Every finding on record at St. Margaret's Daughters Home

Based on observations, interviews, and record reviews, the facility failed to ensure:1. Expired medication was not available for use (Med Prep Area d, Med Storage Room e); 2. Multi-dose medication containers were labeled with an expiration date to ensure medication was removed from use when the expiration date was exceeded (Med Prep Area b, Med Cart a);3. Medication containers contained the necessary resident identifying information (Med Prep Area c). This deficient practice was identified for 3 (Med Prep Area b, Med Prep Area c, Med Prep Area d) of 4 sampled med prep areas, 1 (Med Storage Room e) of 1 sampled medication storage rooms, and 1 (Med Cart a) of 2 sampled medication carts observed for medication storage requirements. Findings: Review of the facility's Insulin policy and procedure, with a revision date of [DATE], revealed, in part, open insulin must be dated the day it was opened and the date it would expire. Further review revealed the life span for insulin was only 28 days from the date the container was opened and must be discarded after 28 days. Review of the facility's undated Liberalized Medication policy and procedure, revealed, in part, the date a multi-dose medication container was opened was to be recorded on the medication container. 1. Review of Lispro's (medication used to treat high blood glucose levels) Manufacturer's Guidelines revealed, in part, after Lispro multi-dose flex pens were opened, the medication could be stored at room temperature up to 86 degrees Fahrenheit (F) (30 degrees Celsius [C]) for up to 28 days. Further review revealed staff were to throw away all opened vials after 28 days of use, even if there was medication left in the vial. Review of Toujeo's (medication used to treat high blood glucose levels) Manufacturer's Guidelines revealed, in part, after Toujeo multi-dose flex pens were opened, the medication could be stored at room temperature up to 86 F (30 C) for up to 28 days. Observation of Med Prep Area d with S6Registered Nurse (RN) on [DATE] at 4:30AM revealed the following opened and unrefrigerated medications were available for resident use:- Resident #R5's Lispro insulin multi-dose flex pen with an opened date of [DATE] (32 days from open date); and,- Resident #R6's Toujeo multi-dose flex pen with an opened date of [DATE] (40 days from open date). Observation of Med Storage Room e with S6RN on [DATE] at 4:35AM revealed Resident #R8's Tramadol (medication used to treat pain) 50 milligrams (mg) with 21 pills remaining, with an expiration date of [DATE] available for use. In an interview on [DATE] at 4:40AM, S6RN indicated the above mentioned insulin flex pens were opened, unrefrigerated, expired, and available for resident use, and should not have been available for use. S6RN further indicated Resident #R8's expired Tramadol should have been removed from Med Storage Room e, and should not have been available for resident use. In an interview on [DATE] at 9:45AM, S2Director of Nursing (DON) indicated multi-dose medication pens were required to be labeled with the date the medication pen was opened and then discarded 28 days later. S2DON further indicated the floor nurses should have contacted S2DON when they had expired controlled substances for S2DON to remove. 2.Review of Novolog's (medication used to treat high blood glucose levels) Manufacturer's Guidelines for Storage before Use revealed, in part, Novolog multi-dose flex pens could be stored at room temperature for up to 28 days. Observation of Med Prep Area b on [DATE] at 4:10AM revealed, in part, Resident #R7's opened and unrefrigerated Novolog insulin multi-dose flex pen did not have an opened date documented. In an interview on [DATE] at 4:20AM, S9Licensed Practical Nurse (LPN) indicated Resident #R7's above-mentioned multi-dose flex pen of insulin was opened, stored at room temperature, and should have been labeled with an opened date. S9LPN further indicated she did not know when the above-mentioned multi-dose flex pen of insulin was opened; therefore, the expiration date was unknown, and Resident #R7's Novolog multi-dose flex pen in Med Prep Area b should not have been available for use. Observation of Med Cart a with S8LPN on [DATE] at 6:15AM revealed Resident #R10's opened and unrefrigerated multi-dose injection pen of Tymlos (medication used to treat osteoporosis) 80 micrograms (mcg) per dose did not have an opened date documented. Further observation revealed Resident #R10's Tymlos multi-dose injection pen contained directions for the multi-dose pen to be discarded after 30 days of opening. In an interview on [DATE] at 6:30AM, S8LPN indicated Resident #R10's above mentioned multi-dose medication was not labeled with an opened date and should have been. In an interview on [DATE] at 9:45AM, S2Director of Nursing (DON) indicated multi-dose medication pens were required to be labeled with the opening date and then discarded after 28 days. 3.Observation of Med Prep Area c with S7RN on [DATE] at 4:54AM revealed Resident #R4's medication storage area contained a medication cup with 17 unlabeled small white pills. In an interview on [DATE] at 4:57AM, S7RN confirmed she was the nurse responsible for Resident #R4's medication storage area which contained a medication cup with 17 unlabeled small white pills. S7RN indicated she was unaware the above mentioned pills were in Resident #R4's medication storage area, when they were placed there, who placed them there, what the above 17 white pills were, or when the pills expired. S7RN further indicated the above mentioned 17 unlabeled unknown small white pills should not have been available for resident administration. In an interview on [DATE] at 9:45AM, S2Director of Nursing (DON) indicated Med Prep Area c should not have had 17 unlabeled small round pills in a medicine cup in Resident #R4's storage area available for administration.

Based on interviews and record reviews, the facility failed to ensure an allegation of neglect was reported to the State Survey Agency for 1 (Resident #3) of 3 sampled residents investigated for neglect. Findings:Review of the facility's Abuse Prevention policy and procedure, revised on 06/17/2002, revealed, in part, neglect was defined as the failure to provide goods or services to avoid physical harm, mental anguish, or mental illness. Further review revealed neglect was interpreted as a failure through inattentiveness, carelessness, or omission to provide timely, consistent, safe, adequate, and appropriate services, and treatment and care, including, but not limited to actives of daily living care. Further review revealed the absence of reasonable accommodations of individual needs or preferences may result in neglect. Further review revealed any person who witnesses or suspected abuse or neglect would immediately inform the house supervisor who would notify the Administrator, and a report would be uploaded or entered to the Statewide Incident Management System (SIMS) portal. Review of the facility's July 2026 SIMS incident log revealed, in part, no SIMS reports were entered for July 2026. Review of S5Licensed Practical Nurse Supervisor's written statement, dated 07/13/2026, revealed in part, Resident #3 felt someone was trying to kill him and that Resident #3 did not feel safe. Further review revealed Resident #3 indicated he was struggling to breathe after the Certified Nursing Assistant (CNA) closed Resident #3's room door and left Resident #3 alone. Further review revealed S1Administartor and S2Director of Nursing were notified of the situation. In an interview on 07/22/2026 at 2:15PM, S4Social Services indicated Resident #3's amyotrophic lateral sclerosis (ALS) social worker informed her on 07/14/2026 that Resident #3's allegation that occurred on 07/13/2026 would need to be reported to state officials. In a telephone interview on 07/23/2026 at 10:11AM, S14Respiratory Therapist (RT) indicated she was the RT who provided care to Resident #3 from 10:45PM on 07/12/2026 through 7:15AM on 07/13/2026. S14RT further indicated Resident #3 had pressed his call bell as well as he texted S14RT several times from 2:30AM to 4:00AM on 07/13/2026 requesting care from S11Certified Nursing Assistant (CNA). S14RT further indicated after receiving the texts from Resident #3 she was not able to locate S11CNA until approximately 5:00AM. S14RT further indicated when S11CNA left Resident #3's room, S11CNA closed Resident #3's door against Resident #3's wishes. S14RT further indicated the facility did not interview her and/or request a written statement from her regarding the above mentioned incident. In a telephone interview on 07/23/2026 at 10:54AM, Resident #3's hospice administrator indicated she notified S1Administrator on 07/13/2026 at 6:30PM that Resident #3 made allegations he had not received adequate care from a CNA and Resident #3 felt unsafe. Resident #3's hospice administrator further indicated she informed S1Administrator the facility should investigate Resident #3's concerns. In an interview on 07/23/2026 at 3:20PM, S1Administrator indicated she was made aware of Resident #3's allegations on 07/13/2026 at 6:31PM. S1Administartor further confirmed a SIMS report was not submitted to the State Survey Agency as required.

Based on record reviews and interviews, the facility failed to ensure:1. An alleged incident of neglect was thoroughly investigated (Resident #3); and,2. Residents were protected from further potential neglect while an investigation was in progress.This deficient practice was identified for 1 (Resident #3) of 3 sampled residents investigated for neglect. Findings:In an interview on 07/22/2026 at 2:15PM, S4Social Services indicated she was informed by the amyotrophic lateral sclerosis (ALS) social worker that the incident on 07/13/2026 with Resident #3 would need to be reported to state officials, due to she was a mandated reporter for abuse and neglect. In a telephone interview on 07/23/2026 at 10:54AM, Resident #1's hospice administrator indicated she notified S1Administrator on 07/13/2026 at 6:30PM that Resident #3 made allegations he had not received adequate care from a CNA, Resident #3 felt unsafe, and the facility should investigate. Review of a written statement, dated 07/13/2026, by S5Licensed Practical Nurse Supervisor, revealed in part, Resident #3 felt someone was trying to kill him and that he did not feel safe. Further review revealed Resident #3 indicated he was struggling to breathe after the Certified Nursing Assistant (CNA) closed his room door and left him alone. Further review revealed S1Administartor and S2Director of Nursing were notified of the situation. 1.Review of the facility's Abuse Prevention policy and procedure, revised on 06/17/2002, revealed in part, a full investigation of neglect would include an interview with the resident, other residents who were in the area, any other witnesses who were in the area, and the complainant. Further review revealed written and signed statements would be solicited. Review of the facility's undated Resident Abuse policy and procedure revealed, in part, upon receipt of a report of an allegation or violation of the resident rights law, the administration shall thoroughly investigate the situation and a written report will be prepared. On 07/22/2026 at 1:50PM, S1Administrator was presented with a request for all documentation related to the facility's investigation of the 07/13/2026 alleged incident involving Resident #3. Review of the facility's investigation evidence of the 07/13/2026 incident involving Resident #3, revealed, in part, no evidence witness interviews were performed and/or witness statements were obtained from any of the direct care staff that were present during the 07/13/2026 alleged incident involving Resident #3. In an interview on 07/22/2026 at 3:00PM, S2Director of Nursing (DON) indicated the only documentation the facility could present related to the facility's investigation of the 07/13/2026 alleged incident involving Resident #3 was a progress note, and 4 written statements by supervisory staff who were not present during the time of the alleged incident. In an interview on 07/22/2026 at 1:55PM, S13Respiratory Therapist (RT) indicated she was the RT assigned to Resident #3 on 07/13/2026 during the 6:45AM to 7:15PM shift. S13RT further indicated Resident #3 required a breathing treatment and suctioning on 07/13/2026 at 7:00AM, which was abnormal for Resident #3. S13RT further indicated the facility did not interview her and/or request a written statement from her regarding the above mentioned incident. In a telephone interview on 07/23/2026 at 10:11AM, S14RT indicated she was the RT who provided care to Resident #3 from 10:45PM on 07/12/2026 through 7:15AM on 07/13/2026. S14RT further indicated Resident #3 had pressed his call bell as well as he texted S14RT several times from 2:30AM to 4:00AM on 07/13/2026 requesting care from S11Certified Nursing Assistant (CNA). S14RT further indicated after receiving the texts from Resident #3 she was not able to locate S11CNA until approximately 5:00AM. S14RT further indicated when S11CNA left Resident #3's room, S11CNA closed Resident #3's door against Resident #3's wishes. S14RT further indicated the facility did not interview her and/or request a written statement from her regarding the above mentioned incident. In an interview on 07/23/2026 at 3:30PM, S1Administrator indicated she did not identify through the investigation that Resident #3's alleged incident actually occurred on the overnight shift of 6:45PM on 07/12/2026 through 7:15AM on 07/13/2026 shift. S1Administrator further indicated she did not discover through the investigation the actual time the event took place. S1Administartor further indicated the facility did not have statements from any staff working the overnight shift from 07/12/2026-07/13/2026. 2.Review of the facility's Abuse Prevention policy and procedure, revised on 06/17/2002, revealed in part, residents will be kept free and protected from any form of abuse or neglect. Further review revealed any current employee who had been identified in a report of alleged abuse or neglect will be immediately suspended from work without pay during the investigation of the report. Review of the facility's undated Resident Abuse policy and procedure, revealed, in part, any employee suspected of abuse or neglect will be removed from direct care of residents while the investigation was in progress. In an interview on 07/22/2026 at 3:10PM, S2DON indicated she was informed of Resident #3's allegations 07/13/2026 prior to 7:00PM. In an interview on 07/22/2026 at 3:30PM, S3Human Resources Coordinator (HRC) indicated S11CNA was not suspended and worked her normal 6:45PM to 7:15AM night shift on 07/13/2026. S3HRC further indicated it wasn't until 07/14/2026 that S11CNA was terminated for unprofessional conduct. In a telephone interview on 07/23/2026 at 11:52AM, S5LPN Supervisor indicated S11CNA was the only CNA assigned to Resident #3 on 07/12/2026 during the 6:45PM to 7:15AM night shift when the alleged incident occurred. Review of S11CNA's time records, dated 07/13/2026 through 07/14/2026, revealed in part, S11CNA was clocked in from 07/13/2026 at 7:25PM to 07/14/2026 at 7:28AM. Review of the facility's 07/13/2026 staffing schedule revealed, in part, S11CNA was assigned and worked on the unit Resident #3 resided on during the 6:45PM to 7:15AM night shift. In an interview on 07/23/2026 at 3:30PM, S1Administrator indicated S11CNA was allowed to work on 07/13/2026 during the 6:45PM to 7:15AM night shift. S1Administrator further indicated S11CNA should not have been allowed to work the night shift of 07/13/2026-07/14/2026 to allow the facility's residents to be protected from S11CNA's potential neglect during the investigation.

Based on interviews and record reviews, the facility failed to provide the required behavioral health training for 4 (S9Licensed Practical Nurse [LPN], S11Certified Nursing Assistant [CNA], S15CNA, S16CNA) of 5 sampled direct care staff's personnel files reviewed for training requirements. Findings:Review of S9LPN's personnel filed revealed a hire date of 04/27/2026. Further review of S9LPN's personnel file revealed no evidence S9LPN had received behavioral health training, as required. Review of S11CNA's personnel file revealed a hire date of 05/19/2026. Further review of S11CNA's personnel file revealed no evidence S11CNA had received behavioral health training, as required. Review of S15CNA's personnel file revealed a hire date of 03/19/2026. Further review of S15CNA's personnel file revealed no evidence S15CNA had received behavioral health training, as required. Review of S16CNA's personnel file revealed a hire date of 11/16/2023. Further review of S16CNA's personnel file revealed no evidence S16CNA had received behavioral health training, as required. On 07/20/2026 at 3:55PM, S3Human Resources (HR) Coordinator was presented with a request for the above mentioned staff's behavioral health training. On 07/22/2026 at 9:38AM, S3HR Coordinator was presented with a request for the above mentioned staff's behavioral health training. In an interview on 07/22/2026 at 9:39AM, S3HR Coordinator indicated she was responsible for all staff members' training and was to ensure staff received the correct training, as required. In an interview on 07/22/2026 at 10:00AM, S3HR Coordinator indicated the facility could not provide any evidence the above mentioned staff had received behavioral health training, as required. In an interview on 07/23/2026 at 3:30PM, S1Administrator was presented with the above mentioned findings. S1Administrator could not present any documented evidence to dispute the above mentioned deficient practice.

Based on interviews and record reviews, the facility failed to ensure a resident's medication administration was accurately documented for 1 (Resident #R11) of 4 sampled residents investigated for accurate medication administration documentation. Findings:Review of the facility's undated Liberalized Medication Policy policy and procedure, revealed, in part, the individual that administered medication shall document under the resident's Electronic Medical Administration Record (eMAR) after giving each medication. Review of the facility's undated Licensed Practical Nurse (LPN) job description revealed, in part, a key responsibility of the LPN was to maintain accurate and timely documentation in accordance with state and federal regulations and facility policies. On 07/21/2026 at 11:00AM, S1Administrator was presented with a request for all July 2026 medication administration records for Resident #R11. Review of Resident #R11's medical record revealed, in part, Resident #R11 was admitted to the facility on [DATE] with diagnoses which included unspecified pain, chronic obstructive pulmonary disease (COPD), and rheumatoid arthritis. Review of Resident #R11's July 2026 physician's orders revealed, in part, an order for oxycodone hydrochloride (HCl) (a Schedule II controlled medication used to treat pain) oral tablet 5 milligrams (mg) one tablet by mouth every 6 hours as needed for pain. Review of Resident #R11's July 2026 Controlled Drug Receive/Record/Disposition Form revealed, in part, Resident #R11's oxycodone 5 mg was documented as having been administered on 07/17/2026 at 5:56PM with a count of 29 tablets remaining. Further review revealed the next administration was on 07/17/2026 at 3:30AM with 28 tablets remaining. Further review revealed Resident #R11's oxycodone 5 mg was documented as having been administered the following additional times:- 07/18/2026 at 2:30PM;- 07/18/2026 with an illegible PM time;- 07/19/2026 at 6:30AM;- 07/19/2026 at 12:23PM;- 07/20/2026 at 6:02AM;- 07/20/2026 at 8:36AM; and,- 07/21/2026 at 4:30AM. Review of Resident #R11's July 2026 eMAR revealed, in part, Resident #R11's oxycodone 5 mg was documented as having been administered the following times:- 07/17/2026 at 5:56PM;- 07/18/2026 at 2:29PM;- 07/20/2026 at 8:33AM; and- 07/20/2026 at 3:41PM. In an interview on 07/21/2026 at 6:30AM, S8LPN indicated Resident #R11's second dose of oxycodone 5 mg administered on 07/17/2026 at 3:30AM should not have been documented with an earlier time than the first dose documented as administered on 07/17/2026 at 5:56PM on Resident #R11's Controlled Drug Receive/Record/Disposition Form. S8LPN further indicated the number of doses of oxycodone 5 mg administered to Resident #R11 should have been the same on Resident #R11's eMAR and Controlled Drug Receive/Record/Disposition Form. In an interview on 07/21/2026 at 9:45AM, S5LPN Supervisor indicated S5LPN Supervisor did not document S5LPN Supervisor administered Resident #R11 a dose of oxycodone 5 mg on 07/20/2026 at 3:41PM on Resident #R11's Controlled Drug Receive/Record/Disposition Form and should have. In an interview on 07/21/2026 at 10:15AM, S2Director of Nursing confirmed Resident #R11's July 2026 eMAR and Controlled Drug Receive/Record/Disposition Form were not accurate and complete, and should have been.

Based on interviews and record reviews, the facility failed to ensure:1. A resident's grievance was formally documented on the facility's Grievance Log (Resident #R12); and,2. The facility's grievance policy included the required components. This deficient practice was identified for 1 (Resident #R12) of 4 sampled residents investigated for grievances. Findings: 1.Review of the facility's undated Complaints/Grievances policy and procedure revealed, in part, all grievances/complaints and the resolutions would be documented in the facility's grievance log. On 07/20/2026 at 9:30AM S1Administrator was presented with a written request for the facility's Grievance Log for the past 3 months. Review of S5Licensed Practical Nurse (LPN) Supervisor's written statement, dated 07/13/2026, revealed, in part, Resident #R12 complained about a night shift Certified Nursing Assistant (CNA) who told Resident #R12 to stop calling the front desk for the CNA. Further review revealed the CNA did not want to empty Resident #R12's urinal or get Resident #R12 up in the morning. Further review revealed the CNA told Resident #R12 the CNA had other things to do. Further review revealed S5LPNSupervisor informed Resident #R12 an investigation would be done, and S1Administrator was notified. Review of the facility's July 2026 Grievance Log revealed, in part, no documentation of Resident #R12's 07/13/2026 grievance against unprofessional CNA conduct. In an interview on 07/22/2026 at 3:15PM, S4Social Services (SS) indicated she was the facility's grievance official. S4SS further indicated the above mentioned July 2026 grievance report was complete. S4SS further indicated the facility's Grievance Log did not include Resident #R12's 07/13/2026 complaint. In an interview on 07/23/2026 at 3:30PM, S2Director Nursing (DON) indicated Resident #R12's complaint was not documented in the facility's Grievance Log because by the time S2DON interviewed Resident #R12, S11CNA had already been terminated for an unrelated issue. 2.On 07/23/2026 at 3:45PM, S1Administrator was presented with a request for the facility's updated and complete grievance policy. Review of the facility's undated Complaints/Grievances policy and procedure, revealed, in part, no documentation the facility's grievance policy included the following required components:- The facility would take immediate action to prevent further potential violations of any resident right while the alleged violation was being investigated;- The facility would ensure all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued; and,- The facility would maintain evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision. In an interview on 07/23/2026 at 4:00PM, S1Administrator indicated the above mentioned policy was the most up to date grievance policy the facility had.

Based on interviews and record reviews, the facility failed to develop an individualized behavioral health care plan to address a resident's behavioral health needs for 1 (Resident #1) of 3 sampled residents reviewed for Findings:Review of Resident #1's Psychiatric Consult Note dated 03/12/2026 revealed, in part, Resident #1 was noted with increased agitation and was verbally aggressive when his needs were not met right away. Further review revealed Resident #1 was defensive and irritable during conversation, and stated he talked loud because he wanted people to understand what he was saying. Further review revealed Resident #1 stated he was a slave in Honduras, and he did not like being disrespected or labeled as something he was not. Review of Resident #1's Nurses Notes dated 04/11/2026, 04/12/202604/18/2026, 04/19/2026, 04/25/2026, and 04/26/2026 was assessed as having behaviors present. Review of Resident #1's Nurses Notes dated 04/08/2026 revealed Resident #1 was observed in the hallway yelling at staff, stating I need a pillowcase. Further review revealed staff promptly provided Resident #1 with a pillowcase; however, Resident #1 continued to yell and display irate behavior. Review of Resident #1's Psychosocial Note dated 04/23/2026 revealed, in part, Resident #1 exhibited increased agitation when his needs or preferences were not met immediately. Review of Resident #1's care plan with a target date of 05/14/2026 revealed a plan of care was not developed to address Resident #1's behaviors, cultural background and preferences, and refusal of outside services. revealed no evidence of a care plan for Resident #1's cultural differences from being from Honduras, nor any evidence of a care plan for Resident #1's refusal for outside services. In an interview on 05/19/2026 at 10:48AM, S5Licensed Practical Nurse (LPN) indicated Resident #1 was a very agitated man and was not easy to calm down when he did not get his way. S5LPN further indicated Resident #1 was never physically aggressive, just verbally aggressive and moved his hands around while yelling. S5LPN further indicated although she was educated on how to de-escalate agitated/aggressive residents, she was never given Resident #1 specific interventions to address Resident #1's above-mentioned behaviors. In an interview on 05/19/2026 at 2:25PM, S3Social Services indicated Resident #1 was scary. S3Social Services further indicated Resident #1 felt as though he was superior to the staff, due to he had to work to become an American citizen. S3Social Services further indicated because of this he viewed situations differently, and was offended by the slightest inconvenience. In an interview on 05/19/2026 at 3:10PM, S3Social Services indicated Resident #1 had refused all therapeutic psychiatric services except the consulting psychiatric group at the facility. S3Social Services further indicated Resident #1 hated answering assessment questions, and he voiced that he felt the assessment questions were questioning his intelligence. In an interview on 05/20/2026 at 12:42PM, S4MDS Nurse indicated Resident #1 would have loud outbursts when things did not go the way he wanted. S4MDS Nurse further indicated the facility should have developed a care plan with interventions on how to handle Resident #1's behaviors and refusal of services. In an interview on 05/20/2026 at 12:55PM, S1Administrator indicated she did not realize this information should have been included on his care plan and confirmed he was having behaviors and refusing services, interventions should have been included on his care plan. In an interview on 05/20/2026 at 1:24PM, S2Director of Nursing (DON) indicated most of Resident #1's behaviors were usually due to misunderstandings and his background growing up in Honduras. S2DON confirmed since he had a different background this information should have been care planned to assist staff in providing care to Resident #1. S2DON further confirmed the refusal of the recommended services should have been care planned, and was not.

Based on observations, interviews, and record reviews, the facility failed to ensure the facility was free of pests. Findings:Observation on 08/18/2025 at 8:56AM revealed 4 black flying insects were present in the kitchen's dry storage room. In an interview on 08/18/2025 at 8:56AM, S11Dietary Manager (DM) confirmed the presence of the black flying insects in the facility's dry storage room and in the facility's kitchen. In an interview on 08/19/2025 at 11:13AM, S11DM confirmed that the facility's kitchen had an increased amount of black flying insects. Observation on 08/19/2025 at 11:20AM revealed 3 black flying insects were present in the kitchen's dry storage room. Observation on 08/19/2025 at 11:23AM revealed 3 black flying insects flying around the kitchen's shelving unit. Observation on 08/19/2025 at 11:24AM revealed a gallon bottle of distilled vinegar with the bottle's cap ajar. Further observation revealed at 4 black insects were floating in the liquid contained in the gallon bottle of distilled vinegar. In an interview on 08/19/2025 at 11:25AM, S11DM confirmed that there were insects floating in the gallon bottle of distilled vinegar. In an interview on 08/19/2025 at 12:12 PM, S2Director of Nursing (DON) was informed of findings in kitchen, including multiple black flying and dead insects. S2DON acknowledged insects should not have been present in the facility's kitchen. In an interview on 08/19/2025 at 12:15PM, S2DON confirmed she was aware that the black flying insects were in the facility, but that she was not aware the insects were in the facility's kitchen. In an interview on 08/20/2025 at 10:33AM, S1Administrator indicated that the black flying insects were periodically present in the facility. S1Administrator further indicated S11DM had not notified S1Administrator that the black flying insects had returned to the facility's kitchen. S1Administrator further indicated that it was part of S11DM's job to be aware of the state of the facility's kitchen. S1Administrator further indicated that S11DM should have notified pest control and facility administration as soon as the black flying insects had returned to the facility's kitchen. S1Administrator confirmed that the black insects should not have been present in the facility.

Based on observations, interviews, and record review, the facility failed to:1. Ensure the facility's ice machine was maintained in a sanitary manner;2. Ensure food stored in the facility's refrigerator and freezer were properly contained and labeled with an open date; and,3. Ensure dietary staff wore proper hair restraints during food handling and preparation (S10Dietary Aide, S11Dietary Manager).This deficient practice was identified for 2 (S10Dietary Aide, S11Dietary Manager) of 2 (S10Dietary Aide, S11Dietary Manager) dietary staff observed for hair restraints. Findings:1. Observation on 08/18/2025 at 9:19AM revealed pink colored residue located on the inside top corner of the facility's ice machine. Further observation revealed a black colored substance on the inside corner of the facility's ice machine. In an interview on 08/18/2025 at 9:19AM, S11Dietary Manager (DM) confirmed the facility's ice machine was not maintained in a sanitary manner and should have been. In an interview on 08/19/2025 at 12:12PM, S2Director of Nursing (DON) acknowledged the ice machine was not maintained in a sanitary manner and should have been. In an interview on 08/20/2025 at 10:30AM, S1Administrator acknowledged the ice machine was not maintained in a sanitary manner as required. 2. Review of the facility's undated policy titled Food Receiving and Storage revealed, in part: the facility's foods were to be stored in a manner that complied with safe handling of food practices. Further review revealed all foods stored in the facility's refrigerator or freezer were to be covered, labeled, and dated so the food would be used by their use-by date, frozen, or discarded. Observation on 08/18/2025 at 9:08AM revealed the following foods were in the facility's refrigerator opened, unlabeled, undated, and available for use: - 1 bag of partially brown shredded lettuce; and, - a fourth of a watermelon. Observation on 08/18/2025 at 9:11AM revealed an opened box of corn dogs in the facility's freezer that was undated, and available for use. Observation on 08/18/2025 at 9:14AM revealed the following foods were in the facility's refrigerator opened, unlabeled, undated, and available for use: - 1 bag of partially brown cilantro; - 1 bag of tortillas; - 1 package of swiss cheese; and, - a half of a red cut onion. Observation on 08/18/2025 at 9:15AM revealed the following cooked foods were in the facility's refrigerator opened, unlabeled, undated, and available for use: - 1 container of a soup like liquid; - 1 container of pureed sweet potatoes; - 1 container of gravy; - 1 container of pureed ham; - 1 container of canned vegetables; - 1 container of pork sausage; and, - 1 container of baked chicken. Observation on 08/18/2025 at 9:16AM revealed the following foods were in the facility's refrigerator opened, unlabeled, undated, and available for use: - 1 package of sliced ham; and, - 1 package of diced ham. In an interview on 08/18/2025 at 9:17AM, S11DM indicated all of the above mentioned items should have been labeled and dated once opened. In an interview on 08/19/2025 at 12:12PM, S2DON Indicated all of the above mentioned items should have been labeled and dated once opened. In an interview on 08/20/2025 at 10:30AM, S1Administrator indicated all of the above mentioned items should have been labeled and dated once opened. 3. Observation on 08/18/2025 at 12:20PM revealed S10Dietary Aide assembled food in Hall g kitchen with her hair not restrained. Observation on 08/20/2025 at 12:38PM revealed S11DM assembled food in the Hall d, her hair not restrained, as required. In an interview on 08/20/2025 at 12:39PM, S11DM indicated she should have restrained her hair while she assembled food in Hall d's kitchen. In an interview on 08/20/2025 at 12:46PM, S1Administrator indicated S10Dietary Aide should have restrained their hair while assembling the residents' food.

Based on observation and interviews, the facility failed to ensure a medication storage room was not accessible to residents and unauthorized staff for 1 (Medication Storage Room a) of 1 (Medication Storage Room a) medication storage rooms observed during general facility observations. Findings:Observation on 08/18/2025 at 11:03AM revealed the door to Medication Storage Room a was unlocked, and unattended. Further observation revealed medications stored in Medication Storage Room a were accessible to residents and unauthorized staff. In an interview on 08/18/2025 at 11:05AM, S3Licensed Practical Nurse (LPN) confirmed Medication Storage Room a was unlocked, and unattended. S3LPN further indicated she left Medication Storage Room a unlocked. In an interview on 08/18/2025 at 11:30AM, S2Director of Nursing indicated Medication Storage Room a should not have been left unlocked and unattended.

Based on observations, interviews, and record reviews, the facility failed to:1. Ensure hazardous chemicals were not accessible to residents (Resident #75's room, Hall c, Hall d, Room f); and, 2. Ensure a resident had sufficient supervision to prevent a fall (Resident #72). This deficient practice was identified for 5 (Resident #75's room, Hall c, Hall d, Room f) of 5 (Resident #75's room, Hall c, Hall d, Room f) locations observed containing unsecured chemicals during observations and for 1 (Resident #72) of 4 (Resident #5, Resident #47, Resident #72, Resident #105) sampled residents investigated for accidents. Findings:1. Observation on 08/18/2025 at 10:26AM revealed a spray bottle with an unknown purple chemical substance on the housekeeper’s cart located on Hall “c”. In an interview on 08/18/2025 at 10:28AM, S5Housekeeper indicated her housekeeper’s cart located on Hall “c” did contain a spray bottle which contained a purple floor cleaner. S5Housekeeper further indicated the floor cleaner was E31, a pH neutralizer cleaner. Observation on 08/18/2025 at 10:30AM revealed a bottle of plant food/fertilizer on a table in the Hall “c” dining room. In an interview on 08/18/2025 at 10:34AM, S6Licensed Practical Nurse (LPN) indicated the plant food/fertilizer should not have been accessible to residents in the Hall “c” dining room. Observation on 08/18/2025 at 10:48AM revealed Hall “d” cabinet next to Room “e” contained a spray bottle with an unknown green chemical substance. In an interview on 08/18/2025 at 10:50AM, S7Certified Nursing Assistant (CNA) indicated the spray bottle located in the Hall “d” cabinet contained a sanitizer. S7CNA further indicted the chemical should be secured and was not. Observation on 08/18/2025 at 11:09AM revealed, in part, the door to Room “f”, a general room for hair care, was propped open. Further observation of Room “f” revealed an cleaning chemicals contained in an unsecured cabinet, and an opened 64 ounce bottle of disinfectant used to clean salon/barbershop equipment/tools. In an interview on 08/18/2025 at 11:13AM, S3LPN indicated the door to Room “f” should always be locked while not in use to avoid resident access to sharps and chemicals. In an interview on 08/18/2025 at 11:30AM, S2Director of Nursing (DON) indicated all chemicals should be secured and not available to residents. Review of Resident #75’s care plan review dated 08/31/2025, revealed, in part, Resident #75 had sensory and perception alterations related to vision. Further review revealed an intervention for staff to remove possible environmental barriers to ensure safety. Further review revealed an intervention for the facility to perform safety risk evaluations as needed. In an interview on 08/18/2025 at 3:57PM, Resident #75 indicted she had two cans of aerosolized insecticide in the room. Observation on 08/18/2025 at 4:00PM revealed two cans of aerosolized insecticide the lower shelf of Resident #75’s room. Observation on 08/19/2025 at 2:44PM revealed S8Licensed Practical Nurse (LPN) picked up the two cans of aerosolized insecticide and placed them in the closet of Resident #75’s room. S8LPN further indicated she was unaware Resident #75 had two cans of aerosolized insecticide in Resident #75’s room. In an interview on 08/20/2025 at 12:30PM, S1Administrator indicated Resident #75 should not have had aerosolized insecticide in her room. 2. Review of the facility’s Accidents/Incidents Policy, last revised on 06/17/2002, revealed, in part the charge nurse and/or the nursing supervisor will initiate a plan of care change that was professionally warranted to ensure a resident’s welfare and safety prior to the end of the shift. Review of Resident #72’s Electronic Medical Record revealed, in part, Resident #72 was admitted to the facility on [DATE] with a history of falling. Review of Resident #72’s Incident and Accident Log, revealed, in part, Resident #72 had a witnessed fall with no injury on 08/17/2025. Review of Resident #72’s Activities of Daily Living (ADL) care plan initiated and revised on 08/19/2025 revealed, in part, Resident #72 required maximal assistance and required the assistance of two person to transfer. Review of Resident #72’s Incident and Accident Log dated 08/20/2025 revealed, in part, S14Certified Nursing Assistant (CNA) attempted to transfer Resident #72 from the bed to the wheelchair without assistance which resulted in a witnessed fall. In an interview on 08/20/2025 at 12:45PM, S2DON indicated Resident #72 was care planned to have two staff assist for transfers. S2DON further indicated Resident #72’s fall care plan was not implemented when S14CNA attempted to transfer Resident #72 without assistance.

Based on observation, interview, and record review, the facility failed to ensure medical documents containing resident health information was stored in a confidential manner for 6 (Resident #2, Resident #13, Resident #65, Resident #92, Resident #97, Resident #106) of 6 (Resident #2, Resident #13, Resident #65, Resident #92, Resident #97, Resident #106) residents identified as not having their health information confidentially maintained. Findings:Observation with S3Licensed Practical Nurse (LPN) on 08/19/2025 at 10:35AM revealed a cardboard box filled with resident records was located under a countertop in the common area, near the kitchen on Hall b. In an interview on 08/19/2025 at 10:36AM, S3LPN indicated after reviewing the documents in the cardboard box, the box contained original copies of the facility's High Risk Meeting sheets, 24-hour Reports, Resident Controlled Drug Record Forms, and Pharmacy Receipts. S3LPN confirmed the documents contained resident health information that should be kept confidential. Observation with S4Assistant Director of Nursing (ADON) on 08/19/2025 at 10:45AM revealed S4ADON reviewed the contents of the above mentioned cardboard box. In an interview on 08/19/2025 at 10:46AM, S4ADON confirmed the above mentioned cardboard box contained facility records with resident specific medical information. S4ADON further indicated these records should not have been placed in a common area and accessible to unauthorized personnel and residents. S4ADON confirmed the contents of the box included original copies of the facility High Risk Meeting Sheets, 24-hour Reports, Resident Controlled Drug Record Forms, and Pharmacy Receipts. In an interview on 08/19/2025 at 10:52AM, S2Director of Nursing (DON) confirmed the box of facility records containing resident specific medical information should not have been placed in a common area which was accessible to the public. In an interview on 08/19/2025 at 10:58AM, S1Administrator confirmed the box which contained facility records containing resident specific medical information should not have been place in a common area which was accessible to unauthorized personnel and residents. Observation of the contents of the above mentioned cardboard box on 08/19/2025 at 11:10AM revealed, in part, multiple documents containing resident specific information. Further review revealed the following documents were contained in the cardboard box: -Resident #65's Controlled Drug Receipt/Record/Disposition Forms for Hydrocodone (narcotic medication used to control pain) and Lorazepam (medication used to treat anxiety) with the date dispensed, drug strength, amount of medication administered and unused medication amount; -The facility's contracted pharmacy's Shipping Manifest dated 06/22/2023 which documented delivery or disposition of Resident #97's Hydralazine (medication used to treat high blood pressure and/or anxiety) and Resident #13's Citalopram (medication used to treat depression);-An untitled document dated 12/30/2024 with a listing of Resident #2, Resident #92, and Resident #97's prescribed antibiotic; and,-A 24-Hour Report for a Resident with a first initial and last name (identified as Resident #106) which revealed documentation of Resident #106's medication received, physician, activities of daily living capabilities, and oxygen orders. In an interview on 08/19/2025 at 11:12AM, S4ADON indicated the resident with the first initial and last name was confirmed as Resident #106

Based on observations, interviews, and record reviews, the facility failed to ensure a resident was assessed to ensure the resident could safely self-administer a medication prior to the resident self-administering medications for 1 (Resident #47) of 4 (Resident #5, Resident #47, Resident #72, Resident #105) sampled residents investigated for accidents. Findings: Review of Resident #47's Minimum Data Set with an Assessment Reference Date of 07/02/2025 revealed, in part, a Brief Interview for Mental status score of 11, which indicated Resident #47 had moderate cognitive impairment. Review of Resident #47's Physician Orders as of 08/20/2025 revealed, in part, no orders for Resident #47 to self-administer his medications, and no order for Voltaren gel (a gel medication used for arthritis pain). Review of Resident #47's Care Plan with a target date of 10/09/2025 revealed, in part, Resident #47 was not care planned to self-administer medications or have medications at his bedside. Review of Resident #47's Electronic Medication Administration Record from 08/01/20225 to 08/31/2025 revealed, in part, documentation that Resident #47's medications were administered by facility staff.Observation on 08/18/2025 at 11:10AM revealed a tube of gel labeled as Voltaren gel was present on Resident #47's bedside table. Observation on 08/19/2025 at 12:19PM revealed a tube of gel labeled as Voltaren gel was present on Resident #47's bedside table. In an interview on 08/19/2025 at 12:22PM, S8Licensed Practical Nurse indicated Resident #47 should not have access to the medication Voltaren. In an interview on 08/19/2025 at 12:31PM, S8LPN indicated Resident #47 was not assessed and/or care planned to self-administer medications. In an interview on 08/20/2025 at 8:47AM, S2Director of Nursing indicated Resident #47 should not have had the medication Voltaren at his bedside because he wasn't assessed and care planned to self-administer medications .

Based on interviews and record reviews, the facility failed to notify the state's Long Term Care (LTC) Ombudsman in writing of a discharge for 1 (Resident #104) of 1 (Resident #104) sampled residents reviewed discharge. Findings: Review of Resident #104's electronic medical record (EMR) revealed, in part, Resident #104 was discharged from the facility on 07/18/2025. Review of Resident #104's nurse's note dated 07/18/2025 at 12:43PM revealed, in part, Resident #104 was discharged from the facility on 07/18/2025 at 10:00AM. Review of the facility's Emergency Transfer Log for June 2025 and July 2025 revealed, in part, the facility only notified the state's LTC Ombudsman of transfers. Further review revealed no evidence Resident #104's discharge was communicated by the facility to the state's LTC Ombudsman. In an interview on 08/19/2025 at 9:34AM, S9Social Services indicated she was unaware the state's LTC Ombudsman had to be notified in writing when any resident was discharged or transferred from the facility; therefore, she had not notified the state's LTC Ombudsman when Resident #104 had discharged on 07/12/2025. In a phone interview on 08/19/2025 at 10:05AM, the facility's assigned state's LTC Ombudsman indicated she had not received a written discharge notice when Resident #104 was discharged . In an interview on 08/20/2025 at 9:55AM, S1Administrator indicated she was unaware the state's LTC Ombudsman had to be notified in writing when any resident was transferred or discharged from the facility. S1Administrator further confirmed the state's LTC Ombudsman was not notified of Resident #104's discharge as required.

Based on interviews and record reviews, the facility failed to ensure a level II Preadmission Screening and Resident Review (PASRR) screening was completed for a resident admitted with a mental health disorder for 1 (Resident #46) of 1 (Resident #46) sampled residents investigated for PASRR. Findings:Review of the Louisiana Department of Health's Instructions for Completing the PASRR Level 1 Screen revised on 06/01/2018 revealed, in part, a resident with a mental illness would not require a Level II screening if the resident did not have a suspected mental illness or intellectual disability. Review of Resident #46's Electronic Medical Record (EMR) revealed Resident #46 was admitted to the facility on [DATE] with diagnoses of, in part, Major Depressive Disorder and Bipolar Disorder. Further review revealed Resident #46 did not have a diagnosis of either dementia and/or Alzheimer's disease. Review of Resident #46's Level 1 PASRR dated 11/12/2024 revealed Resident #46 was identified with a mental disorder of Major Depressive Disorder. Further review revealed the physician documented Resident #46 would need care indefinitely. Review of Resident #46's EMR and physical chart revealed no evidence a Level II PASRR was completed for Resident #46.In an interview on 08/19/2025 at 2:57PM, S9Social Service Designee (SSD) indicated the facility had not submitted a request and ensured a PASRR level II screen was completed prior to or after Resident #46's admit. In an interview on 08/20/2025 at 12:59PM, S2Director of Nursing (DON) indicated Resident #46 did not have a completed PASRR Level II screening, and she was not aware a Level II PASRR was needed for Resident #46.

Based on observations, interviews, and record reviews, the facility failed to:1. Ensure a resident's care plan was revised after a witnessed fall (Resident #72); and,2. Ensure a residents fall care plan interventions were implemented after a witnessed fall (Resident #72). This deficient practice was identified for 1 (Resident #72) of 4 (Resident #5, Resident #47, Resident #72, Resident #105) sampled residents investigated for accidents. Findings:1.Review of the facility's Accidents/Incidents Policy, last revised on 06/17/2002, revealed, in part the charge nurse and/or the nursing supervisor will initiate a plan of care change that was professionally warranted to ensure a resident's welfare and safety prior to the end of the shift. Review of Resident #72's Electronic Medical Record revealed, in part, Resident #72 was admitted to the facility on [DATE] with a history of falling. Review of Resident #72's Incident and Accident Log, revealed, in part, Resident #72 had a witnessed fall with no injury on 08/17/2025. Review of Resident #72's care plan with a next review date of 11/10/2025 and last revision date of 05/19/2025 revealed, in part, Resident #72's care plan was not updated with new goals and/or interventions following Resident #72's fall on 08/17/2025. In an interview on 08/19/2025 at 1:30PM, S2Director of Nursing (DON) indicated Resident #72's care plan was not updated with fall interventions after a witnessed fall on 08/17/2025, and should have been. In an interview on 08/19/2025 at 2:30PM, S13Minimum Data Set (MDS) Nurse indicated the nurse supervisor/charge nurse on duty did not update Resident #72's care plan after Resident #72's fall prior to the end of the shift on 08/17/2025, and should have. 2. Review of Resident #72's Activities of Daily Living (ADL) care plan initiated and revised on 08/19/2025 revealed, in part, Resident #72 required maximal assistance and required the assistance of two person to transfer. Review of Resident #72's Incident and Accident Log dated 08/20/2025 revealed, in part, S14Certified Nursing Assistant (CNA) attempted to transfer Resident #72 from the bed to the wheelchair without assistance which resulted in a witnessed fall. In an interview on 08/20/2025 at 12:45PM, S2DON indicated Resident #72 was care planned to have two staff assist for transfers. S2DON further indicated Resident #72's fall care plan was not implemented when S14CNA attempted to transfer Resident #72 without assistance.

Based on record review, the facility failed to electronically submit payroll information for direct care staffing as required. Findings included: Review of the facility's Payroll Based Journal (PBJ) Staffing Data Report [NAME] Report 1705D Fiscal Year (FY) Quarter 4 2024 (July 1 - September 2024) revealed, in part, the facility failed to submit staffing data for Quarter 4. There was no documented evidence and the facility did not present any documented evidence the facility's PBJ Staffing Data for FY Quarter 4 2024 (July 1 - September 30) was submitted as required.

Based on observations, interviews, record review, and facility document review it was determined that the facility failed to ensure the medication error rate was not greater than 5% by having a medication error rate of 6.66 % for 2 (Resident #3 and Resident #R5) of 7 residents observed during medication administration. Findings Included: Resident #3 Review of Resident #3's medical record revealed, in part, Resident #3 was admitted to the facility on [DATE] with a diagnosis of, in part, Iron Deficiency Anemia (low levels of iron in the blood). Review of Resident #3's Minimum Data Set with an Assessment Reference Date (ARD) of 09/18/2024 revealed, in part, Resident #3 had a brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #3 was cognitively intact. Review of Resident #3's December 2024 physician's orders revealed, in part, Ferrous Gluconate (a medication used to treat low levels of iron in the blood) oral tablet give one tablet once a day by mouth. Observation on 12/17/2024 at 8:15AM revealed S7Licensed Practical Nurse (LPN) attempted to administer one Ferrous Sulfate 325 milligrams (mg) tablet by mouth to Resident #3. In an interview on 12/17/2024 at 8:21AM, Resident #3 indicated she refused to take the iron pill S7LPN attempted to administer to her because she knew it was the incorrect medication. In an interview on 12/17/2024 at 08:24AM S7LPN indicated Resident #3 was ordered 240 mg of Ferrous Gluconate. S7LPN further indicated she attempted to administer 325 mg of Ferrous Sulfate to Resident #3 and should not have. In an interview on 12/17/2024 at 9:40AM, S16Pharmacist indicated Ferrous Sulfate should not be used in place of Ferrous Gluconate unless approved by a physician. In an interview on 12/18/2024 at 3:30PM, S2Director of Nursing (DON) indicated Resident #3's physician's order was for one tablet of Ferrous Gluconate 240 mg once a day by mouth. S2DON further indicated S7LPN should not have attempted to administer Resident #3 one tablet of Ferrous Sulfate 325 mg. Resident #R5 Review of Resident #R5's medical records revealed, in part, Resident #5 was admitted to the facility on [DATE] with diagnoses of, in part, Anemia, Cognitive Deficit, and Dementia. Review of Resident #R5's December 2024 physician's orders revealed, in part, Ferrous Gluconate 324 milligrams (mg) one tablet by mouth daily with breakfast. Observation on 12/17/2024 at 8:43AM revealed S8Licensed Practical Nurse (LPN) attempted to administer one Ferrous Gluconate 240 mg tablet by mouth to Resident #R5. In an interview on 12/17/2024 at 8:57AM, S8LPN indicated Resident #R5 was ordered to receive 324 mg of Ferrous Gluconate. S8LPN further indicated she attempted to administer Resident #R5 240 mg of Ferrous Gluconate, and should not have. In an interview on 12/18/2024 at 3:30PM, S2Director of Nursing (DON) indicated S7LPN should not have attempted to administer Resident #R5 the incorrect dose of Ferrous Gluconate.

Based on observations, interviews, record review, facility document review, and facility policy review it was determined that the facility failed to ensure: 1. Certified Nursing Assistants (CNAs) completed hand hygiene during incontinence care for 2 (Resident #R6 and Resident #R7) of 2 residents observed during incontinence care; and, 2. Clean laundry was kept separate from dirty and/or contaminated laundry for 1 (Laundry Room f) of 7 laundry rooms observed. Findings included: 1. Review of the facility's undated Handwashing policy and procedure revealed, in part, the purpose of handwashing is to prevent cross contamination and control infection. Review of the Centers for Disease Control and Prevention (CDC)'s October 2022 Guidelines for Hand Hygiene in Health-Care Settings revealed, in part, decontaminate hands if moving from a contaminated body site to a clean body site during patient care. Resident #R6 Review of Resident #R6's Minimum Data Set with an Assessment Reference Date (ARD) of 11/06/2024 revealed, in part, Resident #R6 was always incontinent of bowel and bladder. Further review revealed Resident #R6 was dependent on staff for toileting hygiene. Observation on 12/18/2024 at 11:21AM revealed S12Certified Nursing Assistant (CNA) entered Resident #R6's room to perform incontinence care. S12CNA then removed Resident #R6's urine and feces soiled brief, cleaned Resident #R6's buttock's area of feces, and placed a clean brief on Resident #R6 without changing gloves or performing hand hygiene. S12CNA then disposed of Resident #R6's soiled brief into the trash, and then touched Resident #R6's pillow and bed linens with the same gloves used to perform incontinence care. In an interview on 12/18/2024 at 11:45AM, S12CNA confirmed she did not change gloves or perform hand hygiene prior to placing a clean adult brief on Resident #R12, and should have. In an interview on 12/18/2024 at 3:24PM, S2Director of Nursing (DON) confirmed S12CNA did not perform hand hygiene according to infection control standards, and should have. Resident #R7 Review of Resident #R7's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/22/2024 revealed, in part, Resident #R7 was incontinent of bowel and bladder, requiring maximum assistance with toileting, and had a Urinary Tract Infection. Observation on 12/18/2024 at 11:54PM revealed S13Certified Nursing Assistant (CNA) did not perform hand hygiene before putting on gloves to provide peri-care to Resident #R7. Further observation revealed S13CNA did not remove gloves, did not perform hand hygiene, and did not put on new gloves before she placed the clean brief on Resident #R7. Further observation revealed that S13CNA did not perform hand hygiene before she left Resident #R7's room. In an interview on 12/18/2024 at 3:22PM, S13CNA indicated she should have performed hand hygiene before she performed peri-care on Resident #R7, and that she should have changed gloves and performed hand hygiene after she completed peri-care on Resident #R7. In an interview on 12/18/2024 at 3:30PM, S2Director of Nursing (DON) indicated S13CNA should have performed hand hygiene before and after she performed Resident #R7's peri-care. S2DON further indicated S13CNA should have changed gloves, performed hand hygiene, and placed clean gloves on before she placed a clean brief on Resident #R7. 2. In an interview on 12/16/2024 at 11:15AM, S1Administrator confirmed the CNA staff collected, washed, and dried the resident's clothing in the facility's laundry area on each unit. Observation of laundry room f on 12/16/2024 at 12:24PM revealed five unlabeled plastic baskets of laundry on the floor next to each other. In an interview on 12/16/2024 at 12:30PM, S5Housekeeper indicated the above mentioned five baskets of laundry consisted of baskets of both clean and dirty laundry. S5Housekeeper further indicated the clean and dirty laundry should have been labeled, separated, and not left on the floor. In an interview on 12/16/2024 at 12:32PM, S10CNA indicated the baskets of laundry on the floor in the north third floor laundry room were unlabeled, and consisted of clean and dirty laundry. Observation of laundry room f on 12/16/2024 at 1:54PM, revealed visibly soiled linen balled up in the hand wash sink next to the washing machine. Further observation revealed, a pile of clean laundry sitting directly on the top surface of the dryer. In an interview on 12/16/2024 at 1:56PM, S11CNA indicated she placed the above mentioned dirty linen in the handwashing sink and should not have. In an interview on 12/16/2024 at 2:02PM, S4Licensed Practical Nurse (LPN) indicated dirty linen should not have been placed in the handwashing sink. Observation of laundry room f on 12/17/2024 at 9:04AM revealed an uncovered basket on the floor containing contaminated clothing. Further observation revealed cleaned laundry directly on top of the surface of the dryer.

Based on interviews, record review, facility document review, and facility policy review it was determined that the facility failed to follow a physician's order to perform a weekly skin assessment for a resident at risk for pressure ulcers for 1 (Resident #2) of 3 sampled residents reviewed. Findings: Review of the facility's undated Wound Prevention policy and procedure revealed, in part, weekly skin checks will be conducted by the licensed nurse and documented in the resident's Electronic Medical Record (EMR). Review of the facility's undated Skin Care (Decubitus Prevention and Wound Care) policy and procedure revealed, in part, a resident with a score greater than 12 on the Braden Scale with reverse numbering is considered at risk and is checked weekly by the nurse assigned to their care. Review of Resident #2's December 2024 physician orders revealed, in part, complete weekly skin assessment in the morning every Wednesday. Review of Resident #2's care plan with a review date of 02/02/2025 revealed, in part, a care plan for risk for pressure ulcers with approaches which included skin evaluations. Review of Resident #2's assessment report revealed, in part, no documented evidence, and the facility could not provide any documented evidence, a weekly skin assessment was performed on 12/11/2024 as ordered. Review of Resident #2's Braden Scale assessment dated [DATE] revealed, in part, a total score of 8.0 which indicated Resident #2 was at a very high risk of skin breakdown and/or developing a pressure ulcer. In an interview on 12/17/2024 at 1:15PM, S15Licensed Practical Nurse (LPN) indicated Resident #2 was at a high risk for skin breakdown and/or pressure ulcer development. S15LPN further confirmed Resident #2's 12/11/2024 skin assessment was not completed as ordered and should have been. In an interview on 12/17/2024 at 2:45PM, S2Director of Nursing (DON) confirmed Resident #2's skin assessment was not completed on 12/11/2024 as ordered and should have been.