Every finding on record at St. Bernard Nursing & Rehab

Based on observations, interviews, and record review, the facility failed to serve the dietician approved pureed menu for 1 of 2 meals observed for staff following the correct menu. This deficient practice was identified for 2 (Resident #R4, Resident #R8) of the 5 residents who had orders for a pureed diet. Findings:Review of the facility's Week 2 menu revealed, in part, the pureed diet to be served for dinner on 07/30/2026 included: pureed buttermilk pancakes with margarine and syrup, pureed breakfast sausage, and pureed hash browns with thickened gravy. Observation on 07/30/2026 at 5:36PM revealed Resident #R4 was served pureed eggs, pureed pork breakfast sausage patties, and grits. Further observation revealed Resident #R4 was not served pureed buttermilk pancakes or pureed hash browns. Observation on 07/30/2026 at 6:01PM revealed Resident #R8 was served pureed eggs, pureed pork breakfast sausage patties, and grits. Further observation revealed Resident #R8 was not served pureed buttermilk pancakes or pureed hash browns. In an interview on 07/30/2026 at 6:57PM, S1Dietary Manager indicated all of the residents that had pureed diet orders were not served the dietician approved pureed diet menu for dinner on 07/30/2026. S1Dietary Manager further indicated he had not gotten the menu changes of pureed eggs for pureed buttermilk pancakes with margarine and syrup, nor grits for pureed hash browns with thickened gravy approved by the dietician. S1Dietary Manager further indicated staff should have served food from the dietician approved menu.

Based on observations, interviews, and record reviews, the facility failed to ensure residents' meals were served according to their nutritional needs, special dietary needs, and preferences for 4 (Resident #R4, Resident #R5, Resident #R6, Resident #R7) of 6 residents investigated for dietary services. Findings:Review of Resident #R4's meal ticket for dinner on 07/30/2026 revealed, in part, Resident #R4 was to be served chocolate pudding with all meals. Observation of the dietary staff serving resident lunch trays on 07/31/2026 at 5:36PM revealed Resident #R4 was not served chocolate pudding on his dinner tray. In an interview on 07/30/2026 at 6:57PM, S1Dietary Manager indicated that Resident #R4 should have received a chocolate pudding with his dinner tray. Review of Resident #R5's meal ticket for lunch on 07/31/2026 revealed, in part, Resident #R5 was allergic to milk and disliked fresh vegetables. Observation of the dietary staff serving resident lunch trays on 07/31/2026 at 11:47AM revealed Resident #R5 was served fresh/raw lettuce and tomatoes with his fish po-boy (sandwich) on his lunch tray. Further observation revealed Resident #R5 was also served a mighty shake (liquid meal supplement that contained milk) on his lunch tray. Review of Resident #R6's meal ticket for lunch on 07/31/026 revealed, in part, Resident #R6 was to be served chocolate milk and one other beverage/water with her lunch tray. Observation of the dietary staff serving resident lunch trays on 07/31/2026 at 11:47AM revealed Resident #R6 was only served chocolate milk on her lunch tray. Review of Resident #R7's meal ticket for lunch on 07/31/026 revealed, in part, Resident #R7 was to be served a regular diet and had no likes or dislikes listed. Observation of the dietary staff serving resident lunch trays on 07/31/2026 at 11:47AM revealed Resident #R7 was not served lettuce or tomatoes with her fish po-boy on her lunch tray.In an interview on 07/31/2026 at 12:40PM, S1Dietary Manager acknowledged Resident #R5 should not have been served fresh vegetables or a mighty shake with his lunch tray, Resident #R6 should have received a glass of water with her lunch tray in addition to the chocolate milk, and Resident #R7 should have been served lettuce and tomatoes with her fish po-boy.In an interview on 07/31/2026 at 12:41PM, S2Regional Dietary Manager confirmed that residents should be served meals in accordance with their meal tickets.

Based on observations, interviews, and record reviews, the facility failed to ensure physician's orders were followed for 3 (Resident #5, Resident #11, Resident #70) of 3 sampled residents reviewed for compliance with physician's orders.Findings: In accordance with the Louisiana Nurse Practice Act (La. R.S. 37:913), nursing practice includes executing health care regimens as prescribed by a licensed physician or authorized prescriber. Resident #5 Review of Resident #5's June 2026 physician orders revealed, in part, an order to obtain vital signs every week on Wednesday starting on 2/11/2026. Review of Resident #5's record revealed, in part, the last vital signs were dated 04/22/2026. In an interview on 06/09/2026 at 10:05AM, S2Director of Nursing indicated there were no vital signs completed for Resident #5 since 4/22/2026. Resident #11 Review of Resident #11's June 2026 physician orders revealed, in part, an order for oxygen 2 liters per nasal cannula continuous. Observation on 06/07/2026 at 9:51AM revealed, in part, Resident #11's oxygen concentrator was set on 3.5 liters per minute Observation on 06/08/2026 at 8:32AM revealed, in part, Resident #11's oxygen concentrator was set on 3.5 liters per minute Observation on 06/08/2026 at 3:15PM with S6Licensed Practice Nurse present revealed, in part, Resident #11's oxygen concentrator was set on 3.5 liters per minute In an interview on 06/08/2026 at 3:15PM, S6Licensed Practice Nurse confirmed Resident #11's oxygen concentrator was set on 3.5 liters/minute and should have been set at 2 liters per minute as ordered. Resident #70 Review of Resident #70's record revealed, in part, he was admitted to the facility on [DATE] with a diagnosis of end stage renal disease. Review of Resident #70's June 2026 physician orders revealed, in part, daily weights one time a day for hemodialysis. Review of Resident #70's current care plan revealed, in part, Resident #70 had chronic renal failure related to end stage kidney disease with interventions to monitor/document weight gain over 2lbs a day. Review of Resident #70's clinical record revealed the following weights, in part: 04/16/2026-149lbs; 04/20/2026-144.4lbs; 04/21/2026-142.8lbs; 04/22/2026-141.6lbs; 04/23/2026-141.2lbs; 04/24/2026-148.8lbs; 04/25/2026-146.8lbs; 04/26/2026-146lbs; 04/27/2026-145.8lbs; 04/28/2026-147.4lbs; 05/03/2026-147.4lbs; and 05/13/2026-152.1lbs. Further review of Resident #70's weight record revealed, no documentation of weights for any other dates than listed above. In an interview on 06/09/2026 at 1:48PM, S2Director of Nursing confirmed Resident #70 was ordered daily weights. S2Director of Nursing furhter confirmed Resident #70's weights were not being documented daily as ordered but should have been.

Based on interviews and record reviews the facility failed to ensure a resident was monitored for side effects and effectiveness of medications for 1 (Resident #5) of 5 sampled residents reviewed for unnecessary medications. Findings:Review of the facility's Unnecessary Medications policy, with a revision date of 04/28/2025, revealed, in part, each resident's drug regimen will be reviewed on an ongoing basis with consideration for adequate monitoring for efficacy and adverse consequences. Review of Resident #5's record revealed, in part, Resident #5 had diagnoses of, in part, anxiety disorder, depression, bipolar, and major depressive disorder. Review of Resident #5's June 2026 physician orders revealed, in part:- an order to administer trazodone hcl 200 milligram (mg) tablet (a medication used to treat anxiety) by mouth at bedtime started 5/22/2026;- an order to administer two sertraline hcl 100 mg tablets (a medication used to treat depression) by mouth one time a day started 02/03/2026;- an order to administer buspirone hcl 10 mg tablet (a medication used to treat anxiety) by mouth three times a day started 02/02/2026;- an order to administer aripiprazole 15 mg tablet by mouth (a medication used to treat bipolar disorder and major depressive disorder) daily started 02/03/2026;- an order to administer quetiapine fumarate 300 mg and a 50 mg oral tablets (a medication used to treat bipolar disorder) at bedtime started 02/02/2026;- an order to administer divalproex sodium 500 mg tablet (a medication used to treat bipolar disorder) two times a day started 02/02/2026;- an order to administer clopidogrel bisulfate 75 mg tablet (a medication used to prevent blood clots) by mouth daily started 02/03/2026; and,- an order to administer furosemide 20 mg tablet (a medication used to treat swelling) by mouth one time a day started 02/03/2026. Review of Resident #5's care plan with a next review date of 08/03/2026 revealed, in part:- Resident #5 was at risk for adverse drug interactions related to the use of high risk black box medications with an intervention to monitor for signs and symptoms of drug toxicity, side effects, and ineffectiveness;- Resident #5 had the potential for fluid deficit related to diuretic use and had an intervention to monitor/document for side effects and effectiveness;- Resident #5 was at risk for bleeding due to being on an antiplatelet medication and had an intervention to monitor for side effects and effectiveness every shift;- Resident #5 used an antidepressant medication and had an intervention to monitor/document side effects and effectiveness every shift; and,- Resident # 5 was prescribed an antipsychotic, antidepressant, and antianxiety medication and had an intervention to document for side effects and effectiveness. Review of Resident #5's electronic record revealed, in part, no documented evidence of side effect or signs and symptoms monitoring for Resident #5's antipsychotic, antidepressant, anti-anxiety, diuretic, and anticoagulant medications. Further review of Resident #5's record revealed, in part, no documented evidence a Depakote blood level (a test used to determine the concentration of divalproex sodium medication in the blood) had been completed for Resident #5 since 2024. In an interview on 06/08/2026 at 1:57PM, Resident #5's Medical Doctor indicated he was unaware Resident #5 had not had a Depakote level checked since 2024. He further indicated a Depakote level should be drawn every 3 to 6 months for a resident on divalproex acid, as this was a standard of practice. He further indicated Resident #5 should have had Depakote levels being routinely monitored, and had not. In an interview on 06/09/2026 at 10:05AM, S2Director of Nursing indicated there were no orders and nursing staff were not monitoring for specific medication side effects and/or effectiveness related to the above-mentioned medications.

Based on interviews and record reviews the facility failed to ensure current Preadmission Screening and Resident Review (PASARR) Level II determinations were maintained for 3 (Resident #5, Resident #85, Resident #59) of 4 sampled residents reviewed for PASARR requirements.Findings: Resident #5 Review of Resident #5's record revealed, in part, Resident #5 was admitted to the facility on [DATE] and had diagnoses of bipolar disorder and major depressive disorder. Review of Resident #5's Form-142 revealed, in part, Resident #5 was approved for admission by Level II authority for a temporary period effective 06/02/2026 through 06/01/2026. Review of Resident #5's continued stay request dated 06/04/2026 revealed, in part, the timeline for submission was no earlier than 30 days in advance of the expiration of the 142 and no later than 15 days in advance of the expiration of the Form-142. Resident #59 Review of Resident #59's record revealed, in part, Resident #59 had diagnoses of anxiety disorder, bipolar disorder, and major depressive disorder recurrent unspecified. Review of Resident #59's Form-142 revealed, in part, Resident #59 was approved for admission by Level II authority for a temporary period effective 06/05/2025 through 06/04/2026. Review of Resident #59's continued stay request signed by Resident #59 on 06/08/2026 revealed, in part, the timeline for submission was no earlier than 30 days in advance of the expiration of the Form-142 and no later than 15 days in advance of the expiration of the Form-142. Review of the facilities PASARR for mentally disabled and intellectually disabled policy, last revised on 03/2023, revealed, in part, for residents with a Level II determination and recommendations, the facility incorporated the determination and recommendations into the resident's assessment and care plan. Resident #86 Review of Resident #86's record revealed, in part, Resident #86 was admitted to the facility on [DATE] and had diagnoses of mood disorder with depressive features, unspecified psychosis, and major depressive disorder. Review of Resident #86's Form-142 revealed, in part, Resident #86 was approved for admission by Level II authority for a temporary period effective 04/10/2025 through 04/09/2026. Review of Resident #86's continued stay request dated 06/08/2026 revealed, in part, the timeline for submission was no earlier than 30 days in advance of the expiration of the 142 and no later than 15 days in advance of the expiration of the Form-142. In an interview on 06/08/2026 at 1:47PM S1Administrator confirmed Resident #59 did not have a current level II PASARR. S1Administrator indicated Resident #59's continued stay request should have been submitted prior to the expiration date but was not. In an interview on 06/08/2026 at 2:45PM, S1Administrator confirmed Resident #5 and Resident #86 did not have a current level II PASARR. S1Administrator indicated Resident #5's and Resident #86's continued stay request should have been submitted prior to the expiration date but was not.

Number of residents sampled: Number of residents cited: Based on observations and interviews, the facility failed to: 1. eliminate odors; and, 2. have a sanitary restroom. Findings: 1 Observation on 06/07/2026 at 08:12AM, revealed a strong urine smell by Entrance B. Observation on 06/07/2026 at 10:07AM, revealed a strong feces smell down Hall Y. Observation on 06/07/2026 at 12:15 PM, revealed a strong urine smell down Hall W. In an interview on 06/07/2026 at 1 :04PM, the facility's ombudsman indicated when she visited the facility on 04/14/2026 she observed a strong urine smell. In an interview on 06/09/2026 at 5:37PM, S1Administrator indicated odors should not have been throughout the facility during the survey. 2 Review of the facility's housekeeping job description revealed, in part, essential job functions which included, in part, clean up spills, soiled areas, and other conditions as observed or directed. Observation on 06/07/2026 at 8:40AM revealed, in part, in Bathroom A there was an unknown brown substance on the toilet paper holder and around the toilet paper roll. Observation on 06/07/2026 at 10:30AM revealed, in part, in Bathroom A there was an unknown brown substance on the toilet paper holder and around the toilet paper roll. Observation on 06/08/2026 at 3:29PM with S8Environmental Services Supervisor revealed, in part, in Bathroom A there was an unknown brown substance on the toilet paper holder and around the toilet paper roll. In an interview on 06/08/2026 at 3:29PM, S8Environmental Services Supervisor confirmed in Bathroom A the toilet paper holder and the toilet paper had an unknown brown substance on it. She further indicated bathrooms are cleaned daily and there should not have been an unknown brown substance on the toilet paper holder and toilet paper role.

Based on interview, and record reviews the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) was completed upon readmission for 1 (Resident #10) of 1 sampled residents reviewed for PASRR requirements.Findings:Review of Resident #10's medical record revealed she was originally admitted to the facility on [DATE] and was readmitted on [DATE]. Review of Resident #10's Level I Pre-admission Screening and Resident Review dated 04/19/2021 revealed, in part, Resident #10 was admitted to the nursing home and was not identified as having a diagnosis of mental illness and/or mental disability. Review of Resident #10's medical record, revealed, in part, Resident #10 was diagnosed with major depressive disorder on 09/21/2023, and post-traumatic stress disorder on 09/21/2023. Review of Resident #10's quarterly Minimum Data Set with an Assessment Reference Date of 05/14/2026 revealed, in part, Resident #10 was diagnosed with depression and post-traumatic stress disorder. In an interview on 06/09/2026 at 9:30AM, S1Administrator indicated Resident #10 was readmitted on [DATE] and had diagnoses of major depressive disorder and post-traumatic stress disorder with a date of 09/21/2023. S1Administrator further indicated that Resident #10 should have received a Level I PASRR screening upon readmission on [DATE] which would have triggered further review for the resident's mental health diagnoses. S1Administrator also indicated the facility did not have documentation to demonstrate a Level I PASRR or any subsequent PASRR review had been completed upon Resident #10's readmission on [DATE].

Based on observations, interviews, and record reviews, the facility failed to develop a care plan with measurable objectives/timeframes for incontinence care and positioning for 1 (Resident #31) of 30 sample residents whose records were reviewed.Findings:Review of Resident #31's care plan with a target date of 08/17/2026 revealed, in part, interventions directing staff to keep the resident's bed as flat as possible to reduce sheer, reposition the resident with the assistance of two staff members, assist with toileting, observe for incontinence and observe the resident's skin during activities of daily living care for signs of skin breakdown. Further review revealed Resident #31's care plan lacked specific directions regarding the frequency of repositioning and incontinence care necessary to address the resident's risk for impaired skin integrity. Review of Resident #31's care plan with a target date of 08/17/2026 revealed, in part, no measurable interventions directing staff to keep the resident's bed as flat as possible to reduce sheer, reposition the resident with the assistance of two staff members, assist with toileting, observe for incontinence and observe the resident's skin during activities of daily living care for signs of skin breakdown. Further review revealed Resident #31's care plan lacked specific directions regarding the frequency of repositioning and incontinence care necessary to address the resident's risk for impaired skin integrity. In an interview on 06/09/2026 at 12:31PM, S15Minimum Data Set Nurse indicated Resident #31's care plan to assist with toileting and observe for incontinence, assist with incontinence care, and repositioning did not include measurable interventions, and should have. In an interview on 06/09/2026 at 5:53PM, S1Administrator indicated Resident #31's care plan to assist with toileting and observe for incontinence, assist with incontinence care, and repositioning did not include measurable interventions, and should have.

Based on interviews and record reviews, the facility failed to accurately maintain complete and accurate clinical record documentation related to pressure ulcer treatment for 1 (Resident #31) of 30 sampled residents whose records were reviewed.Findings:Review of Resident #31's physician Order Summary Report dated 06/08/2026 at 11:48AM revealed, in part, no physician order for wound care was documented at the time the Stage 3 left buttock wound was identified. Review of Resident #31's physician Order Summary Report dated 06/09/2026 at 1:35PM revealed, in part, Resident #31 had an active physician order dated 06/08/2026 for wound care to Resident #31's Stage 3 left buttock wound directing staff to cleanse the wound with wound cleanser, pat dry, apply barrier cream, and cover with a bordered dressing three times weekly on Tuesday, Thursday, and Saturday as needed. Review of Resident #31's June 2026 Treatment Administration Record revealed, in part, a wound care order for Resident #31's Stage 3 left buttock wound with a documented start date of 06/08/2026 at 9:45AM. Review of the facility's Order Audit Report dated 06/09/2026 at 5:29PM revealed, in part, an order for wound care to Resident #31's Stage 3 left buttock wound directing staff to cleanse the wound Tuesday, Thursday, Saturday, and as needed. The report indicated the order was created by S18Licensed Practical Nurse on 06/09/2026 at 9:43AM and last revised on 06/09/2026 at 9:43AM. In a phone interview on 06/09/2026 at 5:33PM, S18Licensed Practical Nurse was informed of the above mentioned Order Audit Report and indicated she did not enter the wound care order for Resident #31's Stage 3 left buttock wound on 06/09/2026 at 9:43AM. S18Licensed Practical Nurse further indicated S10Wound Care Nurse used her computer which was still logged in under her (S18Licenced Practical Nurse) credentials and entered the above mentioned wound care treatment order for Resident #31.

Based on observations, interviews, and record reviews the facility failed to ensure a resident dependent on staff for positioning and incontinence care, and assessed as being at high risk for pressure ulcer development received necessary preventive interventions to avoid the development of a facility-acquired pressure ulcers.This deficient practice was identified for 1 (Resident #31) of 4 sampled residents reviewed for pressure ulcer development.Findings:Review of the facility's Quality of Care: Skin Integrity policy and procedure, dated 03/20/2026, revealed, in part, the facility, based on a resident's comprehensive assessment, would provide care, consistent with professional standards of practice, to prevent pressure ulcers and promote healing, prevent infection and prevent new ulcers from developing unless the resident's clinical condition demonstrated that they were unavoidable. Further review revealed the facility would evaluate resident specific risk factors and changes in the resident's condition that would impact the development and/or healing of a pressure ulcer/pressure injury. Further review revealed the facility would strive to keep feces and urine off the skin to reduce the risk of pressure ulcer/pressure injury and moisture-related skin damage. Further review of the above mentioned policy and procedure revealed repositioning needed to maintain the resident's skin integrity for residents who were lying in bed and considerations in reposition frequency would include a resident's skin condition. Further review revealed facility staff would monitor resident's skin condition and be alerted to potential changes in the resident's skin condition and would be reported. Further review revealed based on the comprehensive assessment, and the resident's clinical condition interventions would include, but not limited to minimizing exposure to moisture and keeping the skin clean, especially of fecal contamination.Review of the facility's undated Nursing Assistant - Certified Job Description revealed, in part, Certified Nursing Assistant's would maintain resident's positioning as needed, and assist residents with the activities of daily living. Further observation revealed reporting a significant change in a resident's condition including changes in a resident's skin integrity would be reported to the Charge Nurse.Review of Resident #31's Minimum Data Set with an Assessment Reference date of 05/19/2026 revealed, in part, Resident #31 had a Brief Interview for Mental Status of 13, which revealed Resident #31 was cognitively intact. Further review revealed Resident #31 was incontinent of bowel and bladder, and was dependent on two or more staff for toileting hygiene.Review of Resident #31's electronic medical revealed, in part, Resident #31 had a diagnosis of muscle wasting and atrophy (shrinkage or decrease in body parts) of the right and left shoulders, right and left upper arms, and muscle wasting and atrophy with contractures to the right and left lower legs. Further review revealed on 01/01/2026 Resident #31 acquired a blister to her left ankle measuring 1.6 centimeters in length, 1.27 centimeters in width, and 0.2 centimeters in depth, which later developed into a facility acquired Stage 4 pressure ulcer to her right ankle on 04/01/2026 measuring 1.5 by 1 centimeter by 9 by 0.3 in length, 1.36 centimeters in width, and 1.14 centimeters in depth and was later assessed as healing. Review of Residents #31's current medical orders revealed, in part, Further review revealed an order, dated 04/21/2024, for staff to perform and document a weekly head-to-toe skin assessment.Review of Resident #31's active orders as of 06/08/2026 at 1:35PM revealed, in part, no active order for wound care for Resident #31's Stage 3 left buttock pressure ulcer. Review of Resident #31's Care Plan, with a target date of 08/17/2026, revealed, in part, Resident #31 required to be flat as possible in bed to reduce shear, and Resident #31 preferred to be repositioned by 2 staff members. Further review revealed Resident #31 was care planned to be assisted with toileting, observed for incontinence care as needed, observed for skin break down during activities of daily living care, and to clean perineal area with each incontinence episode. Review of Resident #31's Braden Scale for Predicting Pressure Ulcer Risk Evaluation dated 03/06/2023 revealed, in part, Resident #31 was at high risk for the development of pressure ulcers. Further review revealed Resident #31 had very moist skin, was bedfast, was completely immobile, required moderate to maximal assistance with moving, and required frequent repositioning.Review of Resident #31's Wound Care Nurse Practitioner Progress Note dated 03/27/2026 revealed, in part, Resident #31 was evaluated and treated for Moisture Associated Skin Damage (MASD) located to her right gluteal fold and right buttock, which occurred approximately one week ago, and the new skin injury was caused by increased moisture. Further review revealed Resident #31's was assessed to have a Stage 3 pressure ulcer to the right lateral ankle, a wound of the right buttock, subsequent encounter, and dermatitis associated with moisture. Further review revealed Resident #31's wound care plan was to educate Resident #31 and staff on turning or repositioning every 2 hours or sooner. Further review revealed Resident #31's treatment plan was to educate staff on incontinence measures to prevent MASD.Review of Resident #31's Wound Care Nurse Practitioner Progress Note dated 04/01/2026 revealed, in part, wound care treatment plan was to initiate and maintain measures for incontinence care per facility protocol to maintain skin integrity. Further review revealed to educate staff on turning or repositioning every 2 hours or sooner. Further review revealed Resident #31 had a Stage 3 pressure ulcer to the right lateral ankle.Review of Resident #31's Skin assessment dated [DATE] revealed, in part, a Stage 4 pressure ulcer to Resident #31's right ankle measuring 1 by 0 centimeters in length, 1 by 0 centimeters in width and healing. Further review revealed no other skin injury and/or pressure ulcer documented.In an interview on 06/07/2026 at 10:32AM, Resident #31 indicated further indicated staff does not come in the room every 2 hours and sometimes only comes one time during the day to check her adult brief or reposition her. The surveyor then asked Resident #31 if staff are coming into her room every 2 hours and Resident #31 laughed out loud. Resident #31 further indicated when staff does come into her room they do not check her adult brief to see if she is wet and/or soiled or reposition her. Resident #31 further indicated she has had pressure injuries in the past from being wet.In an interview on 06/08/2026 at 9:45AM, Resident #31 further indicated she does not know when she was wet and/or soiled and she relied on staff to ensure she was not wet or soiled.Observation with S11Restorative Aide, S12Certified Nursing Assistant, S10Wound Care Nurse and the surveyor on 06/08/2026 at 10:05AM revealed Resident #31 had a skin injury on her left buttock.Review of Resident #31's Skin assessment dated [DATE] revealed, in part, Resident #31 was assessed as having developed a facility acquired Stage 3 pressure ulcer to her left buttock.In an interview on 06/08/2026 at 10:10AM, S10Wound Care Nurse indicated Resident #31 had a history of MASD which was caused by exposure to moisture from bowel and bladder incontinence. S10Wound Care Nurse further indicated she was not aware Resident #31 had a new skin injury, a Stage 3 pressure ulcer to her left buttock, which was caused by exposure to moisture and from bowel and bladder incontinence.In an interview on 06/08/2026 at 11:40AM, S10Wound Care Nurse further indicated Resident #31's pressure injuries, which was caused by exposure to moisture and bowel and bladder incontinence were avoidable by keeping repositioning Resident #31 and keeping her dry.In an interview on 06/09/2026 at 10:15AM, S2Director of Nursing indicated she was not aware a facility acquired Stage 3 pressure ulcer to Resident #31's left buttock was discovered on 06/08/2026. In an interview on 06/09/2026 at 12:01PM the facility's contracted Wound Care Nurse Practitioner indicated Resident #31 was at high risk for pressure injuries due to immobility, bowel and bladder incontinence, and MASD from incontinence. The facility's contracted Wound Care Nurse Practitioner further indicated and confirmed Resident #31's pressure ulcers were from exposure to moisture from bowel and bladder incontinence, immobility, and Resident #31's pressure injuries were absolutely avoidable. The facility's contracted Wound Care Nurse Practitioner further indicated Resident #31's pressure sores or ulcers could be avoided by repositioning Resident #31 and keeping her dry.In a phone interview on 06/09/2026 at 12:15PM, S12Certified Nursing Assistant indicated on the morning of 06/07/2026 she was assigned to Resident #31 and did not observe a skin injury on Resident #31's left buttocks. S12Certified Nursing Assistant further indicated she checked on Resident #31 at the beginning of her shift after 6:30AM on 06/08/2026 and found her adult brief wet, and at that time she changed Resident #31's adult brief. She further indicated she did not recall the time; however, she checked Resident #31's adult brief again, before the observation with the surveyor during incontinence care on 06/08/2026 at 10:00AM, and noticed blood on Resident #31's adult brief and a new skin injury to Resident #31's left buttock. She further indicated she completed incontinence care and did not inform a nurse of Resident #31's new skin injury because she thought the new skin injury on Resident #31's left buttocks was already reported to a nurse.In an interview on 06/09/2026 at 12:31PM, S15Minimum Data Set Nurse indicated Resident #31 was care planned for incontinence care which included interventions to assist with incontinence care and to check Resident #31's incontinence brief to prevent her from being wet or soiled. She further indicated Resident #31 was at a higher risk for skin breakdown due to exposure to moisture.In an interview on 06/09/2026 at 5:53PM, S1Administrator indicated Resident #31's care plan for interventions to assist with toileting and observe for incontinence, assist with incontinence care as needed should have had a measurable interventions. She further indicated staff were expected to round every 2 hours and report significant changes in a resident's condition to nursing staff.

Based on observations and interviews, the facility failed to keep a resident's nails trimmed and clean for 1 (Resident #18) of 5 residents investigated for activities of daily living. Findings:Review of Resident #18's Admit Minimum Data Set with an Assessment Reference Date of 04/08/2026, revealed, in part, Resident #18 required substantial/maximal assistance for personal hygiene. Review of Resident #18's Care Plan, dated 04/20/2026, with a goal date of 08/2/2026, revealed in part, Resident #18 was to be kept clean and Resident #18's nails were to be kept short with the assistance of staff. Observation on 06/07/2026 at 9:26AM, revealed Resident #18's nails extended about 1/4 inch past the fingertips. Observation on 06/08/2026 at 11:40AM, revealed Resident #18's nails extended about 1/4 inch past the fingertips with an unknown brown substance underneath Resident #18's nails. Observation 06/08/2026 at 4:08PM, revealed Resident #18's nails extended about 1/4long past the nail bed with an unknown brown substance underneath Resident #18's nails. Observation on 06/08/2026 at 4:15PM with S9Certifified Nursing Assistant (CNA) Supervisor revealed Resident #18's nails extended about 1/4 inch past the fingertips with an unknown brown substance underneath Resident #18's nails. In an interview on 06/08/2026 at 4:15PM, S9CNA Supervisor indicated Resident #18's nails needed to be trimmed and cleaned. S9CNA Supervisor further indicated nail care should be completed by the CNA during baths or showers. Observation on 06/08/2026 at 4:38PM with S3Assistant Director of Nursing (ADON) revealed Resident #18's nails extended about 1/4 inch past the fingertips with an unknown brown substance underneath Resident #18's nails. In an interview on 06/08/2026 at 4:48PM, S3ADON indicated Resident #18's nails should not have extended about 1/4 inch past the fingertips with an unknown brown substance underneath Resident #18's nails. S3ADON further indicated Resident #18's nails needed to be trimmed and cleaned.

Based on interviews and record reviews, the failed to ensure the required interdisciplinary team (IDT) members participated in a resident's care plan conference for 1 (Resident #80) of 30 sampled residents reviewed for care plan requirements. Findings:Review of the facility's undated, IDT Care Conference policy and procedure revealed, in part, the IDT team which includes social services, unit manager or designee, director of rehab (if involved), dietary manager or designee as needed, and the activities director would participate in resident care conferences. Review of Resident #80's IDT Care Plan Conference Evaluation notes revealed the following:On 02/16/2026, Resident #80 and S12Former Social Worker were in attendance.On 01/12/2026, Resident #80, S12Former Social Worker and S13Former Certified Nursing Assistant (CNA) Supervisor were in attendance; and, on 10/06/2026, Resident #80, Resident #80's emergency contact, S12Former Social Worker, and S16Former MDS Nurse were in attendance. In an interview on 06/09/2026 at 11:24AM, 17Social Worker indicated the IDT members involved in a Resident's care should be in attendance at an IDT Care Plan Conference. Surveyor requested documentation of the IDT member present for Resident #80's IDT Care Plan Conferences on 06/09/2026 at 11:55AM from S3Assistant Director of Nursing (ADON). In an interview on 06/09/2026 at 11:55AM, S3ADON indicated she could not present any documentation of IDT team members who attended Resident #80's IDT care plan conferences on 10/06/2026, 01/12/2026, and 02/16/2026. In an interview on 06/09/2026 at 12:20PM, S2Director of Nursing (DON) indicated the social worker documents who was in attended for IDT Care Plan Conferences. On 06/09/2026 at 12:20PM, surveyor requested documentation of other IDT team member being present at Resident #80's above-mentioned IDT Care Plan Conferences from S2DON. In an interview on 06/09/2026 at 1:59PM, S2DON indicated she did not have any additional evidence to dispute the above-mentioned practice of having IDT team members present at Resident #80's IDT Care plan Conferences.

Based on observations, interviews, and record reviews the facility failed to ensure resident self-administration requirements were followed by allowing medications and other medication-related items to remain accessible at the residents' bedside without evidence the residents had been assessed and approved for self-administration for 2 (Resident #118, resident #131) of 2 sampled residents observed with physician ordered items at the bedside.Resident #118Review of Resident #118's June 2026 physician orders revealed, in part, Triamcinolone Ointment External Cream 0.1%, apply to affected area topically every morning and at bedtime for plaque psoriasis and Aquaphor Advanced Therapy External Ointment 41% Emollient, apply to affected areas topically every morning and at bedtime for skin irritation.Further review of Resident #118's physician orders revealed Resident #118 did not have an order to self- administer medications.Review of Resident #118's current care plan revealed Resident #118 was not assessed and care planned to self-administer any physician ordered medication and/or items.Observation on 06/07/2026 at 9:06AM, revealed Resident #118 had one unknown cream and one unknown ointment in an unlabeled medicine cup unattended by staff on Resident #118's bedside table.In an interview on 06/07/2026 at 9:07AM, S7Licensed Practical Nurse confirmed Resident #118 had an unlabeled medicine cup with cream and/or ointment unattended on the bedside table.In an interview on 06/09/2026 at 1:24PM, S3Assistant Director of Nursing indicated Resident #118 should not have had creams or ointments in a medication cup at the bedside. Resident #131Review of Resident #131's June 2026 physician's orders revealed Resident #131 did not have an order to self-administer medications.Review of Resident #131's current care plan revealed Resident #131 was not assessed and care planned to self-administer any physician ordered medication and/or items.Observation on 06/07/2026 at 9:24AM, revealed Resident #131 had a tube of Antifungal Ointment (used to treat skin with a fungal infection) and a tube of Zinc Oxide Paste Skin Protectant (used to protect and/or treat irritated skin) stored at her bedside.In an interview on 06/07/2026 at 9:33AM, S14Licensed Practical Nurse confirmed Resident #131 had a tube of antifungal cream and a tube of zinc oxide paste stored at her bedside and should not have.In an interview on 06/09/2026 at 1:33PM, S3Assistant Director of Nursing, indicated Resident #131 should not have had the above stored at the bedside. S3Assistant Director of Nursing further indicated Resident #131 was not care planned for and/or did not have an order to self-administer medications.

Based on observations, interviews, and record review the facility failed to treat a resident with respect and dignity that promoted maintenance or enhanced his quality of life for 1 (Resident #50) of 4 residents investigated for resident rights/dignity.Findings:Review of Resident #50's electronic medical record revealed, in part, Resident #50 required extensive assistance with activities of daily living.Review of Resident #50's quarterly Minimum Data Set with an Assessment Reference Date of 05/28/2026 revealed, in part, Resident #50 had a Brief Interview for Mental Status of 8, which revealed Resident #50 was moderately cognitively impaired. Further review revealed Resident #50 was frequently incontinent of bowel and bladder, needed assistance with toileting, shower/bath, transfers, and personal hygiene.Observation on 06/07/2026 8:45AM revealed Resident #50 was lying directly on his mattress with a fitted sheet that was not secured to the mattress corners, without additional bed linens, and wearing only an adult brief.Observation on 06/07/2026 at 11:25AM revealed Resident #50 lying directly on his mattress with a fitted sheet that was not secured to the mattress corners, without additional bed linens, and wearing only an adult brief.In an interview on 06/08/2026 at 9:10AM, Resident #50 indicated he does not ambulate and was dependent on staff for his activities of daily living. Resident #50 further indicated yesterday he did not have any linens on his bed and was only in his adult brief until approximately 11:30AM.In an interview on 06/09/2026 at 8:35AM, S9Certified Nursing Assistant Supervisor indicated Resident #50 should not have been lying in his bed without any linens and only in an adult brief for that long. She further indicated Resident #50 should have been dressed and should have had linens on his bed.In an interview on 06/09/2026 at 9:00AM. S1Administrator indicated Resident #50 should not have been lying in his bed without any linens and only in an adult brief for that long.

Based on observations, interviews, and record reviews, the facility failed to perform hand hygiene after glove removal and wear proper personal protective equipment during incontinence care for 1 (Resident #31) of 30 sampled residents observed for infection control.Findings:Review of the facility's Infection Prevention and Control Program policy and procedure last revised 04/28/2025 revealed, in part, Standard Precautions: Hand hygiene should be performed in accordance with the facility's established hand hygiene procedure. Review of the facility's Hand Hygiene policy and procedure last revised on 07/2025 revealed, in part, common situations that require hand hygiene was before and after direct resident contact (for which hand hygiene was indicated by acceptable professional practice).Review of the facility's Infection Prevention & Control: Transmission Based Precaution, Enhanced Barrier Precautions policy and procedure, undated revealed, in part, gown and gloves are worn by staff during high contact care activities and high contact resident care activities include changing briefs or assisting with toileting.Review of Resident #31's physician orders dated 05/12/2026, revealed, in part, enhanced barrier precautions, don gown and gloves during high contact care activities including wound care, dressing, bathing/shower, transfers, providing care/hygiene, changing linens, changing briefs, or assisting with toileting.Observation on 06/08/2026 at 11:33AM revealed an Enhanced Barrier Precautions sign on the outside of Resident #31's door. Further observation revealed gown and glove should be worn when providing hygiene care for residents on Enhanced Barrier Precautions.Observation of incontinence care for Resident #31 on 06/08/2026 at 10:00AM revealed S11Restorative Aide and S12Certified Nursing Assistant were wearing two pairs of gloves prior to Resident #31's incontinence care observation. Further observation revealed S11Restorative Aide and S12Certified Nursing Assistant did not don a gown prior to providing incontinence care, and both (S11Restorative Aide, S12Certified Nursing Assistant) did not perform hand hygiene after glove removal. In an interview on 06/08/2026 at 10:13AM, S11Restorative Aide indicated she was wearing two pairs of gloves while providing Resident #31's incontinence care and she did not perform hand hygiene after glove changes. S11Restorative Aide indicated she should not have been wearing two pairs of gloves and should have performed hand hygiene after glove changes. In an interview on 06/08/2026 at 11:45AM, S11Restorative Aide indicated she did not wear a gown when she performed incontinence care for Resident #31, and should have. In an interview on 06/08/2026 at 10:14AM, S12Certified Nursing Assistant indicated she was wearing two pairs of gloves while providing Resident #31's incontinence care and she did not perform hand hygiene after gloves changes. S12Certified Nursing Assistant further indicated she should have not been wearing two pairs of gloves and should have performed hand hygiene after glove changes. In an interview on 06/08/2026 at 11:35AM, S12Certified Nursing Assistant indicated she did not wear a gown when she performed incontinence care for Resident #31, and should have.In an interview on 06/08/2026 at 11:40AM, S10Wound Care Nurse indicated S11Restorative Aide and S12Certified Nursing Assistant should not have been wearing two pairs of gloves, should have performed hand hygiene after glove removal, and should have worn a gown during Resident #31's incontinence care observation.In an interview 06/08/2026 at 10:16AM, S2Director of Nursing indicated S11Restorative Aide and S12Certified Nursing Assistant should not have been wearing two pairs of gloves, should have performed hand hygiene after glove removal, and should have worn a gown during Resident #31's incontinence care observation.

Based on interview and record reviews, the facility failed to complete and/or transmit Minimum Data Set (MDS) assessments within the required regulatory time frames for 4 (Resident #15, Resident #87, Resident #97, Resident #101) of 4 sampled residents reviewed for MDS assessment requirements.Resident #15Review of Resident #15's MDS Assessment Section Z (Assessment Administration), revealed Resident #15's MDS assessment was completed and electronically signed by S5Regional Clinical Reimbursement Specialist on 06/07/2026.Review of the facility's Final Validation Report/Centers for Medicare & Medicaid Services (CMS) Submission Report dated 06/08/2026 revealed, in part, Resident #15's MDS assessment had a target date of 02/05/2026 and a completion date of 06/08/2026. Resident #87Review of Resident #87's MDS Assessment Section Z (Assessment Administration), revealed the MDS assessment was completed and electronically signed by S5Regional Clinical Reimbursement Specialist on 06/07/2026.Review of the facility's Final Validation Report/CMS Submission Report dated 06/08/2026 revealed, in part, Resident #87's assessment had a target date of 02/06/2026 and a completion date of 06/07/2026. Resident #97Review of Resident #97's MDS Assessment Section Z (Assessment Administration), revealed the MDS assessment was completed and electronically signed by S5Regional Clinical Reimbursement Specialist on 06/08/2026.Review of the facility's Final Validation Report/CMS Submission Report dated 06/08/2026 revealed, in part, Resident #97's assessment had a target date of 02/05/2026 and a completion date of 06/08/2026. Resident #101Review of Resident #101's MDS Assessment Section Z (Assessment Administration), revealed the MDS assessment was completed and electronically signed by S5Regional Clinical Reimbursement Specialist on 06/07/2026.Review of the facility's Final Validation Report/CMS Submission Report dated 06/08/2026 revealed, in part, Resident #101's assessment had a target date of 01/17/2026 and a completion date of 06/07/2026.In an interview on 06/08/2026 at 8:53AM, S5Regional Clinical Reimbursement Specialist indicated all the above assessments were completed and transmitted late and should not have been.

Based on interviews and record review, the facility failed to ensure a residents responsible party was immediately notified of a fall for 1 (Resident #1) of 4 sampled residents reviewed for falls. Findings: Review of Resident #1's Incident Report dated 01/11/2026 revealed, in part, Resident #1 had an unwitnessed fall on 01/11/2026 which resulted in a hematoma (closed wound were blood collects) and bleeding to her forehead. Further review revealed S7Licensed Practical Nurse received orders to send Resident #1 to the emergency room for an evaluation, and S7Licensed Practical Nurse attempted to notify Resident #1's responsible party/daughter twice with no success. Review of Resident #1's Nurse Note dated 01/11/2026 revealed, in part, Resident #1 was found to have bleeding and a large hematoma to her forehead. Further review revealed S7Licensed Practical Nurse received orders to send Resident #1 to the emergency room for an evaluation, and S7Licensed Practical Nurse attempted to notify Resident #1's responsible party/daughter twice with no success. In a telephone interview on 03/11/2026 at 8:55AM, Resident #1's responsible party indicated the facility did not notify her on 01/11/2026 when Resident #1 fell and was sent to the emergency room for evaluation of a fall which resulted in a hematoma and bleeding to her forehead. Resident #1's responsible party further indicated she was made aware of Resident #1's fall and emergency room transfer on 01/11/2026 by the hospital staff. In an interview on 03/11/2026 at 2:53PM, 7Licensed Practical Nurse indicated she sent Resident #1 as ordered by the physician to the emergency room on [DATE] for evaluation for a fall which resulted in a hematoma and bleeding to her forehead. S7Licensed Practical Nurse further indicated that the documented date and time the responsible party was notified on Resident #1's incident report dated 01/11/2026 was the date and time she attempted to notify Resident #1's responsible party. S7Licensed Practical Nurse confirmed she attempted twice to notify Resident #1's responsible party of Resident #1's fall but was unsuccessful. In an interview on 03/12/2026 at 3:51PM, S1Director of Nursing confirmed S7License Practical Nurse should have notified Resident #1's responsible party of Resident #1's fall on 01/11/2026 and emergency room transfer.

Based on interviews and record reviews, the facility failed to ensure a resident's care plan to prevent falls included an individualized resident-centered intervention for 2 (Resident #1, Resident #2) of 4 sampled residents reviewed for falls. Findings: Resident #1Review of Resident #1's Minimum Data Set with an Assessment Reference Date of 12/16/2025 revealed, in part, Resident #1 had a Brief Interview for Mental Status score of 5, which indicated Resident #1 had severe cognitive impairment. Further review revealed Resident #1 had a diagnosis dementia (memory loss) and reduced mobility. Review of Resident #1's unwitnessed fall report dated 12/24/2025 revealed Resident #1 had an unwitnessed fall and was found on the floor in the hallway. Further review revealed Resident #1 was confused and unable to explain how the fall occurred. Review of Resident #1's unwitnessed fall report dated 01/11/2026 revealed Resident #1 had an unwitnessed fall and was found on the floor in her room. Further review revealed Resident #1 was confused and unable to explain how the fall occurred. Review of Resident #1's care plan revealed, in part, Resident #1 was at risk for falls related to impaired functional mobility and dementia. Further review revealed fall interventions were implemented on 12/24/2025 to encourage Resident #1 to ask for assistance with transfers and ambulation; and, on 01/11/2026 to make sure Resident #1's call light was within reach. In an interview on 03/10/2026 at 5:23PM, Resident #1's physician indicated Resident #1 was not aware of her physical inabilities, had poor safety awareness, and was difficult for Resident #1 to follow commands. In an interview on 03/12/2026 at 3:30PM, S2Assistant Director of Nursing indicated educating Resident #1 was not an appropriate fall intervention due to her impaired cognition and poor safety awareness. S2Assistant Director of Nursing further indicated Resident #1 would not remember due to poor cognition to use the all light to ask for staff assistance. Resident #2Review of Resident #2's Quarterly Minimum Data Set with an Assessment Reference Date of 01/13/2026 revealed, in part, Resident #2 had a Brief Interview of Mental Status score of 5, which indicated Resident #2 had severe cognitive impairment. Further review revealed Resident #2 was dependent on staff for transfers and had a diagnosis of dementia. Review of Resident #2's care plan revealed, in part, Resident #2 had a self-care deficit and required staff assistance with activities of daily living. Further review revealed Resident #2 was at risk for falls related to dementia and confusion and staff were to encourage the resident to use call light for staff assistance. Review of Resident #2's witnessed fall report dated 09/24/2025 revealed, in part, Resident #2 had a fall in his room witnessed by his wife. Further review revealed Resident #2's wife indicated she told Resident #2 to wait for help but he did not follow her command and attempted to get into the bed own his own, and fell to the floor. Review of Resident #2's Nursing Post Fall Risk Evaluation dated 09/24/2025 revealed, in part, Resident #2 was confused and/or disoriented. Further review revealed the immediate action taken by staff to prevent Resident #2 from further falls was to educate Resident #1 on the importance of calling for staff assistance. In an interview on 03/10/2026 at 12:09PM, S6Licensed Practical Nurse indicated Resident #2 would not understand to use a call light for staff assistance. In an interview on 03/10/2026 at 2:44PM, S5Director of Social Services and Recreation indicated educating Resident #2 to use his call light for staff assistance was not an appropriate fall intervention because Resident #2 could not be able to recall a command after he was told.In an interview on 03/10/2026 at 5:30PM, Resident #2's physician indicated Resident #2's dementia had progressed, had poor cognition, and Resident #2 would not remember to use a call light for staff assistance. In an interview on 03/12/2026 at 12:35PM, Resident #2 was asked and he was unable to understand what a call light was used for. In an interview on 03/12/2026 at 12:37PM, S4Certified Nursing Assistant indicated Resident #2 would not remember to use a call light if staff assistance was needed. In an interview on 03/12/2026 at 12:42PM, S4Licensed Practical Nurse indicated Resident #2 would not remember to use a call light if staff assistance was needed. In an interview on 03/12/2026 at 3:30PM, S2Assistant Director of Nursing indicated educating Resident #2 was not an appropriate fall intervention because Resident #2 would not remember to use a call light if staff assistance was needed

Based on interviews and record review, the facility failed to document a resident's newly identified wound in the resident's clinical record for 1 (Resident #6) of 3 sampled residents reviewed for pressure ulcers Findings:Review of the facility's undated Skin and Wound Management Guidelines revealed, revealed all pressure related injuries and/or moisture associated skin damage would be documented in the Skin and Wound Module. Further review revealed alterations in skin integrity which are not monitored in the Skin and Wound Module as mentioned above would require a detailed description in the resident's progress notes. Review of Resident #6's care plan revealed, in part, Resident #6 had a potential for impaired skin integrity related to decreased mobility and bladder/bowel incontinence. In a telephone interview on 03/12/2026 at 2:20PM, S8Licensed Practical Nurse indicated on 03/08/2026 when she was preparing to transfer Resident #6 to the hospital for an evaluation, she identified a new reddened area on Resident #6's buttocks. S8Licensed Practical Nurse further indicated she did not document the assessment of Resident #6's change in skin condition in Resident #6's clinical record. In an interview on 03/12/2026 at 3:23PM, S2Assistant Director of Nursing indicated when S8Licensed Practical Nurse identified a new reddened area to Resident #6's buttocks she should have documented the new reddened area in Resident #6's clinical record. In an interview on 03/12/2026 at 3:43PM, S1Director of Nursing further indicated when S8Licensed Practical Nurse identified a new reddened area to Resident #6's buttocks she should have documented the new reddened area in Resident #6's clinical record.

Based on interviews and record reviews, the facility failed to ensure residents were free from financial misappropriation for 1 (Resident #2) of 3 sampled residents investigated for abuse. Findings::Review of the facility's undated Residents' Rights policy and procedure, revealed, in part, residents had the right to be free from misappropriation. Review of the facility's incident report, dated 10/02/2025, revealed, in part, S3Certified Nursing Assistant (CNA) was accused of taking a personal check from Resident #2's unsecured checkbook, wrote Resident #2's check out to herself, and deposited the funds into S3CNA's own personal account. Further review revealed the facility substantiated the above mentioned allegation of misappropriation. Review of the facility's documentation revealed, in part, Resident #2's check was written to S3CNA for the amount of $400.00. Further review revealed S3CNA endorsed the check with her signature. In an interview on 12/03/2025 at 12:20PM, Resident #2 indicated she did not give S3CNA a personal check from her bank account. Resident #2 further indicated S3CNA was not authorized to write or cash a personal check from Resident #2's bank account. In an interview on 12/04/2025 at 11:45AM, S1Administrator confirmed the above mentioned allegation of misappropriation of Resident #2's financial property by S3CNA was substantiated.