/2025 at 3:28 p.m. S2Director of Nursing (DON) was notified of the resident being left exposed during care.

Based on observation, record review, and interview the facility failed to ensure the resident's call light was within reach for 3 (#102, #141 #143) of 3 residents observed with call lights out of reach and were high risk for falls. Findings: Resident #102 On 03/10/2025 at 10:45 a.m., observation of resident #102's room revealed the call light was out of the resident's reach. Resident #102 was in a wheelchair and call light was out of reach on the bed. She agreed she would not be able to call for assistance if needed. Review of the medical record for resident #102 revealed diagnoses in part of cerebral infarction, psychotic disorders with delusions, chronic respiratory failure with hypercapnia, major depressive disorder with psychotic symptoms, vascular dementia with behavioral disturbances, neuropathy, convulsions, type 2 diabetes, and heart failure. Review of the Quarterly Minimum Data Set (MDS) assessment revealed resident #102 had a Brief Interview Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. Further review of the MDS revealed resident #102 was always incontinent of bladder and bowel and was dependent on staff for all activities of daily living. Review of the current fall risk assessment revealed resident #102 was at high risk for falls. Resident 141 On 03/10/2025 at 10:50 a.m. observation of resident #141 revealed he was lying in bed and the call light was draped over the back of the recliner at the foot of the resident's bed out of the resident's reach. At that time the resident asked for a glass of water and he was unable to call for assistance. On 03/10/2025 at 11:05 a.m. observation again of resident #141's room revealed the call light remained out of reach of the resident and draped over the back of the recliner at the foot of the resident's bed out of the resident's reach. On 03/10/2025 at 2:10 p.m. observation again of resident #141's room revealed the call light remained draped over the back of the recliner out of the resident's reach. Review of the medical record for resident #141 revealed diagnoses in part of metabolic encephalopathy, unspecified protein calorie malnutrition, interstitial pulmonary disease with fibrosis, chronic atrial fibrillation, dysphagia following cerebrovascular disease, muscle wasting and atrophy lower leg and multiple sites, falls, seizures, anxiety, dementia mild with anxiety, and depression. Review of the significant change MDS assessment dated [DATE] revealed resident #141 had a BIMS score of 2 indicating significant cognitive impairment. Further review of the MDS revealed resident #141 was always incontinent of bladder and bowel and was dependent on staff for all activities of daily living. Further review of the medical record revealed resident #141 was at high risk for falls. Resident 143 On 03/10/2025 at 10:50 a.m. observation of resident #143's room revealed the resident was sitting up in a high back wheelchair. Further observation revealed the call light was lying on the bed out of the reach of the resident. Review of the medical record for resident #143 revealed diagnoses in part of Parkinson's disease, coronary artery disease, dysphagia following cerebrovascular disease. Review of the quarterly MDS assessment dated [DATE] revealed resident #143 had a BIMS score of 11 indicating moderate cognitive impairment. Further review of the MDS revealed resident #143 was always incontinent of bladder and bowel and required assistance from staff for all activities of daily living. Further review of the medical record revealed resident #143 was at high risk for falls. On 03/11/2025 at 3:27 p.m., S2Director of Nursing (DON) was notified of the call bells being out of reach of the residents #102, #141 and #143 who were all at high risk for falls and required assistance from staff.

Based on observation and interview the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes or enhances his or her quality of life for 2 (#143, #14) of 2 residents. Findings: On 03/09/2025 at 1:06 p.m. observation of resident #143 revealed he was sitting in a high back wheelchair with a clean disposable brief behind his head cushioning his head and neck against the wheelchair headrest. On 03/11/2025 at 2:03 p.m., record review revealed diagnoses in part of Parkinson's disease, coronary artery disease, hypertension, dysphagia following cerebrovascular disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed resident #143 had a Brief Interview Mental Status (BIMS) of 11 indicating resident #143 had moderate cognitive impairment. Further review of the MDS revealed resident #143 was dependent on staff for activities of daily living. On 03/11/2025 at 3:29 p.m. S2Director of Nursing (DON) was notified of the disposable brief that was placed behind resident #143 head while in the high back wheelchair. 32231 Resident #14 Review of resident #14's medical record revealed that he was admitted to the facility on [DATE] with diagnoses including Parkinson's disease. Review of the Quarterly MDS assessment dated [DATE] revealed resident #14 had a brief interview for mental status score of 12, which indicated that she had moderate cognitive impairment with daily decision making skills. Further review of the MDS revealed that resident #14 had a self-care deficit and he needed set-up or clean up assistance with eating. Review of resident #14's record revealed he was care planned for having an activities of daily living self-care performance deficit related to the disease process Parkinson's and impaired balance. On 03/10/2025 at 8:05 a.m., an observation revealed resident #14 sitting in his wheelchair in the main dining room, eating his breakfast. Further observation revealed resident #14 was served a diet that consisted of in part, a patty sausage, scrambled eggs, and a biscuit. There were pieces of the patty sausage, scrambled eggs, and the biscuit observed lying on top of and in direct contact with the table top. Further observation revealed resident #14 picked up the food items directly from with his hand then in his mouth. S11Licensed Practical Nurse (LPN) was standing near to resident #14 at that time and observed resident #14 retrieving the pieces of the patty sausage, scramble eggs, and biscuit from the table top with his hand. S11LPN, S12Certified Nursing Assistant (CNA) and S13CNA was observed standing in the dining area, but did not address resident #14 eating his breakfast meal from the table top with his hand. On 03/10/2025 at 8:17 a.m., S8Assistant Director of Nursing was notified of the observation regarding resident #14 picking up his food from the table top and eating it with his hands without being offered assistance by staff during that time. S8ADON confirmed the staff should have offered to assist the resident with his meal. On 03/11/2025 at 3:45 p.m., S2Director of Nursing was notified of the observation regarding resident #14 eating his breakfast meal directly from the table top with his hands without assistance from the staff. On 03/11/2025 at 3:55 p.m., S1Administrator was notified of the above findings.

Based on record review and interviews, the facity failed to document a discharge summary when a resident was discharged from the facility for 1 (#160) of 3 (#34, #160, and #213) sampled residents reviewed for discharge. Findings: Review of the closed record for resident #160 revealed an admitted [DATE] with diagnoses including cerebral infarction, acute and chronic respiratory failure with hypoxia, unspecified protein-calorie malnutrition, morbid obesity, epilepsy, and type 2 diabetes mellitus. Review of resident #160's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident required partial to moderate assistance with activities of daily living. Review of the closed record revealed resident #160 was discharged home on 12/30/2024. Further review of the record revealed no documentation of a discharge summary was completed. An interview on 03/11/2025 at 2:06 p.m. with S2Director of Nursing (DON) confirmed that resident #160 was discharged from the facility on 12/30/2024, and the facility failed to document a discharge summary on discharge for this resident.

Based on observations and interviews, the facility failed to maintain a sanitary environment and to help prevent the development and transmission of communicable diseases and infections by, having employee's personal items lying on top of and in direct contact with tables that were designed for the folding of clean clothing and linen items. Findings: On 03/11/2025 at 3:09 p.m., an observation of the laundry department revealed S14Laundry Worker and S15Laundry Worker standing in the designated clean laundry room. S14Laundry Worker was holding a cell phone in her hand. Observation revealed S14Laundry Worker placing the cell phone on the top of and in direct contact with a table that contained clean clothing items and a bed pad. S14Laundry Worker confirmed the cell phone belonged to her (S14Laundry Worker). S14Laundry Worker further confirmed the table was designed for folding clean resident clothing and linen items. Observation of the clean laundry room further revealed a second table that had a cell phone lying on the table top of and in direct contact with the table top. S15Laundry Worker confirmed the table was also used for the folding of resident items such as clothing, linens, and bed pads. On 03/11/2025 at 3:15 p.m., S16Laundry Supervisor entered the clean laundry room and she was notified of the observations regarding the cell phones. S16Laundry Supervisor confirmed that the laundry worker's personal belongings should not have been placed on the top of and in direct contact with the two tables that were designated for the folding of the resident's clean clothing, linens, and bed pads due to potential cross contamination. On 03/11/2025 at 3:55 p.m., S1Administrator was notified of the findings regarding the laundry department.

Based on observation, record review and interview the facility failed to ensure: 1) dietary orders were followed for 2 (#38, #62) of 2 (#38, #62) residents having orders for mighty shakes and 2) dietary preferences were followed for 1 (#73) of 1 (#73) resident reviewed for dining. Findings: Resident #38 On 04/16/2024 at 2:35 p.m. record review for Resident #38 revealed diagnoses in part of end stage renal disease, cerebral vascular accident due to embolism of pre-cerebral artery, type 2 diabetes, chronic atrial fibrillation, dysphagia, systolic congestive heart failure, and stage 3 pressure ulcer of the sacral region. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 10 indicating moderate cognitive impairment. Review of the current physician orders for April 2024 revealed an order for mighty shakes, three times a day (TID). Review of the dietary card revealed Resident #38 was receiving a regular, no added salt, low concentrated sweet diet. Further review of the dietary card under preferences for Resident #38 revealed for breakfast, lunch and supper Resident #38 was to receive mighty shakes. On 04/16/2024 at 4:59 p.m., observation of Resident #38 supper meal revealed Resident #38 did not receive the mighty shake. On 04/17/2024 at 7:30 a.m. observation of the breakfast meal revealed Resident #38 did not receive the mighty shake. On 04/17/2024 at 8:20 a.m. an interview with S4Culinary Supervisor Asst. revealed the dietary staff are supposed to put the mighty shakes in the tub on top of cart in ice with the other drinks. Observation at that time of the refrigerator revealed there was a full case of un-opened mighty shakes in the refrigerator available for the residents. S4 Culinary Supervisor Asst. confirmed the dietary department should have put the mighty shakes on the meal carts. On 04/17/2024 at 9:00 a.m., an interview with S5CNA (Certified Nursing Assistant) revealed they are supposed to read the diet cards and give the drinks from that to the residents with their meals. S5CNA confirmed there were no mighty shakes on the cart for the residents and then said, they don't drink them anyway. Resident #62 On 04/17/2024 review of the record for Resident #62 revealed diagnoses in part of bilateral above the knee amputation, abnormal weight loss, cerebral vascular disease, stage 3 pressure ulcer sacrum, type 2 diabetes, unspecified protein-calorie malnutrition, hypertension, vascular dementia, and atrial flutter. Review of the MDS assessment dated [DATE] revealed a BIMS of 8, indicating moderate cognitive impairment. Further review of the record revealed a current order for mighty shakes three times a day with meals. On 04/16/2024 at 8:22 a.m. observation of Resident #62's breakfast meal revealed there was no mighty shake on breakfast tray. On 04/16/2024 at 11:30 a.m. observation of Resident #62's lunch meal revealed there was no mighty shake served to Resident #62. On 04/16/24 at 4:22 p.m., review of the dietary card for Resident #62 revealed mighty shakes were listed to be served to Resident #62. On 04/16/24 at 5:00 p.m., observation of Resident #62 supper meal revealed there was no mighty shake served to Resident #62. On 04/17/2024 at 7:30 a.m., observation of Resident #62 breakfast tray revealed there was no mighty shake served to Resident #62. On 04/17/2024 at 8:20 a.m., an interview with S4 Culinary Supervisor Asst. revealed the dietary staff are supposed to put the mighty shakes in the tub on top of cart in ice with the other drinks. Observation at that time of the refrigerator revealed there was a full case of un-opened mighty shakes in the refrigerator available for the residents. S4 Culinary Supervisor Asst. confirmed the dietary department should have put the mighty shakes on the meal carts. On 04/17/2024 at 9:00 a.m., interview with S5CNA revealed they are supposed to read the diet cards and give the drinks from that to the residents with the meals. S5 CNA confirmed there were no mighty shakes on the cart for the residents and then said, they don't drink them anyway. 41829 Resident # 73 Record review revealed resident #73 was admitted to the facility on [DATE] with diagnoses that include atherosclerotic heart disease of native coronary artery with unstable angina pectoris, chronic obstructive pulmonary disease, chronic atrial fibrillation, type 2 diabetes mellitus with diabetic neuropathy, mild protein-calorie malnutrition, anemia, chronic pain, essential hypertension, dysphagia following unspecified cerebrovascular disease, hypothyroidism, and vascular dementia unspecified severity without behavioral disturbance. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 15 which indicated resident #73 was cognitively intact. Review of the active April 2024 physician orders revealed resident #73 was to receive a regular Low Concentrated Sugar (LCS), No Added Salt (NAS) diet. On 04/15/2024 at 09:52 a.m. an interview with resident #73 reported that she prefers wheat bread, but for the last couple months all they give her was white bread. On 04/15/2024 at 12:24 p.m. an observation of resident #73's lunch meal consisted of a chef salad, ranch dressing, turkey and Swiss cheese sandwich on white bread, vanilla pudding, ice water and ice tea. Review of resident #73's lunch meal slip revealed the following: regular, LCS, NAS diet. Dislikes: chili seasoning, toast, corndogs, fruit punch, gravy or BBQ sauce, white bread, [NAME]. Preferences: baked potato, broccoli, Brussel sprouts, cabbages, squash, chicken, cold sandwich on wheat, pasta sometimes, roast beef non gravy, thin liquids ice tea (1 cup). On 04/17/2024 at 08:20 a.m. an observation of resident #73's breakfast meal consisted of scrambled eggs, bacon, oat meal, white toast, jelly, salt/pepper, water and apple juice. Resident #73 reported that she already told them she does not like white bread and prefers wheat bread, but they keep giving her white bread. On 04/17/2024 at 08:35 a.m. an interview with S3Culinary Supervisor reveal they have wheat bread available. S3Culinary Supervisor was informed that resident #73 was served a turkey and Swiss cheese sandwich on white bread and chef salad for lunch on 04/15/2024. S3Culinary Supervisor was also informed resident #73 was served white bread toast with her breakfast meal today. S3Culinary Supervisor confirmed resident #73 should have been served wheat bread instead of white bread according to her preference.

Based on observation, interviews, and record review, the facility failed to accurately obtain pharmaceutical services, including supplying routine medications with the appropriate strength as ordered by the physician for 1 (#90) of 2 (#46 and #90) residents observed during medication administration pass. Findings: Resident #90: Review of the record for resident #90 revealed an admitted [DATE] with diagnoses including cerebral infarction, dysphagia, pressure ulcer of left hip, hemiplegia following cerebral infarction affecting left non-dominant side, type 2 diabetes mellitus, and hypertension. Observation on 04/16/2024 at 7:20 a.m of resident #90's medication pass revealed S7Licensed Practical Nurse (LPN) administered a blood pressure medication, Nifedipine Extended Release (ER) 30 milligrams (mg) 1 tablet by mouth (po). Review of resident #90's April 2024 Physician's Orders revealed an order dated 02/04/2024 for Procardia XL 90 mg 1 tablet po daily (Nifedipine ER generic name for Procardia XL). An interview on 04/17/2024 at 12:20 p.m. with pharmacist (from pharmacy listed on medication label) revealed that Nifiedipine XR 30 mg 1 po daily was filled on 03/07/2024 for resident #90. An interview on 04/17/2024 at 12:40 p.m. with S2Director of Nursing (DON) revealed that a nurse sent in a label from a previously discontinued dosage of Nifedipine for resident #90, therefore Nifedipine ER 30 mg was filled by pharmacy on 03/07/2024. S2DON confirmed resident #90 should be receiving Nifedipine ER 90 mg tablet po daily.

Based on observation, interviews, and record reviews, the facility failed to provide services that met professional standards during medication administration for 1 (#90) of 2 (#46 and #90) sampled residents. The facility failed to follow policies and procedures to ensure safe medication administration practices. Findings: Review of the facility's Medication Administration Policy and Procedure dated 08/27/2018 revealed the following, in part: Procedure: 1. Medication Administration: Prior to administration, the Nursing staff member administering the medication shall ensure that the following steps are accomplished. a. verify the medication selected matches the order and label; b. verify the medication is being administered at the proper time, in the prescribed dose, and by the correct route; Resident #90: Review of the record for resident #90 revealed an admitted [DATE] with diagnoses including cerebral infarction, pressure ulcer of left hip, hemiplegia following cerebral infarction affecting left non-dominant side, type 2 diabetes mellitus, and hypertension. An observation on 04/16/2024 at 7:20 a.m. of resident #90's medication pass revealed S7Licensed Practical Nurse (LPN) administered a blood pressure medication, Nifedipine Extended Release (ER) 30 milligrams (mg) 1 tablet by mouth (po). Review of resident #90's April 2024 Physician's Orders revealed an order dated 02/04/2024 for Procardia XL 90 mg 1 tablet po daily (Nifedipine ER generic name for Procardia XL). On 04/16/2024 at 10:40 a.m., S7LPN and surveyor reviewed resident #90's current blister pack medication card label and found the following: Nifedipine ER 30 mg tablet, give 1 tablet po daily, and the date medication was filled 03/07/2024. S7LPN confirmed that resident #90's April 2024 Physician's orders revealed an order for Procardia XL 90 mg tablet po daily. S7LPN confirmed she did administer the wrong dosage of Nifedipine to resident #90 on 04/16/2024. S7LPN confirmed she did not check the medication card label against the Electronic- Medication Administration Record (e-MAR) before administration. An interview on 04/17/2024 at 12:20 p.m. with pharmacist (from pharmacy listed on medication label) revealed that Nifiedipine XR 30 mg was filled on 03/07/2024 for resident #90. An interview on 04/17/2024 at 12:40 p.m. with S2DON revealed that a nurse sent in a label from a previously discontinued dosage of Nifedipine for resident #90, therefore Nifedipine ER 30 mg was filled by pharmacy on 03/07/2024. S2DON confirmed that S7LPN did not follow policy and procedure for medication administration for resident #90 by failing to verify the medication selected matches the order and label, and verifying the medication being administered at the prescribed dose.