Every finding on record at The Oaks of Houma

Based on observations, interviews, and record reviews, the facility failed to ensure:1. Staff used Enhanced Barrier Precautions (EBP) when providing care to residents (Resident #21, Resident #27, Resident #47); and,2. Staff followed infection control guidelines during wound care (Resident #57).This deficient practice was identified for 3 (Resident #21, Resident #27, Resident #47) of 5 sampled residents observed with EBP, and 1 (Resident #57) of 4 sampled residents observed during wound care. Findings:1. Review of the facility's Enhanced Barrier Precautions (EBP) Policy and Procedure, last revised on 03/2024, revealed EBP involves gown and gloves use during high-contact resident care activities for residents known to be colonized or infected with Multi-drug Resistant Organisms (MDRO) as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices), wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities such as: bathing/showering, providing hygiene, changing briefs or assisting with toileting, and/or device care. Resident #21 Review of Resident #21's Care Plan revealed Resident #21 had an indwelling catheter (a medical device used to drain the bladder) with a goal for Resident #21 to show no signs or symptoms of urinary infection through the next review date. Further review revealed an intervention was to ensure EBP was followed. Observation on 03/23/2026 at 10:22AM revealed S6Certified Nursing Assistant (CNA) brought Resident #21 into shower room a on a shower bed. Further observation revealed Resident #21 had an indwelling urinary catheter. Further observation revealed S6CNA and S7CNA proceeded to give Resident #21 a shower without the use of a gown. Observation on 03/24/2026 at 1:30PM revealed an enhanced barrier precautions sign outside of the door of Resident #21's room. Observation further revealed gowns were available for use behind Resident #21's door inside the room. In an interview on 03/23/2026 at 3:12PM, S7CNA confirmed she was not wearing a gown when she showered Resident #21 and she should have. In an interview on 03/24/2026 at 1:27PM, S6CNA confirmed she was not wearing a gown when she showered Resident #21, and she should have been. In an interview on 03/25/2026 at 12:46 PM, S2Director of Nursing (DON) indicated that staff should use a gown and gloves when providing residents, who have indwelling catheter, a bath or a shower. Resident #27 Review of Resident #27's care plan with a target date of 04/03/2026 revealed Resident #27 had a stage 2 pressure ulcer (open wound caused by unrelieved pressure to the skin) to Resident #27's sacrum (upper buttock area). Further review revealed an intervention of, in part, staff were to implement EBP. Observation on 03/23/2026 at 10:00AM revealed, in part, S4CNA removed Resident #27's bed linen, removed Resident #27's soiled diaper, and performed incontinence care to Resident #27 without wearing a gown. In an interview on 03/23/2026 at 10:10AM, S4CNA indicated she was only required to wear gloves when performing high contact resident care activities. S4CNA further indicated she was only required to wear a gown if a resident had Covid (viral infection). S4CNA further indicated the EBP sign hanging outside of Resident #27's door was only if the resident was sick. Resident #47 Review of Resident #47's care plan with a target date of 03/23/2026 revealed Resident #47 had an indwelling urinary catheter with an intervention of, in part, staff were to implement EBP. Observation on 03/23/2026 at 9:30AM revealed an EBP sign was posted outside of Resident #47's room. Observation on 03/23/2026 at 9:35AM revealed S5CNA performed incontinence care to Resident #47 and lifted Resident #47's catheter drainage bag and held it while Resident #47 pulled up his pants without wearing a gown. Observation on 03/23/2026 at 9:38AM revealed S4CNA entered Resident #47's room to assist with care. Further observation revealed S4CNA then emptied Resident #47's catheter drainage bag without wearing a gown. 2. Review of the facility's Hand Hygiene policy and procedure, latest revision date of 01/2024, revealed, in part, hand hygiene should be performed and gloves changed before and after every procedure. Review of the facility's Dressing Change policy and procedure, latest review date of 08/2021, revealed, in part, after removing a dressing, remove gloves, and perform hand hygiene. Further review revealed cleanse the area as ordered and dry the wound. Further review revealed then perform hand hygiene apply new gloves and apply the dressing. Resident #57 Review of Resident #57's March 2026 physician orders revealed Resident #57 was to have the right dorsal foot (top of the right foot) wound cleaned with normal saline, the nurse was to apply bacitracin (topical antibiotic used to treat or prevent infections) ointment, then cover the wound with a clean dressing, and the dressing was to be changed every three days and as needed until healed. Observation on 03/24/2026 at 1:35PM of Resident #57's wound care completed by S3Treatment Nurse revealed, in part, S3Treatment Nurse removed Resident #57's dressing from Resident #57's right foot. S3Treatment Nurse then cleaned the wound with normal saline, at which time S3Treatment Nurse identified a second wound to the right dorsal foot, which was distal (closer to the toes of the foot) to the previously identified wound. S3Treatment Nurse then cleaned the second newly identified wound with the same gauze S3Treatment Nurse used to clean the first wound. Further observation revealed S3Treatment Nurse did not remove her gloves nor perform hand hygiene between wounds. Further observation revealed S3Treatment Nurse then performed hand hygiene applied new gloves, used her gloved hands to remove loose skin from Resident #57's toes. Further observation revealed S3Treatment Nurse then without removing gloves or performing hand hygiene, grabbed the new dressing, touching the surface which was placed against Resident #57's skin with the same gloved hands. In an interview on 03/24/2026 at 1:46PM, S3Treatment Nurse indicated she should have changed her gloves, performed hand hygiene, and used a new gauze between cleaning the two wounds. S3Treatment Nurse further indicated she should have removed her gloves and performed hand hygiene after removing the dry skin on Resident #57's toes and prior to applying the new dressing. In an interview on 03/26/2026 at 11:33AM, S2Director of Nursing (DON) was informed of the above mentioned findings, and S2DON indicated S3Treatment Nurse should have changed her gloves, performed hand hygiene, and used a new gauze for cleaning each wound. S2DON further indicated S3Treatment Nurse should have also changed her gloves and performed hand hygiene after touching the skin between Resident #57's toes and applying the new dressing. In an interview on 03/26/2026 at 11:41AM, S1Administrator was made aware of the above mentioned findings, and indicated he had no further evidence to present for the above-mentioned findings.

Based on record reviews and interviews, the facility failed to document and address complaints voiced by the Resident Council during the facility's Resident Council meetings for 3 of 3 Resident Council meeting minutes reviewed. Findings: Review of the facility's Grievances-Residents policy, dated 03/1993 and revised on 05/2024 revealed, in part, the minutes of each Resident Council meeting should be recorded and future meetings should indicate progress made on each suggestion/recommendation, and/or the reason(s) for rejection if changes suggested could not be implemented. Further review of the policy revealed the grievance official was responsible for overseeing the grievance process, which included receiving, investigating and tracking grievances. Review revealed concerns which could not be promptly resolved should be treated as a grievance. Further review revealed the administrator or grievance official would conduct an impartial investigation of the allegations and would discuss the findings and recommendations within five working days of receiving the complaint. Review revealed the resident had the right to review the grievance and obtain a written decision regarding the grievance. In interview during a meeting held by the surveyor with members of the Resident Council on 03/11/2025 at 10:00AM, Resident #72 indicated the facility did not respond to the resident council's concerns discussed during the meetings regarding the taste and quality of food served from the kitchen. Resident #72 further indicated food concerns were discussed for the last three months and the food had not improved. Resident #15, Resident #59, and Resident #75 all agreed the taste and quality of the food served from the kitchen was discussed monthly for the last three months. Resident #72, Resident #15, Resident #59, and Resident #75 indicated there had been no follow-up from administration regarding the concerns of the taste and quality of food, and there had been no improvements in the taste and quality of food served from the kitchen. In an interview on 03/11/2025 at 10:15AM, Resident #72 indicated the food was over cooked, was under cooked, not seasoned, or was of poor quality overall. Resident #72 further indicated S4Dietary Manager was present at the Resident Council meetings and told the resident council members that the kitchen was short of staff at the time. In an interview on 03/12/2025 at 9:45AM, Resident #20 stated she attended the Resident Council meeting the last three months, and residents expressed concerns regarding the taste and quality of the food served. Resident #20 further indicated there were times when the beans were still hard and not cooked, the salads offered only had lettuce, and/or the food was just not cooked properly. Review of the Resident Council's meeting minutes for the months of January, February, and March 2025 revealed, in part, there were no documentation of the Resident Council's concerns regarding the taste and quality of food served from the kitchen as discussed in the resident council meetings. Review of the facility grievance logs from 12/2024 to 03/2025 revealed, in part, there were no documented grievances regarding the taste and/or quality of food served from the kitchen. In an interview on 03/11/2025 at 10:20AM, S5Activity Director indicated she was responsible for documenting the residents' concerns discussed during the resident council meetings. S5Activity Director further indicated residents discussed food displeasures during the meetings, but she did not document the concerns because she considered the concerns personal dislikes and not a generalized issue. In an interview on 03/11/2025 at 11:40AM, S6SocialWorker indicated she did not have any documented grievances regarding the taste and quality of food served from the kitchen. In an interview on 03/11/2025 at 5:45PM, S2Director of Nursing (DON) indicated she had recently received several complaints from residents regarding food served from the kitchen. S2DON further indicated she reported the concerns to S1Administrator. In an interview on 03/11/2025 at 5:52PM, S1Administrator indicated the resident council concerns regarding the taste and quality of food served from the kitchen should have been documented in the Resident Council meeting minutes. S1Administrator further indicated the residents' concerns should have been treated as a grievance with an investigation and response given to the residents.

Based on observations and interviews, the facility failed to: 1. Contain a used resident wash basin (Resident #31); and, 2. Maintain the smoking area in a clean manner (Resident #20). This deficient practice was identified for 2 (Resident #31 and Resident #20) of 31 (Resident #1, Resident #2, Resident #4, Resident #5, Resident #6, Resident #11, Resident #22, Resident #28, Resident #31, Resident #32, Resident #35, Resident #38, Resident #42, Resident #49, Resident #52, Resident #57, Resident #60, Resident #66, Resident #67, Resident #72, Resident #75, Resident #81, Resident #101, Resident #105, Resident #106, Resident #109, Resident #111, Resident #112, Resident #163, Resident #165, Resident #363) sampled residents observed during the initial pool process. Findings: 1. Observation on 03/10/2025 at 9:05AM revealed Resident #31's name was written on a wash basin which was under the sink on the floor of Resident #31's shared bathroom and not contained. Observation on 03/10/2025 at 3:45PM revealed Resident #31's name was written on a wash basin which was under the sink on the floor of Resident #31's shared bathroom and not contained. In an interview on 03/10/2025 at 3:52PM, S7Certified Nursing Assistant (CNA) indicated the wash basin was for Resident #31. S7CNA further indicated Resident #31's wash basin should not have been on the bathroom floor and should be contained in a plastic bag. In an interview on 03/10/2025 at 4:14PM, S2Director of Nursing indicated Resident #31's wash basin should not have been on the bathroom floor and should have been contained in a plastic bag. 2. In an interview on 03/10/2025 at 9:56AM, Resident #20 complained to the surveyor that the smoking area was dirty. Resident #20 then pointed to a cigarette that was on a window ledge and cigarette ashes all over the window ledge. Observation on 03/10/2025 at 9:58AM revealed a cigarette and cigarette ashes were present on the window ledge. Observation further revealed the smoking patio wall had an unknown black substance. Observation on 03/11/2025 at 10:25AM revealed a cigarette and cigarette ashes were present on the window ledge. Observation further revealed the smoking patio wall had an unknown black substance on the surface. In an interview on 03/12/2025 at 9:45AM, S1Administrator confirmed the smoking patio areas needed to be cleaned.

Based on interviews and record reviews, the facility failed to implement an appropriate fall intervention for a resident to prevent future falls for 1 (Resident #4) of 3 (Resident #4, Resident #32, Resident #49) sampled residents reviewed for falls. Findings: Review of Resident #4's Minimum Data Set with an Assessment Reference Date of 01/14/2025 revealed, in part, Resident #4 had a Brief Interview for Mental Status score of 3, which indicated Resident #3 had severe cognitive impairment, a diagnosis of dementia (memory loss), used a manual wheelchair for mobility, was dependent on staff for transfers, and had 2 or more falls since her prior assessment. Review of Resident #4's incident report dated 02/14/2025 revealed Resident #4 had an unwitnessed fall in her room and was found on the floor in front of her unlocked wheelchair. Review of Resident #4's care plan dated 02/17/2025 and revised on 03/11/2025 revealed, in part, Resident #4 had a history of falls with an intervention implemented on 02/14/2025 for staff to ensure brightly colored tape was applied to Resident #4's wheelchair brakes. In an interview on 03/11/2025 at 2:21PM, Resident #4 was unable to appropriately respond when questioned about the use of the brightly colored tape on her wheelchair brakes. In an interview on 03/12/2025 at 12:12PM, S10Licensed Practical Nurse (LPN) indicated Resident #4 had severe dementia and would not be able to remember to use her wheelchair brakes and/or identify the brightly colored tape on the brake handles as a reminder to use her wheelchair brakes. In an interview on 03/12/2025 at 12:15PM, S3Assistant Director of Nursing (ADON) indicated Resident #4's had poor safety awareness and severe cognitive impairment. S3ADON further indicated Resident #4 would not know how to use her wheelchair brakes and/or identify the brightly colored tape on the brake handles as a reminder to use her wheelchair brakes. In an interview on 03/12/2025 at 2:04PM, S9LPN indicated Resident #4 was definitely not cognitive enough to understand how to use her wheelchair brakes or identify the brightly colored tape on the brake handles as a reminder to use her wheelchair brakes.

Based on observations, interviews, and record reviews, the facility failed to follow the physician's order for oxygen administration for 1 (Resident #165) of 2 (Resident #164, Resident #165) sampled residents investigated for oxygen administration. Findings: Review of the facility's Oxygen-Administration, Concentration, Storage, Assemblage policy revised January 2024 revealed, in part, the procedure was to check the resident's oxygen flowmeter for the correct liter flow. Review of Resident #165's March 2025 Physician's Orders revealed, in part, an order for oxygen at two liters per minute (LPM) per nasal cannula continuously every shift related to chronic obstructive pulmonary disease. Observation on 03/10/2025 at 9:44AM revealed Resident #165's oxygen per nasal cannula was set between 1 and 1.5 LPM on the oxygen concentrator. Observation on 03/11/2025 at 2:09PM revealed Resident #165's oxygen per nasal cannula was set at 1.5 LPM on the oxygen concentrator. In an interview on 03/11/2025 at 2:10PM, S8Licensed Practical Nurse indicated Resident #165's oxygen was set at 1.5 LPM on the oxygen concentrator and should have been at 2 LPM per Resident #165's physician's orders. In an interview on 03/11/2025 at 3:25PM, S2Director of Nursing (DON) indicated the nurses should follow the physician's orders for oxygen administration. In an interview on 03/11/2025 at 4:05PM, S2DON confirmed Resident #165's oxygen order was for 2 LPM.

Based on interviews and record reviews, the facility failed to ensure a resident's hospice plan of care and certification of terminal illness was obtained from the contracted hospice agency for 1 (Resident #4) of 1 (Resident #4) sampled resident reviewed for hospice services. Findings: Review of Resident #4's Significant Change Minimum Data Set with an Assessment Reference Date of 01/14/2025 revealed, in part, Resident #4 had a life expectancy of less than 6 months and received hospice services. Review of Resident #4's March 2025 Physician's Orders revealed, in part, an order to admit Resident #4 to the contracted hospice agency on 01/03/2025. Review of the facility's Hospice Service Agreement dated 01/03/2025 revealed, in part, the facility was responsible for obtaining the most recent contracted hospice agency's plan of care and physician certification of terminal illness. Review of Resident #4's contracted hospice agency's binder revealed, in part, Resident #4 was admitted to hospice services on 01/03/2025. Further review revealed there was no documented evidence, and the facility was unable to present any documented evidence of Resident #4's physician certification of terminal illness or contracted hospice agency's plan of care. In an interview on 03/12/2025 at 1:43PM, S2Director of Nursing (DON) indicated it was the responsibility of S11Medical Records to ensure all hospice documents were maintained in Resident #4's clinical records. S2DON confirmed Resident #4's contracted hospice agency binder and electronic chart did not contain Resident #4's certification of terminal illness or Resident #4's contracted hospice agency's plan of care as required. In an interview on 03/12/2025 at 1:55PM, S11Medical Records indicated she was responsible to ensure all hospice documents were maintained in Resident #4's clinical record. S11Medical Records further indicated she did not know the specific hospice documents that should have been maintained in Resident #4's clinical record. S11Medical Records confirmed Resident #4's physician certification of terminal illness and contracted hospice agency's plan of care were not in Resident #4's clinical records as required.

Based on interview and record review, the facility failed to ensure a grievance was addressed and acted upon promptly per the facility's Grievance procedure for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents investigated for grievances. Findings: Review of the facility's policy titled, Resident's Right, last revised in 12/2023, revealed, in part, a resident should be encouraged to exercise their rights as a resident and present grievances. Review of the facility's policy/procedure titled ,Grievances-Residents, last revised in 10/2023, revealed, in part, the facility shall make prompt efforts to resolve grievances. Further review revealed the Administrator or Designee appointed as the Grievance Official, was responsible for overseeing the grievance process, receiving and tracking the grievances through their conclusion, leading any necessary investigations by the facility, and issuing written grievance decisions to the residents. Further review revealed the Social Worker or Social Services Designee had been appointed by the Administrator to receive concerns, grievances and recommendations by the residents. Further review revealed concerns that cannot be resolved within a shift shall be treated as a grievance. Further review revealed, these grievances shall be directed to the appropriate Department Head and/or Administrator for investigation and follow-up according to the following procedure: -Upon the receipt of a grievance/complaint the staff receiving the complaint would initiate the Grievance/Complaint Form NS-795, and an investigation led by the Administrator based on the allegations would be set forth. Further review revealed the Grievance/Complaint Form NS-795 would be completed electronically in the Quality Assurance module. In an interview on 04/23/2024 at 1:25 p.m., Resident #2 stated her personal underwear, a white undershirt, and an outfit were missing from her room. Resident #2 further stated she asked staff for the missing underwear, and they were unable to produce the missing items. In an interview on 04/23/2024 at 1:30 p.m., S4Certified Nursing Assistant (CNA) indicated she knew of Resident #2 missing personal items, and further indicated Resident #2's missing personal items were unable to be located. In an interview on 04/23/2024 at 2:05 p.m., S3LPN indicated she was not aware of Resident #2's missing personal items. In an interview on 04/23/2024 at 2:15 p.m., S5Houskeeping/Laundry Supervisor indicated staff had not reported Resident #2's missing personal items to him. In an interview on 04/23/2024 at 2:51p.m., S2Social Services Director indicated a resident's missing personal items should be reported to her immediately. In an interview on 04/24/2024 at 9:05 a.m., Resident #2 indicated her missing personal items had not been found. In an interview on 04/24/2024 at 9:14 a.m., S2Social Services Director indicated she was unaware of any grievance for Resident #2's missing personal items reported yesterday. In an interview on 04/24/2024 at 9:14 a.m., S1Administrator indicated she was unaware of any grievance for Resident #2's missing personal items reported yesterday. In an interview on 04/24/2024 at 9:15 a.m., S2Social Services Director indicated the facility had no documented evidence that a Grievance/Complaint Form NS-795 had been started regarding Resident #2's missing personal items from yesterday. There was no documented evidence, and the facility did not present any documented evidence, the facility's grievance procedure was started regarding Resident #2's grievance of missing personal items. In a phone interview on 04/24/2023 at 9:17 a.m., S5Houskeeping/Laundry Supervisor confirmed he was made aware of Resident #2 missing personal items yesterday, and did not report Resident #2's missing personal items to S2Social Services Director.

Based on record reviews and interviews, the facility failed to conduct a thorough investigation following an allegation of abuse for 4 (Resident #8, Resident #10, Resident #53, and Resident #56) of 8 (Resident #8, Resident #10, Resident #18, Resident #25, Resident #53, Resident #56, Resident #80, and Resident #84) sampled residents investigated for abuse. Findings: Review of a policy and procedure titled, Incident Investigation and Reporting (LA Only), most recently reviewed and/or revised on 10/2022 revealed, in part, the facility would thoroughly investigate all alleged violations under the direct supervision of the Administrator. Further review revealed, the investigation would include a signed statement from all witnesses including the accused, if applicable, stating the date and time with a detailed account of the incident. Resident #8 and Resident #10 Review of Resident #8's nurse's progress note dated 12/17/2023 revealed, in part, Resident #8 was slapped by Resident #10 on the right upper arm and on the side of his face. Review of Resident #10's nurse's progress note dated 12/17/2023 revealed, in part, at 10:10 a.m., it was reported by staff Resident #10 had slapped Resident #8 on the right upper extremity and face, when Resident #10 was asked by the staff to wait her turn at the door to facility's activity room. Review of the facility's documentation dated 12/17/2023 related to the above mentioned incident for Resident #8 revealed, in part, Resident #8 was slapped on the upper right arm and on the right side of his face by another resident. Further review revealed documentation the above mentioned incident was not witnessed. Review of the facility's documentation dated 12/17/2023 related to the above mentioned incident for Resident #10 revealed, in part, Resident #10 had slapped Resident #8 on the right upper extremity and the face when asked to wait her turn at the door to the activity room. Further review revealed documentation the above mentioned incident was not witnessed. In an interview on 03/07/2024 at 11:45 a.m., S6Activities Staff stated Resident #10 was upset Resident #8 was in her way. S6Activities Staff further stated she witnessed Resident #10 hit Resident #8 on the arm. There was no documented evidence, and the facility was unable to present any documented evidence, a thorough investigation, including validating if the allegation occurred through witness statements was completed following Resident #8's physical abuse of Resident #10. In an interview on 03/07/2024 at 3:36 p.m., S4Adminstrator indicated the documents he presented to the survey team was the only documentation the facility had regarding the above mentioned incident. S4Administrator further indicated the facility did not have any further documentation of written statements or interviews with staff. Resident #53 and Resident #56 Review of Resident #53's nurse's note dated 02/03/2024 revealed, in part, Resident #53 approached S5Medical Records in the hall and was very upset. Further review revealed Resident #53 stated another resident hit the top of his hand. Review of Resident #56's nurse's note dated 02/03/2024 revealed, in part, Resident #56 struck another resident who was seated at the table with her and continued to be upset and combative. In an interview on 03/07/2024 at 11:16 a.m., S5Medical Records stated Resident #53 reported to her Resident #56 had slapped his hand and he was upset. S5Medical Records further stated she has seen Resident #56 trying to aggravate Resident #53 after the incident. In a phone interview on 03/07/2024 at 12:05 p.m., S13LPN stated she was in the facility's dining area when she saw Resident #56 picking on Resident #53. S13LPN further stated that she separated Resident #56 from Resident #53, and then went to speak to another resident that needed assistance. S13LPN further stated she heard Resident #53 yell out, she hit me, and when she turned around, she saw Resident #56 was back by Resident #53 and was swinging her arms. There was no documented evidence and the facility was unable to present any documented evidence a thorough investigation, including validating if the allegation occurred through witness statements and/or video surveillance, was completed following Resident #56's alleged physical abuse of Resident #53. In an interview on 03/07/2024 at 3:36 p.m., S4Adminstrator indicated the documents he presented to the survey team was the only documentation the facility had regarding the above mentioned incident. S4Administrator further indicated the facility did not have any further documentation of written statements or interviews with staff.

Based on interviews and record reviews, the facility failed to report an allegation of abuse and the results of the investigation as required for 6 (Resident #8, Resident #10, Resident #25, Resident #53, Resident #56, and Resident #80) of 8 (Resident #8, Resident #10, Resident #18, Resident #25, Resident #53, Resident #56, Resident #80, and Resident #84) sampled residents investigated for abuse. Findings: Review of a policy and procedure titled, Incident Investigation and Reporting (LA Only) , most recently reviewed and/or revised on10/2022 revealed, the administrator shall report to the State Survey Agency, no later than two hours after forming the suspicion, if the event that cause the suspicion involve abuse. Resident #8 and Resident #10 Review of Resident #8's nurse's progress note dated 12/17/2023 revealed, in part, Resident #8 was slapped by Resident #10 on the right upper arm and on the side of his face. Review of Resident #10's nurse's progress note dated 12/17/2023 revealed, in part, at 10:10 a.m., it was reported by staff Resident #10 had slapped Resident #8 on the right upper extremity and face, when Resident #10 was asked by the staff to wait her turn at the door to facility's activity room. Review of the facility's documentation dated 12/17/2023 related to the above mentioned incident for Resident #8 revealed, in part, Resident #8 was slapped on the upper right arm and on the right side of his face by another resident. Review of the facility's documentation dated 12/17/2023 related to the above mentioned incident for Resident #10 revealed, in part, Resident #10 had slapped Resident #8 on the right upper extremity and the face when asked to wait her turn at the door to the activity room. In an interview on 03/07/2024 at 11:45 a.m., S6Activities Staff stated Resident #10 was upset Resident #8 was in her way. S6Activities Staff further stated she witnessed Resident #10 hit Resident #8 on the arm. In an interview on 03/07/2024 at 3:08 p.m., S1Administrator stated she would have reported the incident between Resident #8 and Resident #10 on 12/17/2023 to the state agency. In an interview on 03/07/2024 at 3:09 p.m., S4Administrator stated he did not report the incident of Resident #10 hitting Resident #8 to the state agency. Resident #25 and Resident #80 Review of Resident #25's nurse's note dated 12/04/2023 revealed, in part, staff heard Resident #25 and Resident #80 yelling and cursing at each other regarding the air conditioner. Further review revealed Resident #80 hit Resident #25 on the right arm. Review of the facility's documentation dated 12/17/2023 related to the above mentioned incident for Resident #25 revealed, in part, incident was witnessed by a Certified Nursing Assistant that Resident #80 hit Resident #25 on the right arm. In a phone interview on 03/07/2024 at 1:38 p.m., S7CNA stated she saw Resident #80 hit Resident #25 in the arm. In a phone interview on 03/07/2023 at 2:42 p.m., S8CNA stated she witnessed resident #80 hit Resident #25. S8CNA stated the incident was started due to Resident #25 touching Resident #80's personal items and the air conditioner in their room. In an interview on 03/07/2024 at 3:04 p.m., S4Administrator stated he did not report the incident of Resident #80 hitting Resident #25 to the state agency. Resident #53 and Resident #56 Review of Resident #53's nurse's note dated 02/03/2024 revealed, in part, Resident #53 approached S5Medical Records in the hall and was very upset. Further review revealed Resident #53 stated another resident hit the top of his hand. Review of Resident #56's nurse's note dated 02/03/2024 revealed, in part, Resident #56 struck another resident who was seated at the table with her and continued to be upset and combative. In an interview on 03/07/2024 at 11:16 a.m., S5Medical Records stated Resident #53 reported to her Resident #56 had slapped his hand and he was upset. S5Medical Records further stated she has seen Resident #56 trying to aggravate Resident #53 after the incident. In a phone interview on 03/07/2024 at 12:05 p.m., S13LPN stated she was in the facility's dining area when she saw Resident #56 picking on Resident #53. S13LPN further stated that she separated Resident #56 from Resident #53, and then went to speak to another resident that needed assistance. S13LPN further stated she heard Resident #53 yell out, she hit me, and when she turned around, she saw Resident #56 was back by Resident #53 and was swinging her arms. In an interview on 03/07/2024 at 3:36 p.m., S4Administrator stated he did not report the incident of Resident #56 allegedly hitting Resident #53 to the state agency.

Based on interviews and record reviews, the facility failed to ensure residents were free from resident-to-resident abuse for 2 (Resident #8 and Resident #25) of 8 (Resident #8, Resident #10, Resident #18, Resident #25, Resident #53, Resident #56, Resident #80, and Resident #84) sampled residents investigated for abuse. Findings: Review of a policy and procedure titled, Incident Investigation and Reporting (LA Only), most recently reviewed and/or revised on 10/2022 revealed, in part, abuse was the willful infliction of injury or punishment with resulting physical harm, pain, or mental anguish. Further review revealed, instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Further review revealed, willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Resident #8 Review of Resident #8's nurse's progress note dated 12/17/2023 revealed, in part, Resident #8 was slapped by Resident #10 on the right upper arm and on the side of his face. Review of Resident #10's nurse's progress note dated 12/17/2023 revealed, in part, at 10:10 a.m., it was reported by staff Resident #10 had slapped Resident #8 on the right upper extremity and face, when Resident #10 was asked by the staff to wait her turn at the door to facility's activity room. Review of the facility's documentation dated 12/17/2023 related to the above mentioned incident for Resident #8 revealed, in part, Resident #8 was slapped on the upper right arm and on the right side of his face by another resident. Review of the facility's documentation dated 12/17/2023 related to the above mentioned incident for Resident #10 revealed, in part, Resident #10 had slapped Resident #8 on the right upper extremity and on the face when asked to wait her turn at the door to the activity room. In an interview on 03/07/2024 at 11:45 a.m., S6Activities Staff stated Resident #10 was upset Resident #8 was in her way. S6Activities Staff further stated she witnessed Resident #10 hit Resident #8 on the arm. Resident #25 Review of Resident #25's nurse's progress note dated 12/04/2023 revealed, in part, staff heard Resident #25 and Resident #80 yelling and cursing at each other regarding the air conditioner. Further review revealed Resident #80 hit Resident #25 on the right arm. Review of the facility's documentation dated 12/17/2023 related to the above mentioned incident for Resident #25 revealed, in part, the incident was witnessed by a Certified Nursing Assistant that Resident #80 hit Resident #25 on the right arm. In a phone interview on 03/07/2024 at 1:38 p.m., S7CNA stated she saw Resident #80 hit Resident #25 on the arm. In a phone interview on 03/07/2023 at 2:42 p.m., S8CNA stated she witnessed resident #80 hit Resident #25. S8CNA stated the incident was started due to Resident #25 touching Resident #80's personal items and the air conditioner in their room.

Based on observation and interviews, the facility failed to ensure a Certified Nursing Assistant performed hand hygiene after providing incontinence care for 1 (Resident #26) of 1 (Resident #26) sampled resident observed for incontinence care. Findings: Observation on 03/06/2024 at 12:28 p.m., revealed S12Certified Nursing Assistant (CNA) performed incontinence care for Resident #26 by wiping her vaginal area and then cleaning stool from her buttocks with gloved hands. Further observation revealed, after S12CNA completed Resident #26's incontinence care, S12CNA did not remove her gloves or perform hand hygiene. S12CNA then proceeded to assist Resident #26 back in her wheelchair and rolled Resident #26's wheelchair back to her bed. S12CNA pulled back the bed covers, and assisted with transferring Resident #26 to bed with same pair of gloves and without performing hand hygiene. S12CNA proceeded to adjust Resident #26's bed remote, fluff the bed pillows, pull up the bed covers, and hand Resident #26 her television remote with the same pair of gloves used to perform incontinence care and without performing hand hygiene. In an interview on 03/06/2024 at 12:40 p.m., S12CNA stated she did not usually remove her gloves after performing incontinence care and prior to putting the residents in bed. S12CNA agreed she should have changed her gloves and/or performed hand hygiene before she touched Resident #26's wheelchair, bed remote, pillows, blankets, and television remote after she performed Resident #26's incontinence care. In an interview on 03/07/2024 at 9:04 a.m., S2Director of Nursing indicated the CNA should have removed her gloves and/or performed hand hygiene after performing Resident #26's incontinence care, and before going to a clean area, and touching Resident #26's pillows, blankets, bed remote, and television remote.

Based on observations, record reviews, and interviews, the facility failed to maintain accurate count of the disposition of controlled medications for 2 (Resident #17 and Resident #27) of 2 (Resident #17 and Resident #27) who received controlled medications from Medication Cart a. Findings: Resident #17 On 03/07/2024 at 11:25 a.m. a reconciliation was completed of the controlled substances on Medication Cart a and the controlled substance binder for Medication Cart a and revealed the following: Observation of Resident #17's medication card for Phenobarbital 32.4milligrams (mg) (a medication used for seizures) revealed 56 pills remained on the medication card. Review of Resident #17's individual resident narcotics record for Phenobarbital 32.4mg tablet revealed 57 pills remained on the card. In an interview on 03/07/2024 at 11:26 a.m., S9Licensed Practical Nurse (LPN) stated she failed to document the administration of Resident #17's Phenobarbital 32.4mg on the individual resident narcotics record after she administered the controlled medication. Resident #27 On 03/07/2024 at 12:00 p.m. a reconciliation was completed of the controlled substances on Medication Cart b and the controlled substance binder for Medication Cart b and revealed, in part, the following: Observation of Resident #27's medication card for Lorazepam 0.5mg (medication used for anxiety) revealed the card had 5 pills. Review of Resident #27's individual resident narcotics record for Lorazepam 0.5mg tablet revealed 6 pills remained on the card. In an interview on 03/07/2024 at 12:02 p.m., S11Registered Nurse (RN) stated she failed to document the administration of Resident #27's Lorazepam 0.5mg on the individual resident narcotics record after she administered the medication. In an interview on 03/07/2024 at 1:27 p.m., S2Director of Nursing (DON) stated nurses were expected to update the individual resident narcotics record when a medication was administered. S2DON confirmed Resident #17 and Resident #27's individual resident narcotic records were not correct.

Based on observation and interview, the facility failed to post daily nurse staffing data as required for 3 of 3 days observed. Findings: Observation on 03/04/2024 at 3:10 p.m. revealed the facility's posted nursing staffing data was dated 03/03/2024. Observation on 03/05/2024 at 10:20 a.m. revealed the facility's posted staffing information was dated 03/05/2024, with only the 6:00 a.m. to 2:00 p.m. shift information documented. Observation on 03/06/2024 at 9:34 a.m. revealed the facility's posted staffing information was dated 03/05/2024, with only the 6:00 a.m. to 2:00 p.m. shift information documented. Observation on 03/06/2024 at 11:13 a.m. revealed no staffing information for 03/06/2024 was posted in the facility. In an interview on 03/06/2024 at 11:14 a.m., S2Director of Nursing confirmed the nursing staffing data was not current. S2Director of Nursing stated S3Human Resources was in charge of posting the nursing staffing information daily. In an interview on 03/06/2024 at 11:17 a.m., S3Human Resources stated she posted the previous day's nursing staffing information on the bulletin board in the facility. S3Human Resources stated she was unaware she had to post the current day's nursing staffing information.

Based on record reviews and interviews, the facility failed to ensure a resident's care plan was implemented by failing to document meal intakes. This deficient practice was identified for 2 (Resident #92 and Resident #105) of 6 residents investigated for nutrition in a total investigative sample of 25. Findings: Review of the facility's Food Intake Records policy and procedure revealed, in part, the intake of each resident must be documented at each meal. Resident #92 Review of Resident #92's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/27/2022 revealed, in part, Resident #92 had diagnoses including cancer, anorexia nervosa, and abnormal weight loss. Further review revealed Resident #92 weighed 102 pounds and had nutrition and hydration as a treatment intervention for skin issues. Review of Resident #92's weights revealed, in part, on 02/09/2023 Resident #92 weighed 106.6 pounds, and on 03/09/2023 Resident #92 weighed 96.8 pounds. Further review revealed Resident #92 had a significant weight loss of 5.3% in one month. Review of Resident #92's care plan revealed, in part, Resident #92 was at risk for skin breakdown as a result of skin cancer with an intervention for staff to record meal intake. Further review revealed Resident #92 was care planned for skin cancer lesions to the face with interventions for staff to record the percentage of meals eaten daily. Review of Resident #92's Meal Intake documentation from 01/15/2023 through 03/15/2023 revealed, in part, no documented evidence and the facility was unable to present any documented evidence of meal intake documentation for the following meals on the following dates: - 01/15/2023 - breakfast, lunch, and dinner; - 01/17/2023 - lunch and dinner; - 01/19/2023 - breakfast and lunch; - 01/20/2023 - lunch; - 01/21/2023 - lunch; - 01/22/2023 - lunch; - 01/23/2023 - lunch and dinner; - 01/24/2023 - lunch; - 01/25/2023 - breakfast, lunch, and dinner; - 01/26/2023 - breakfast, lunch, and dinner; - 01/27/2023 - breakfast, lunch, and dinner; - 01/28/2023 - breakfast, lunch, and dinner; - 01/29/2023 - dinner; - 01/30/2023 - dinner; - 01/31/2023 - breakfast, lunch, dinner; - 02/01/2023 - breakfast and lunch; - 02/02/2023 - breakfast, lunch, and dinner; - 02/04/2023 - breakfast, lunch, and dinner; - 02/06/2023 - breakfast and lunch; - 02/07/2023 - breakfast, lunch, and dinner; - 02/08/2023 - breakfast and lunch; - 02/09/2023 - breakfast, lunch, and dinner; - 02/10/2023 - lunch; - 02/11/2023 - lunch and dinner; - 02/12/2023 - lunch; - 02/13/2023 - breakfast and lunch; - 02/14/2023 - breakfast, lunch, and dinner; - 02/15/2023 - lunch; - 02/16/2023 - dinner; - 02/17/2023 - dinner; - 02/18/2023 - breakfast and lunch; - 02/19/2023 - breakfast and lunch; - 02/20/2023 - lunch and dinner; - 02/21/2023 - breakfast and lunch; - 02/23/2023 - breakfast and lunch; - 02/24/2023 - dinner; - 02/25/2023 - breakfast and lunch; - 02/26/2023 - breakfast, lunch, and dinner; - 02/27/2023 - breakfast and lunch; - 02/28/2023 - dinner; - 03/02/2023 - dinner; - 03/04/2023 - breakfast, lunch, and dinner; - 03/05/2023 - lunch; - 03/08/2023 - dinner; - 03/10/2023 - lunch; - 03/11/2023 - dinner; - 03/13/2023 - breakfast and dinner; and, - 03/14/2023 - dinner. Resident #105 Review of Resident #105's MDS with an ARD of 02/09/2023 revealed, in part, Resident #105 had a diagnosis of malnutrition. Further review revealed Resident #105 had a feeding tube and a therapeutic diet. Review of Resident #105's March 2023 Physician's Order revealed, in part, an order with a start date of 02/17/2023 for a pureed diet with no added salt and low concentrated sweets. Further review revealed an order for Diabetisource tube feeding formula at 60 milliliters per hour via pump continuously from 6:00 p.m. to 6:00 a.m. infused though Resident #105's feeding tube. Review of Resident #105's Care Plan revealed, in part, Resident #105 was care planned for the potential for aspiration related to being prescribed mechanically altered therapeutic pleasure feedings with interventions for staff to record meal intake. Review of Resident #105's Meal Intake documentation from 02/17/2023 through 03/15/2023 revealed, in part, no documented evidence and the facility was unable to present any documented evidence of meal intake documentation for the following meals on the following dates: - 02/17/2023 - breakfast, lunch, and dinner; - 02/18/2023 - breakfast, lunch, and dinner; - 02/19/2023 - breakfast, lunch, and dinner; - 02/20/2023 - breakfast, lunch, and dinner; - 02/21/2023 - dinner; - 02/22/2023 - dinner; - 02/23/2023 - lunch and dinner; - 02/24/2023 - lunch; - 02/25/2023 - lunch and dinner; - 02/27/2023 - dinner; - 02/28/2023 - breakfast, lunch, and dinner; - 03/04/2023 - breakfast and lunch; - 03/06/2023 - lunch and dinner; - 03/08/2023 - dinner; - 03/09/2023 - lunch; - 03/11/2023 - breakfast and lunch; - 03/12/2023 - breakfast and lunch; and, - 03/14/2023 - lunch. In an interview on 03/16/2023 at 1:54 p.m., S5Certified Nursing Assistant (CNA) stated the CNA feeding a resident would be responsible for documenting the meal intake percentage on the meal ticket, then the resident's assigned CNA would document the meal intake in the computer. S5CNA further stated every resident's meal intake should be documented for every meal. In an interview on 03/16/2023 at 2:12 p.m., S6Assessment Nurse stated breakfast, lunch, and dinner should be recorded every day to reflect a resident's nutritional status. In an interview on 03/16/2023 at 2:16 p.m., S7Dietary Manager stated CNAs should document meal intakes for every meal every day on all residents. In an interview on 03/16/2023 at 2:33 p.m., S8Assistant Director of Nursing (ADON) stated meal intakes should be documented for every meal for every resident. S8ADON stated meal intake would be utilized to complete a resident's weight evaluation. In an interview on 03/16/2023 at 3:06 p.m., S1Director of Nursing (DON) confirmed meal intake documentation was lacking for Resident #92 and Resident #105. S1DON stated meal intakes should be documented for every meal every day on every resident. S1DON further stated meal intake documentation is especially important for the nutritional evaluation of residents with known weight loss, feeding tubes, and wounds.

Based on record review, observations, and interviews, the facility failed to provide appropriate urinary catheter care according to professional standards for 2 (Resident #26 and Resident #89) residents investigated for urinary catheters in a total investigative sample of 25. This failed practice had the potential to effect any of the 11 residents with urinary catheters as documented on the facility's Resident Census and Conditions of Residents form (CMS-672). Findings: Review of the facility's Urinary Catheter Policy revealed, in part, perform hand hygiene and apply clean gloves. Using a clean washcloth or wash wipe, start at the meatus and wash the tubing in a circular motion away from the body about 4-5 inches. Rinse using same method. RESIDENT #89 Review of Resident #89's record revealed, in part, an admitted [DATE] with diagnoses of Hydronephrosis (a condition of an excess accumulation of urine in the kidneys which causes swelling) with renal and ureteral calculous obstruction, and retention of urine. Review of Resident #89's yearly Minimum Data Set with an Assessment Reference Date of 03/07/2023 revealed, in part, Resident #89 had an in-dwelling catheter. Review of Resident #89's Care Plan revealed, in part, catheter care every shift. An observation on 03/15/2023 at 11:30 a.m., of catheter care on Resident #89 revealed S3Certified Nursing Assistant (CNA) placed her soiled gloved hand into the multipack of wipes three times. Observation also revealed CNA wiped the catheter tubing both away from the resident and towards the resident. Additionally, the CNA left the contaminated multipack of wipes at Resident #89's bedside for future usage. In an interview on 03/15/2023 at 12:30 p.m., S3CNA stated if there were no body wipes in a resident room for use and none in the storage room she would look in another resident's room for a pack. S3CNA further stated that she considered Resident #89's multipack of wipes to be contaminated with stool, and the pack of wipes should have been thrown away. In an interview on 03/15/2023 at 4:30 p.m., S1Director of Nursing (DON) stated once gloves touched a soiled area the gloves are considered contaminated. S1DON further stated if body wipes are retrieved from a body wipe multipack with contaminated gloves, the pack should be thrown away and not available for future use. RESIDENT 26 Review of Resident #26's record revealed, in part, an admitted [DATE] with a diagnosis of Urinary Tract Infection. Review of Resident #26's Care Plan revealed, in part, Catheter Care every shift. An observation on 03/15/2023 at 11:10 a.m., revealed S4CNA provided catheter care to Resident #26 without changing gloves and sanitizing hands after cleaning stool from Resident #26. Observation also revealed S4CNA wiped the catheter tubing both away from the resident and towards the resident. S4CNA was observed obtaining body wipes from a multi pack two times while cleaning stool from Resident #26 with the same gloves on. S4CNA placed the contaminated body wipe pack on the shelf in the storage room. In an interview on 03/15/2023 at 4:30 p.m. S1DON stated once gloves touch a soiled area they are considered contaminated. S1DON further stated S4CNA should have changed her gloves and sanitized her hands after cleaning Resident #26's stool and before proceeding with Resident #26's catheter care. S1DON further stated if body wipes are retrieved from a body wipe multipack with contaminated gloves, the pack should be thrown away and not available for future use.

Based on observation, record review, and interview the facility failed to: 1.) Appropriately post signage outside the door for a resident placed on contact precautions (Resident #65); 2.) Ensure a Certified Nursing Assistant (CNA) wore an isolation gown during direct contact of urine while providing incontinence care of a resident with a transmissible infection (Resident #65); 3.) Ensure a Certified Nursing Assistant (CNA) changed gloves and performed hand hygiene when moving from a contaminated body site to a clean body site during resident care (Resident #65); 4.) Appropriately discard contaminated gloves following resident care into a red biohazard bag that was available in the resident's room (Resident #65). 5.) Appropriately discard contaminated percutaneous endoscopic gastrostomy (PEG) site dressing after removal (Resident #31). Findings: Review of the facility's policy entitled Standard Precautions (F880) with a latest revision September 2014 revealed, in part, Standard Precautions are based on the principle that all body fluids may contain transmissible infectious agents; Standard Precautions apply to all residents, regardless of suspected or confirmed infection status. Further review revealed in all settings health care is delivered which includes hand hygiene, use of gloves, gown, mask, eye protection, or face shield, depending on the anticipated exposure. Review also revealed handwashing is recognized as the most important way to prevent the transmission of infection, and all employees are to wash their hands after every unprotected contact with blood or other potentially infectious materials and after removing gloves. Review of the facility's policy entitled Procedure for Isolation: Isolation Precautions with a latest revision date of November 2011 revealed, in part, Contact Precautions (Use Orange Bordered Sign): In addition to Standard Precautions, use Contact Precautions for residents known or suspected to be infected with microorganisms that can be easily transmitted by direct or indirect contact, such as handling environmental surfaces or resident-care items. Further review revealed, in part, Obtain appropriate signage and post outside the door frame. Resident #65 Review of Resident # 65's medical record revealed, in part, resident was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #65 had severe cognitive impairment. Review of Resident #65's care plan revealed, in part, Resident #65 had bowel/bladder incontinence with intervention for staff to provide incontinence care every two hours and as needed, and report signs and symptoms of urinary tract infection to resident's physician. Review of Resident #65's Nurses Notes dated 04/26/2022 at 11:36am revealed, in part, [MEDICATION(S)] Double Strength administered to Resident #65 per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . ESBL is a contact transmissible organism. Observation on 04/25/2022 at 12:46pm, revealed Resident # 65's door did not have signage posted or personal protective equipment on the outside of Resident #65's door. Observation on 04/26/2022 at 03:55pm, revealed Resident #65's door did not have signage posted for contact isolation precautions. Further observation revealed S6CNA and S8CNA entered Resident #65's room without donning isolation gown. Observation further revealed S6CNA provided incontinence care to Resident #65, did not remove soiled gloves or complete hand hygiene, dressed Resident #65 and placed Resident #65 into a Geri-chair. Observation further revealed S6CNA entered Resident #65's bathroom, which is shared by other residents, and disposed of her soiled gloves into the restroom garbage can. In an interview on 04/26/2022 at 04:15pm, S8CNA acknowledged she should have worn a gown and gloves to enter Resident #65's room, but confirmed she did not wear gown. S8CNA further acknowledged contaminated trash should go into the red bin placed in Resident #65's room. S8CNA further acknowledged that the contaminated gloves S6CNA placed in the shared restroom garbage can should have been placed in the red bin in Resident #65's room. In an interview on 04/27/2022 at 01:19pm, S7Licened Practical Nurse (LPN) stated when a resident is placed on contact precautions PPE is hung on the door and any staff performing care or hygiene should fully garb up using gloves and gown. S7LPN further stated the red biohazard bag should be used to throw away contaminated trash. In an interview on 04/27/2022 at 01:49pm, S7LPN acknowledged S6Certified Nursing Assistant (CNA) should have worn a gown when she changed Resident #65's diaper. S7LPN additionally acknowledged S6CNA should have removed her gloves and completed hand hygiene after Resident #65's diaper change, and S6CNA should not have discarded gloves soiled with infectious urine in the shared restroom garbage can. In an interview on 04/27/2022 at 02:05pm, S6CNA acknowledged when a resident is placed on precautions she is usually informed by the nurse of the precautions. S6CNA further acknowledged she was not aware Resident #65 was on contact precautions and she was just helping her coworker. S6CNA stated the PPE was hanging on the door but she missed it. S6CNA agreed that she should have worn an isolation gown when she provided incontinence care and changed Resident #65's diaper. S6CNA agreed after changing Resident #65's diaper she should have removed her contaminated gloves and performed hand hygiene prior to dressing Resident #65 in a new pair of pants. S6CNA acknowledged after removing the contaminated gloves used to change the Resident #65's she should not have discarded the gloves into the shared restroom garbage can, instead the gloves should have been placed in the red bin inside Resident #65's room. In an interview on 04/27/2022 at 02:45pm, S3Director of Nursing (DON) and Infection Control Preventionist acknowledged S6CNA should have worn a gown while completing incontinence care and diaper change of Resident #65. S3DON agreed S6CNA should have also changed gloves and performed hand hygiene between the diaper change and before placing new pants on Resident #65. S3DON agreed S6/CNA should not have placed contaminated gloves into the shared restroom garbage can. S3DON further stated a sign for contact precautions and the sequencing of donning and doffing of PPE was placed on Resident #65's door after the incident was reported to her by S6CNA. Resident #31 Review of Resident #31 record revealed, in part, an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 04/27/22 at 10:20am, Resident #31's old percutaneous endoscopic gastrostomy (PEG) tube dressing with yellowish brown drainage and tape visible on the over-bed table next to the PEG tube feeding infusion. Resident #31 was cognitively impaired and did not communicate when the PEG site dressing was changed. In a joint interview on 04/27/22 at 10:21am, S4LPN and S6CNA acknowledged the PEG site wound care dressing with yellow/brown drainage and tape dated 04/26/2022 should not have been left on Resident #31's over-bed table. S6CNA and S4LPN further stated the wound care nurse did the dressing change this morning after they had made their initial rounds on 04/27/2022 at 7:00am. In an interview on 04/27/22 at 10:25am, S3DON and Infection Control Preventionist acknowledged the PEG site dressing with yellow/brown drainage and tape dated 04/26/2022 should not have been left on Resident # 31's over-bed table. S3DON further stated this was a fluke and it should not have happened.

Based on observation and interview, the facility failed to ensure milk stored for residents use was not expired. This deficient practice had the potential to affect any of the 90 residents who consumed meals from the facility kitchen as listed on the facility's Resident Census and Condition of Residents Form CMS-672. Findings: Observation on [DATE] at 8:50am, revealed the following items in the facility's reach-in refrigerator: 3 unopened fat free white milk cartons with an expiration date of [DATE]; 4 unopened fat free chocolate milk cartons with an expiration date of [DATE]; 2 unopened regular chocolate milk cartons dated [DATE]; and, 1 fat free chocolate milk dated [DATE]. Further observation revealed the facility's walk-in cooler contained a crate with 51 fat free chocolate milk cartons with an expiration date of [DATE]. In an interview on [DATE] at 8:54am, S2Dietary Aide stated the cartons of milk on the tray were available for resident consumption. S2Dietary Aide further stated the expired cartons of milk should not have been in the reach-in cooler. In an interview on [DATE] at 9:05am, S1Dietary Manager stated the cartons of milk were available for resident consumption and acknowledged they should be discarded because they were expired.

Based on observation, record review, and interview the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment which helped prevent the development and transmission of communicable diseases and infections by: I.) failing to ensure a wound was properly dressed and covered according to physician's orders [REDACTED]. II.) failing to ensure a Certified Nursing Assistant (CNA) cleaned and sanitized her hands between glove changes during catheter care (S6/CNA); and III.) failing to ensure 2 (S8/Licensed Practical Nurse (LPN) and S9/LPN) of 3 (S8/LPN, S9/LPN, S11/LPN) nurses performed hand hygiene between glove changes and after resident contact during medication administration This deficient practice had the potential to affect any of the 113 residents residing in the facility as documented on the facility's Resident Census and Conditions of Resident's Form (CMS-672). Findings: Review of the CDC's (Centers for Disease Control and Prevention)Standard Precautions and Prevention of Transmission of HIV(Human Immunodeficiency Virus), [MEDICAL CONDITION] Virus, [MEDICAL CONDITION] Virus, and Other Blood borne Pathogens in Health Care Settings revealed in part: staff should perform hand hygiene before having direct contact with patients, after contact with a patient's intact skin, if hands are likely to move from a contaminated body site to a clean body site during patient care, after contact with inanimate objects (including medical equipment), and after removing gloves. Review of the facility's Policy and Procedure entitled Hand Hygiene with a latest revision date of October/2017 revealed in part, hand hygiene should be performed between all contact with residents or when entering and exiting a resident's room; before and after applying gloves; after contact with a resident's intact skin, and after contact with inanimate (not alive) objects (including medical equipment). I and II.) Resident #97 Review of Resident #97's record revealed Resident #97 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #97's (MONTH) (YEAR)'s physician's orders [REDACTED]. Further review of orders revealed an order dated 05/03/18 to clean Resident #97's right heel diabetic ulcer with normal saline, apply silver alginate, cover with dressing on Tuesday, Thursday, and Saturday and prn (as needed). Observation on 09/18/18 at 10:23am with S10/Registered Nurse (RN), revealed Resident #97 lying in bed with bilateral heel float boots on. Further observation revealed, when the right heel float boot was removed by S10/RN, Resident #97's diabetic ulcer to his right heel had no dressing present, and the right heel wound surface was in direct contact with the heel area of the right float boot. Further observation revealed Resident #97's right heel wound was circular in shape with pink edges and a whitish, moist appearing center which was in direct contact with the surface of the heel area of the right float boot. During Resident #97's catheter care observation on 09/20/18 at 9:37am S6/Certified Nursing Assistant (CNA) washed hands with soap and water, placed gloves on, cleansed the area of Resident #97's catheter entrance and the catheter tubing with soap and water, removed dirty gloves, and placed new gloves on without washing or sanitizing her hands prior to placing the new gloves on her hands. In interview on 09/19/18 at 8:43am S6/CNA stated she cared for Resident #97 and Resident #97 had wounds on both heels and the right heel wound was to be covered with a dressing. When asked what she would do if the right heel dressing came off, S6/CNA stated she would seek the wound care nurse or the floor nurse. When asked if she would ever place the heel float boot directly on Resident #97's uncovered right heel wound, she stated yes, so the heel could be floated. In interview on 09/20/18 at 9:05am S8/LPN stated Resident #97 had a wound to the right heel. S8/LPN was asked if at any time should the staff place the right heel float boot on Resident #97's right heel wound without a dressing on the wound, and she stated definitely not. In interview on 09/20/18 at 9:37am S6/CNA was questioned when should hands be washed or sanitized and she stated hands should be washed or sanitized in between every resident and after care and after removing dirty gloves and prior to placing clean gloves on. In interview on 09/20/18 at 11:35am S1/DON confirmed all staff should wash and sanitize hands between glove changes. In interview on 9/20/18 at 11:30am, S1/Director of Nursing (DON) was informed Resident #97's right heel wound was found without the ordered dressing in place allowing Resident #97's right diabetic ulcer wound opening to be in direct contact with Resident #97's float boot. S1/DON stated staff should know if a wound dressing comes off and the floor nurse or wound care nurse should be notified so the wound can be covered with a new dressing or at least with a temporary gauze covering. S1/DON confirmed Resident #97's wound should have been covered at all times and stated he was at risk for infection without his open wound being covered and coming in direct contact with the float boot surface. III.) Observation on 09/17/18 at 3:15pm revealed S9/LPN entered Resident #84's room to perform a blood sugar check to determine the need for sliding scale insulin administration. Further observation revealed S9/LPN washed her hands, placed gloves on both hands and proceeded to perform a finger stick on Resident #84, and obtained a reading. S9/LPN stated she would recheck Resident #84's blood sugar due to obtaining an elevated reading. S9/LPN then removed her right glove, didn't wash or sanitize her hand, and rechecked Resident #84's blood sugar using her gloved left hand. S9/LPN then removed her remaining glove from the left hand, proceeded to the room door, touched the door knob to open the door, exited the room, checked the computer to verify correct sliding scale dose, all without washing or sanitizing hands after glove removal. S9/LPN then placed new gloves without washing or sanitizing hands prior to placing the new gloves. During medication administration observation on 09/18/18 at 7:50am S8/LPN approached Resident #45 in the dining room and touched Resident #45's finger to apply a device used to check heart rate and obtained a low heart rate. S8/LPN then left Resident #45, proceeded to the medication cart, typed information into the medication cart computer, and walked to the nursing station, and picked up and utilized the nursing station phone. Observation revealed no hand washing or hand sanitizing by S8/LPN after coming in contact with Resident #45's intact skin, typing on the medication cart computer, making a phone call, and returning to administer Resident #45's medication. Further observation revealed S8/LPN administered Resident #45's medication, then returned to the medication cart, and did not wash her hands or use hand sanitizer following the medication administration. In interview on 09/20/18 at 11:15am S8/LPN was asked when hands should be washed or sanitized during medication administration, and S8/LPN stated hands should be sanitized prior to preparing medications for a resident and in between residents. When informed during the medication administration observation she did not wash or sanitizing her hands prior to gathering Resident #45's medications or after coming in contact with Resident #45's intact skin, after touching potentially contaminated devices such as the computer or the nursing station phone, after completing Resident #45's medication administration and prior to proceeding with her next resident medication preparation, S8/LPN stated agreement and stated she should have washed or sanitized her hands after leaving Resident #45, after touching the potentially contaminated devices, and prior to preparing another resident's medications. In interview on 09/20/18 at 11:30am S1/DON was asked when should nurses wash or sanitize their hands during medication administration, S1/DON stated nurses are to clean/sanitize their hands before contact with a resident, before entering a room, after exiting a room, between glove changes, and prior to preparing medications. When informed of the above findings, S1/DON stated S9/LPN should have washed/sanitized her hands after removing her gloves, prior to exiting Resident #84's room, and prior to placing clean gloves on. S1/DON stated S8/LPN should have washed/sanitized her hands prior to preparing Resident #45's medications, after contact with Resident #45, after contact with the nursing station phone, prior to returning to the resident to administer his medication and after completing the administration of Resident #45's medications.

Based on observation, record review and interview the facility failed to offer a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet for 1 (Resident #214) of 44 residents sampled residents reviewed in the investigation stage. This deficient practice had the potential to affect any of the 33 residents who receive mechanically altered diet as identified on the Resident Census and Conditions of Residents Form (CMS -672). Findings: Resident #214 was admitted to the facility on [DATE] with diagnoses, in part, [MEDICAL CONDITION] following a Cerebral Infarction affecting Resident #214's left dominant side and Dysphagia. Review of Resident #214's (MONTH) (YEAR) Physician order [REDACTED]. Further review revealed an order for [REDACTED]. Review of Resident #214's baseline care plan revealed, in part, diet as ordered. Review of Resident #214's Plan of treatment for [REDACTED]. Further review of the plan of treatment revealed precautions and contradictions include swallowing precautions and aspiration risk . Review of Resident #214's follow up notes from the facility's Nurse Practitioner dated 09/14/18 revealed, in part, he states he is eating and swallowing fine but they were giving him pureed meats at the rehab facility. He reports he has no difficulty swallowing and would like to be on a regular diet. Further review of the follow-up note revealed the NP explained to him that he will need to be evaluated by ST and they will make recommendations about if he would be able to tolerate advancing his diet. Observation on 09/18/18 at 8:20am revealed Resident #214 was in the dining room for the breakfast meal. Observation of the meal provided revealed chopped meat and a carton of milk with no ice in the carton. Resident #214 drank the milk out of the carton. Review of Resident #214's breakfast meal ticket revealed, in part, diet mechanical soft, low concentrated sweets, no salt on table, puree meat, and heavily iced liquids. In interview on 09/18/18 at 8:25am S3/Social Services Designee (SSD)/Assistant Administrator confirmed the meal provided to Resident #214 included chopped meat and milk in a carton. In interview on 09/18/18 at 8:35am S4/Speech Language Pathologist confirmed that Resident #214 had a diet order for pureed meats and heavily iced liquids. She stated the goal of therapy was to upgrade the diet, but as of this time the current diet order should be followed. In interview on 09/20/18 at 9:30am S2/Dietary Manager stated that the diet card should have been followed and Resident #214 did not sign a refusal of treatment form. In interview on 09/20/17 at 9:50am S4/Speech Language Pathologist stated that Resident #214 needed to continue with the prescribed diet. In interview on 09/20/18 at 10:05am S5/Assistant Director of Nursing confirmed Resident #214 had a diet order for pureed meats and heavily iced liquids. She confirmed Resident #214 did not sign a waiver for refusal of the prescribed diet and should have received the prescribed diet.

Based on record review and interview the facility failed to provide services in accordance with each resident's written plan of care for 1 of 3 Stage 2 residents reviewed for Pressure Ulcers in a total Stage 2 sample of 67 (#100) as evidenced by the facility failing to change the resident's diet per the dietician's recommendations and the physician's orders [REDACTED]. Findings: Review of Resident #100's Face Sheet revealed [DIAGNOSES REDACTED]. Review of Resident #100's record revealed the resident had right and left lateral ankle pressure ulcers which developed in the hospital on [DATE]. Review of Resident #100's Care Plan with a problem of potential for injury related to disease process of diabetes with a goal date of 10/22/13 revealed an approach of diet as ordered. Further review of the resident's Care Plan with a problem of the resident has pressure ulcers with a goal date of 10/22/13 revealed an approach of the resident will be evaluated by dietician every month and on an as needed basis for nutritional status. Review of Resident #100's Dietician Departmental Notes dated 11/11/13 revealed S5/Consultant Registered Dietician had made a recommendation to change Resident #100's diet to a regular LCS (low concentrated sweet) diet due to the resident's [DIAGNOSES REDACTED].#100's diet to a regular LCS diet. In interview on 12/19/13 at 12:42pm S5/Consultant Registered Dietician indicated Resident #100's diet intake had been good in the past several months, therefore in November 2013 S5/Consultant Registered Dietician indicated she felt the resident would benefit from a LCS diet since the resident had non-healing pressure ulcers to bilateral ankles. Review of Resident #100's Physician order [REDACTED]. In interview on 12/19/13 at 7:45am S2/DON (Director of Nursing) indicated she was unsure of the diet Resident #100 was presently prescribed and acknowledged the inconsistencies between the dietician's recommendations on 11/11/13 and Resident #100's current diet order of a regular diet.