Every finding on record at Riverbend Nursing and Rehabilitation Center, Inc.

Based on observations, interviews, and record reviews, the facility failed to ensure:1. The licensed practical nurse (LPN) followed infection control guidelines during medication administration (S16LPN); and,2. The LPN changed gloves and performed hand hygiene appropriately during wound care (S16LPN).This deficient practice was identified for 1 (S16LPN) of 5 nurses observed during medication administration observations, and 1 (S16LPN) of 2 nurses observed during wound care. Findings:1.Review of the facility's undated Administering Medication policy revealed, in part, staff shall follow established infection control procedures, such as antiseptic techniques (techniques to stop harmful germs from being spread to residents). Observation on 08/04/2026 at 7:19AM revealed S16LPN pushed a folic acid tablet out of Resident #25's folic acid tablet blister pack, grabbed the tablet with S16LPN's ungloved hand, and placed Resident #25's medication in a medicine cup. Further observation revealed S16LPN administered Resident #25 the folic acid tablet. In an interview on 08/04/2026 at 2:52PM, S16LPN indicated she should have not grabbed Resident #25's medication with her bare hand and placed it in the medicine cup. In an interview on 08/05/2026 at 11:36AM, S2Director of Nursing (DON) indicated S16LPN should have discarded the pill that was grabbed with her ungloved hand and retrieved a new tablet. 2.Review of the facility's undated Handwashing/Hand Hygiene policy revealed, in part, staff were to perform hand hygiene before moving from a contaminated body site to a clean body site during resident care. Review of Resident #9's August 2026 physician orders revealed, in part, an order to clean Resident #9's left great toe deep tissue injury (bruised area of skin caused by pressure with suspected tissue injury below the skin level) wound with normal saline, pat Resident #9's left great toe wound dry, apply betadine to the wound, cover the wound with an abdominal dressing (a multi layered, highly absorbent medical pad), kerlix (a cotton gauze bandage roll), and secure with tape. Further review revealed an order to clean Resident #9's sacral wound with normal saline, pat the wound dry, apply gentian violet (a purple-colored topical antiseptic used to kill bacteria) around the peri-area (area of intact skin around the open wound), apply xeroform (an absorbent dressing) to the wound bed, cover the wound with silver alginate (an absorbent dressing with silver which inhibits bacterial growth), and cover Resident #9's wound with a border foam dressing. Observation on 08/04/2026 at 1:58PM revealed S16LPN performed wound care on Resident #9's stage 3 (open wound caused by pressure which extends into the fatty tissue) sacral pressure ulcer. Further review revealed after S16LPN cleaned Resident #9's sacral wound, S16LPN did not remove her gloves and did not perform hand hygiene. Further observation revealed S16LPN then proceeded to place a clean dressing on Resident #9's sacral wound. Observation on 08/04/2026 at 2:27PM revealed S16LPN performed wound care on Resident #9's left great toe deep tissue injury. Further observation revealed after S16LPN cleaned Resident #9's left great toe wound, S16LPN did not remove her gloves and did not perform hand hygiene. Further observation revealed S16LPN then placed a clean dressing on Resident #9's left great toe wound. In an interview on 08/04/2026 at 2:50PM, S16LPN indicated her gloves should have been changed in between cleaning Resident #9's wounds and placing clean dressings. In an interview on 08/05/2026 at 11:35AM, S2DON indicated S16LPN should have removed her gloves and performed hand hygiene in between cleaning Resident #9's wounds and placing the clean dressings.

Based on observations, interviews, and record reviews, the facility failed to:1. Ensure opened foods stored in the facility's walk-in refrigerator were dated on 08/03/2026 as required;2. Ensure food stored in the pantry was not expired and available for resident consumption on 08/03/2026; and, 3. Ensure staff wore hair restraints and beard restraints when working with food and/or ice in the facility's kitchen on 08/03/2026 and 08/04/2026. The deficient practice was identified for 2 (08/03/2026, 08/04/2026) of 4 days observed for food preparation and storage requirements. Findings: 1. Review of the facility's undated Dietary Department General Procedures policy revealed, in part, all items are to be dated and stored properly. Observation on 08/03/2026 at 9:00AM of the facility's walk-in refrigerator revealed the following items were opened, undated, and available for resident consumption:-14 Caesar salads;-4 bags of cheese; and,-A jar of cherries. In an interview on 08/03/2026 at 9:10AM, S5Dietary Supervisor indicated the foods in the refrigerator should have been dated once the item was opened. 2.Review of the facility's undated Dietary Department General Procedures policy revealed, in part, all expired foods were to be discarded. Observation on 08/03/2026 at 9:00AM revealed 6 bags of marshmallows stored in the pantry, which expired on 03/29/2026 and were available for resident consumption. In an interview on 08/03/2026 at 9:10AM, S5Dietary Supervisor indicated the expired marshmallows should not have been available for resident consumption. 3.Review of the facility's undated Dietary Department General Procedures policy revealed, in part, dietary personnel shall maintain clean and safe work habits in the food service areas, and shall wear hair nets. Observation on 08/03/2026 at 11:37AM revealed S20Dietary Staff was present in the facility's kitchen and prepared residents' plates of food without a hair restraint in place. Observation on 08/04/2026 at 11:20AM revealed S4Maintenance Supervisor was present in the facility's kitchen and scooped ice into an ice chest without a hair restraint in place. In an interview on 08/04/2026 at 11:22AM, S5Dietary Supervisor indicated any staff in the kitchen should wear a hair restraint. Observation on 08/04/2026 at 11:33AM revealed S17Dietary Staff, S18Dietary Staff, and S19Dietary Staff had facial hair. Further observation revealed S17Dietary Staff, S18Dietary Staff, and S19Dietary Staff were preparing lunch in the facility's kitchen without beard restraints in place. In an interview on 08/04/2026 at 11:35AM, S5Dietary Supervisor indicated she did not have beard restraints available for the above-mentioned staff members. S5Dietary Supervisor further indicated she was unaware the above-mentioned dietary personnel required beard restraints to cover their facial hair while in the facility's kitchen. Observation on 08/04/2026 at 11:38AM revealed S5Dietary Supervisor helped prepare lunch, and S5Dietary Supervisor's ponytail was not contained in her hair restraint. In an interview on 08/04/2026 at 11:38AM, S5Dietary Supervisor indicated all of her hair should have been contained in the hair restraint.

Based on interviews and record reviews, the facility failed to ensure residents and/or responsible party were informed of psychotropic medication risk and benefits for 2 (Resident #95, Resident #119) of 5 residents reviewed for unnecessary medications. Findings: Review of the facility's undated Consent for Psychotropic (medication used to treat psychiatric and mood disorders) Medication Use policy revealed, in part, prior to the initial order for psychotropic medications, written and informed consent from the resident/responsible party shall be obtained. Resident #95 Review of Resident #95's record revealed, in part, Resident #95 was admitted to the facility on [DATE], and had diagnosis of anxiety disorder. Review of Resident #95's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 07/27/2026 revealed, in part, Resident #95 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated Resident #95 was severely cognitively impaired. Further review revealed Resident #95 was diagnosed with anxiety and was prescribed antianxiety medications. Review of Resident #95's August 2026 physician orders revealed, in part, Resident #95 was prescribed lorazepam (a psychotropic medication used to treat short-term anxiety) 1 milligram (mg) to be administered by mouth every 8 hours as needed for anxiety for 14 days, with a start date of 07/30/2026. Review of Resident #95's August Medication Administration Record (MAR) revealed, in part, Resident #95 received lorazepam 1mg on 08/01/2026, 08/03/2026, and 08/05/2026. Review of Resident #95's record revealed, in part, Resident #95 did not have a completed consent for psychotropic medication related to Resident #95's lorazepam 1mg administration. In an interview on 08/05/2026 at 3:35PM, S14Licensed Practical Nurse (LPN) indicated residents or their responsible party signed a consent for psychotropic medications upon admission, even if the resident was not on psychotropic medications. S14LPN further indicated she did not provide psychotropic medication risks and benefits information to the resident and/or the responsible party prior to signing the consent. S14LPN further indicated the consent for psychotropic medications was left blank and did not contain specific medications or the physician's signature prior to the residents or the responsible party signing the consent. S14LPN further indicated the only time the resident or the responsible party signed the consent, was during the admission process. In an interview on 08/05/2026 at 3:37PM, S3Admissions indicated she informed the resident or the responsible party that the consents were obtained in the event the physician prescribed the resident a psychotropic medication. In an interview on 08/05/2026 at 3:43PM, S2Director of Nursing (DON) indicated she was unsure who informed the residents' families of the risks and benefits of the prescribed psychotropic medication or who obtained consents for psychotropic medications if the residents were started on new psychotropic medications. In an interview on 08/05/2026 at 3:46PM, S12LPN indicated she was unsure who informed the residents or residents' responsible party of the risks and benefits of the prescribed psychotropic medications or who obtained consents for psychotropic medication. S12LPN further indicated she did not obtain a consent or inform the resident and/or resident's responsible party of the risks and benefits of psychotropic medication prior to placing new orders for psychotropic medication into the computer system. In an interview on 08/05/2026 at 4:11PM, S16LPN indicated she was unsure who was responsible for obtaining consents or informing the resident and/or resident's responsible party of the risks and benefits of psychotropic medication when new psychotropic medications were ordered. In an interview on 08/06/2026 at 9:24AM, S7Registered Nurse (RN) indicated she was not sure who was responsible to explain the risks and benefits of psychotropic medications to the residents or the resident representative. In an interview on 08/06/2026 at 1:10PM, S2DON indicated the consent for Resident #95's lorazepam 1 mg was not completed, but it should have been completed. S2DON further indicated it was the responsibility of S12LPN to inform the residents and/or their responsible party of the risks and benefits of psychotropic medication use, but did not. Resident #119 Review of Resident #119's record revealed, in part, Resident #119 was admitted to the facility on [DATE]. Further review revealed Resident #119 had diagnoses of altered mental status and an encounter for palliative care. Review of Resident #119's August 2026 physician orders revealed, in part, the following: -a order to administer trazodone hydrochloride (HCL) 25mg tablet (a psychotropic medication to help with sleep) at bedtime, with a start date of 07/13/2026; -a order to administer Seroquel 25mg oral tablet (a psychotropic medication to help with mental illness) at bedtime, with a start date of 07/13/2026; and, -a order to administer haloperidol 5mg oral tablet (a psychotropic medication to help with agitation) one time a day, with a start date of 06/16/2026. Review of Resident #119's August 2026 MAR revealed the above mentioned medications were administered as ordered. Review of Resident #119's Attachment B Informed Consent for Psychotropic Medication revealed, in part, the document was signed but not dated by Resident #119's responsible party. Further review revealed Resident #119's physician signed the document on 05/28/2026. Further review revealed no psychotropic medications were listed with their individual risks and benefits. In an interview on 08/03/2026 at 1:45PM, S14LPN indicated she was responsible for ensuring Resident #119's psychotropic medication consents were filled out completely upon admission, and Resident #119's consent was not complete. In an interview on 08/05/2026 at 1:43PM, S3Admissions indicated all residents and/or resident responsible parties signed a blank psychotropic consent form upon admission. S3Admissions further indicated the pre-signed psychotropic medication consent was used in case the doctor decided to prescribe something. In an interview on 08/05/2026 at 3:20PM, Resident #119's responsible party indicated he had not been informed of the risks and benefits of the psychotropic medications Resident #119 was administered

Based on interviews and record reviews, the facility failed to ensure a resident's laboratory tests were completed as ordered by the physician for 1 (Resident #87) of 13 sampled residents investigated for laboratory results. Findings:Review of Resident #87's medical record revealed, in part, Resident #87 was admitted to the facility on [DATE] with diagnoses which included end stage renal disease, dependence on renal dialysis, hypomagnesemia (low levels of magnesium in the blood), hypokalemia (low levels of potassium in the blood), and multiple myeloma (a cancer of plasma cells which causes low blood count levels). Review of Resident #87's Minimum Data Set with an Assessment Reference Date of 07/28/2026 revealed, in part, Resident #87 had a brief interview for mental status score of 7, which revealed Resident #87 had severe cognitive impairment. Review of Resident #87's August 2026 Physician's Orders revealed, in part, an order with a start date of 07/21/2026 to obtain a Complete Metabolic Panel (CMP) (a blood test that measures several body functions and processes, such as kidney and liver functioning), a Complete Blood Count (CBC) (a blood test that measures the amount of white blood cells, red blood cells, and platelets), a Magnesium (mag) level (a blood test that measures the amount of magnesium in the blood), and a Phosphorus (phos) level (a blood test that measures the amount of phosphorus in the blood) every week. Review of Resident #87's medical record revealed no documentation Resident #87 had the above mentioned weekly laboratory tests collected since 07/23/2026 as ordered. Further review revealed no documentation Resident #87 refused the above mentioned laboratory tests. Review of Resident #87's Dialysis Communication Forms from 07/04/2026 through 08/04/2026 revealed, in part, Resident #87 did not have the above mentioned laboratory tests completed while at Resident #87 received dialysis at a local dialysis clinic. In a telephone interview on 08/06/2026 at 10:38AM, the facility's contracted clinical laboratory phlebotomist indicated Resident #87 had not had CMP, CBC, mag, and/or phos laboratory tests collected or attempted to be collected since 07/23/2026. The facility's contracted clinical laboratory phlebotomist further indicated Resident #87 was not on scheduled laboratory testing collection. In an interview on 08/06/2026 at 10:45AM, S13Licensed Practical Nurse (LPN) indicated Resident #87 had not had the above mentioned weekly laboratory tests collected since 07/23/2026 and should have. In an interview on 08/06/2026 at 12:20PM, S2Director of Nursing confirmed Resident #87's weekly laboratory tests were last collected on 07/23/2026.

Based on observations, interviews, and record reviews, the facility failed to provide medications to meet each resident's needs for 1 (Resident #3) of 1 resident who voiced concerns about adequate medication supply and 1 (Resident #27) of 6 sampled residents observed for medication administration. Findings: Review of the facility's undated Procedure for Ordering and Receiving Medications from Pharmacy revealed, in part, the following procedures would be followed when ordering and receiving medications from the pharmacy for reordered medications: -The nurse was responsible to pull all medication card labels on a timely basis; -Place the labels on the drug reorder form or reorder via the facility's electronic medical record system; and, -The medication card labels should be pulled no sooner than 7 days before the last dose on medication card was scheduled. Review of the facility's undated Director of Nursing (DON) Services job description revealed, in part, the DON was to ensure proper and adequate supplies were available to provide needed care for the residents. Resident #3 Review of Resident #3's clinical record revealed, in part, Resident #3 was readmitted to the facility on [DATE] with diagnoses which included pain to Resident #3's right foot, osteomyelitis (infection of the bone), and an acquired absence of the left leg above the knee. Review of the Resident #3's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/23/2026 revealed, in part, a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #3 had no cognitive impairment. Review of Resident #3's current care plan revealed, in part, Resident #3 required pain medication therapy with an initiated date of 11/10/2025. Further review revealed an intervention of, in part, to administer Resident #3's analgesic medications as ordered by the physician. Review of Resident #3's August 2026 physician's orders revealed, in part, an order for oxycodone hydrochloride (HCL) (narcotic medication used to treat pain) oral tablet 10 milligrams (mg), give 1 tablet by mouth every 4 hours as needed for pain related to Resident #3's osteomyelitis and pain. Review of Resident #3's August 2026 medication administration record (MAR) revealed, in part, Resident #3 was administered one tablet of oxycodone HCL 10mg on 08/03/2026 at 8:35PM by S8Licensed Practical Nurse (LPN). Review of Resident #3's oxycodone HCL 10mg Controlled Medication Administration Record revealed, in part, on 08/03/2026 at 8:35PM, Resident #3 received 1 oxycodone HCL 10mg tablet was administered by S8LPN with no remaining pills available after this medication administration. In an interview on 08/04/2026 at 2:20PM, Resident #3 indicated she requested her as needed pain medication today (08/04/2026), and the medication was not available. Resident #3 further indicated when she requested her as needed pain medication today, her pain level was an 8 out 10 on the pain scale (with 0 being no pain and 10 being the worst pain). In an interview on 08/04/2026 at 2:30PM, S9LPN indicated Resident #3 had requested pain medication, and Resident #3's oxycodone HCL was not available to be administered. S9LPN further indicated Resident #3's oxycodone HCL should be available for Resident #3 as ordered by the physician. S9LPN further indicated she was not aware Resident #3's oxycodone HCL needed to be refilled prior to trying to administer the medication. S9LPN further indicated S12LPN usually checked each medication cart routinely to determine if any controlled substances needed refills. S9LPN indicated S12LPN was notified today Resident #3's oxycodone HCL was not available to be administered when requested. In an interview on 08/04/2026 at 3:25PM, S12LPN indicated she checked with each nurse twice a week to determine if any narcotic refills were needed, and if refills were needed, S12LPN would contact the resident's physician. S12LPN further indicated she was notified today Resident #3's oxycodone HCL not being available to be administered when requested. S12LPN indicated she did not recall the last time she checked Resident #3's oxycodone HCL supply. S12LPN further indicated each resident should have a 7 day supply of medications on hand at all times. S12LPN further indicated residents' medications should be available to be administered as ordered. In an interview on 08/05/2026 at 8:44AM, S8LPN indicated she provided care to Resident #3 on the night of 08/03/2026. S8LPN further indicated Resident #3's last dose of oxycodone HCL was administered on 08/03/2026. S8LPN further indicated she completed the narcotic refill request form and left the form for S12LPN. S8LPN further indicated residents should have a 7 day supply of medications on hand and should not run out of medications. In an interview on 08/05/2026 at 9:45AM, S2Director of Nursing (DON) indicated the resident's nurse was to complete a narcotic refill request form when the resident had only a 7 day supply left and provide the narcotic refill request form to S12LPN. S2DON further indicated all residents should have a 7 day supply of medications on hand, and a resident should not run out of medications. Resident #27 Review of Resident #27's August 2026 physician orders revealed, in part, Resident #27 was prescribed Bactroban (antibiotic ointment used to treat infections) 2 percent cream apply to Resident #27's chest wall one time a day related to a cutaneous abscess (an area of infection to the skin). Review of Resident #27's electronic medical administration record dated 08/01/2026 through 08/04/2026 revealed, in part, Resident #27 did not receive Bactroban on 08/04/2026. Observation on 08/04/2026 at 7:50AM revealed S10LPN could not locate Resident #27's Bactroban. In an interview on 08/04/2026 at 7:50AM, S10LPN indicated she would inform the pharmacist Resident #27's Bactroban needed to be refilled. In an interview on 08/04/2026 at 11:11AM, S10LPN indicated she had not called the pharmacist to refill Resident #27's Bactroban. In an interview on 08/05/2026 at 11:36AM, S2DON indicated per the facility's policy, nurses were responsible to reorder medications 7 days prior to the medication running out. S2DON further indicated if a nurse was running low on a medication, the medication should be reordered within the 7 day window.

Based on interviews and record reviews, the facility failed to ensure new individualized fall prevention interventions were implemented to prevent future falls for 2 (Resident #11, Resident #95) of 4 sampled residents investigated for falls. Findings: Review of facility's undated Falls Clinical Protocol policy revealed, in part, the fall care plan shall be updated immediately after a fall. Resident #11 Review of Resident #11's medical record revealed, in part, Resident #11 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included rheumatoid arthritis, spinal stenosis, and muscle weakness. Review of Resident #11's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/23/2026 revealed, in part, Resident #11 had a brief interview for mental status (BIMS) score of 12, which revealed Resident #11 had moderate cognitive impairment. Further review revealed Resident #11 used a manual wheelchair for ambulation and was dependent on staff for transfers. Review of the facility's incident report from 05/2026 through 08/2026 revealed, in part, Resident #11 had un-witnessed falls on the following dates: -05/31/2026 at 8:15AM; -06/04/2026 at 1:19PM; -06/24/2026 at 1:50AM; -07/02/2026 at 7:10PM; -07/03/2026 at 12:32PM; and, -08/02/2026 at 12:30AM. Review of Resident #11's August 2026 physician's orders revealed, in part, no fall prevention orders for Resident #11 from 05/01/2026 through 08/03/2026. Review of Resident #11's care plan, initiated on 05/04/2026 and last revised on 05/09/2026, revealed, in part, Resident #11 had a potential for falls related to muscle weakness, history of falls, and lumbar spinal stenosis and required assistance with transfers. Further review revealed Resident #11's care plan was not updated with new individualized interventions and/or had supervision increased to prevent future falls after the above mentioned falls occurred. Review of Resident #11's Falling Star Program care plan, dated 05/31/2026, revealed, in part, no new post-fall interventions were documented as implemented immediately after Resident #11's falls on 07/02/2026, 07/03/2026, and 08/02/2026. Further review revealed no documentation the effectiveness of post-fall interventions was evaluated for post-fall interventions following Resident #11's 05/31/2026, 06/04/2026, and 06/24/2026 falls. In an interview on 08/05/2026 at 11:30AM, S12Licensed Practical Nurse (LPN) indicated Resident #11 did not have new individualized fall prevention interventions implemented after Resident #11's 07/02/2026, 07/03/2026, and 08/02/2026 falls as required. S12LPN further indicated there was no documentation Resident #11's postall interventions were evaluated for effectiveness after Resident #11's 05/31/2026, 06/04/2026, and 06/24/2026 falls. In an interview on 08/05/2026 at 11:30AM, S11LPN indicated she was assigned to provide care to Resident #11. S11LPN further indicated she had not received individualized post-fall intervention updates after each of Resident #11's falls on 05/31/2026, 06/04/2026, 06/24/2026, 07/02/2026, 07/03/2026, and/or 08/02/2026. Resident #95 Review of Resident #95's medical record revealed, in part, Resident #95 was admitted to the facility on [DATE] with diagnoses which included vascular dementia, right femur fracture, history of falling, and lower back pain. Review of Resident #95's August 2026 physician's orders revealed, in part, an order dated 07/14/2026 for Resident #95 to be placed in the facility's Falling Star Program. Review of Resident #95's nurse's progress note dated 08/02/2026 at 2:30PM revealed, in part, Resident #95 had fallen and was on the floor at the nurse's station. Review of Resident #95's care plan revealed, in part, no documented evidence Resident #95 had a new individualized fall prevention intervention implemented to prevent future falls following Resident #95's fall on 08/02/2026. Review of the facility's Falling Star care plan binder on 08/04/2026 at 4:20PM with S12LPN revealed, in part, a Falling Star care plan was not initiated or documented for Resident #95. Further review revealed no documentation new individualized fall prevention interventions were implemented after Resident #95's fall on 08/02/2026. In an interview on 08/04/2026 at 4:20PM, S12LPN indicated the nurse caring for Resident #95 was responsible for adding the resident's fall incident to the Falling Star care plan binder. S12LPN further indicated Resident #95 did not have individualized fall prevention interventions implemented after Resident #95's fall on 08/02/2026 and should have. In an interview on 08/05/2026 at 11:50AM, S16LPN indicated she was present when Resident #95 fell on [DATE]. S16LPN further indicated she did not add Resident #95's fall with new interventions to the Falling Star care plan binder. S16LPN further indicated S12LPN was responsible for completing Resident #95's post-fall individualized fall prevention interventions. In an interview on 08/06/2026 at 12:20PM, S2Director of Nursing (DON) indicated individualized post-fall interventions should be documented after each resident fall. S2DON further indicated the facility could not provide any documented evidence Resident #11's and/or Resident #95's individualized post-fall interventions were identified, implemented, and/or evaluated for effectiveness.

Based on observations, interviews, and record review, the facility failed to ensure:1. Certified Nursing Assistants (CNAs) were competent in the facility's procedure for implementation of Enhanced Barrier Precautions (EBP) for a resident with a wound; and,2. A Registered Nurse (RN) was competent in the facility's procedure for implementation of EBP for a resident with a Peripherally Inserted Central Catheter (PICC) (A PICC is a thin, flexible tube inserted into a vein in the arm and threaded into a large vein near the heart to provide long-term access for treatments such as medications).This deficient practice was identified for 3 (S5RN, S7CNA, S8CNA) of 3 (S5RN, S7CNA, S8CNA) staff observed for implementation of EBP. Findings:Review of the facility's undated Enhanced Barrier Precautions (EBP) policy and procedure revealed, in part, an effort to reduce the transmission of multidrug-resistant organisms (MDROs), EBP will be implemented. 1. Observation on 09/09/2025 at 1:40PM of signage on the door or Room a revealed EBP. Further review revealed everyone must clean their hands, including before entering room and when leaving the room. Providers and staff must wear gloves and a gown for high-contact resident care activities. Further observation revealed S7CNA and S8CNA entered Room a. In an interview on 09/09/2025 at 1:44PM, the surveyor asked S8CNA which of the 2 residents in Room a required EBP. S8CNA indicated she did not know which of the residents in Room a required EBP. S8CNA further indicated she did not believe either resident in Room a required EBP. In an interview on 09/09/2025 at 1:50PM, S5RN indicated she was the nurse for the residents who reside in Room a. S5RN indicated she did not know which of the residents in Room a required EBP. In an interview on 09/09/2025 at 2:02PM, S6Infection Preventionist (IP) indicated Resident #18, who resided in Room a, had a wound to her sacrum and was on EBP. S6IP indicated S5RN, S7CNA, and S8CNA should have known Resident #18 required EBP. In an interview on 09/10/2025 at 9:00AM, S3Assistant Director of Nursing (ADON) indicated all staff should have had knowledge, and all staff should have implemented EBP for residents as required. In an interview on 09/10/2025 at 9:03AM, S2Director of Nursing (DON) indicated Resident #18, who resided in Room a, required EBP. S2DON indicated S5RN, S7CNA, and S8CNA should have had knowledge of and should have demonstrated competency that Resident #18 required EBP. S2DON further indicated the above documented staff did not identify the resident in Room a who required EBP. In an interview on 09/10/2025 at 10:30AM, S1Administrator indicated S5RN, S7CNA, and S8CNA should have known which residents required EBP. 2. Observation of signage on Resident #89's door revealed EBP. Further review revealed everyone must clean their hands, including before entering room and when leaving the room. Providers and staff must wear gloves and a gown for high-contact resident care activities. Observation on 09/09/2025 at 1:40PM revealed S5RN entered Resident #89's room, flushed Resident #89's PICC line and started administration of an intravenous (IV) medication through the use of Resident #89's left arm PICC line without wearing a surgical gown as required. Observation on 09/09/2025 at 2:35PM revealed S5RN entered Resident #89's room, and disconnected Resident #89's IV from the PICC line, and flushed Resident #89's PICC line without wearing a surgical gown as required.In an interview on 09/09/2025 at 1:35PM, S5RN indicated gloves were the only Personal Protective Equipment (PPE) required for EBP. S5RN further indicated she had never worn a surgical gown when she administered an IV medication through the use of the PICC line. In an interview on 09/09/2025 at 2:06PM, S6 Infection Preventionist (IP) indicated S5RN should have worn a surgical gown when she accessed Resident #89's PICC line for IV medication administration. In an interview on 09/09/2025 at 2:35PM, S5RN confirmed Resident #89 was on EBP and indicated she did not know a surgical gown had to be worn during IV medication administration through the use of a PICC line. In an interview on 09/10/2025 at 8:00AM, S2DON confirmed S5RN should have worn a surgical gown when she accessed Resident #89's PICC line for medication administration.

Based on observations, interviews, and record reviews, the facility failed to ensure a staff member (S5Registered Nurse [RN]) implemented Enhanced Barrier Precautions (EBP) for a resident (Resident #89). This deficient practice was identified for 1 (Resident #89) of 1 (Resident #89) sampled residents observed on EBP. Findings:Review of the facility's undated EBP policy revealed, in part, EBP was implemented in an effort to reduce the transmission of multidrug-resident organisms (MDRO), and requires employees to wear gowns and gloves during high-contact resident care activities for residents known to be infected with a MDRO or those at increased risk of a MDRO infection. Further review of the EBP policy revealed EBP was to be used for residents with indwelling medical devices. Review of the facility's undated Administering Medications via Peripherally Inserted Central Catheter (PICC) policy revealed, in part, staff should apply personal protective equipment (PPE) when providing care for residents on EBP. Review of Resident #89's record revealed, in part, Resident #89 had a PICC line for the administration of intravenous (administered directly into the vein) medication due to a bacterial wound infection in a right foot wound. Observation on 09/09/2025 at 1:35PM revealed an EBP signage was present on Resident #89's door indicating staff were to wear gloves and a gown for the high-contact resident care activities such as central line device care or use. In an interview on 09/09/2025 at 1:40PM, S5RN indicated Resident #89 had a PICC line for intravenous (IV) medication administration. S5RN indicated she has never worn a surgical gown when administering Resident #89's IV medication via the PICC line. Observation on 09/09/2025 at 1:40PM revealed S5RN entered Resident #89's room, flushed Resident #89's PICC line and started administration of an IV medication via Resident #89's left arm PICC line without wearing a surgical gown. In an interview on 09/09/2025 at 2:06PM, S6Infection Preventionist (IP) indicated S5RN should have worn a gown when she accessed Resident #89's PICC line for IV medication administration. Observation on 09/09/2025 at 2:35PM revealed S5RN entered Resident #89's room and disconnected Resident #89's IV from the PICC line and flushed Resident #89's PICC line without wearing a surgical gown. In an interview on 09/09/2025 at 2:35PM, S5RN confirmed Resident #89 was on EBP, and indicated she did not know a surgical gown had to be worn during IV medication administration via a PICC line. In an interview on 09/10/2025 at 8:00AM, S2Director of Nursing confirmed S5RN should have worn a gown when she accessed Resident #89 PICC line for medication administration as required.

Based on interviews and record reviews, the facility failed to:1) Designate an interdisciplinary team member to be responsible for coordinating hospice care and services; and, 2) Obtain a resident's most recent hospice plan of care and recertification of terminal illness from the contracted hospice agency for 1 (Resident #18) of 1 (Resident #18) sampled resident reviewed for hospice services. Findings:Review of Resident #18's Quarterly Minimum Data Set with an Assessment Reference Date of 06/18/2025 revealed, in part, Resident #18 received hospice services. Review of Resident #18's September 2025 Physician's Orders revealed, in part, an order to admit Resident #18 to the contracted hospice agency on 06/04/2025. 1. In an interview on 09/09/2025 at 12:02PM, S6Infection Preventionist indicated the facility did not have a staff member designated to coordinate hospice care and services. In an interview on 09/09/2025 at 2:55PM, S2Director of Nursing (DON) indicated the facility did not have an interdisciplinary team staff member designated to coordinate hospice care and services. 2.Review of Resident 18's contracted hospice agency's binder on 09/09/2025 at 12:38PM with the contracted hospice agency's medical clerk revealed no documented evidence of Resident #18's current physician certification of terminal illness or contracted hospice agency's plan of care. In an interview on 09/09/2025 at 12:38PM, the contracted agency's medical clerk confirmed Resident #18's contracted hospice agency binder did not contain Resident #18's current physician certification of terminal illness or contracted hospice agency's plan of care as required. Review of Resident 18's contracted hospice agency's binder on 09/09/2025 at 2:55PM with S2DON and S4Quality Assurance Nurse revealed no documented evidence of Resident #18's current physician certification of terminal illness or contracted hospice agency's plan of care. In an interview on 09/09/2025 at 2:55PM, S2DON confirmed Resident #18's contracted hospice agency binder and clinical record did not contain Resident #18's current physician certification of terminal illness or contracted hospice agency's plan of care as required.

Based on interview and record reviews, the facility failed to ensure a resident's Foley catheter (a medical device inserted into the bladder to collect urine) was changed according to physician's orders for 1 (Resident #2) of 3 (Resident #1, Resident #2, Resident #3) sampled residents reviewed for catheter use. Findings: Review of Resident #2's medical record revealed, in part, he was admitted to the facility on [DATE] with diagnosis, in part, of urinary retention and had an indwelling Foley catheter. Review of Resident #2's March 2025 Physician's Orders revealed, in part, to not remove Resident #2's Foley catheter. Further review revealed Resident #2's Foley catheter was to be changed every month by urology. Review of Resident #2's indwelling catheter Care Plan revealed, in part, Resident #2's catheter was to be changed every month at Resident #2' urology office. Review of Resident #2's electronic medical record revealed, in part, no documented evidence and the facility was unable to present any documented evidence Resident #2's Foley catheter was changed/replaced in March 2025. In an interview on 05/29/2025 at 3:50PM, S2Director of Nursing confirmed the above findings and indicated she did not have any documented evidence to present to dispute the above findings.

Based on observations, interviews, and record reviews, the facility failed to provide a privacy cover for a urinary catheter drainage bag for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) residents reviewed with urinary catheters. Findings: Review of Resident #1's Care Plan revealed, in part, Resident #1 has a urinary catheter bag related to Urinary Retention, revised on 01/26/2025, with an intervention to keep Resident #1's catheter drainage bag in a privacy cover. Review of Resident #1's Quarterly Minimum Data Set with an Assessment Reference Date of 04/16/2025 revealed, in part, Resident #1 had Brief Interview for Mental Status score of 5, which indicated Resident #1 had impaired cognition. Observation on 05/27/2025 at 11:23AM revealed Resident #1 was in her wheelchair in the dining area. Further observation revealed Resident #1's catheter drainage bag was attached under her wheelchair seat, and yellow urine was visible in the catheter drainage bag. Observation on 05/27/2025 at 1:41PM revealed Resident #1 was in her room, lying in bed. Further observation revealed Resident #1's catheter drainage bag was attached to the bottom of the bed railing, and her urine was visible in the catheter drainage bag from the doorway. Further observation revealed Resident #1 has a roommate that resided in the room with Resident #1. Observation on 05/27/2025 at 3:32PM revealed Resident #1 was in her room, lying in bed. Further observation revealed Resident #1's catheter drainage bag was attached to the bottom of the bed railing, and her urine was visible in the catheter drainage bag from the doorway. In an interview on 05/28/2025 at 9:12AM, S3Licensed Practical Nurse indicated Resident #1 should have a privacy cover for her catheter drainage bag at all times. In an interview on 05/28/2025 at 10:33AM, S4Certified Nursing Assistant, confirmed Resident #1 did not have a privacy cover over Resident #1's urinary catheter bag on 05/27/2025 during her shift. In an interview on 05/28/2025 at 2:01PM, S2Director of Nursing, indicated urinary catheter bags should be covered at all times, and confirmed Resident #1's urinary catheter bag should have been covered.

Based on interviews and record review, the facility failed to ensure a resident's medical record reflected the resident's medical treatment wishes following a cardiopulmonary arrest (sudden unexpected loss of heart function, breathing, and/or consciousness) for 1 (Resident #262) of 4 (Resident #28, Resident #52, Resident #94, and Resident #262) sampled residents investigated for advanced directives. Findings: Review of the facility's undated policy/procedure titled LaPOST (Louisiana Physician Orders For Scope of Treatment), revealed, in part, a LaPOST is a physician order form that translates a resident's end of life wishes and goals of care into physician orders that transfer with the resident across health care settings. Further review revealed, when completing a LaPOST Form with a resident, the LaPOST document must be signed by a physician and by the resident or resident's legally recognized personal health care representative. Review of a LaPOST Fact Sheet dated ,d+[DATE] located on the website https:// la-post.org revealed, in part, the LaPOST document must be signed by a physician and the patient or the patient's personal health care representative in order to be valid. Review of Resident #262's Electronic Medical Record (EMR) revealed, in part, Resident #262 was admitted to the facility on [DATE]. Review of Resident #262's LaPOST dated [DATE] revealed, in part, Resident #262's wishes for his/her code status was Do Not Resuscitate ([DNR] which instructed a healthcare provider not to perform cardiopulmonary resuscitation [CPR] if a resident's heart stops beating or a resident stops breathing). Further review revealed Resident #262's physician had not signed the above mentioned LaPOST. Review of Resident #262's [DATE] physician's orders revealed, in part, no order that reflected Resident #262's wishes for a DNR code status. In an interview on [DATE] at 9:42 a.m., Resident #262's responsible party indicated Resident #262's wishes were to be a DNR code status. In an interview on [DATE] at 11:24 a.m., S2Director of Nursing indicated the LaPOST was the facility's approved method to determine a resident's code status. In an interview on [DATE] at 10:57 a.m., S24Agency Licensed Practical Nurse (LPN) (nurse assigned to Resident #262) indicated per the LaPOST in Resident #262's chart, Resident #262's wishes were to be a DNR. S24Agency LPN confirmed Resident #262's LaPOST was not signed by a physician, and indicated it was not a complete order. S24Agency LPN further indicated that she would perform CPR on Resident #262 due to the LaPOST not being completed. S24Agency LPN acknowledged Resident #262's LaPOST should have been signed by a physician so that her wishes for a DNR code status would be implemented. In an interview on [DATE] at 9:49 a.m., S22Agency LPN (nurse assigned to Resident #262) indicated if a resident wanted their code status to be a DNR on a LaPOST, but it was not signed by a physician, S22Agency LPN would treat the resident as a Full Code (instructed a healthcare provider to perform cardiopulmonary resuscitation [CPR] if a resident's heart stops beating or a resident stops breathing). S22Agency LPN further indicated the facility should have gotten the LaPOST signed by the physician, as that was the resident/resident's responsible party's wishes for a DNR code status.

Based on record review and interviews, the facility failed to ensure ongoing communication regarding a resident's condition was completed with the dialysis facility for 1 (Resident #31) of 1 (Resident #31) sampled residents investigated for dialysis services. Findings: In an interview on 10/09/2024 at 2:25 p.m., S10Assistant Director of Nursing (ADON) indicated the facility's staff used the Dialysis Communication sheet to communicate with the dialysis center. Review of the facility's Dialysis Communication sheets for Resident #31 dated 06/03/2024, 06/14/2024, 06/19/2024, 06/28/2024, 07/01/2024, and 08/14/2024 revealed, in part, there was no documented evidence, and the facility did not present any documented evidence of communication from the dialysis center regarding the dialysis treatment provided and the resident's response to the dialysis treatment. Review of the facility's Dialysis Communication sheets for Resident #31, revealed, in part, no documented evidence, and the facility did not present any documented evidence of communication between the facility and the dialysis center regarding Resident #31's condition before and after dialysis on 08/21/2024, 08/28/2024, 08/30/2024, 09/02/2024, 09/04/2024, 09/09/2024, 09/13/2024, 09/18/2024, and 09/23/2024. In an interview on 10/09/2024 at 2:25 p.m., S10Assistant Director of Nursing (ADON) indicated the facility's staff used the Dialysis Communication sheet to communicate with the dialysis center. In an interview on 10/10/2024 at 2:14 p.m., S2Director of Nursing (DON) indicated the facility's Dialysis Communication sheet was the method used for the facility to communicate with the dialysis center. S2DON further indicated there should be a Dialysis Communication sheet completed by the facility for each dialysis treatment for Resident #31. S2DON acknowledged the facility's Dialysis Communication sheets for Resident #31 should be completely filled out with the above missing information and they were not on 06/03/2024, 06/14/2024, 06/19/2024, 06/28/2024, 07/01/2024, and 08/14/2024. S2DON further indicated she was unable to present any documented evidence the facility communicated with the dialysis center regarding Resident #31 on 08/21/2024, 08/28/2024, 08/30/2024, 09/02/2024, 09/04/2024, 09/09/2024, 09/13/2024, 09/18/2024, and 09/23/2024.

Based on interviews and record review, the facility failed to maintain a system to periodically reconcile controlled drugs for 2 (Medication Cart a and Medication Cart b) of 2 (Medication Cart a and Medication Cart b) medication carts reviewed for the reconciliation documentation of controlled substances. Findings: Review of the facility's undated policy titled, Controlled Substances, revealed, in part, the nursing staff must count controlled medication at the end of each shift. Further review revealed the nurse coming on duty and the nurse going off duty must make the count together. Review of the facility's August 2024 Medication Cart a Controlled Drugs-Count Record revealed, in part, the following shifts had an incomplete reconciliation of controlled drugs by the nurse coming on duty and the nurse going off duty: -08/05/2024 on the 6:00 p.m. to 6:00 a.m. shift; -08/07/2024 on the 6:00 p.m. to 6:00 a.m. shift; -08/09/2024 on the 6:00 p.m. to 6:00 a.m. shift; -08/10/2024 on the 6:00 a.m. to 6:00 p.m. shift; -08/10/2024 on the 6:00 p.m. to 6:00 a.m. shift; -08/12/2024 on the 6:00 a.m. to 6:00 p.m. shift; -08/12/2024 on the 6:00 p.m. to 6:00 a.m. shift; -08/23/2024 on the 6:00 p.m. to 6:00 a.m. shift; -08/24/2024 on the 6:00 a.m. to 6:00 p.m. shift; -08/24/2024 on the 6:00 p.m. to 6:00 a.m. shift; -08/25/2024 on the 6:00 a.m. to 6:00 p.m. shift; -08/25/2024 on the 6:00 p.m. to 6:00 a.m. shift; -08/26/2024 on the 6:00 p.m. to 6:00 a.m. shift; -08/27/2024 on the 6:00 a.m. to 6:00 p.m. shift; -08/29/2024 on the 6:00 p.m. to 6:00 a.m. shift; and, -08/30/2024 on the 6:00 a.m. to 6:00 p.m. shift. Review of the facility's September 2024 Medication Cart a Controlled Drugs-Count Record revealed, in part, the following shifts had an incomplete reconciliation of controlled drugs by the nurse coming on duty and the nurse going off duty: -09/01/2024 on the 6:00 a.m. to 6:00 p.m. shift; -09/08/2024 on the 6:00 a.m. to 6:00 p.m. shift; -09/08/2024 on the 6:00 p.m. to 6:00 a.m. shift; -09/11/2024 on the 6:00 a.m. to 6:00 p.m. shift; -09/11/2024 on the 6:00 p.m. to 6:00 a.m. shift; -09/12/2024 on the 6:00 a.m. to 6:00 p.m. shift; -09/12/2024 on the 6:00 p.m. to 6:00 a.m. shift; -09/13/2024 on the 6:00 a.m. to 6:00 p.m. shift; -09/16/2024 on the 6:00 p.m. to 6:00 a.m. shift; -09/17/2024 on the 6:00 a.m. to 6:00 p.m. shift; -09/17/2024 on the 6:00 p.m. to 6:00 a.m. shift; -09/21/2024 on the 6:00 p.m. to 6:00 a.m. shift; -09/22/2024 on the 6:00 p.m. to 6:00 a.m. shift; -09/26/2024 on the 6:00 p.m. to 6:00 a.m. shift; and, -09/27/2024 on the 6:00 a.m. to 6:00 p.m. shift. Review of the facility's October 2024 Medication Cart a Controlled Drugs-Count Record revealed, in part, the following shifts had an incomplete reconciliation of controlled drugs by the nurse coming on duty and the nurse going off duty: -10/01/2024 on the 6:00 p.m. to 6:00 a.m. shift; -10/02/2024 on the 6:00 a.m. to 6:00 p.m. shift; -10/06/2024 on the 6:00 p.m. to 6:00 a.m. shift; and, -10/10/2024 on the 6:00 a.m. to 6:00 p.m. shift. In an interview on 10/10/2024 at 10:00 a.m., S22Agency Licensed Practical Nurse (LPN) indicated the facility's Controlled Drugs-Count Record was supposed to be signed by the off-going and on-coming nurse when they verified the narcotic counts. Review of the facility's October 2024 Medication Cart b Controlled Drugs-Count Record revealed, in part, the following shifts had an incomplete reconciliation of controlled drugs by the nurse coming on duty and the nurse going off duty: -10/01/2024 on the 6:00 p.m. to 6:00 a.m. shift; -10/02/2024 on the 6:00 a.m. to 6:00 p.m. shift; -10/02/2024 on the 6:00 p.m. to 6:00 a.m. shift; -10/03/2024 on the 6:00 a.m. to 6:00 p.m. shift; and, -10/07/2024 on the 6:00 p.m. to 6:00 a.m. shift. In an interview on 10/10/2024 at 1:57 p.m., S23LPN indicated there should not have been any undocumented signature areas on the facility's Controlled Drugs-Count Record for off going and on coming nurse signatures. In an interview on 10/10/2024 at 2:13 p.m., S2Director of Nursing indicated the Controlled Drugs-Count Records should have been signed off with completed signatures of the nurses reconciling the narcotics at shift change.

Based on observations, interviews, and record reviews, the facility failed to ensure: 1. Opened insulin (a medication that lowers blood glucose) pens were dated when opened and discarded as required for 2 (Medication Cart a and Medication Cart b) of 2 (Medication Cart a, Medication Cart b) medication carts observed; and, 2. Heparin (a medication used to prevent blood clots) was stored in a locked compartment and only accessible to authorized personnel. Findings: Review of the facility's undated policy titled, Storage/Handling of Medications, revealed, in part, the facility's nursing staff shall be responsible for maintaining medication storage in a safe manner. Further review revealed, the facility shall not use outdated drugs. 1. Review of the facility's undated policy/procedure titled, Beyond Use Dates of Selected Insulin Products, revealed, in part, Humalog ([Insulin lispro] a type of insulin) pen's beyond use date was after 28 days of the insulin pen being in use. Further review revealed Novolog ([Insulin aspart] a type of insulin) pen's should be discarded after 28 days of use. Observation on 10/10/2024 at 10:00 a.m. of Medication Cart a revealed: -Resident #103's open Insulin aspart pen was not labeled with an opened date; and, -Resident #10's open Insulin lispro pen had an opened date of 08/27/2024. In an interview on 10/10/2024 at 10:00 a.m., S22Agency Licensed Practical Nurse (LPN) confirmed Resident #103's above mentioned insulin pen had been opened and confirmed the above mentioned insulin pen should have been labeled with an opened date. S22Agency (LPN) further confirmed Resident #10's above mentioned insulin pen was dated 08/27/2024 and should have been discarded. Observation on 10/10/2024 at 1:25 p.m. of Medication Cart b revealed Resident #78's Insulin lispro had an opened date of 09/01/2024. In an interview on 10/10/2024 at 1:57 p.m., S23LPN indicated Resident #78's above mentioned insulin pen should have been discarded and not stored in Medication Cart b and available for resident use. In an interview on 10/10/2024 at 2:13 p.m., S2Director of Nursing indicated the above mentioned insulin pens should have been dated when opened and/or discarded per the facility's policy/procedure. 2. Review of the facility's undated policy and procedure titled Medication Pass Administration revealed, in part, medications are not to be left in the resident's room. Review of Resident #42's Minimum Data Set with an Assessment Reference Date of 09/20/2024 revealed, in part, Resident #42's Brief Interview for Mental Status (BIMS) summary score was 11, which indicated Resident #42 was moderately cognatively impaired. Observation of Resident #42's room on 10/07/2024 at 11:00 a.m. revealed an unused blue syringe labeled Heparin 50 units/5milliliters (mL) flush lying on Resident # 42's bedside table. In an interview on 10/07/2024 at 11:05 a.m., Resident #42 indicated the blue flush had been sitting on his bed side table for a couple of days. In an interview on 10/07/2024 at 11:22 a.m., S19Licensed Practical Nurse (LPN) accompanied this surveyor to Resident #42's room and confirmed there was a syringe of 5mL Heparin lying on Resident # 42's bedside table. S19LPN further indicated the syringe of Heparin should not have been left on Resident #42's bedside table. In an interview on 10/08/2024 at 2:45 p.m., S2Director of Nursing indicated a syringe of heparin should not have been left on Resident #42's bedside table. In an interview on 10/10/2024 at 2:15 p.m., S1Administrator acknowledged a syringe of heparin was found on Resident #42's bedside table and should not have been left on Resident #42's bedside table.

Based on record reviews, observations, and interviews, the facility failed to provide a resident with the correct diet to meet the residents needs for 1 (Resident #25) of 1 (Resident #25) sampled residents reviewed for dining services. Findings: Review of facility's Resident Nutrition Services Policy revealed, in part, nursing personnel will inspect food trays delivered to ensure that the correct meal has been delivered. Further review revealed if an incorrect meal is delivered, nursing staff will report it to dietary services so a new tray can be issued. Review of Resident #25's record revealed, Resident#25 was admitted to the facility on [DATE] with diagnoses of, in part, moderate protein-calorie malnutrition, nutritional deficiency, and abnormal weight loss. Review of Resident #25's October 2024 Physician Orders revealed, in part, a diet order for No Added Salt (NAS), mechanical soft with chopped meat. Review of Resident #25's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/31/2024 revealed, in part, Resident #25 was on a mechanically altered diet and therapeutic diet. Review of Resident #25's Certified Dietary Manager's note dated 09/20/2024 at 9:35 a.m., revealed, in part, Resident #25's was a mechanical soft with chopped meat diet. Observation on 10/08/2024 at 12:36 p.m., revealed Resident #25's lunch meal ticket read Resident #25 was to receive a NAS mechanical soft diet with ground meat and was served sliced carrots, white rice, turkey pot roast with gravy, and a moon pie. Further observation revealed Resident #25 was served a regular diet tray for lunch. In an interview on 10/08/2024 at 12:37 p.m., S11Certified Nursing Assistant (CNA) indicated Resident #25 is on a mechanical soft with chopped meat diet. S11CNA confirmed Resident #25 should have been served a mechanical soft chopped meat diet. S11CNA indicated Resident #25's lunch tray was not a mechanical soft diet and further indicated the meat was not chopped. In an interview on 10/08/24 at 1:11 p.m., S12Dietary Supervisor confirmed Resident #25's diet order was a mechanical soft with chopped meat diet. S12Dietary Supervisor indicated Resident #25's turkey pot roast should have been chopped by the kitchen staff before being served and it was not. S12Dietary Supervisor further indicated Resident #25 was not served a diet as ordered.

Based on observations, interviews, and record reviews the facility failed to: 1. Ensure opened food products stored in the walk-in cooler were sealed and labeled with the date the product was opened; 2. Ensure prepared food was stored, cooked, and maintained at the correct temperatures; and, 3. Ensure dishes were cleaned at the correct temperatures with the correct sanitizer levels to prevent foodborne illnesses. Findings: 1. Review of the facility's policy and procedure titled Food Label/Dating/Storage Policy dated 08/15/2018 revealed, in part, luncheon meat can be kept for 3-5 days after opening. Further review revealed salad dressing may be kept up to 30 days in the refrigerator or use best by date. Observation on 10/07/2024 at 12:16 p.m. revealed an opened package of [NAME]-O sliced turkey breast in an unsealed bag with no opening date written on the package or bag. Further observation revealed an opened jar of Culinary Secrets Creamy [NAME] Slaw Dressing without an open date written on it. In an interview on 10/07/2024 at 12:17 p.m., S12Dietary Supervisor (DS) confirmed the package of [NAME]-O sliced Turkey breast and the jar of Culinary Secrets Creamy [NAME] Slaw Dressing were opened and not dated and should have been. Observation of the facility's walk in cooler on 10/10/2024 at 8:56 a.m. revealed an opened undated plastic bag containing Hormel Deli sliced ham. In an interview on 10/10/2024 at 9:00 a.m., S12DS confirmed the plastic bag containing Hormel Deli sliced ham in the facility's walk in cooler was opened and undated and should not have been. In an interview on 10/10/2024 at 2:15 p.m., S1Administrator acknowledged the packages of ham and turkey and the jar of dressing were found opened and undated in the walk-in cooler and should not have been. 2. Review of the facility's undated policy and procedure titled Preventing Foodborne Illness-Food Handling revealed, in part, the refrigeration and food temperatures will be monitored at designated intervals throughout the day and documented. Review of the facility's Prepared Food Temperature Record dated 10/2024 revealed no entries. Review of the facility's Record of Refrigeration Temperatures dated 09/2024 through 10/2024 revealed no documented evidence, and the facility could not provide any documented evidence, the facility's walk-in freezer or walk- in cooler's temperatures were monitored and recorded from 09/03/2024 through 10/06/2024. In an interview on 10/07/2024 at 12:25 p.m., S12Dietary Supervisor (DS) confirmed the facility's walk-in freezer and cooler temperature logs for September and October 2024 were not completed and should have been. S12DS further confirmed the Prepared Food Temperature Record for October 2024 was not completed and should have been. In an interview on 10/10/2024 at 2:15 p.m., S1Administrator acknowledged the facility's walk-in freezer and cooler temperature logs for September and October 2024 were not completed and should have been. S1Administrator further acknowledged the Prepared Food Temperature Record dated 10/01/2014-10/06/2024 was not completed and should have been. 3. Review of the facility's Dish Machine Temperature Log dated 09/2024 revealed, in part, no entries for 9/22/2024, 9/23/2024, 9/27/2024, 9/28/2024, and 9/30/2024. Review of the facility's Dish Machine Temperature Log and Sanitizer Test Log dated 10/2024 revealed no entries. In an interview on 10/07/2024 at 12:25 p.m., S12Dietary Supervisor (DS) confirmed the facility's Dish Machine Temperature Log and the Sanitizer Test Log for October 2024 were not completed and should have been. S12DS further indicated there was no documented evidence, and the facility could not provide any documented evidence the facility's dish machine reached the correct temperature and sanitizer levels to prevent foodborne illness from 10/01/2024 through 10/06/2024. In an interview on 10/10/2024 at 2:15 p.m., S1Administrator acknowledged the facility's Dish Machine Temperature Log and the Sanitizer Test Log dated 10/01/2014-10/06/2024 were not completed and should have been.

Based on observation, record reviews, and interviews, the facility failed ensure a resident's right to maintain a homelike environment for 1 (Resident #94) of 1 (Resident #94) sampled residents reviewed for resident's rights. Findings: Review of Resident # 94's medical record revealed, in part, Resident #94 was admitted to the facility on [DATE] with diagnoses of, in part, malignant neoplasm of the lung, Chronic Obstructive Pulmonary Disease (COPD), Nicotine dependence, weakness, anxiety, and Major Depressive Disorder. Review of Resident #94's Minimum Data Set with an Assessment Reference Date of 03/12/2025 revealed, in part, Resident #94's Brief Interview for Mental Status (BIMS) summary score was 12. Review of Resident #94's care plan with a goal date of 12/08/2024 revealed, in part, no care plan for safety or behavior modification with an intervention for locking Resident #94's air conditioning control panel. Observation on 10/07/2024 at 12:52 p.m. revealed the air conditioning unit in Resident # 94's room was not running. Further observation revealed the control panel cover was closed with a lock on it preventing the air conditioning unit's control panel from being opened. In an interview on 10/07/2024 at 12:55 p.m., Resident # 94 indicated he had previously asked the staff to remove the lock from the air conditioner controller cover in his room. Resident #94 further indicated he had cancer, frequently got cold, and preferred the room temperature to be warmer. In an interview on 10/07/2024 at 2:10 p.m., S17Maintenance Supervisor (MS) confirmed the air conditioning unit in Resident #94's room had a lock on the control panel door. S17MS further indicated the lock was placed so Resident #94 could not turn the thermostat up making the room warmer. S17MS further indicated Resident #94 could not control the thermostat as the thermostat cover was locked and only maintenance personnel had the keys to open and adjust the thermostat. In an interview on 10/10/2024 at 11:27 a.m., S18Social Services Director (SSD) indicated the air conditioner control panel in Resident #94's room was locked because Resident #94 likes the room temperature warmer than his roommate. In an interview on 10/10/2024 at 2:15 p.m., S1Administrator confirmed there was a lock on Resident #94's air conditioning control panel preventing him from adjusting the temperature in his room. S1Administrator offered no explanation as to why there was no documented evidence for this intervention.

Based on observations, interviews, and record reviews, the facility failed to provide nail care for 1 (Resident #51) of 1 (Resident #51) sampled residents reviewed for activities of daily living (ADLs). Findings: Review of the facility's undated policy and procedure titled Care of Fingernails/Toenails revealed, in part, nail care includes daily cleaning and regular trimming. Review of Resident #51's Electronic Medical Record (EMR) revealed, in part, Resident #51 was admitted to the facility on [DATE] with a diagnosis, in part, of severe vascular dementia with psychotic disturbance, lack of coordination, and cerebral palsy. Review of Resident #51's Minimum Data Set with an Assessment Reference Date of 12/08/2024 revealed, in part, Resident #51's Brief Interview for Mental Status (BIMS) summary score was 15, which indicated Resident #51 was cognitively intact. Further review of section GG revealed, Resident #51 was dependent on staff for personal hygiene needs. Review of Resident #51's Care Plan with a goal date of 12/05/2024 revealed Resident #51 was totally dependent on staff for personal hygiene including nail care. Observation on 10/07/2024 at 10:48 a.m. revealed Resident #51's fingernails extended past the tips of her fingers on both hands with visible dirt underneath the portion of the nails that extended past the nailbed. In an interview on 10/07/2024 at 10:55 a.m., Resident #51 indicated her nails have not been trimmed since she has been at the facility. Resident #51 further indicated she wanted to have her nails trimmed and had previously asked staff to have them trimmed. Observation on 10/09/2024 at 9:17 a.m. revealed Resident # 51's fingernails on both hands remained untrimmed with visible dirt underneath the portion of the nail that extended past the nailbed. In an interview on 10/09/2024 at 9:18 a.m., S14Certified Nursing Assistant (CNA) indicated a resident's nails should be trimmed if they extend past the nail bed. In an interview on 10/09/2024 at 11:10 a.m., S13Certified Nursing Assistant Supervisor confirmed Resident # 51's fingernails were too long and should have been cleaned and trimmed.

Based on record reviews and interviews, the facility failed to ensure physician's orders were followed for 1 (Resident #42) of 1 (Resident #42) sampled residents reviewed for physician order compliance. Findings: Review of Resident #42's Electronic Medical Record (EMR) revealed, in part, Resident #42 was admitted to the facility on [DATE] with diagnoses of, in part, post operative left knee replacement, pyogenic arthritis, and acute pancreatitis. Review of Resident #42's written physician's telephone orders dated 10/08/2024 revealed, in part, an order by S21Medical Director for 1 gram of Ceftriaxone 1 gram intramuscular (IM) twice per day for 1 day. Review of Resident #42's EMR physician's orders dated 10/08/2024 revealed, in part, an order for Ceftriaxone 1 gram IM for 2 doses. Review of Resident #42's Minimum Data Set with an Assessment Reference Date of 09/20/2024 revealed, in part, Resident #42's Brief Interview for Mental Status (BIMS) summary score was 11, which indicated Resident #42 was moderately cognatively impaired. Review of Resident # 42's Electronic Medication Administration Record (eMAR) revealed, in part, Ceftriaxone 1 gram IM was administered on 10/08/2024 at 12:45 p.m. Further review revealed, no documented evidence, and the facility could not provide any documented evidence Resident # 42 was administered a second dose of Ceftriaxone 1 gram IM on 10/08/2024 at 10:00 p.m. as ordered. In an interview on 10/10/2024 at 9:30 a.m., Resident #42 indicated on 10/08/2024 he only received 1 of the 2 doses of Ceftriaxone antibiotic shots the doctor had ordered. In an interview on 10/10/2024 at 1:31 p.m., S16Licensed Practical Nurse (LPN) indicated she was Resident # 42's nurse on 10/08/2024 during the 6 p.m.-6 a.m. shift. S16LPN further indicated she did not administer Resident # 42's Ceftriaxone 1 gram IM as ordered on her shift. In an interview on 10/10/2024 at 1:42 p.m., S2Director of Nursing indicated the facility could not provide any documented evidence Resident #42 was administered 2 doses of Ceftriaxone 1 gram IM as ordered and should have. In an interview on 10/10/2024 at 2:15 p.m., S1Administrator acknowledged Resident #42 was not administered 2 doses of IM Ceftriaxone 1 gram as ordered and should have.

Based on record review and interview, the facility failed to: 1. Protect a resident from physical abuse for 1 (Resident #1) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents; and, 2. Protect a resident from sexual abuse (Resident #4) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents. This deficient practice resulted in an actual harm for Resident #1 when Resident #2 pushed Resident #1 out of Resident #1's wheelchair and to the floor. Resident #1 required emergency medical evaluation at the hospital which revealed a fracture to Resident #1's proximal femur (bone in the upper leg). Resident #1 was subsequently hospitalized and received surgical intervention to repair the fractured femur on 07/12/2022. Once readmitted to the facility on [DATE], Resident #1 required physical therapy and the administration of pain medication due to pain. Based on this complaint investigation, abuse was identified to have occurred on 07/11/2022 and on 04/25/2023. The incident on 7/11/2022 resulted in an actual harm for Resident #1. After the incident on 7/11/2022, there were no subsequent incidents of abuse involving Resident #2 due to having a decline in her condition upon her return to the facility. The incident on 04/25/2023 resulted in no actual harm with potential for more than minimum harm for Resident #4. Findings: Review of the facility's Abuse/Neglect policy dated 01/04/2022 revealed, in part, the purpose of the policy was to ensure the safety and wellbeing of residents was maintained at all times. Review revealed sexual abuse included sexual assault and physical abuse included hitting, slapping, pinching, kicking and other means used to cause physical injury to a resident. 1. Review of Resident #1's record revealed, in part, Resident #1 was admitted to the Alzheimer's Unit on 10/07/2021 with diagnoses, in part, dementia with behavioral disturbances and altered mental status. Review of Resident #1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/20/2022 revealed, in part, a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. Review of Resident #2's record revealed, in part, Resident #2 was admitted to the Alzheimer's Unit on 02/20/2022 with diagnoses of, in part, Major Depressive Disorder, Alzheimer's and Bipolar Disorder. Review of Resident #2's Quarterly MDS with an ARD of 06/23/2022 revealed a BIMS score of 3, which indicated severe cognitive impairment. Review of Resident #2's Care Plan dated 02/28/2022 revealed Resident #2 had combative behaviors related to cognitive impairment with interventions which included remove resident from the area when behavior was disruptive and approach resident warmly and positively. Review of the facility's incident and accident log revealed, in part, Resident #1 was found on the floor on 07/11/2022. Further review revealed Resident #1's disposition was documented as emergency room . Review of Resident #1's nurse's notes dated 07/11/2022 at 4:06 p.m. revealed, in part, at 3:45 p.m. a certified nursing assistant (CNA) informed her that Resident #1 was on the floor, lying on her left side. Further review revealed Resident #1 was not able to extend her left leg, and Resident #1 yelled when her left leg was touched. Review also revealed Resident #1's physician was notified, and the physician ordered to send Resident #1 to the emergency room for evaluation. Review of Resident #1's note addendum created on 07/11/2022 at 4:24 p.m. revealed Resident #1's incident occurred due to Resident #1 being pushed down to the floor by another resident. Review of Resident #2's nurse's note dated 07/11/2022 at 4:29 p.m. revealed, in part, at 3:45 p.m., Resident #2 pushed Resident #1 from her chair to the floor. Review of Resident #1's medical records revealed, in part, Resident #1 was admitted to the hospital on 07/11/2022 after Resident #1 was pushed out of her wheelchair by another resident. Further review revealed Resident #1's pelvic x-ray obtained on 07/11/2022 revealed a fracture of Resident #1's proximal left femur. Review also revealed Resident #1 required surgical repair of her femur fracture on 07/12/2022. In an interview on 05/09/2023 at 9:57 a.m., S4Licensed Practical Nurse (LPN) stated she was informed on 07/11/2022 that Resident #2 pushed Resident #1 out of her wheelchair when Resident #1 entered Resident #2's room. S4LPN stated she had completed an assessment of Resident #1 following the fall which revealed Resident #1 had pain to her left leg. S4LPN stated Resident #1 was transferred to the emergency room . In an interview on 05/09/2023 at 11:59 a.m., S5CNA stated she witnessed Resident #2 push Resident #1 to the floor on 07/11/2022. In an interview on 05/10/2023 at 1:04 p.m., S1Administrator confirmed the incident between Resident #1 and Resident #2 was resident to resident physical abuse. 2. Review of the facility's Statewide Incident Management System (SIMS) report revealed, in part, Resident #4 had an incident of sexual abuse that occurred on 04/25/2023. Review of Resident #4's SIMS report revealed, in part, on 04/25/2023 at approximately 12:00 p.m., Resident #4's aunt notified S6Social Worker that Resident #4's roommate, Resident #3, had put his hands into Resident #4's pants and fondled him. Further review revealed S1Adminitrator wrote: Allegation of sexual abuse was substantiated. Resident #3 did not deny the allegation and confirmed that Resident #4 made him stop. Review of Resident #4's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/26/2023 revealed, in part, Resident #4 had a Brief Interview for Mental Status score of 13, which indicated he was cognitively intact. Review of Resident #3's MDS with an ARD of 02/09/2023 revealed, in part, Resident #3 had a BIMS of 13, which indicated he was cognitively intact. Review of Resident #3's Care Plan revealed, in part, Resident #3's was care planned for inappropriate sexual behavior on 04/25/2023, the same date he sexually abused his roommate. In an interview on 05/10/2023 at 8:43 a.m., Resident #4 stated on 04/25/2023 Resident #3 came to his bed and touched his penis while he was sleeping. In an interview on 05/10/2023 at 9:10 a.m., S6Social Worker stated Resident #3 admitted he touched Resident #4 on his genitals on 04/25/2023. In an interview on 05/08/2023 at 10:58 a.m., S1Administrator stated she investigated the report of sexual abuse on 04/25/2023 that Resident #3 committed against Resident #4 and it was substantiated. 41876 44336 46127