Every finding on record at The Broadway Nursing and Rehabilitation CTR

Based on interviews and record reviews, the facility failed to report alleged/witnessed physical and verbal abuse to the state survey agency within two hours for 2 (Resident #77, Resident #128) of 2 sampled residents investigated for abuse reporting. Findings:Review of the facility's undated Abuse and Neglect Policy and Procedure revealed, in part, each resident had the right to be free from abuse. Further review revealed residents must not be subjected to abuse by anyone, including other residents. Further review revealed instances of abuse of all residents, irrespective of any mental or physical condition, caused physical harm, pain, or mental anguish. Further review revealed verbal abuse included the use of oral or gestured communication regardless of a resident's age, ability to comprehend, or disability. Further review revealed physical abuse included hitting, slapping, or kicking. Further review revealed, a facility employee, who became aware of abuse, shall immediately report the matter to the facility's Administrator or Director of Nursing (DON). Further review revealed the facility's Administrator or designee shall complete a report to the mandated stated agency. Further review revealed if the allegation involved abuse, immediately would have been defined as not later than 2 hours after the allegation is made. Review of Resident #128's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/17/2025 revealed, in part, Resident #128 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. Review of Resident #77's incident report dated 01/25/2026 revealed, in part, Resident #77 had a verbal altercation with another resident when Resident #77 called Resident #128 a dirty f***ing b***h. Further review revealed Resident #128 then slapped Resident #77. Further review revealed the altercation was heard by multiple staff members. Further review revealed Resident #77 indicated that they (he and Resident #128) were arguing and Resident #128 slapped him. Review of Resident #128's incident report dated 01/25/2026 revealed, in part, Resident #128 got into an altercation with Resident #77. Further review revealed Resident #77 had come up and started arguing with Resident #128 and then called her a dirty f***ing b***h. Resident #128 then slapped Resident #77. Further review revealed staff witnessed Resident #128 and Resident #77's altercation.Review of Resident #77's progress note dated 01/25/2026, revealed, in part, Resident #77 called another resident a b***h. Further review revealed Resident #77 was then slapped according to witnesses. Review of Resident #128's progress note dated 01/25/2026 revealed, in part, Resident #128 was involved in an altercation with another resident. Further review revealed Resident #128 was called a b***h and then slapped the other resident per witnesses. Further review revealed Resident #128 denied slapping the other resident and indicated she had just kicked at the other resident's wheelchair. Review of S3Licensed Practical Nurse's (LPN) Incident/Accident Witness Statement dated 01/25/2026 revealed, in part, S3LPN wrote she saw Resident #128 slap Resident #77 across the face and Resident #77's head snapped back. Review of S4Certified Nursing Assistant's (CNA) Incident/Accident Witness Statement dated 01/25/2026 revealed, in part, S4CNA wrote she was standing at the nurse's station when she heard you dirty f***ing b***h then a slap. Review of S5LPN's Incident/Accident Witness Statement dated 01/25/2026 reveled, in part, S5LPN wrote she heard residents screaming at each other, Resident #77 loudly called Resident #128 a dirty f***ing b***h, and then she heard a loud slap. Further review revealed S5LPN wrote she immediately went to the scene and Resident #77 appeared visibly angry. Further review revealed S5LPN wrote, when questioned, both residents (Resident #77 and Resident #128) reported kicking each other and Resident #128 reported slapping Resident #77. There was no documented evidence the above mentioned allegations/observations of physical and verbal abuse were reported to the state agency as required within 2 hours as required. In an interview during entrance conference on 05/26/2026 at 9:02AM, S1Administrator indicated he did not have any State Incident Management System (SIMS) reports for the last 6 months. In an interview on 05/29/2026 at 10:44AM, S7Activities Director indicated Resident #77 and Resident #128 had verbal disagreements with each other at times, and she had told Resident #77 and Resident #128 to remain distant from each other, but Resident #77 and Resident #128 always wanted to sit together anyway. In a telephone interview on 05/29/2026 at 11:48AM, S3LPN indicated she had witnessed Resident #128 slap Resident #77 in the face, and the hit was intentional because she saw Resident #128 swing to hit Resident #77's face.In an interview on 05/29/2026 at 11:52AM, S1Administrator indicated he did not consider the above mentioned incident that occurred between Resident #128 and Resident #77 verbal or physical abuse because Resident #128's BIMS score was low, she hit Resident #77 out of frustration, and Resident #128 did not even remember slapping him. S1Administrator further indicated he had not reported this incident into the SIMS because Resident #128 did not have the mental ability to make decisions. S1Administrator offered no further information that disputed the above mentioned deficient practice. In a telephone interview on 05/29/2026 at 12:11PM, S4CNA indicated on 01/25/2026, she was standing by the nursing station, and Resident #77 had cursed and she saw Resident #77 said something like you b***h to Resident #128. S4CNA further indicated she witnessed Resident #128 and Resident #77 kicking each other's wheelchairs.

Based on interviews and record reviews, the facility failed to ensure a referral was made to the Louisiana Office of Behavioral Health's Preadmission Screening and Resident Review (PASRR) program for a resident with a serious mental disorder for 1 (Resident #108) of 1 sampled resident investigated for PASRR. Findings: Review of Resident #108's electronic medical record (EMR) revealed, in part, Resident #108 was admitted to the facility on [DATE]. Further review revealed Resident #108 did not have a serious mental disorder at the time of admission. Review of Resident #108's Form 142 dated 07/14/2021 revealed, in part, Resident #108 did not have a serious mental disorder. Review of Resident #108's diagnosis information list dated 06/24/2024 revealed Resident #108 had diagnoses, of in part, Psychosis, Major Depressive Disorder, and Anxiety. Further review revealed there was no diagnosis of Dementia or Alzheimer's disease. Review of Resident #108's medical record revealed there was no documented evidence a PASRR Level II evaluation was completed for Resident #108, which indicated Resident #108 had a serious mental disorder. Review of Resident #108's most recent MDS with an ARD of 04/02/2026 revealed, in part, Resident #108 had diagnoses of Anxiety Disorder, Depression, and Psychotic Disorder. In an interview on 05/28/2026 at 1:44PM, S2Social Worker indicated Resident #108's serious mental disorder occurred after Resident #108's admission to the facility. S2Social Worker further indicated Resident #108 required a referral to the Louisiana Office of Behavioral Health's PASRR program due to a serious mental disorder diagnoses of Anxiety Disorder, Depression, and Psychotic Disorder, and it was not completed as required. In an interview on 05/28/2026 at 1:45PM, S1Administrator indicated a submission to the Office of Behavioral Health program to evaluate Resident #108 for a Level II PASRR due to Resident #108's serious mental disorders was not completed, and should have been completed as required.

Based on observations, interviews, and record reviews, the facility failed to: 1. Ensure staff performed hand hygiene when assisting residents with meals (Resident #10, Resident #57, and Resident #63); 2. Ensure infection surveillance was performed after a resident tested positive for a communicable disease (Resident #104); This deficient practice was identified for 5 (Resident #10, Resident #57, Resident #63, Resident #104) of 5 (Resident #10, Resident #57, Resident #63, Resident 91, Resident #104) sampled residents reviewed for infection control. Findings: 1. Review of the facility's Hand Hygiene policy and procedure, dated February 2025, revealed, in part, hand hygiene should be performed after direct contact with residents and before and after assisting residents with meals. Observation on 05/13/2025 at 11:23AM revealed S5Certified Nursing Assistant (CNA) touched Resident #63's leg with ungloved hands then proceeded to touch Resident #63's dining utensils without performing hand hygiene. Further observation revealed S5CNA then proceeded to feed Resident #10, Resident #57, and Resident #63 without performing hand hygiene before and/or after assisting the above mentioned residents with their meal. In an interview on 05/13/2025 at 11:3AM, S5CNA confirmed she did not perform hand hygiene between Resident #10, Resident #57 and Resident #63 and she should have. In an interview on 05/13/2025 at 12:12PM, S3Assistant Director of Nursing/Infection Preventionist (ADON/IP) confirmed hand hygiene should be performed before and after touching a resident and assisting another resident with meals. 2. Review of the facility's undated COVID-19 Testing policy and procedure revealed, in part, after having had high-risk exposure to COVID-19, staff should have had a series of three viral tests for COVID-19. Further review revealed testing was recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again in 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. Further review revealed the tests typically occur at day 1(where day of exposure is day 0), day 3, and day 5. Review of Resident #104's electronic medical record (EMR) revealed, in part, Resident #104 as admitted to the facility on [DATE]. Further review of Resident #104's EMR revealed she tested positive for COVID-19 on 04/12/2025 at 2:55PM. There was no documented evidence, and the provider did not present any documented evidence, the facility performed COVID-19 testing for staff members who were exposed to Resident #104 after she tested positive for COVID-19. In an interview on 05/13/2025 at 4:25PM, S3ADON/IP indicated she had no documented evidence of outbreak testing was completed after Resident #104 tested positive for COVID-19 on 04/12/2025. 3. Review of Resident #91's Minimum Data Set with an Assessment Reference Date of 04/21/2025 revealed, in part, Resident #91 had a urinary catheter. Observation on 05/12/2025 at 9:15AM revealed Resident #91's urinary catheter tubing was on the floor of Resident #91's room. Observation on 05/12/2025 at 2:44PM revealed Resident #91's urinary catheter tubing was on the floor in Resident #91's room. Observation on 05/13/2025 at 3:56PM revealed Resident #91's urinary catheter tubing was on the floor in Resident #91's room. In an interview on 05/13/2025 at 4:00PM, S2Director of Nursing indicated Resident #91's urinary catheter tubing should not be on the floor of Resident #91's room. 48855

Based on observations and interviews the facility failed to ensure the facility was free of pests. Findings: Room A Observation on 05/13/2025 at 8:31AM revealed a brown colored flying insect in Room A. In an interview on 05/13/2025 at 9:23AM, Resident #36, Resident #71's roommate, indicated she had noticed brown colored flying insects in Room A. Observation of Room A 05/14/2025 at 7:50AM revealed S1Administrator tapped Resident #71's live potted plant, and a brown colored flying insect came out of the live potted plant. In an interview on 05/14/2025 at 7:51AM, S1Administrator indicated there was a fly that came out of the live potted plant in Room A. In an interview on 05/14/2025 at 9:50AM, S8Certified Nursing Assistant (CNA) indicated in the past, Resident #36 stored food in Room A, which attracted flying insects. Room B Observation on 05/14/2025 at 8:40AM revealed a brown colored flying insect flew out of a cabinet when the cabinet door was opened in Room B. In an interview on 05/14/2025 at 8:42AM, S3Assistant Director of Nursing/Infection Preventionist (ADON/IP) confirmed there was a brown colored flying insect that flew out of a cabinet in Room B. Room C Observation on 05/14/2025 at 8:55AM, S3ADON/IP revealed a brown colored flying insect in Room C. In an interview on 05/14/2025 at 8:56AM, S3ADON/IP confirmed there was a brown colored flying insect in Room C. Room D Observation on 05/13/25 at 8:45AM revealed a brown colored flying insect in Room D. Room E Observation on 05/14/2025 at 11:20AM revealed a brown colored flying insect in Room E. Room F Observation on 05/14/2025 at 7:55AM revealed a fly light (a device that used light bulbs to attract flying insects) was present in Room F, but the light bulbs were not functioning. Observation on 05/14/2025 at 9:45AM revealed a fly light in Room F, the light bulbs were not functioning. In a phone interview on 05/14/2025 at 8:14AM, S9Exterminator further indicated the light bulbs in the fly light in Room F were not working and needed to be replaced. In an interview on 05/14/2025 at 11:20AM, S1Administrator indicated the light bulbs in the fly light in Room F were not working.

Based on observations, interviews, and record reviews, the facility failed to follow a physician's order for oxygen administration for 1 (Resident #48) of 4 (Resident #27, Resident #34, Resident #48, Resident #77) sampled residents investigated for oxygen administration. Findings: Review of Resident #48's Minimum Data Set with an assessment reference date of 03/27/2025 revealed, in part, a Brief Interview Mental Status score of 12, which was indicative of moderate cognitive impairment. Further review revealed Resident #48 had a medical history of chronic obstructive pulmonary disease, respiratory failure, shortness of breath with exertion, and oxygen therapy. Review of Resident #48's Care Plan with a target date of 07/11/2025 revealed, in part, Resident #48 had an intervention for staff to initiate Resident #48's oxygen as ordered. Review of Resident #48's May 2025 Physician's Orders dated May 2025 revealed, in part, Resident #48 to receive oxygen at a rate of 3 liters per minute (LPM) via nasal cannula (NC) continuously. to prevent hypoxia every shift related to chronic respiratory failure with hypoxia. Observation on 05/12/2025 at 9:25AM revealed Resident #48's oxygen flow meter was set to deliver oxygen to Resident #48 at a rate of 4.5 LPM per NC. Observation on 05/12/2025 at 3:40PM revealed Resident # 48's oxygen flow meter was set to deliver oxygen to Resident #48 at a rate of 4.5 LPM per NC. In an interview on 05/12/2025 at 3:43PM, S11Licensed Practical Nurse (LPN) confirmed Resident #48's oxygen rate was set at 4.5 LPM per the flow meter, but Resident #48's oxygen should have been set at 3 LPM as per the physician's orders. In an interview on 05/13/2025 at 8:30AM, S2Director of Nursing confirmed Resident #48's oxygen rate should have been set at 3 LPM as ordered per the physician.

Based on interviews and record reviews, the facility failed to ensure a resident's choice to eat breakfast in the dining room was supported for 1 (Resident #53) of 4 (Resident #51, Resident #53, Resident #66, Resident #77) sampled residents investigated for choices. Findings: Review of Resident #53's Minimum Data Set with an assessment reference date of 03/13/2025 revealed, in part, Resident #53's Brief Interview Mental Status score was 11, which indicated moderately impaired cognition. Further review revealed Resident #53 used a wheel chair for mobility and required set up or clean up assistance for eating. Review of Resident #53's care plan with a target date of 06/27/2025 revealed, in part, Resident #53 required staff assistance for activities of daily living related to activity intolerance, poor endurance and shortness of breath on exertion and needed set up and/or clean up assistance with meals. Further review revealed Resident #53 required substantial/maximal assistance with transfers. In an interview on 05/12/2025 at 9:23AM, Resident #53 indicated the staff did not help her up out of bed for breakfast this morning. Resident #53 further indicated because of this, Resident #53 had to eat breakfast in her room this morning. In an interview on 05/13/2025 at 10:03AM, S6Certified Nursing Assistant (CNA) indicated Resident #53 sometimes liked to eat in the dining room. S6CNA indicated on 05/12/2025 she was working the hall and indicated by the time she went check in on Resident # 53 it was too late to get her out of bed for breakfast. In an interview on 05/14/2025 at 8:05AM, S1Administrator confirmed he was informed about the incident where Resident # 53 complained about not being taken out of bed to go to the dining room to go eat breakfast, and S1Adminstrator acknowledged the surveyors findings that Resident #53's choice to brought to breakfast should have been supported. In an interview on 05/14/2025 at 11:38AM, S2Director of Nursing confirmed Resident # 53 needs staff help to get her out of bed and into her wheel chair to go eat in the dining room.

Based on interview and record reviews, the facility failed to ensure assessments of a resident's nonoperational dialysis access site were accurately documented in the resident's electronic Medication Administration Record (eMAR) for 1 (Resident #370) of 1 (Resident #370) sampled resident investigated for dialysis. Findings: Review of Resident #370's May 2025 Physician's Orders revealed, in part, an order dated 05/06/2025 for staff to monitor Resident #370's right forearm dialysis AV fistula (a connection between an artery and an vein used for resident's to receive dialysis) for a thrill and a bruit (assessments to indicate if a dialysis fistula was patent and functioning)every shift. Review of Resident #370's May 2025 eMAR revealed, in part, on 05/07/2025, 05/08/2025, 05/09/2025, 05/11/2025, 05/12/2025 on the day shift, 05/10/2025 on the evening shift, and 05/07/2025, 05/08/2025, 05/09/2205, and 05/11/2025 on the night shift, staff documented a Y, indicated that Resident #370's right forearm dialysis AV fistula had a thrill and bruit. In an interview on 05/13/2025 at 10:36AM, S2Director of Nursing (DON) indicated Resident #370's right forearm dialysis AV fistula had not been functioning since Resident #370 returned to the facility on [DATE]. S2DON acknowledged the facility's nurses should have documented a N in Resident #370's eMAR when assessing Resident #370's right forearm dialysis AV fistula, to indicate Resident #370's AV fistula was not functioning.

Based on interviews, and record reviews the facility failed to ensure personnel had the appropriate state licensure to provide care and services to residents. This deficient practice was identified for 1 (S5Unlicensed Personnel) of 50 (S1Administrator, S2Director of Nursing [DON], S3Assistant Director of Nursing [ADON], S5Unlicensed Personnel, S14Agency Licensed Practical Nurse [LPN], S16LPN, S17LPN, S18Registered Nurse [RN], S19LPN, S20RN, S21Physician, S22Physician, S23Podiatrist, S24RN, S25RN, S26RN, S27RN, S28Treatment RN, S29LPN, S30LPN, S31LPN, S32LPN, S33LPN, S34LPN, S35LPN, S36Minimum Data Set [MDS]Coordinator/LPN, S37LPN, S38LPN, S39LPN, S40LPN, S41LPN, S42LPN, S43LPN, S44LPN, S45LPN, S46LPN, S47LPN, S48LPN, S49LPN, S50LPN, S51LPN, S52Quality Assurance [QA] LPN, S53Physician Assistant, S55Agency LPN, S56Agency LPN, S57LPN, S58LPN, S59LPN, S60Agency LPN, S61Agency LPN) personnel files reviewed for active and current licensure. The deficient practice resulted in an immediate jeopardy situation on 11/20/2024 when S5Unlicensed Personnel worked in the capacity of a LPN and performed nursing tasks without a Louisiana nursing license. This deficient practice affected 87 residents who were identified by the facility as having received care and services from S5Unlicensed Personnel until S5Unlicensed Personnel was suspended on 01/24/2025 and terminated on 01/24/2025. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a past noncompliance citation. Findings: Cross reference F839 Review of the facility's undated Professional Licensure Verification Policy revealed, in part, all employees with a professional license would be verified upon hire and as required through the appropriate licensure board. Review of the facility's undated Administrator Job's Description revealed, in part, the Administrator reported to the Regional Director and was responsible for adopting and enforcing rules and for the healthcare and safety of patients and others. Review of the facility's undated Director of Nursing's Job Description revealed, in part, the DON reported to the Administrator. Further review revealed the DON's responsibility was to assist with interviewing, evaluating and selecting new personnel. Review of the facility's undated Human Resources/Payroll Manager Job Description revealed, in part, the Human Resources/Payroll Manager reported to the Administrator and was responsible for maintenance of all personnel files in compliance with local and federal laws. Review of S5Unlicensed Personnel's Employee Status Change signed by S7Team Member Specialist (TMS) on 11/20/2024 revealed, in part, S5UnlicensedPersonnel had a title change from Certified Nurse Aide (CNA) to LPN. Review of S5Unlicensed Personnel's personnel file revealed, in part, S5Unlicensed Personnel signed the Licensed Staff (Registered Nurse/Licensed Practical Nurse) Job Description on 11/22/2024. Review of an email communication received by S7TMS dated 01/29/2025 at 12:15PM from the Louisiana State Board of Practical Nurse Examiners revealed, in part, S5Unlicensed Personnel did not have an active Practical Nurse License in the state of Louisiana. In an interview on 02/10/2025 at 12:30PM, S7TMS indicated she was responsible for verifying licensure for newly hired staff at the time of hire, and when there was a position change. S7Team Member Specialist/Human Resources further indicated on 11/20/2024 she officially changed S5Unlicensed Personnel's status from a CNA to a LPN. S7TMS further indicated on 01/24/2025 she emailed the Louisiana State Board of Practical Nurse Examiners inquiring about S5Unlicensed Personnel's LPN status and received an answer that S5Unlicensed Personnel did not pass the National Council Licensure Examination for Practical Nurses (NCLEX-PN) with the Louisiana State Board of Practical Nurse Examiners. In an interview on 02/10/2025 at 2:41PM, S2DON indicated S5Unlicensed Personnel started training as a LPN on 11/20/2024. S2DON further indicated a nurse in training would observe and provide nursing care under supervision of another licensed nurse. S2DON further indicated she should have called the Louisiana State Board of Practical Nurse Examiners to verify S5Unlicensed Personnel had a Louisiana nursing license before allowing S5Unlicensed Personnel to provide care and services to residents in the capacity of a LPN. In an interview on 02/12/2025 at 3:15PM S1Administrator indicated he directed S7TMS to change S5Unlicensed Personnel's status from CNA to LPN. S1Administrator further indicated he directed S2DON to allow S5Unlicensed Personnel to perform duties as a LPN. S1Administrator further indicated he should have verified S5Unlicensed Personnel had a valid Louisiana Practical Nurse license before allowing her to perform care and services as a Louisiana Practical Nurse. In an interview on 02/17/2025 at 10:15AM S1Administrator indicated there was a likelihood of serious injury, serious harm, serious impairment or death due to having unlicensed personnel providing nursing services. In an interview on 02/17/2025 at 11:15AM S6Chief Operations Officer (COO) indicated there was a likelihood of serious injury, serious harm, serious impairment or death due to having unlicensed personnel providing nursing services. He further indicated he would be providing administrative on site supervision and remote oversite for 3 months as part of the correction plan. The facility implemented the following actions to correct the deficient practice beginning on 01/24/2025 with a completion date of 01/31/2025: 1. S5Unlicensed Personnel was suspended on 01/24/2025, and terminated on 01/29/2025. 2. All 87 residents identified on the electronic medical record system audit trail report had the potential to be affected by the deficient practice. 3. To ensure the deficient practice would not reoccur the following measures had been implemented. a. S1Administrator, S2DON, and S7TMS were in-serviced on licensure verification and reporting wrong doing. S1Administrator was in-serviced on 01/24/2025, S2DON was in-serviced on 01/29/2025 and S7TMS was in-serviced on 01/30/2025. b. Cognitive resident interviews were completed by S51Regional RN regarding any medication administration concerns or other nursing concerns on 01/30/2025. c. Full facility wide audit started on 01/24/2025 on all nurses to ensure active license in place. d. In-service on reporting wrongdoing was completed by S1Administrator, S2DON, S7TMS, and staff by 01/31/2025. e. Audits were completed on 01/31/2025 of resident's electronic medical records documentation who received care from S5Unlicensed Personnel while S5Unlicensed Personnel worked in the capacity as a LPN to ensure no harm occurred. 4. The facility would monitor its performance to ensure solutions were sustained by completing the following: a. S7TMS to verify licensure prior to nurse hired or role change if currently working. S2DON would be provided with a copy for double verification at the facility level. b. S4Corporate Compliance Officer to audit weekly for compliance for three months and annually. 5. Plan of Correction to be completed by 01/31/2025.

Based on interviews, and record reviews the facility failed to ensure personnel had the appropriate state licensure to provide care and services to residents. This deficient practice was identified for 1 (S5Unlicensed Personnel) of 50 (S1Administrator, S2Director of Nursing [DON], S3Assistant Director of Nursing [ADON], S5Unlicensed Personnel, S14Agency Licensed Practical Nurse [LPN], S16LPN, S17LPN, S18Registered Nurse [RN], S19LPN, S20RN, S21Physician, S22Physician, S23Podiatrist, S24RN, S25RN, S26RN, S27RN, S28Treatment RN, S29LPN, S30LPN, S31LPN, S32LPN, S33LPN, S34LPN, S35LPN, S36Minimum Data Set [MDS]Coordinator/LPN, S37LPN, S38LPN, S39LPN, S40LPN, S41LPN, S42LPN, S43LPN, S44LPN, S45LPN, S46LPN, S47LPN, S48LPN, S49LPN, S50LPN, S51LPN, S52Quality Assurance [QA] LPN, S53Physician Assistant, S55Agency LPN, S56Agency LPN, S57LPN, S58LPN, S59LPN, S60Agency LPN, S61Agency LPN) personnel files reviewed for active and current licensure. The deficient practice resulted in an immediate jeopardy situation on 11/20/2024 when S5Unlicensed Personnel worked in the capacity of a LPN and performed nursing tasks without a Louisiana nursing license. This deficient practice affected 87 residents who were identified by the facility as having received care and services from S5Unlicensed Personnel until S5Unlicensed Personnel was suspended on 01/24/2025 and terminated on 01/29/2025. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a past noncompliance citation. Findings: Review of the facility's undated Professional Licensure Verification Policy revealed, in part, all employees with a professional license would be verified upon hire and as required through the appropriate licensure board. Review of the facility's undated Administrator Job's Description revealed, in part, the Administrator reported to the Regional Director and was responsible for adopting and enforcing rules and for the healthcare and safety of patients and others. Review of the facility's undated Director of Nursing's Job Description revealed, in part, the DON reported to the Administrator. Further review revealed the DON's responsibility was to assist with interviewing, evaluating and selecting new personnel. Review of the facility's undated Human Resources/Payroll Manager Job Description revealed, in part, the Human Resources/Payroll Manager reported to the Administrator and was responsible for maintenance of all personnel files in compliance with local and federal laws. Review of S5Unlicensed Personnel's Employee Status Change signed by S7Team Member Specialist (TMS) on 11/20/2024 revealed, in part, S5UnlicensedPersonnel had a title change from Certified Nurse Aide (CNA) to LPN. Review of S5Unlicensed Personnel's personnel file revealed, in part, S5Unlicensed Personnel signed the Licensed Staff (Registered Nurse/Licensed Practical Nurse) Job Description on 11/22/2024. Review of facility documentation revealed, in part, the facility identified 87 residents had received care and services from S5Unliensed Personnel working in the capacity of an LPN from 11/20/2024 until 01/24/2025. Review of an email communication received by S7TMS dated 01/29/2025 at 12:15PM from the Louisiana State Board of Practical Nurse Examiners revealed, in part, S5Unlicensed Personnel did not have an active Practical Nurse License in the state of Louisiana. In an interview on 02/10/2025 at 12:30PM, S7TMS indicated she was responsible for verifying licensure for newly hired staff at the time of hire, and when there was a position change. S7Team Member Specialist/Human Resources further indicated on 11/20/2024 she officially changed S5Unlicensed Personnel's status from a CNA to a LPN. S7TMS further indicated on 01/24/2025 she emailed the Louisiana State Board of Practical Nurse Examiners inquiring about S5Unlicensed Personnel's LPN status and received an answer that S5Unlicensed Personnel did not pass the National Council Licensure Examination for Practical Nurses (NCLEX-PN) with the Louisiana State Board of Practical Nurse Examiners. In an interview on 02/10/2025 at 2:41PM, S2DON indicated S5Unlicensed Personnel started training as a LPN on 11/20/2024. S2DON further indicated a nurse in training would observe and provide nursing care under supervision of another licensed nurse. S2DON further indicated she should have called the Louisiana State Board of Practical Nurse Examiners to verify S5Unlicensed Personnel had a Louisiana nursing license before allowing S5Unlicensed Personnel to provide care and services to residents in the capacity of a LPN. In an interview on 02/12/2025 at 3:15PM S1Administrator indicated he directed S7TMS to change S5Unlicensed Personnel's status from CNA to LPN. S1Administrator further indicated he directed S2DON to allow S5Unlicensed Personnel to perform duties as a LPN. S1Administrator further indicated he should have verified S5Unlicensed Personnel had a valid Louisiana Practical Nurse license before allowing her to perform care and services as a Louisiana Practical Nurse. In an interview on 02/17/2025 at 10:15AM S1Administrator indicated there was a likelihood of serious injury, serious harm, serious impairment or death due to having unlicensed personnel providing nursing services. The facility implemented the following actions to correct the deficient practice beginning on 01/24/2025 with a completion date of 01/31/2025: 1. S5Unlicensed Personnel was suspended on 01/24/2025, and terminated on 01/29/2025. 2. All 87 residents identified on the electronic medical record system audit trail report had the potential to be affected by the deficient practice. 3. To ensure the deficient practice would not reoccur the following measures had been implemented. a. S1Administrator, S2DON, and S7TMS were in-serviced on licensure verification and reporting wrong doing. S1Administrator was in-serviced on 01/24/2025, S2DON was in-serviced on 01/29/2025 and S7TMS was in-serviced on 01/30/2025. b. Cognitive resident interviews were completed by S51Regional RN regarding any medication administration concerns or other nursing concerns on 01/30/2025. c. Full facility wide audit started on 01/24/2025 on all nurses to ensure active license in place. d. In-service on reporting wrongdoing was completed by S1Administrator, S2DON, S7TMS, and staff by 01/31/2025. e. Audits were completed on 01/31/2025 of resident's electronic medical records documentation who received care from S5Unlicensed Personnel while S5Unlicensed Personnel worked in the capacity as a LPN to ensure no harm occurred. 4. The facility would monitor its performance to ensure solutions were sustained by completing the following: a. S7TMS to verify licensure prior to nurse hired or role change if currently working. S2DON would be provided with a copy for double verification at the facility level. b. S4Corporate Compliance Officer to audit weekly for compliance for three months and annually. 5. Plan of Correction to be completed by 01/31/2025.

Based on interviews and record reviews, the facility failed to ensure a resident's physician was notified when a scheduled medication was withheld for 1 (Resident #9) of 19 (Resident #1, Resident #7, Resident #8, Resident #9, Resident #11, Resident #13, Resident #15, Resident #16, Resident #17, Resident #19, Resident #21, Resident #22, Resident #26, Resident #29, Resident #40, Resident #41, Resident #43, Resident #50, Resident #57) sampled residents reviewed for pharmacy services. Findings: Review of the facility's undated Medication Administration General Guidelines policy revealed, in part, medications were to be administered as ordered by the physician. Further review revealed if a scheduled medication was withheld, the medication would be documented as not given and an explanatory note was to be entered in the electronic document. Further review revealed if several doses of a vital medication were withheld, the physician should be notified and a response documented. Review of Resident #9's clinical record revealed, in part, Resident #9 was admitted to the facility on [DATE] with a diagnosis of, in part, type 2 diabetes mellitus (a condition which causes uncontrolled blood sugars). Review of Resident #9's Order Summary revealed, in part, an order with a start date of 10/08/2024 to administer Novolog (a medication to control blood sugar) 10 units subcutaneously (SQ) with meals related to type 2 diabetes mellitus. Review of Resident #9's November 2024 electronic Medication Administration Record (eMAR) revealed the following documentation: - On 11/05/2024 at 8:00AM, Novolog 10 units SQ with meals was not administered with a documented code 5 (5 indicated medication was held and see progress notes); - On 11/06/2024 at 8:00AM, Novolog 10 units SQ with meals was not administered with a documented code 5; - On 11/06/2024 at 6:00PM, Novolog 10 units SQ with meals was not administered with a documented code 13 (13 indicated insulin was not required); - On 11/12/2024 at 8:00AM, Novolog 10 units SQ with meals was not administered with a documented code 5; - On 11/12/2024 at 6:00PM, Novolog 10 units SQ with meals was not administered with a documented code 5; - On 11/15/2024 at 6:00PM, Novolog 10 units SQ with meals was not administered with a documented code 13; - On 11/18/2024 at 6:00PM, Novolog 10 units SQ with meals was not administered with a documented code 13; - On 11/19/2024 at 6:00PM, Novolog 10 units SQ with meals was not administered with a documented code 13; - On 11/20/2024 at 12:00PM, Novolog 10 units SQ with meals was not administered with a documented code 5; - On 11/20/2024 at 6:00PM, Novolog 10 units SQ with meals was not administered with a documented code 13; - On 11/21/2024 at 12:00PM, Novolog 10 units SQ with meals was not administered with a documented code 5; - On 11/21/2024 at 6:00PM, Novolog 10 units SQ with meals was not administered with a documented code 13; - On 11/22/2024 at 6:00PM, Novolog 10 units SQ with meals was not administered with a documented code 13; - On 11/25/2025 at 12:00PM, Novolog 10 units SQ with meals was not administered with a documented code 5; - On 11/25/2025 at 6:00PM, Novolog 10 units SQ with meals was not administered with a documented code 13; - On 11/26/2025 at 8:00PM, Novolog 10 units SQ with meals was not administered with a documented code 13; - On 11/26/2025 at 6:00PM, Novolog 10 units SQ with meals was not administered with a documented code 13; - On 11/27/2025 at 6:00PM, Novolog 10 units SQ with meals was not administered with a documented code 13; and, - On 11/28/2025 at 8:00AM, Novolog 10 units SQ with meals was not administered with a documented code 13. Review of Resident #9's November 2024 progress notes revealed, in part, no documented evidence, and the facility did not present any evidence, Resident #9's physician was notified when the above mentioned medication was not administered as ordered. In an interview on 02/11/2025 at 4:36PM, S3Assistant Director of Nursing (ADON) indicated there was no documented evidence Resident #9's physician was notified when the above mentioned medication was not administered as ordered, and should have been. In an interview on 02/12/2025 at 2:04PM, S4Corporate Compliance Officer indicated Resident #9's physician should have been notified when his medication was not administered as ordered.

Based on interviews and record reviews, the facility failed to ensure the required number of Certified Nursing Assistants (CNAs) were present and working per the facility assessment for 2 (02/05/2025, and 02/06/2025) of 2 (02/05/2025, and 02/06/2025) days reviewed for sufficient CNA staff. Findings: Review of the facility's assessment, dated 10/20/2024 revealed, in part, the average facility census was 116 residents. Further review revealed based on the acuity and needs of its resident population, the facility identified 19 CNAs were required on the weekday day shift, 12 CNAs were required on the weekday evening shift, and 8 CNAs were required on the weekday night shift. Review of the facility's 24 hour staffing sheets dated 02/05/2025 and 02/06/2025 revealed, in part, the day shift was from 6:00AM to 2:00PM, the evening shift was from 2:00PM to 10:00PM, and the night shift was from 10:00PM to 6:00AM. Review of the facility's Nursing Staff Directly Responsible for Resident Care form dated 02/05/2025 and 02/06/2025 revealed, in part, the facility's census was 113 residents. In an interview on 02/10/2025 at 10:18AM, S49Licensed Practical Nurse (LPN) indicated he often worked without CNAs to care for his residents at or around shift change because the off going CNAs left without giving report to the oncoming CNAs. In an interview on 02/13/2025 at 2:45PM, S1Administrator indicated the facility usually staffed 12 CNAs on the day shift, 8 CNAs on the evening shift, and 8 CNAs on the night shift to provide care to residents. Review of the facility's time sheets dated 02/04/2025 to 02/05/2025 for the 10:00PM to 6:00AM shift revealed, in part: -On 02/05/2025, from 12:00AM to 4:12AM, S54CNA, S63CNA, S64CNA, S65CNA, S66CNA, S67CNA, and S68CNA were clocked in for a total of 7 CNAs working in the facility. Review of the facility's time sheets dated 02/05/2025 for the 6:00AM to 2:00PM shift revealed, in part: -On 02/05/2025, from 6:00AM to 6:06AM, S10CNA, S69CNA, S70CNA, S71CNA, S72CNA, S73CNA, S74CNA, S75CNA, S76CNA, and S78CNA were clocked in for a total of 10 CNAs working in the facility; and, -On 02/05/2025, from 6:07AM to 6:15AM, S10CNA, S69CNA, S70CNA, S71CNA, S72CNA, S73CNA, S74CNA, S75CNA, S76CNA, S78CNA, and S79CNA were clocked in for a total of 11 CNAs working in the facility. Review of the facility's time sheets dated 02/05/2025 for the 2:00PM to 10:00PM shift revealed, in part: -On 02/05/2025, from 4:57PM to 6:22PM, S63CNA, S70CNA, S80CNA, S81CNA, S82CNA, S83CNA, and S84CNA were clocked in for a total of 7 CNAs working in the facility; -On 02/05/2025, from 6:49PM to 8:31PM, S54CNA, S63CNA, S70CNA, S80CNA, S81CNA, S82CNA, and S83CNA were clocked in for a total of 7 CNAs working in the facility; and, -On 02/05/2025, from 8:32PM to 8:59PM, S54CNA, S63CNA, S70CNA, S80CNA, S81CNA, and S83CNA were clocked in for a total of 6 CNAs working in the facility; and, -On 02/05/2025, from 9:00PM to 9:02PM, S54CNA, S63CNA, S70CNA, S80CNA, S81CNA, S83CNA, and S85CNA were clocked in for a total of 7 CNAs working in the facility. Review of the facility's time sheets dated 02/05/2025 to 02/06/2025 for the 10:00PM to 6:00AM shift revealed, in part: -On 02/05/2025, from 10:35PM to11:58PM, S54CNA, S64CNA, S63CNA, S83CNA S85CNA, S86CNA, and S87CNA were clocked in for a total of 7 CNAs working in the facility. -On 02/05/2025, from 11:59PM to 4:29AM on 02/06/2025, S85CNA, S86CNA, S64CNA, S63CNA, S83CNA, and S54CNA were clocked in for a total of 6 CNAs working in the facility. -On 02/05/2025, from 4:30AM to 4:50AM on 02/06/2025, S85CNA, S86CNA, S64CNA, S63CNA, S83CNA, S54CNA, and S88CNA were clocked in for a total of 7 CNAs working in the facility. Review of the facility's time sheets dated 02/06/2025 to 02/07/2025 for the 10:00PM to 6:00AM shift revealed, in part: -On 02/06/2025, from 10:07PM to 10:27PM, S63CNA, S77CNA, S64CNA, S85CNA, S54CNA, and S86CNA were clocked in for a total of 6 CNAs working in the facility. There was no documented evidence, and the facility did not present any documented evidence, any other CNAs worked during the above mentioned time frames. In an interview on 02/17/2025 at 11:59AM, S6Chief Operations Officer acknowledged the facility should be staffed according to the facility assessment.

46361 47487 Based on record review and interview, the facility failed to: 1. Ensure medications were available for use for 3 (Resident #1, Resident #8, Resident #57) of 19 (Resident #1, Resident #7, Resident #8, Resident #9, Resident #11, Resident #13, Resident #15, Resident #16, Resident #17, Resident #19, Resident #21, Resident #22, Resident #26, Resident #29, Resident #40, Resident #41, Resident #43, Resident #50, Resident #57) sampled residents reviewed for pharmacy services; and, 2. Maintain a system to periodically reconcile controlled drugs for 3 (Medication Cart a, Medication Cart b, Medication Cart c) of 4 (Medication Cart a, Medication Cart b, Medication Cart c, Medication Cart d) medication carts reviewed for the reconciliation documentation of controlled substances. 1. Review of the facility's undated Medication Administration General Guidelines policy revealed, in part, medications were to be administered as ordered by the physician. Further review revealed when a medication could not be located the pharmacy was to be contacted and/or the medication was to be removed from the Emergency Drug Kit. Further review revealed if a scheduled medication was withheld or not available, the medication was documented as not given and an explanatory note should have been entered in the electronic document. Resident #1 Review of Resident #1's clinical record revealed, in part, Resident #1 had diagnoses, which included, hypertension (a condition with elevated blood pressure), upper respiratory infection (an infection that affects the upper part of your respiratory system, including your sinuses and throat) and urinary tract infection (an infection of any part of the urinary system, including kidneys, ureters, bladder, and urethra). Review of Resident #1's February 2025 physician's orders revealed, in part, Resident #1 had the following orders: - Cozaar (a medication used to treat high blood pressure) 50 milligrams (mg) daily with a start date of 07/01/2024; - Levofloxacin (an antibiotic used to treat respiratory infections) 500 mg daily with a start date of 02/07/2025; and, - Doxycycline (a medication used to treat urinary treat infections) 100 mg two times daily for seven days with a start date of 02/07/2025. Review of Resident #1's February 2025 electronic Medication Administration Record (eMAR) revealed, in part, the following documentation: - On 02/01/2025 Cozaar 50 mg was not administered; - On 02/02/2025 Cozaar 50 mg was not administered; - On 02/07/2025 doxycycline 100 mg was not administered; - On 02/08/2025 levofloxacin 500 mg was not administered; and, - On 02/09/2025 levofloxacin 500 mg was not administered. Review of Resident #1's progress notes revealed, in part, the following documentation: - On 02/01/2025 Cozaar 50 mg was not available for administration; - On 02/02/2025 Cozaar 50 mg was not available for administration; - On 02/07/2025 doxycycline 100 mg was not available for administration; - On 02/08/2025 levofloxacin 500 mg was not available for administration; and, - On 02/09/2025 levofloxacin 500 mg was not available for administration; Record review revealed there was no documented evidence, and the provider did not present any documented evidence, Resident #1's above mentioned medications were available and/or administered as ordered. Resident #8 Review of Resident #8's clinical record revealed, in part, Resident #8 admitted to the facility on [DATE] with diagnoses, which included, hypertension and overactive bladder (a condition that caused sudden urination). Review of Resident #8's Order Summary Report revealed, in part, the following orders: - Ciprofloxacin hydrochloride 500 mg tablet to be administered twice a day related to urinary tract infection with a start date of 12/13/2024; - Tamsulosin hydrochloride 0.4 mg capsule to be administered once a day related to overactive bladder with a start date of 11/20/2024; and, - Potassium chloride 20 milliequivalent (mEq) to be administered twice a day related to hypertensive heart disease (heart condition caused by high blood pressure) with a start date of 12/30/2024. Further review of Resident #8's December 2024 and January 2025 eMAR revealed, in part, the following documentation: - On 12/24/2024 the morning (AM) dose of ciprofloxacin hydrochloride 500 mg was documented as a 9 (9 indicated other and see progress notes); - On 12/30/2024 the evening (HS) dose of tamsulosin hydrochloride 0.4 mg was documented as 9; and, - On 01/02/2025 the HS dose of potassium chloride 20 mEq was documented as a 9. Review of Resident #8's progress notes revealed, in part, S5Unlicensed Personnel documented the following documentation: - On 12/24/2024 at 12:09PM, ciprofloxacin hydrochloride 500 mg was reordered; - On 12/30/2024 at 9:39PM, tamsulosin hydrochloride 0.4 mg was waiting on insurance; and, - On 01/02/2025 at 7:38PM, potassium chloride 20 mEq was reordered. Record review revealed there was no documented evidence, and the provider did not present any documented evidence, Resident #8's above mentioned medications were available and/or administered as ordered. In an interview on 02/12/2025 at 8:58AM, S3Assistant Director of Nursing (ADON) indicated ciprofloxacin hydrochloride was maintained in the facility's Emergency Drug Kit. S3ADON further indicated Resident #8's ciprofloxacin hydrochloride could have been administered by the facility's nurses from the Emergency Drug Kit. In an interview on 02/12/2025 at 2:56PM, S2Director of Nursing indicated Resident #8's above mentioned medications were not available for use and/or not administered as ordered, and should have been. Resident #57 Review of Resident #57's clinical record revealed, in part, Resident #57 admitted to the facility on [DATE] with diagnoses, which included, hypertension and chronic heart failure. Review of Resident #57's January 2025 eMAR revealed, in part, an order for hydralazine hydrochloride 25 mg (a medication use to treat high blood pressure) to be administered every 8 hours with a start date of 01/27/2025. Further review revealed the following documentation: - On 01/27/2025 at 4:00PM, hydralazine hydrochloride 25 mg was documented as 9; - On 01/28/2025 at 12:00AM, hydralazine hydrochloride 25 mg was documented as 9; - On 01/28/2025 at 8:00AM, hydralazine hydrochloride 25 mg was documented as 9; - On 01/29/2025 at 12:00AM, hydralazine hydrochloride 25 mg was documented as 9; and, - On 01/29/2025 at 4:00PM, hydralazine hydrochloride 25 mg was documented as 9. Review of Resident #57's January 2025 progress notes revealed, in part, the following documentation: - On 01/27/2025 at 8:16PM, hydralazine hydrochloride 25 mg was not available; - On 01/28/2025 at 1:13AM, hydralazine hydrochloride 25 mg was faxed to pharmacy; - On 01/28/2025 at 9:52AM, hydralazine hydrochloride 25 mg was not available; and, - On 01/29/2025 at 2:41AM, hydralazine hydrochloride 25 mg was not available. In an interview on 02/12/2025 at 2:04PM, S4Corporate Compliance Officer acknowledged Resident #1, Resident #8, and Resident #57 should have received their medications as ordered. S4Corporate Compliance Officer further indicated it was the responsibility of the nurses to obtain medications from the Emergency Drug Kit if the medication was available in the Emergency Drug Kit, and to ensure medication were received from the pharmacy in a timely manner to be available for use. 2. Review of the facility's undated Medication-Controlled Substances policy and procedure, revealed, in part, nurses were to perform a reconciliation of all controlled substances at the beginning and the end of every shift according to the narcotic log. Review of the facility's undated Narcotic Count Sign Sheet form revealed, in part, by signing, the nurses were verifying the narcotic count was accurate, the nurses had reconciled the narcotics with the applicable off going/oncoming licensed nurse, and both licensed nurses verified by signatures that the facility's policy and procedure had been followed. Review of November 2024 Narcotic Count Sign Sheet for Medication Cart b revealed, in part, the following shifts had an incomplete reconciliation of controlled drugs by the nurse coming on duty and/or the nurse going off duty: -11/13/2024 at 11:00PM. Review of November 2024 Narcotic Count Sign Sheet for Medication Cart c revealed, in part, the following shifts had an incomplete reconciliation of controlled drugs by the nurse coming on duty and/or the nurse going off duty: -11/22/2024 at 11:00PM; -11/28/2024 at 3:00PM; and, -11/28/2024 at 11:00PM. Review of the February 2025 Narcotic Count Sign Sheet for Medication Cart a revealed, in part, the following shifts had an incomplete reconciliation of controlled drugs by the nurse coming on duty and/or the nurse going off duty: -02/09/2025 at 11:00PM; and, -02/09/2025 at 7:00AM. Review of the February 2025 Narcotic Count Sign Sheet for Medication Cart b revealed, in part, the following shifts had an incomplete reconciliation of controlled drugs by the nurse coming on duty and/or the nurse going off duty: -02/10/2025 at 11:00PM. In an interview on 02/17/2025 at 1:19PM, S2DON indicated S16LPN did not sign the November 2024 Narcotic Count Sign Sheet for Medication Cart b, S17LPN did not sign the November 2024 Narcotic Count Sign Sheet for Medication Cart c, S14Agency LPN did not sign the February 2025 Narcotic Count Sign Sheet for Medication Cart a, and S15LPN did not sign the February 2025 Narcotic Count Sign Sheet for Medication Cart b on the above mentioned dates and times, as required. S2DON further indicated anyone who reconciled the medication carts' narcotics should have signed the Narcotic Count Sign Sheet.

Based on interviews and record reviews, the facility failed to ensure physician's orders were followed for 1 (Resident#16) of 19 (Resident #1, Resident #7, Resident #8, Resident #9, Resident #11, Resident #13, Resident #15, Resident #16, Resident #17, Resident #19, Resident #21, Resident #22, Resident #26, Resident #29, Resident #40, Resident #41, Resident #43, Resident #50, Resident #57) residents reviewed for physician order compliance. Findings: Review of Resident #16's clinical record revealed, in part, Resident #16 was admitted to the facility on [DATE] a diagnosis of, in part, type 2 diabetes mellitus (a condition which causes uncontrolled blood sugars). Review of Resident #16's January 2025 electronic Medication Administration Record (eMAR) revealed, in part, an order with a start date of 01/07/2025 for blood glucose (sugar) monitoring before meals and at bedtime related to type 2 diabetes mellitus. Further review revealed staff was to call the physician if Resident #16's blood sugar was less than 60 milligrams per deciliter or greater than 250 mg/dL. Review of Resident #16's Weights and Vitals Summary- Blood Sugar for January 2025 revealed the following blood sugars were greater than 250 mg/dL: - On 01/23/2025 at 10:21PM, Resident #16's blood sugar was 569 mg/dL; - On 01/21/2025 at 8:35PM, Resident #16's blood sugar was 289 mg/dL; - On 01/21/2025 at 4:09PM, Resident #16's blood sugar was 559 mg/dL; - On 01/20/2025 at 7:03PM, Resident #16's blood sugar was 340 mg/dL; - On 01/20/2025 at 12:22PM, Resident #16's blood sugar was 298 mg/dL; - On 01/18/2025 at 9:45PM, Resident #16's blood sugar was 415 mg/dL; - On 01/18/2025 at 5:23PM, Resident #16's blood sugar was 375 mg/dL; - On 01/15/2025 at 10:53PM, Resident #16's blood sugar was 385 mg/dL; - On 01/15/2025 at 5:39PM, Resident #16's blood sugar was 403 mg/dL; - On 01/15/2025 at 5:56AM, Resident #16's blood sugar was 401 mg/dL; - On 01/14/2025 at 6:57PM, Resident #16's blood sugar was 254 mg/dL; - On 01/13/2025 at 10:02PM, Resident #16's blood sugar was 285 mg/dL; - On 01/13/2025 at 4:23PM, Resident #16's blood sugar was 314 mg/dL; - On 01/11/2025 at 6:17PM, Resident #16's blood sugar was 405 mg/dL; - On 01/10/2025 at 5:48PM, Resident #16's blood sugar was 354 mg/dL; and, - On 01/08/2025 at 9:31PM, Resident #16's blood sugar was 313 mg/dL. Further review revealed no documented evidence, and the facility did not present any documented evidence, Resident #16's physician was notified when Resident #16's blood sugar was greater than 250 mg/dL on the above mentioned dates, and should have been. In an interview on 02/12/2025 at 2:46PM, S2Director of Nursing confirmed the facility had no evidence Resident #16's physician was notified when Resident #16's blood sugar was greater than 250 mg/dL on the above mentioned dates, and should have been.

Based on interviews and record review, the facility failed to ensure the staff properly completed the grievance report form and failed to document a resolution of the grievance for 1 (Resident #13) of 1 (Resident #13) sampled residents investigated for grievances. Findings: Review of the facility's undated Grievance policy and procedure revealed, in part, the facility administrator or designee will act as the grievance official, and all grievances made by a resident or resident's family would be documented on the grievance form by the grievance official. Further review revealed the grievance form would 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 pertinent findings or conclusions regarding the resident's concerns, a statement as whether the grievance was confirmed or not confirmed, corrective action taken by the facility as a result of the grievance, and the date the written decision was issued. Review of the facility's Grievance Log from 11/2024 to 2/2025 revealed, in part, Resident #13 filed a nurse-related grievance on 01/05/2025, and the grievance was resolved on 01/06/2025. In an interview on 02/11/2025 at 1:50PM, S4Coporate Compliance Officer indicated S8Social Service Director (SSD) was the facility's grievance official and S1Administrator was responsible for overseeing and signing all grievance reports. Review of Resident #13's Grievance Report revealed, in part, Resident #13's above mentioned grievance was not signed by S1Administrator. Further review of Resident #13's grievance report revealed there was no documented statement as whether the grievance was confirmed or not confirmed, there was no documented evidence of a resolution of Resident #13's grievance, there was no documented evidence of action taken by the facility as the result of the grievance, and there was no documented evidence the facility notified Resident #13 and/or Resident #13's responsible party of a resolution to Resident #13's grievance. In an interview on 02/11/2025 at 2:30PM, S8SSD indicated she was not aware of the resolution and had not received the investigation completed by S1Administrator for Resident #13's Grievance Report dated 01/06/2025. S8SSD further indicated Resident #13's grievance investigation and resolution were not properly documented on the Grievance Report form and they should have been. There was no documented evidence, and the facility did not present any documented evidence, Resident #13's above mentioned Grievance Report was properly documented. In an interview on 02/12/2025 at 1:10PM, S1Administrator indicated he did not submit the investigation of Resident #13's grievance dated 01/06/2025 to the grievance official. S1Administrator further indicated Resident #13's Grievance Report did not include a resolution on the Grievance Report form, did not include the notification of Resident #13 or Resident #13's responsible party of the resolution, and was not signed by the administrator. S1Administrator confirmed Resident #13's above mentioned written Grievance Report was not properly completed by the grievance official and it should have been.

Based on interviews and record reviews the facility failed to ensure an incident of neglect was reported to the Louisiana Department of Health no later than 24 hours after the incident was discovered. Findings: Review of the facility's undated Abuse and Neglect policy revealed, in part, a type of Abuse included Neglect. Further review revealed, neglect was defined the failure of the facility, its employees, or service providers to provide goods and services to a resident that were necessary to avoid physical harm, pain, mental anguish or emotional distress. Further review revealed neglect occurred when the facility was aware of, or should have been aware of, goods or services that a resident (s) required but the facility failed to provide them to the resident(s), that had resulted in or may had resulted in physical harm, pain mental anguish, or emotional distress. Further review revealed the facility administrator or designee shall complete a report to the mandated state agency according to state guidelines upon notification of alleged abuse. Review of a facility document titled Employee Status Change revealed, in part, S5Unlicensed Personnel had a status change from Certified Nursing Aide to Licensed Practical Nurse effective 11/20/24. Review of S5Unlicsened Personnel's personnel record revealed, in part, no documented evidence S5Unlicesened Personnel had a current valid Louisiana Practical Nurse License. Review of S5Unlicensed Personnel's time records from 11/20/2024 through 01/23/2025 revealed S5Unlicensed Personnel worked 37 shifts as a LPN. Review the facility's investigative report for neglect dated 01/31/2025 at 11:33AM revealed, in part, on 01/24/2024, S7Team Member Specialist/Human Resources was informed by the Louisiana State Board of Nursing that S5Unlicensed Personnel had not passed the NCLEX-PN (a standardized test that a nurses must pass to become a LPN.) Further review revealed S5Unlicensed Personnel began her training as a facility LPN on 11/20/2024 and started working as a facility LPN without direct supervision on 12/12/2024. Further review revealed this incident had occurred on 01/24/2025 at 12:18PM and was reported to the Louisiana Department of Health through the Statewide Incident Management System (SIMS) on 01/31/2025 at 11:33AM. In an interview on 02/17/2025 at 10:15AM, S1Administrator indicated on 01/24/2025 S7Team Member Specialist/Human Resources informed him S5Unlicensed Personnel did not have a valid Louisiana state nursing license. S1Administrator further indicated there was a likelihood of serious injury, serious harm, serious impairment or death due to having an unlicensed personnel providing nursing services. S1Administrator further indicated a report should have been entered into the SIMS within 24 hours of the discovery of the incident.

Based on observation, interview, and record review, the facility failed to ensure medications were administered as ordered for 2 (Resident R1, Resident R2) of 8 (Resident R1, Resident R2, Resident R3, Resident R4, Resident R5, Resident R6, Resident R7, Resident R8) sampled residents observed and reviewed for medication administration which resulted in a medication error rate of 7.6%. Findings: Resident R1 Review of Resident R1's January 2025 Physician's Orders revealed, in part, an order to administer Valsartan-Hydrochlorothiazide (HCTZ) (a medication to treat high blood pressure) 160-25 milligrams (mg) tablet once a day. Observation on 01/14/2025 at 9:09AM revealed S4Licensed Practical Nurse (LPN) administered Valsartan/HCTZ 160/12.5 mg tablet. In an interview on 01/14/2025 at 3:32 PM, S4Licensed Practical Nurse (LPN) indicated she administered Valsartan/HCTZ 160/12.5 MG Tab. S4LPN further indicated this was not the correct dosage as ordered by the physician In an interview on 01/14/2025 at 4:00 PM, S1Administrator indicated Resident R1 should have received his medication as ordered by the physician and did not. Resident R2 Review of Resident R2's January 2025 Physician's Orders revealed, in part, an order to administer Artificial Tears Ophthalmic Solution 1% Carboxymethylcellulose Sodium eye drops (eye drops used for dry eyes) instill one drop in both eyes every 6 hours. Observation on 01/14/2025 at 11:12AM revealed S5Licensed Practical Nurse (LPN) instill 1 ddrop of Advance Relief Eye Drops Polyethylene Glycol 400 1% Tetrahydrozoline HCI 0.05% Lubricant/Redness Reliever (eye drops to treat allergic reactions in the eyes) in each of Resident R2's eyes. In an interview on 01/14/2025 at 3:32PM, S5LPN indicated he administered Advance Relief Eye Drops Polyethylene Glycol 400 1% Tetrahydrozoline HCI 0.05% Lubricant/Redness Reliever one drop in each eye to Resident R2. S5LPN further indicated this was not the medication that was ordered by the physician for Resident R2. In an interview on 01/14/2025 at 4:00PM, S1Administrator indicated Resident R2 received Advance Relief Eye Drops Polyethylene Glycol 400 1% Tetrahydrozoline HCI 0.05% Lubricant/Redness Reliever and should have received Artificial Tears Ophthalmic Solution 1% Carboxymethylcellulose Sodium. S1Administrator further indicated S5LPN administered the wrong medication to Resident R2.

Based on interviews, policy review, and record reviews it was determined the provider failed to ensure staff provided planned restorative services to assist with active range of motion, passive range of motion, walking, transfer, and eating for 12 (Resident #2, Resident #5, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, Resident #14, Resident #15, Resident #16, Resident #17, and Resident #18) of 12 sampled residents reviewed for restorative services. Findings included: Review of the facility's policy titled Restorative Program Policy and Procedure undated, in part, residents will be assessed to identify possible need or benefit of a restorative program. After potential benefit is identified, specific program will be implemented as deemed medically. Restorative activities including repetition (reps), physical or verbal cueing, and task segmentation will be provided by any trained staff member under the supervision of a licensed nurse. Review of Resident #2's task schedule with a start date of 11/18/2024 revealed Resident #2 was to receive active range of motion to bilateral lower extremities x 1 limited assistance up to 3 sets of 10 reps each. Further review of task schedule with a start date of 11/18/2024 revealed Resident #2 was to receive walking with rolling walker x 1 person limited assistance up to 300 feet. Review of Resident #5's review of restorative program list Resident #5 was to receive passive range of motion and eating swallowing service. Review of Resident #5's therapy referral to restorative nursing with a date of 08/29/2024 revealed resident is to consume no more than 3 ounces of pleasure feeding of puree bolus with use of feeding strategies (small 1/2 tsp bolus, dry swallow after 2 boluses) with trained staff without signs and symptoms of aspirating (cough, wet voice, throat clearing) to maintain current swallow function. Review of Resident #9's task schedule with a start date of 11/18/2024 revealed Resident #9 was to receive active range of motion to bilateral lower extremities x 1 person with standby assistance for cueing and supervision up to 3 sets of 10 reps each. Further review of task schedule with a start date of 11/19/2024 revealed Resident #9 was to receive assistance with sit to stand transfers using grab bars and or wheelchair up to 3 reps. Review of Resident #10's task schedule with a start date of 11/22/2024 revealed Resident #10 was to receive active range of motion to bilateral lower extremities x 1 person standby assistance for cueing and supervision up to 3 sets of 10 reps each. Further review of task schedule with a start date of 11/22/2024 revealed Resident #10 was to receive walking with rolling walker up to 200 feet with staff assistance and with staff reminding resident of safety and proper body mechanics when ambulating. Review of Resident #11's task schedule with a start date of 11/25/2024 revealed Resident #11 was to receive active range of motion to bilateral lower extremities up to 3 sets of 10 reps each. Further review of task schedule with a start date of 11/25/2024 revealed Resident #11 was to receive walking with rolling walker up to 200 feet or more with staff assistance and with staff reminding resident of safety and proper body mechanics when ambulating. Review of Resident #12's task schedule with a start date of 11/26/2024 revealed Resident #12 was to receive active range of motion to bilateral upper and lower extremities at 3 sets of 10. Further review of task schedule with a start date of 11/26/2024 revealed Resident #12 was to receive walking using a rolling walker with standby assistance for 15 feet or more. Review of Resident #13's task schedule with a start date of 12/11/2024 revealed Resident #13 was to receive active range of motion exercises to bilateral lower extremities up to 3 sets of 10 reps each. Further review of task schedule with a start date of 12/11/2024 revealed Resident #13 was to receive walking with rolling walker and staff assistance up to 200 feet or more. Review of Resident #14's task schedule with a start date of 12/11/2024 revealed Resident #14 was to receive active range of motion exercises to bilateral lower extremities up to 3 sets of 10 reps each. Further review of task schedule with a start date of 12/11/2024 revealed Resident #14 was to receive walking with rolling walker and staff assistance up to 20 feet or more. Review of Resident #15's task schedule with a start date of 12/11/2024 revealed Resident #15 was to receive active range of motion exercises to bilateral lower extremities x1 person standby assistance for cuing and supervision up to 3 sets of 10 reps each. Further review of task schedule with a start date of 12/11/2024 revealed Resident #15 was to receive walking with rolling walker x 1 person standby limited to extensive assistance up to 100 feet or more and to remind resident of safety and proper body mechanics when ambulating. Review of Resident #16's task schedule with a start date of 12/11/2024 revealed Resident #16 was to receive active range of motion to right upper extremity x 1 person standby assistance with cuing and supervision up to 3 sets of 10 reps each. Further review of task schedule with a start date of 12/11/2024 revealed Resident #16 was to receive passive range of motion exercises to left upper extremity up to 3 sets of 10 reps each. Review of Resident #17's task schedule with a start date of 10/25/2024 revealed Resident #17 was to receive active range of motion to bilateral lower extremities joints at 3 sets of 10. Further review of task schedule with a start date of 10/25/2024 revealed Resident #17 was to receive walking using a rolling walker and standby assist of one person to ambulate 250 feet or more. Review of Resident #18's task schedule with a start date of 10/30/2024 revealed Resident #18 was to receive active range of motion to bilateral lower extremities up to 3 sets of 10 reps each. Further review of task schedule with a start date of 10/30/2024 revealed Resident #18 was to receive dressing/grooming tasks to upper body with staff set up assistance. In an interview on 12/16/2024 at 1:02 PM, S18Certified Nursing Assistant (CNA), indicated she was pulled from restorative services to work the hall. In an interview on 12/17/2024 at 12:57 PM, S18CNA indicated both restorative aides were pulled to the floor and no restorative services were completed on 12/16/2024. In an interview on 12/17/2024 at 2:28 PM, S7Certified Nursing Assistant (CNA) Supervisor, indicated restorative services were not provided on 12/16/2024. In an interview on 12/17/2024 at 2:35 PM, S3Assistant Director of Nursing (ADON), indicated restorative was to be done Monday through Saturday and due to restorative aides being pulled to the hall on 12/16/2024, restorative services were not provided on 12/16/2024 as required. In an interview on 12/18/2024 at 10:15 AM, S18CNA, indicated restorative schedule was Monday through Friday and every other Saturday and due to being pulled to the floor on 12/16/2024, restorative services were not provided. In an interview on 12/18/2024 at 10:15 AM, S7CNASupervisor, indicated the restorative aides were pulled to the floor on 12/16/2024 and restorative services were not provided as required.

Based on observations, interviews, record reviews, facility document review, and facility policy review it was determined the facility failed to ensure: 1. A resident who was cognitively impaired, had a high risk of falls, and a history of falls had appropriate interventions to decrease the risk of future falls (Resident #4); and, 2. A resident who required a two-person assistance with transfers received adequate assistance with transfers (Resident #8). This deficient practice was identified for 2 (Resident #4 and Resident #8) of 8 sampled residents reviewed for accidents. Findings included: 1. Review of Resident #4's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/16/2024, revealed, in part, Resident #4 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated Resident #4 had severe cognitive impairment. Further review revealed Resident #4 required limited assistance of one person physical assist for bed mobility; and extensive assistance of one person physical assist for transfers. Review of Resident #4's annual MDS with an ARD date of 07/23/2024 revealed, in part, Resident #4 had a BIMS of 3, which indicated Resident #4 had severe cognitive impairment. Review of the facility's incident report dated 11/20/2024 revealed, in part, Resident #4 had an unwitnessed fall on 11/20/2024. Further review of the facility's incident report revealed Resident #4 had unwitnessed fall on 10/15/2024 and 10/29/2024. Review of Resident #4's care plan with an initiation date of 08/09/2024 and a revision date of 11/21/2024, revealed in part, Resident #4 was at risk for falls due to a diagnosis of Parkinson's disease. Further review of Resident #4's fall care plan revealed: Resident #4 had a fall on 02/03/2024 with an intervention of staff to offer coffee in AM upon arrival to dining, a fall on 05/23/2024 with an intervention to apply bright colored tape to brake extender and apply grip strips to the floor in front of the recliner, a fall on 06/04/2024 with an intervention to remove the lotion from room and staff to apply as needed, a fall on 10/15/2024 with an intervention for the fall mat to be removed from the room, a fall on 10/29/2024 with an intervention to offer a busy blanket when in the recliner, and a fall on 11/20/2024 with an intervention of grip strips to floor in front of commode. Other interventions for falls included place Resident #4's call bell in reach and encourage resident too call for assistance. Further review of Resident #4's care plan revealed, in part, Resident #4 had impaired cognitive function, impaired thought processes, and episodes of confusion due to Parkinson's disease. Observation on 12/16/2024 of Resident #4's wheelchair revealed, in part the bright colored tape on the extender arms was peeling off of the left side and there was no bright colored tape on the right side extender. Further observation revealed a sign was posted on the wall as to remind Resident #4 to call for assistance. In an interview on 12/16/2024 at 11:50 AM, S11Certified Nursing Assistant (CNA) indicated Resident #4 was care planned for colored tape, but could not explain the purpose of the colored tape. Observation on 12/16/2024 of Resident #4's wheelchair revealed, in part, the bright colored tape was removed from the left arm extender and replaced with a rubber gray stopper to both extenders. In an interview on 12/18/2024 9:45 AM, Resident #4 indicated she could not see the sign posted on the wall and did not know what the sign posted was for, nor could Resident #4 verbalize why the bright color tape was on the extender of the wheelchair. Observation on 12/18/2024 of Resident #4 revealed, in part, the colored tape was absent from both brake extenders. The facility staff was informed of the above mentioned interview with Resident #4 and was unable to offer any evidence, cognitively impaired Resident #4 understood the sign posted on the wall as a reminder to call for assistance, or understood the reason for the bright colored tape was applied to the wheelchair extenders. 2. A review of the facility's Transfer of the Resident policy, undated, revealed, in part, the purpose of the policy is to provide and assist residents with transfers in a safe manner, and staff is to obtain help when necessary when assisting residents with transfers. Review of Resident #8's Quarterly/State Optional Assessment Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/11/2024 revealed, in part, Resident #8 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated Resident #8 had moderate cognitive impairment, and required extensive assistance of two or more persons for transfers. Review of Resident #8's electronic care plan with a revision date of 09/06/2024 revealed, in part, Resident #8 required assistance of two staff members for transfers. Review of the facility's incident report revealed, in part, S8Certified Nursing Assistant (CNA) attempted to transfer Resident #8 without assistance of a second staff member on 11/29/2024 and Resident #8 sustained a 6 centimeter x 3 centimeter bruise to the left forearm. Review of Resident #8's Nurses Progress Notes dated 11/29/2024 revealed, in part, S8CNA reported she attempted to transfer Resident #8, and Resident #8 was unsteady and S8CNA grabbed Resident #8 left arm to keep Resident #8 from falling. Review of S8CNA's witness statement dated 11/29/2024 revealed, in part, S8CNA attempted to transfer Resident #8 without assistance of a second staff member and Resident #8 started to fall and S8CNA grabbed Resident #8's arm to stop her from falling. Review of Resident #8's witness statement dated 11/30/2024 revealed, in part, on 11/29/2024 S8CNA attempted to transfer Resident #8 without assistance of a second staff member. Further review of Resident #8's witness statement revealed Resident #8 told S8CNA she needed two people to transfer because Resident #8 could not stand. Review of the facility's investigation report revealed, in part, Resident #8's cognitively intact (BIMS 13) roommate witnessed the above mentioned incident on 11/29/2024, and verified S8CNA attempted to transfer Resident #8 without the assistance of a second staff member. In an interview on 12/16/2024 at 3:00 PM, S7CNA Supervisor indicated Resident #8 required the assistance of two staff members for assistance for assistance with transfers. S7CNA Supervisor further indicated on 11/29/2024, S8CNA attempted to transfer Resident #8 without the assistance of a second staff member. In an interview on 12/16/2024 at 3:07 PM, S9CNA indicated on 11/29/2024 she asked S8CNA for assistance in transferring Resident #8 from the chair to the bed because Resident #8 required two staff members for assistance with transfers. S9CNA further indicated S8CNA attempted to transfer Resident #8 without assistance of a second staff member. In an interview on 12/16/2024 at 4:12 PM, S10Licensed Practical Nurse (LPN) indicated on 11/29/2024 S8CNA reported while transferring Resident #8 she grabbed Resident #8's arm to keep her from falling, and Resident #8 sustained a bruise to her left arm. S10LPN further indicated Resident #8 required two staff members assist with transfers and S8CNA attempted to transfer Resident #8 without assistance of a second staff member. In an interview on 12/17/2024 at 1:00 PM, S2Director of Nursing (DON) verified Resident #8 required two or more persons for assistance with transfers. S2DON confirmed S8CNA attempted to transfer Resident #8 without assistance of a second staff member. S2DON indicated S8CNA should not have not attempted to transfer Resident #8 without assistance of a second staff member. In an interview on 12/17/2024 at 1:05 PM, S1Administrator indicated after the facility's investigation it was determined S8CNA failed to follow Resident #8's required transfer assistance of two staff members and she should have.

Based on observations, interviews, and record review, it was determined the facility failed to ensure a resident's adaptive call light was within reach for 1 (Resident #5) of 2 sampled residents with the ability to use a call light in a total sample of 8 investigated for Activities of Daily Living (ADLs). Findings included: Review of Resident #5's Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 11/01/2024 revealed, in part, Resident #5 had a diagnosis of hemiplegia (a condition that causes weakness) affecting both left and right side of the body and was dependent on staff for ADLs. Review of Resident #5's Care Plan revealed, in part, Resident #5 required staff assistance with ADL's due right sided weakness and impaired mobility. Further review revealed staff was to ensure Resident #5's adaptive call light was within reach. Observation on 12/16/2024 at 11:45 AM revealed Resident #5 was lying in bed and Resident #5's adaptive call light was noted out of reach on the bed above her left shoulder. Observation on 12/17/2024 at 8:30 AM revealed Resident #5's adaptive call light was out of reach on Resident #5's bed above her left shoulder. In an interview on 12/17/2024 at 8:30 AM, Resident #5 indicated she had a bowel movement and needed to be changed. Resident #5 indicated she knew how to use the adaptive call light, but did not know where the adaptive call light was. In an interview on 12/17/2024 at 9:34 AM, S19Certified Nursing Assistant (CNA) indicated Resident #5 was dependent on staff for all ADLs. S19CNA further indicated Resident #5 was able to use her adaptive call light. Observation on 12/18/2024 at 10:40 AM revealed Resident #5 was lying in bed and Resident 5's Adaptive call light was out of reach on the bed above her left shoulder. In an interview on 12/18/2024 at 10:40 AM, Resident #5 indicated she did not know where the adaptive call light was. Resident #5 further indicated she could not reach above her left shoulder to use the adaptive call light to get staff assistance. Resident further indicated it bothered her that she was unable to reach her call light/pad to get staff assistance.

Based on observation, record review, facility policy review, and interviews, it was determined the facility failed to administer a resident's enteral feeding (intake of food through a tube placed into the stomach) as ordered for 1 (Resident #5) of 1 sampled residents who received enteral feedings in a total sample of 8 investigated for dietary services. Findings included: Review of the facility's undated policy titled, Enteral Nutritional Therapy-Tube Feeding Policy and Procedure revealed, in part, for enteral feedings using a feeding pump the nurse was to enter the amount to be infused according to the physician's order and to verify pump settings each shift. Review of Resident #5's Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 11/01/2024 revealed, in part, Resident #5 had dysphagia (difficulty swallowing) and required nutrition and hydration through a feeding tube. Review of Resident #5's December 2024 physician's orders revealed, in part, an order with a start date of 12/13/2024 for Glucerna 1.2 Cal (a tube feeding formula) 65 milliliters per hour (mL/hour ) nocturnal feedings (occurring at night). Start feeding at 6:00 PM and stop feeding at 6:00 AM. Observation on 12/16/2024 at 10:58 AM revealed Resident #5 had Glucerna 1.2 Cal infusing at 55 mL/hour via a tube feeding pump. In an interview on 12/17/2024 at 1:02 PM, S5Licensed Practical Nurse (LPN) indicated Resident #5's physician's order for the enteral feeding had recently changed and she was not aware. S5LPN confirmed Resident #5's enteral feeding should have been stopped at 6:00 AM, and should not have been infusing at 55 mL/hr. In an interview on 12/18/2024 at 9:15 AM, S3Assistant Director of Nursing (ADON) indicated S6LPN, the night nurse, should have stopped Resident #5's enteral feeding on 12/16/2024 at 6:00 AM. In an interview on 12/18/2024 at 12:36 PM, S6LPN indicated she was responsible to stop Resident #5's enteral feedings on 12/16/2024 at 6:00 AM. S6LPN further indicated she could not recall if she verified Resident #5's formula was infusing at the rate as order, and could not recall if she stopped Resident #5's enteral feeding at 6:00 AM as required.