Every finding on record at Thibodaux Healthcare and Rehabilitation Center

Based on observations, interviews, and record reviews, the facility failed to ensure a resident was free from neglect when the facility's staff failed to provide the necessary care and services according to the resident's plan of care for 1 (Resident #1) of 5 residents investigated for neglect. The deficient practice resulted in an Immediate Jeopardy situation on 07/26/2026 at 9:28PM when facility staff did not physically check on Resident #1 as per Resident #1's physician's order for physical elimination checks every two hours. The Immediate Jeopardy situation continued on 07/27/2026 at 7:22AM when facility staff was alerted by Resident #1's family member who discovered Resident #1 lying on the floor of Bathroom B on 07/27/2026 at 7:19AM. During the time period of 07/26/2026 at 9:28PM through 07/27/2026 at 7:22AM, Resident #1 was not provided physical elimination checks every two hours by facility staff, and Resident #1 sustained an unwitnessed fall. This deficient practice had the likelihood to cause more than minimal harm to all 29 dependent residents who required activities of daily living (ADL) assistance, by placing those residents at risk for neglect due to the facility's identified deficient practice. S1Administrator was notified of the Immediate Jeopardy situation on 08/19/2026 at 7:40PM. The Immediate Jeopardy was removed on 08/20/2026 at 3:11PM after it was verified through observations, interviews, and record reviews, the facility implemented an acceptable Plan of Removal, prior to the survey exit. Findings:Review of the facility's Incident and Accident Log for July 2026 revealed, in part, Resident #1 had an unwitnessed fall on 07/27/2026 at 7:30AM. Review of the facility's incident report dated 07/30/2026 revealed, in part, on 07/27/2026 at 7:20AM, Resident #1 was found on the floor of Bathroom B by a family member. Further review revealed Resident #1's family member indicated Resident #1 had fallen and was on the floor in Bathroom B. Review of Resident #1's Fall Risk Assessment revealed, in part, on 06/30/2026, 07/10/2026, and 07/27/2026 Resident #1 was identified as a high risk for falls. Review of Resident #1's Minimum Data Set with an Assessment Reference Date of 07/11/2026 revealed, in part, Resident #1 had a Brief Interview of Mental Status score of 15, indicating Resident #1 was cognitively intact. Review of Resident #1's hospice record revealed an admit date of 07/17/2026 with diagnoses including, in part, malignant neoplasm (cancer) of the cranial nervous system, neoplasm of unspecified behavior of brain, and unspecified Myasthenia Gravis (an autoimmune disorder that caused weakness in voluntary skeletal muscles) without exacerbation. Further review revealed Resident #1 was wheelchair bound, a fall risk due to lower extremity weakness and unsteady gait, was incontinent of bowel and bladder requiring adult briefs, and Resident #1 required total assistance with bathing, dressing, toileting, taking medications, and transfers. Review of Resident #1's physician's order dated 07/25/2026 at 11:45AM revealed Resident #1 required physical elimination checks every two hours. Review of the facility's policy and procedure titled, Activities of Daily Living (ADL), Supporting Policy and Procedure, last revised March 2018, revealed, in part, appropriate care and services would be provided for residents who were unable to carry out ADL's independently, with the consent of the resident and in accordance with the resident's plan of care; including appropriate support and assistance with hygiene; mobility (transfer and ambulation, including walking); and elimination (toileting). Review of the facility's Certified Nursing Assistant (CNA) and Licensed Practical Nurse (LPN) job descriptions, dated March 2017, revealed, in part, job responsibilities were to make routine rounds on each assigned resident every two hours. Review of Resident #1's hospice progress note dated 07/25/2026 at 12:00PM revealed, in part, Resident #1 was incontinent of urine, had neurological changes of increased weakness, increased ataxia (unsteady and/or staggering gait), increased fatigue, increased confusion, and forgetfulness. Further review revealed every two hour physical elimination checks were implemented for Resident #1 on 07/25/2026. Review of the facility's daily nursing schedule dated 07/26/2026 revealed, in part, S4CNA and S5Licensed Practical Nurse were assigned to provide care for residents who resided on Hall A from 10:00PM on 07/26/2026 until 06:00AM on 07/27/2026. Review of Resident #1's hospice progress note dated 07/27/2026 at 9:45AM revealed Resident #1 had a fall and Resident #1's family member discovered Resident #1 on Bathroom B's floor. Further review revealed Resident #1 reported she was in the shower stall in Bathroom B all night. Further review revealed Resident #1 reported she had fallen towards the shower and her head landed under the shower bench in Bathroom B's shower stall. In a telephone interview on 08/17/2026 at 8:09AM, Resident #1's family member indicated on the morning of 07/26/2026, the family visited Resident #1 along with other family members. Resident #1's family member further indicated he returned to the facility the morning of 07/27/2026 approximately at 7:30AM and entered Resident #1's room on Hall A. Resident #1's family member further indicated he entered Bathroom B and discovered Resident #1 lying on her left side, Resident #1's head was in Bathroom B's shower stall and lying on the shower drain, and Resident #1's head was under Bathroom B's shower bench. Resident #1's family member further indicated when he discovered Resident #1 in Bathroom B she was unresponsive and lying in urine. Resident #1's family member further indicated he grabbed Resident #1's hand, called her name several times, Resident #1 awoke and was very slow to respond, and indicated she had been on Bathroom B's floor in the shower stall all night. In an interview on 08/17/2026 at 2:16PM, S1Administrator indicated during a phone interview S5LPN admitted to S1Administrator that she did not enter Resident #1's room on Hall A during her entire scheduled shift beginning at 10:00PM on 07/26/2026 and ending at 6:00AM on 07/27/2026. In an interview on 08/18/2026 at 10:27AM, the facility's outsourced hospice Registered Nurse (RN) indicated she was alerted on 07/27/2026 by Resident #1's family member that Resident #1 experienced a fall on 07/27/2026 at the facility. The facility's outsourced hospice RN further indicated she assessed Resident #1 and noted bruising to her right side, Resident #1 was anxious, and did not exhibit any visible signs of pain. The facility's outsourced hospice RN further indicated Resident #1 experienced a change in condition prior to Resident #1's fall on 07/27/2026. The facility's outsourced hospice Registered Nurse further indicated Resident #1 required toileting assistance due to increased lower extremity weakness and a physician's order was in place for facility staff to physically check Resident #1 for incontinence checks every two hours. Surveyor attempted to telephone S4CNA on 08/18/2026 at 11:00AM without success. There was no answer and no return telephone call to the surveyor. Surveyor attempted to telephone S5LPN on 08/18/2026 at 11:01AM without success. There was no answer and no return telephone call to the surveyor. Observation of the facility's video surveillance on 08/18/2026 at 12:30PM, of Hall A was conducted with S1Administrator. Observation of the video surveillance that began on 07/26/2026 at 7:28PM through 07/27/2026 at 7:30AM. Observation of the video surveillance revealed S5LPN, S4CNA and S6CNA did not enter Resident #1's room on Hall A after 7:28PM on 07/26/2026 through 07/27/2026 at 7:22AM. The video observation further revealed on 07/27/2026 at 7:19AM, Resident #1's family member entered Resident #1's room, and at 7:22AM on 07/27/2026 S11Registered Nurse (RN) entered Resident #1's room after being alerted by Resident #1's family member. Further, per the video surveillance with S1Administrator, S4CNA did not enter Resident #1's room the entire shift. In an interview on 08/18/2026 at 1:00PM, S1Administrator indicated S5LPN and S4CNA did not enter Resident #1's room on Hall A for their entire scheduled shift beginning at approximately 10:00PM on 07/26/2026 and ending at 6:00AM on 07/27/2026. S1Administrator further indicated that Resident #1 was discovered on the floor in Bathroom B by Resident #1's family member at 7:19AM on 07/27/2026. In an interview on 08/18/2026 at 1:32PM, S11RN indicated she was aware Resident #1 had an order for physical elimination checks every 2 hours. She further indicated Resident #1 exhibited a decline prior to her fall on 07/27/2026 and staff should have checked Resident #1 every two hours as indicated on the physician's order dated 07/25/2026. In interviews on the following dates and times, facility staff verified the need to round on all residents every two hours:S9CNA on 08/19/2026 at 12:29PMS8CNA on 08/19/2026 at 12:31PMS12CNA on 08/19/2026 at 2:27PMS13CNA on 08/19/2026 at 2:35PMS14CNA on 08/19/2026 at 2:37PMS15LPN on 08/19/2026 at 2:39PM In a telephone interview on 08/20/2026, S16CNA, who cared for Resident #1, indicated even though a resident does not need assistance staff is still required to round on residents every 2 hours. Observation of the facility's video surveillance on 08/19/2026 at 3:43PM of Hall A was conducted with S1Administrator. Further, observation of the facility's video surveillance began on 07/26/2026 at 7:11PM through 07/26/2026 at 10:00PM and revealed S6CNA entered Resident #1's room on 07/26/2026 at 7:11PM, exited Resident #1's room on 07/26/2026 at 7:28PM, and Resident #1's family exited Resident #1's room on 07/26/2026 at 7:37PM. The Immediate Jeopardy situation was removed on 08/20/2026 at 3:11PM, after it was verified through observations, interviews, and record reviews, the facility implemented an acceptable Plan of Removal, prior to the survey exit. A Plan of removal was accepted on 08/20/2026 at 3:11PM which included the following actions to correct the deficient practice: On 08/19/2026 the S7Director of Nursing initiated a review of all current residents to identify residents with: Physician order/orders which required scheduled monitoring, checks, or assistance;care planned interventions which required scheduled monitoring or assistance;assessed needs requiring nursing/Certified Nursing Assistant monitoring or assistance;increased risk for fall;assistance needed related to toileting and/or transfers; and,other identified clinical or safety risks which required resident-specific monitoring. Effective on 08/19/2026, nursing leadership reinforced the facility's expectation that nursing staff to provide care, supervision, monitoring, rounding, and assistance in accordance with all 72 residents' current: physician order/order;assessments;individualized plan of care;identified clinical and safety risks; and,current condition needs. On 08/19/2026 S7DON completed validation rounds and record review to ensure residents received necessary care, supervision, monitoring rounding, and assistance. The validation included review of the residents identified as requiring: scheduled physician-ordered monitoring;care-planned monitoring;assistance with toileting;assistance with transfers;fall risk interventions; and,other resident-specific supervision or assistance. By 08/20/2026, all licensed nurses and nursing assistants currently working in the facility were educated regarding: The requirement to follow resident-specific physician order/orders and care-planned interventions;completion of assigned resident care, rounding, and monitoring;providing resident checks and assistance based upon resident-specific needs, order/orders, and plans of care;timely response to and follow-up of identified resident needs;communication between nursing assistants and licensed nurses when ordered or care-planned care cannot be completed as expected;the responsibility of the licensed nurse to follow up on identified changes, concerns, or missed care; and,the requirement that documentation accurately reflects care and monitoring actually provided. The facility utilized an established Daily Start-Up process as part of its ongoing clinical oversight which included plan of care completion to identify documented resident care has been completed and if additional follow up is required. Following completion and validation of the above actions, S1Administrator, S7DON, and/or designee reviewed the facility's resident-care processes to ensure all 72 residents' files were checked as follows: Residents which required physician-ordered monitoring were receiving monitoring consistent with physician orders;care -planned interventions were being implemented;direct-Care staff understood resident-specific care and monitoring requirements;residents requiring assistance with toileting, transfers, or other identified needs were receiving appropriate assistance;staff understood their responsibility to communicate missed or incomplete care to the licensed nurse;licensed nurses understood their responsibility for follow-up; and,Any identified concern was immediately corrected. Monitoring will include review of a sample of residents with physician-ordered and/or care-planned monitoring requirements to validate that required care, supervision, monitoring, and assistance are being provided. The likelihood of serious harm no longer existed for residents related to the facility providing necessary care and services on 08/20/2026 at 3:11PM.

Based on interviews and record reviews, the facility failed to ensure a resident received the required two-person assistance during a transfer for 1 (Resident #2) of 5 residents investigated for accident hazards.This deficient practice resulted in an actual harm on 07/25/2026 at 5:05AM when S2Certified Nursing Assistant (CNA) transferred Resident #2 from her bed to the wheelchair unassisted. Resident #2's legs gave out and Resident #2 slid to the ground during the transfer as documented by S2CNA, which resulted in a left leg oblique moderately displaced comminuted fracture of the distal diaphysis of the femur (a break in the lower shaft of the thighbone near the knee). Resident #2 was transferred to a local Emergency Department and she underwent surgical repair of her left femur on 07/26/2026.Findings:Review of Resident #2's electronic medical record (EMR) revealed, in part, Resident #2 was admitted to the facility on [DATE] for skilled services for a fractured right femur.Review of Resident #2's admission Minimum Data Set with an Assessment Reference Date of 06/30/2026 revealed, in part, Resident #2 had a Brief Interview of Mental Status of 15, which indicated Resident #2 was cognitively intact. Further review revealed, in part, Resident #2 was dependent on staff for bed to chair/chair to bed transfers.Review of Resident #2's care plan with an initiation date of 06/29/2026 revealed, in part, Resident #2 had an activities of daily living performance deficit with an intervention for two-person mechanical transfer.Review of Resident #2's record revealed a Fall Risk Evaluation dated 06/26/2026 completed upon admission, which indicated Resident #2 was at a high risk for falls.Review of the facility's incident report (SO said you cannot state a SIMS report in a tag)completed on 07/27/2026 revealed, in part, it was determined by S1Administrator's investigation S2CNA transferred Resident #2 unassisted when Resident #2 required two-person assistance with transfers.Review of the nurse's progress note dated 07/25/2026 at 5:11AM revealed, in part, S2CNA attempted to transfer Resident #2 into a wheelchair alone when Resident #2's left leg gave out causing Resident #2 to slide out of the wheelchair and onto the floor. Further review revealed Resident #2 complained of left leg pain after the incident and requested to be sent to a local emergency room for evaluation.Review of Resident #2's Computed Tomography (imaging test) Report dated 07/25/2026 revealed, in part, Resident #2 had a left leg oblique moderately displaced comminuted fracture of the distal diaphysis of the femur above the femoral component of the prosthesis, extending into the region just above the lateral component.Review of Resident #2's operative report dated 07/26/2026 revealed, in part, Resident #2 had an open reduction and internal fixation of the left distal periprosthetic femur fracture (a major orthopedic surgery to repair a broken thigh bone that happens around or near an existing artificial joint implant [such as a hip or knee replacement] on the left side of the body).In an interview on 08/18/2026 at 11:50AM, Resident #2's physician's office Medical Assistant indicated Resident #2 experienced a fall on 07/25/2026 at the nursing facility resulting in a fractured left femur, which required Resident #2 to undergo surgical repair of the left leg.Review of the facility's video surveillance of Hall A with S1Administrator revealed S2CNA entered Resident #2's room alone on 07/25/2026 at 5:05AM. Further review of video surveillance revealed on 07/25/2026 at 5:07AM S2CNA exited Resident #2's room, walked to the nurse's station, and re-entered Resident #2's room with another staff member.Surveyor attempted telephone interviews with S2CNA on 08/19/2026 at 8:40AM and 10:18AM without success. There was no answer from S2CNA.Review of S2CNA's written witness statement dated 07/27/2026 revealed, in part, S2CNA indicated she was not aware Resident #2 required a two person assistance with transfers. Further review revealed S2CNA assisted Resident #2 from her bed to her wheelchair alone when Resident #2's legs gave out. S2CNA documented that she assisted Resident #2 to the floor.In an interview on 08/18/2026 at 2:00PM, S1Administrator indicated Resident #2 required two-person assistance for transfers. S1Administrator further indicated he reviewed video surveillance of the morning of 07/25/2026 and confirmed S2CNA entered Resident #2's room alone and later exited Resident #2's room, then S2CNA re-entered Resident #2's room with another staff member. S1Administrator further indicated Resident #2 should have been transferred with two staff members as required per physician's orders and care plan. In an interview on 08/19/2026 at 8:25AM, S3Physicial Therapy (PT) indicated on 07/09/2026 Resident #2 was transitioned from mechanical lift transfer to two-person assistance (maximum assist) with a sliding board or a walker. Resident #2 was non-weight bearing to her right lower extremity and required two-person assistance. S3PT further indicated the facility staff was aware Resident #2 required two-person assistance with transfers as documented on an index card upon arrival in Resident #2's room with instructions for their transfer status.In an interview on 08/18/2026 at 9:30AM, S10CNA indicated the process for resident transfer status when entering a resident room, was to view a status transfer index card from PT that is visibly located inside each resident's room which contained instructions for their transfer. S10CNA further indicated if a resident does not have an index card in their room, it is the process to consult with PT prior to transferring residents.In an interview on 8/18/2026 at 9:35AM, S11Registered Nurse (RN) indicated the unit secretary placed a transfer status card, generated by PT, into each resident room. S11RN further indicated upon arrival into a resident room, the index card is in clear view above each resident's bed, which indicated the transfer status for each resident. S11RN further indicated if a resident does not have an index card in their room, it is the process to consult with PT prior to transferring residents.In an interview on 08/19/2026 at 9:30AM, Resident #2 indicated on 07/25/2026 S2CNA attempted to transfer her from the bed to the wheelchair unassisted. Resident #2 further indicated her legs gave out and S2CNA could not hold her up. Resident #2 indicated she requested to be sent out to a local emergency room post the incident. Resident #2 further indicated she was evaluated at a local emergency room and was diagnosed with a fractured femur to her left leg and required surgical repair.

Based on interviews and record reviews the facility failed to ensure corrective action and monitoring was performed after an allegation of neglect was substantiated for 2 (Resident #1, Resident #2) of 2 residents reviewed for neglect. Findings:Review of the facility's Employee List as of 08/17/2026 revealed 31 of 51 Licensed Practice Nurses, Registered Nurses, and Certified Nursing Assistants. Resident #1Review of the facility's Statewide Incident Management System dated 07/29/2026 at 4:03PM revealed, in part, S1Administrator reviewed video surveillance of Hall A, which revealed S4Certified Nursing Assistant and S5Licensed Practical Nurse did not check on Resident #1 during their scheduled shift on 07/26/2026 beginning at 10:00PM to 07/27/2026 at 6:00AM.Review of the facility's In-service Training Report completed on 07/30/2026 revealed, in part, residents must be checked during their shifts at least every two hours or more frequently if needed. Further review revealed staff should not document on a resident if staff did not visualize a resident. Further review revealed false documentation would result in disciplinary actions and/or termination. Further review of an attached sign in sheet for 07/30/2026 revealed a total of 31 out of 51 staff signatures documented.Review of the facility's Life Satisfaction rounds completed for S5Licensed Practical Nurse and S4Certified Nursing Assistant on 07/30/2026 revealed, in part, 6 residents were questioned on care received by S5Licensed Practical Nurse and S4Certified Nursing Assistant, and there were no documented concerns. Further review revealed no documentation Life Satisfaction Rounds were completed after 07/30/2026.Review of the facility's Peer Review neglect questionnaire form completed on 07/30/2026 for S5Licensed Practical Nurse and S4Certified Nursing Assistant revealed, in part, 6 staff members were questioned on care provided by S5Licensed Practical Nurse and S4Certified Nursing Assistant, and there were no documented concerns. Further review revealed no documentation Peer Review rounds were completed after 07/30/2026.In an interview on 08/20/2026 at 2:00PM, S1Administrator indicated he could not produce continued monitoring for the above mentioned allegation of neglect after the initial monitoring on 07/30/2026. In an interview on 08/19/2026 at 12:31PM, S8CNA indicated she was not working on 07/30/2026 when S1Administrator conducted an in-service on rounding on 07/30/2026 and had not been in-serviced. Resident #2Review of the facility's Statewide Incident Management System (SIMS) report completed on 07/27/2026 at 11:19AM revealed, in part, it was determined through S1Administrator's investigation S2Certified Nursing Assistant (CNA) transferred Resident #2 alone when Resident #2 required two-person assistance with transfers. Review of the facility's In-service training report completed 07/27/2026 for resident transfers revealed, in part, all staff must check the documented card notification in each resident's room regarding each resident's transfer status prior to transferring residents to ensure proper transfer and technique. Further review revealed a total of 31 out of 51 signatures documented. Review of the facility's Life Satisfaction rounds completed for S2Certified Nursing Assistant on 07/27/2026 revealed, in part, 6 residents were questioned on care received by S2CNA and there were no documented concerns identified for resident care provided by S2CNA. Further review revealed no documented Life Satisfaction rounds were completed after 07/27/2026. Review of the facility's Peer Review neglect questionnaire completed 07/27/2026 for S2CNA revealed, in part, 7 out of 51 staff members were questioned on care provided by S2CNA and there were no documented concerns identified for resident care provided by S2CNA. Further review revealed no documentation Peer Review rounds were completed after 07/30/2026. In an interview on 08/18/2026 at 3:20PM S1Administrator indicated that if staff did not sign the in-service sheet dated 07/27/2026 they were not in-serviced. He further indicated the only monitoring he completed was occasionally checking the video cameras, and had no documentation of any other monitoring completed after 07/27/2026.In an interview on 08/19/2026 at 11:02AM, S9CNA indicated she did not attend the in-service that was provided for resident transfers on 07/27/2026. In an interview on 08/19/2026 at 11:05AM, S8CNA indicated she did not attend the in-service that was provided for resident transfers 07/27/2026.

Based on interviews and record reviews, the facility failed to maintain accurately documented records in accordance with accepted professional standards and practices for 1 (Resident #1) of 5 resident electronic medical records (eMAR) reviewed.Findings:Review of Resident #1's vital signs on 07/26/2026 at 9:28PM revealed, in part, S5Licensed Practical Nurse (S5LPN) documented Resident #1's oxygen saturation of 98%. Review of Resident #1's Activities of Daily Living Task Report from 07/22/2026 to 07/30/2026 revealed, in part, S4Certified Nursing Assistant (S4CNA) documented she provided Resident #1 with activities of daily living assistance on 07/26/2026 at 11:31PM. Review of Resident #1's eMAR for July 2026 revealed, in part, Resident #1 received assistance for transfers in and out of bed and wheelchair on 07/26/2026 during the night shift (10:00PM to 6:00AM) by S5LPN. Review of a telephone obtained witness statement dated 07/30/2026 revealed, in part, S1Administrator interviewed S5LPN wo indicated she entered Resident #1's room on Hall A on 07/26/2026 at 11:30PM. Further review revealed after further questioning by S1Administrator, S5LPN indicated she peeked into Resident #1's room on Hall A on 07/26/2026 (no time was indicated by S5LPN). Further review revealed S5LPN was asked by S1Administrator how she obtained Resident #1's documented oxygen saturation percentage documented in Resident #1's eMAR on 07/26/2026 at 9:28PM if she did not enter Resident #1's room on Hall A on 07/26/2026 at 9:28PM. Further review revealed S5LPN indicated to S1Administrator, Oh shit, I am just trying to cover my ass. I am sorry. Further review of the above mentioned telephone obtained witness statement revealed S1Administrator indicated to S5LPN he reviewed the video surveillance on Hall A for 07/26/2026 at 7:11PM to 07/27/2026 at 6:00AM and S1Administrator confirmed S5LPN did not enter Resident #1's room on Hall A during on the above mentioned dates and times. Review of a telephone obtained Witness Statement dated 07/30/2026 revealed, in part, S1Administrator interviewed S4CNA and S4CNA indicated to S1Administrator she entered Resident #1's room on Hall A at some time around 11:00PM on 07/26/2026 and then again on 07/26/2026 at 1:30AM. Further review of the above mentioned witness statement revealed S1Administrator questioned S4CNA if she entered Resident #1's room on Hall A after 1:30AM on 07/27/2026 and S4CNA indicated she peeked in Resident #1's room on Hall A around 4:15AM on 07/27/2026. Further review of the above mentioned witness statement revealed S4CNA continued to indicate to S1Administrator she entered Resident #1's room on the above mentioned dates and times; however, it was confirmed by S1Administrator after review of video surveillance, S4CNA did not enter Resident #1's room on the above mentioned dates and times. In an interview on 08/17/2026 at 2:16PM, S1Administrator confirmed S5LPN was responsible for Resident #1's care on the night shift on 07/26/2026 and the morning shift on 07/27/2026 to 6:00AM and S5LPN did not enter Resident #1's room on Hall A to check on Resident #1 nor did she obtain Resident #1's vital signs documented in Resident #1's eMAR on 07/26/2026 at 9:28PM. S1Administrator further indicated S5LPN indicated to S1Administrator she did not enter Resident #1's room on Hall A during her shift on 07/26/2026 from 9:28PM to 07/27/2026 to 6:00AM. S5LPN further indicated she falsified documentation on Resident #1's eMAR because she was trying to cover her ass. In an interview on 08/20/2026 at 11:45AM, S1Administrator indicated S4CNA was responsible for Resident #1's care on the night shift on 07/26/2026 and the morning shift on 07/27/2026. S1Administrator further indicated S4CNA did falsify documentation that S4CNA provided activities of daily living care on 07/26/2026 at 11:31PM. S1Administrator further indicated he confirmed by video surveillance S4Certified Nursing Assistant did not enter Resident #1's room on Hall A as it was documented on Resident #1's Activities of Daily Living Task Report for the above mentioned dates and times.

Based on interviews and record reviews, the facility failed to ensure: Resident #1's allegation of neglect was reported to the State Agency no later than 24 hours after the discovery of the allegation; and,Resident #2's fall which resulted in a major injury was reported to the State Agency no later than 2 hours after the allegation. This deficient practice was identified for 2 (Resident #1, Resident #2) of 5 residents investigated for quality of care and services. Findings: Review of the facility's Abuse Prohibition policy and procedure, with a revision date of 06/29/2026, revealed, in part, the abuse coordinator would report all allegations of neglect with serious bodily injury within two hours of the allegation. Further review of the above mentioned policy revealed, in part, neglect occurred when the facility was aware of, or should have been aware of goods or services that a resident required, but the facility failed to provide to the resident and resulted in physical harm and pain. Resident #1Review of the facility's Incident and Accident Log for July 2026 revealed, in part, Resident #1 had an unwitnessed fall on 07/27/2026 at 7:30AM. Review of the facility's Statewide Incident Management System (SIMS) report revealed, in part, an incident was entered into the State Survey Agency system on 07/29/2026 at 4:03PM by S1Administrator. Further review revealed Resident #1 was found on the floor in the bathroom by a family member on 07/27/2026 at 7:20AM. Cross Reference F600In an interview on 08/17/2026 at 2:16PM, S1Administrator indicated he was notified of Resident #1's incident on 07/27/2026 around 8:00AM or 8:15AM by Resident #1's son after he discovered Resident #1 on the floor in Bathroom B. S1Administrator indicated he began an investigation and determined Resident #1's fall in Bathroom B did not result in a fall with major injury; therefore, S1Administrator did not report to the State Survey Agency within 24 hours of being notified by Resident #1's son of the above mentioned incident, as required. S1Administrator further indicated he did not report Resident #1's allegation of neglect until the local police department issued a subpoena on 07/28/2026 for video surveillance of Hall A for 07/26/2026 and 07/27/2026. In an interview on 08/18/2026 at 2:16PM, S1Administrator indicated he should have reported the allegation of neglect involving Resident #1 to the State Survey Agency within 24 hours of being notified of Resident #1's incident, as required. Resident #2Review of the facility's Incident and Accident Log for July 2026 revealed, in part, Resident #2 had a witnessed fall on 07/25/2026. Review of the facility's SIMS report dated 07/27/2026 at 11:19AM revealed, in part, S1Administrator's investigation revealed S2Certified Nursing Assistant (CNA) transferred Resident #2 alone, who required two-person assistance with transfers. Further review revealed, Resident #2 fell during the transfer which resulted in a left femur fracture. Cross Reference F689In an interview on 08/18/2026 at 2:00PM, S1Administrator indicated Resident #2 was improperly transferred which resulted in a major injury. S1Administrator indicated he did not report the incident until 07/27/2026 at 11:19AM because he was not aware Resident #2 fractured her left femur until that time.

Based on observations, interviews, and record reviews, the facility failed to ensure soiled laundry and biohazard waste in an isolation room was maintained in a sanitary manner for1 (Resident #65) of 1 sampled residents on transmission based precautions investigated for infection control practices. Findings: Review of the facility's Infection Prevention and Control Program policy, dated 01/2020 and reviewed 03/03/2026, revealed an infection prevention and control program was established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Review of the facility's Medical Waste - Segregating and Separating policy, dated 05/2012, revealed everyone who generated or handled medical waste would be responsible for discarding it into appropriate receptacles, and medical waste would be discarded into designated containers. Review of the facility's Isolation Protocol In-Service Training Report dated 01/14/2026 revealed, in part, red biohazard containers should be used for trash and yellow biohazard containers should be used for linen. Review of Resident #65's electronic medical record revealed, in part, Resident #65 was admitted to the facility on [DATE] and had diagnoses of conjunctivitis, bilateral hearing loss, and macular degeneration. Review of Resident #65's March 2026 physician's orders revealed, in part, Resident #65 had an order dated 03/10/2026 for contact isolation due to a diagnosis of bacterial conjunctivitis for 10 days. Review of Resident #65's Minimum Data Set with an Assessment Reference Date of 12/18/2025 revealed, in part, Resident #65 had a Brief Interview Mental Status Score of 13, which indicated Resident #65 was cognitively intact. Further review revealed Resident #65 had no documented mood or behavior issues. Review of Resident #65's current care plan revealed, in part, a plan of care was developed indicating Resident #65 was visually impaired, had difficulty hearing, had an Activities of Daily Living self-care performance deficit, which required a need for assistance to meet emotional, intellectual, physical, and social needs. Observation on 03/16/2026 at 11:15AM revealed Resident #65 was on isolation, and Resident #65's room had a foul odor.Observation further revealed a red biohazard bag in an opened box and a yellow biohazard bag in an opened box were located in Resident #65's room. Further observation revealed Resident #65's yellow biohazard container had unidentified, small flying insects flying above the yellow biohazard container. Further observation of the yellow biohazard container revealed the yellow container contained a soiled towel stained with a brown unknown substance and used disposal gowns and gloves. In an interview on 03/16/2026 at 11:15AM, Resident #65 indicated his room stunk. Resident #65 further indicated his trash had not been emptied. Observation on 03/16/2026 at 3:15PM revealed Resident #65's room had a foul odor. Observation further revealed Resident #65's yellow biohazard container contained a soiled towel stained with a brown unknown substance. Further observation revealed unidentified, small flying insects were in Resident #65's room. Observation on 03/17/2026 at 7:35AM revealed Resident #65's room had a foul odor and the yellow biohazard container contained a soiled towel stained with a brown unknown substance. Further observation revealed the yellow biohazard container also contained Resident #65's soiled clothing along with used disposal gowns and gloves. In an interview on 03/17/2026 at 7:35AM, Resident #65 indicated it stunk in his room and the trash needed to be emptied. In an interview on 03/17/2026 at 7:51AM, S4Certified Nursing Assistant indicated Resident #65 was on isolation and staff should check on him daily to see if his needs are met. S4Certified Nursing Assistant further indicated the nursing staff were responsible for emptying the biohazard containers in Resident #65's room at least daily. In an interview on 03/17/2026 at 8:11AM, S3Licensed Practical Nurse indicated Resident #65 was on isolation and nursing staff were responsible for managing the biohazard waste in Resident #65's room. S3Licensed Practical Nurse further indicated the red biohazard container should be used to dispose of trash and the yellow biohazard container should be used for soiled linens and Resident #65's soiled clothes. In an interview on 03/17/2026 at 8:21AM, S7Housekeeper indicated nursing staff were responsible for emptying the biohazard containers in Resident #65's room. In an interview on 03/17/2026 at 8:26AM, S4Certified Nursing Assistant indicated the red biohazard containers should be used for trash and the yellow biohazard containers should be used for linen and Resident #65's clothes. S4Certified Nursing Assistant further indicated trash should not be disposed with the linen in the yellow biohazard containers. On 03/17/2026 at 8:42AM, Surveyor and S1Director of Nursing entered Resident #65's room. Observation revealed Resident #65 was sitting in his recliner chair and unidentified, small flying insects were observed in Resident #65's room. On 03/17/2026 at 8:42AM Resident #65 indicated to S1Director of Nursing the trash had not been emptied. In an interview on 03/17/2026 at 8:42AM, S1Director of Nursing indicated Resident #65's biohazard containers would have been emptied if Resident #65 would have asked. In an interview on 03/17/2026 at 1:01PM, S5Certified Nursing Assistant indicated if there was an odor observed in an isolation room, she would identify the source of the odor and remove the identified source of the smell. In an interview on 03/17/2026 at 1:30PM, S6Certified Nursing Assistant indicated if there was an odor observed in an isolation room, she would identify the source of the odor and remove the identified source of the smell. In a telephone interview on 03/17/2026 at 4:05PM, Resident #65's Responsible Party indicated Resident #65 complained to her daily about the odor in Resident #65's room, and the biohazard container not being emptied. Resident #65's Responsible Party further indicated she contacted S2Assistant Director of Nursing on 03/13/2026 and informed her of Resident #65's complaints. Resident #65's Responsible Party further indicated she attempted to contact S2Assistannt Director of Nursing on 03/16/2026 due to Resident #65's continued complaints of the smell in the room, and the trash not being emptied. In a telephone interview on 03/17/2026 at 4:32PM, Resident #65's daughter indicated she visited her father on 03/11/2026 and observed food and clothes were disposed in the yellow biohazard container. Resident #65's daughter further indicated she reported the complaint to S2Assistant Director of Nursing on 03/11/2026 at 4:30PM. Resident #65's daughter further indicated Resident #65 also complained about an odor in Resident #65's room on 03/16/2026. In an interview on 03/18/2026 at 8:15AM, S2Assistant Director of Nursing confirmed she was contacted by Resident #65's Responsible Party on 03/13/2026 and Resident #65's daughter on 03/11/2026 regarding the biohazard containers not being emptied and the trash and linen being disposed together in the yellow biohazard containers. S2Assistant Director of Nursing further indicated she did not communicate Resident #65's concerns to the staff on the hall and did not re-educate the staff on handling biohazard waste in an isolation room at that time. S2Assistant Director of Nursing further indicated it was the responsibility of the nursing staff to empty the biohazard containers and to ensure the environment was sanitary and comfortable for Resident #65. In an interview on 03/18/2026 at 11:40AM, S1Director of Nursing indicated the nursing staff was responsible for emptying the biohazard containers in Resident #65's room. S1Director of Nursing further indicated trash and linen should not be stored in the same biohazard container. In an interview on 03/18/2026 at 1:15PM, S8Corporate Compliance Nurse indicated the provider could not present any documented evidence the provider addressed the odors and gnats observed in Resident #65's room.

Based on observations, interviews, and record reviews, the facility failed to ensure a resident's medications was maintained in the original manufacturer's or pharmacy's label for 1 (Medication Cart e) of 3 (Medication Cart e, Medication Cart f, and Treatment Cart g) medication carts observed. Findings: Review of the facility's Medication Administration policy and procedure, dated 04/01/2019 and last reviewed 07/08/2024, revealed, in part, the individual administering the medications should check the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before administering the medications. Observation on 03/24/2025 at 3:33PM revealed Medication Cart e contained a medication cup for Resident #1, Resident #17, Resident #28, Resident #32, Resident #30, Resident #45, Resident #55 and Resident #39 and two medication cups for Resident #14 and Resident #22. Further observation revealed the above mentioned medication cups contained each residents' medications, but were only labeled with the residents' names. Further observation revealed the second cup for Resident #14 and Resident #22 were also labeled with the time 9:00PM. Further observation revealed no evidence that any of the above mentioned cups were labeled with the names or doses of the medications they contained. In an interview on 03/23/2025 at 3:34PM, S5Licensed Practical Nurse (LPN) indicated she had pre-prepared the above mentioned residents' medications for later administration during her shift. S5LPN confirmed she should not have prepared the above mentioned residents' medications until she was ready to administer them. In an interview on 03/23/2025 at 3:45PM, S2Director of Nursing confirmed medications should not be prepared and placed in medication cups until they were ready to be administered.

Based on interview and record reviews, the facility's administration failed to ensure the facility provided 2.35 hours of direct nursing care per resident for 4 (09/15/2024, 10/27/2024, 11/10/2024, 12/08/2024) of 27 (09/15/2024, 10/05/2024, 10/06/2024, 10/12/2024, 10/13/2024, 10/19/2024, 10/20/2024, 10/26/2024, 10/27/2024, 11/02/2024, 11/03/2024, 11/09/2024, 11/10/2024, 11/16/2024, 11/17/2024, 11/23/2024, 11/24/2024, 11/30/2024, 12/01/2024, 12/07/2024, 12/08/2024, 12/14/2024, 12/15/2024, 12/21/2024, 12/22/2024, 12/28/2024, and 12/29/2024) weekend days reviewed for required staffing hours. Findings: Review of the facility's Administrator job description, dated March 2017, revealed, in part, the Administrator's responsibilities were to maintain and guide the implementation of the facility's policies and procedures in compliance with corporate, state, federal and other regulatory guidelines. Review of the Louisiana Administrative Code Chapter 97-Nursing Facilities, last updated in 11/2023, revealed, in part, the nursing facility shall provide 2.35 hours of care per resident per day. Review of the facility's staffing sheet dated 09/15/2024 revealed, in part, the facility's census was 72 residents. Review of the facility's time sheets from 09/15/2024 revealed, in part, the total number of nurse staffing hours provided by the facility's nursing staff was 150.18 hours, which was 19.02 hours less than the required 169.2 hours. Review of the facility's Nursing/Ancillary Personnel Staffing Pattern Reporting Forms, dated 10/02/2024 through 12/29/2024, signed as complete and accurate by S1Administrator on 03/24/2025 revealed, in part, the following weekend days: On 10/27/2024 the facility was required to provide 171.55 hours of direct care based on their facility census of 73 residents. Further review revealed the facility provided 167.73 hours, which was 3.82 hours less than the required 171.55 hours. On 11/10/2024 the facility was required to provide 178.60 hours of direct care based on their facility census of 76 residents. Further review revealed the facility provided 177.63 hours, which was 0.97 hours less than the required 178.60 hours. On 12/08/2024 the facility was required to provide 180.95 hours of direct care based on their facility census of 77 residents. Further review revealed the facility provided 177.26 hours, which was 3.69 hours less than the required 180.95 hours. In an interview on 03/24/2025 at 3:07PM, S1Administrator indicated the facility did not provide 2.35 hours of direct nursing care per resident on 09/15/2024, 10/27/2024, 11/10/2024, and 12/08/2024 as required.

Based on observations, interviews, and record reviews, the facility failed to ensure enhanced barrier precautions (EBP) were maintained while emptying a urinary catheter bag for 1 (Resident #54) of 1 (Resident #54) sampled residents investigated for urinary catheter care. Findings: Review of the facility's Enhanced Barrier Precautions policy and procedure, dated 04/01/2024 and revised on 03/19/2025, revealed EBP referred to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities. Further review revealed EBP was used in conjunction with standard precautions and expanded the use of Personal Protective Equipment (PPE) to don (put on) a gown and gloves during high-contact resident care activities. Further review revealed, in part, EBP was indicated for residents with indwelling medical devices which included, in part, urinary catheters. Review of Resident #54's medical record revealed Resident #54 was admitted to the facility on [DATE] with diagnoses of diabetes mellitus type 2, hypertension, gout, acute cystitis without hematuria, obstructive and reflux uropathy (a blockage in the urinary tract), and urinary retention. Review of Resident #54's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/16/2024 revealed, in part, Resident #54 had an indwelling catheter. Observation on 03/25/2025 at 2:00PM revealed Resident #54 had a sign posted on his bedroom door for Enhanced Barrier Precautions. Observation on 03/25/2025 at 2:02PM revealed S7Certified Nursing Assistant (CNA) did not put on a gown when she entered Resident #54's room and emptied Resident #54's urinary catheter bag. In an interview on 03/25/2025 at 2:08PM, S7CNA confirmed she did not put on a gown before she entered Resident #54's room and emptied Resident #54's urinary catheter bag. S7CNA further indicated she should have put on a gown. In an interview on 03/25/2025 at 2:10PM, S6Assistant Director of Nursing confirmed S7CNA should have put on a gown before she entered Resident #54's room to empty Resident #54's urinary catheter bag. 45877

Based on observations, interviews, and record reviews the facility failed ensure a resident's Percutaneous Endoscopic Gastrostomy (PEG) tube (a soft, plastic feeding tube that goes into the stomach used to provide nutrition when oral intake is inadequate) feeding was not administered while a resident was in a flat position for 1 (Resident #37) of 1 (Resident #37) resident investigated for PEG tube feedings. Findings: Review of Resident #37's electronic medical record revealed, in part, Resident #37 was admitted to the facility on [DATE] with a diagnosis of dysphagia (difficulty swallowing). Review of Resident #37's March 2025 physician orders revealed, in part, an order to administer Resident #37's Glucerna 1.2 (a form of liquid nutrition) at 70 milliliters/hour (mls/hr) through Resident #37's PEG tube. Further review revealed an order for staff to keep the head of Resident #37's bed elevated during PEG tube feedings. Review of Resident #37's care plan revealed, in part, an intervention to keep the head of Resident #37's bed elevated during PEG tube feedings. Observation on 03/23/2025 at 10:20AM revealed Resident #37 was administered Glucerna 1.2 at 70 mls/hr through Resident #37's PEG tube. Further observation revealed S8Certified Nursing Assistant (CNA) repositioned Resident #37's head of bed to a flat position to provide incontinence care while Resident #37's PEG tube feeding was administered. In an interview on 03/23/2025 at 10:23AM, S8CNA indicated she was unaware Resident #37's PEG tube feeding should have been paused prior to positioning Resident #37's head of bed to a flat position. In an interview on 03/23/2025 at 10:24AM, S4Licensed Practical Nurse indicated Resident #37's PEG tube feeding should have been paused prior to positioning Resident #37's head of bed to a flat position. In an interview on 03/24/2025 at 9:10AM, S2Director of Nursing confirmed Resident #37's tube feedings should have been paused prior to positioning Resident #37's head of bed to a flat position.

Based on observations, interviews, and record reviews, the facility failed to store a resident's respiratory equipment in a sanitary manner for 1 (Resident #54) of 3 (Resident #25, #35, #54) residents investigated for respiratory care. Findings: Review of Resident #54's electronic medical record revealed Resident #54 was admitted to the facility on [DATE] with diagnoses of acute and chronic respiratory failure. Review of Resident #54's March 2024 Physician's Orders revealed, in part, the following orders: - continuous positive airway pressure (CPAP) full mask with oxygen at 2 liters (L) per minute every night and as needed; - ipratropium-albuterol solution (a breathing treatment) 0.5-2.5 (3) milligrams (mg)/3 milliliters (mls), inhale 3 mls orally every 4 hours, as needed, for shortness of breath or wheezing via nebulizer; and, - oxygen at 2L per minute via nasal cannula continuously every shift related to chronic respiratory failure. Observation on 03/24/2025 at 7:55AM revealed Resident #54's CPAP mask and nebulizer/breathing treatment mask were on the bedside table and not contained in a bag. Observation on 03/24/2025 at 9:48AM revealed Resident #54's CPAP mask and nebulizer/breathing treatment mask were on the bedside table and not contained in a bag. Observation on 03/24/2025 at 4:05PM revealed Resident #54's CPAP mask and nebulizer/breathing treatment mask were on the bedside table and not contained in a bag. In an interview on 03/24/2025 at 4:23PM, S9Licensed Practical Nurse (LPN) confirmed Resident #54's CPAP mask and nebulizer/breathing treatment masks were not contained in bags. S9LPN further indicated Resident #54's CPAP mask and nebulizer/breathing treatment mask should be contained in bags when not in use. In an interview on 03/24/2025 at 5:00PM, S2Director of Nursing (DON) indicated CPAP masks and nebulizer/breathing treatment masks should be contained when not in use.

Based on observations, interviews, and record reviews, the facility failed to ensure: 1. Food was stored in a sanitary manner for 2 (Refrigerator a and Refrigerator c) of 3 (Refrigerator a, Refrigerator b, Refrigerator c) refrigerators and 1 (Freezer d) of 1 (Freezer d) freezers observed for food storage; and, 2. Ensure the facility's kitchen was maintained in a sanitary manner. Findings: 1. Observation of Refrigerator a on 03/23/2025 at 8:40AM revealed an opened and undated bag of browned lettuce, an opened and undated container or parmesan cheese, an onion with a black spot that was approximately 1/4 of the size of the onion inside of a clear plastic tub with other onions. Observation of Freezer d on 03/23/2025 at 8:40AM revealed a bag of white beans which was unlabeled with the contents of the bag. Observation of Refrigerator c on 03/23/2025 at 8:45AM revealed shredded cheese was scattered across the bottom of Refrigerator c. Observation of the kitchen with S3Dietary Manager on 03/24/2025 at 11:07AM revealed an opened and undated container of parmesan cheese and an onion with a black spot that was approximately 1/4 of the size of the onion inside of a clear plastic tub with other onions which was in Refrigerator a. Further observation revealed a bag of white beans which was unlabeled with the contents of the bag in Freezer d. In an interview on 03/24/2025 at 11:15AM, S3Dietary Manager indicated the bag of browned lettuce and the container of parmesan cheese should have been labeled with an opened date. S3Dietary Manager further indicated the onion with the black spot that was 1/4 the size of the onion should not have been in the container and available for resident consumption. S3Dietary Manager further indicated the shredded cheese should not have been on the bottom of Refrigerator c. S3Dietary Manger further indicated the bag of white beans in Freezer d should have been labeled with the contents of the bag. 2. Observation of the facility's kitchen on 03/23/2025 at 8:39AM revealed a rack of clean dishes contained various stacks of blue bowls. Further observation revealed 3 of the bowls on top of the various stacks had debris and a greasy film on them. Observation of the facility's kitchen on 03/23/2025 at 8:44AM revealed a rack of clean dishes contained various stacks of dome covers (a cover that helps to keep a resident's food warm during transport) and various stacks of pellets (a metal plate that is placed under a resident's plate to help keep food warm during transport). Further observation revealed 4 of the pellets on top of the various stacks had dust and a greasy film on them and 5 of the dome covers had dust on them. Observation of the kitchen with S3Dietary Manager on 03/24/2025 at 11:07AM revealed a rack of clean dishes contained various stacks of blue bowls. Further observation revealed 3 of the bowls on top of the various stacks had debris and a greasy film on them. Further observation revealed a rack of clean dishes contained various stacks of dome covers and various stacks of pellets. Further observation revealed 4 of the pellets on top of the various stacks had dust and a greasy film on them and 5 of the dome covers had dust on them. Further observation revealed a dried brown substance in a splash pattern located on the wall directly behind the facility's steam table. In an interview on 03/24/2025 at 11:15AM, S3Dietary Manager indicated the above mentioned bowls, dome covers, and pellets should not have dust, debris, and/or a greasy film on them. In an interview on 03/24/2025 at 1:20PM, S3Dietary Manager indicated the dried brown substance should not have been on the wall behind the steam table.

Based on record reviews, observations, and interviews, the facility failed to implement physician ordered interventions to prevent future falls for 2 (Resident #2 and Resident #3) of 3 (Resident #1, Resident #2 and Resident #3) sampled residents reviewed for accidents. Findings: Review of the facility's policy and procedure titled, Resident Incident and Visitor Accident Report revised on 07/23/2018 revealed, in part, the Director Of Nursing (DON) or designee completes the investigation and comes to a reasonable conclusion regarding causative factors surrounding the incident and the actions necessary to prevent further incidents/accidents. Resident #2 Review of Resident #2's fall scale evaluation dated 12/03/2024 revealed, in part, a score of 55. A score of 55 indicated Resident #2 was at a high risk for falls. Review of Resident #2's January 2025 Physician's Orders revealed, in part, on 09/13/2023 an order was received for a pommel cushion (A pommel cushion is a wheelchair cushion with a raised center section, or pommel, that helps keep the user's legs apart and supported) placed to resident's wheelchair to prevent thrusting, improve posture while sitting up in wheelchair, and to promote safety. Review of Resident #2's Care Plan initiated on 09/19/2024 revealed, in part, Resident #2 was at risk for falls related to a right leg prosthesis, muscle weakness, lack of coordination, and impulsiveness status post a cerebrovascular accident (stroke) with a documented intervention, in part, to follow the facility's fall protocol. Observation on 01/14/2025 at 10:10 a.m. revealed Resident #2's wheelchair did not have a pommel cushion. Observation on 01/14/2025 at 11:40 a.m. revealed Resident #2's wheelchair did not have a pommel cushion. Observation on 01/14/2025 at 1:15pm revealed Resident #2's wheelchair did not have a pommel cushion. In an interview on 01/14/2025 at 2:00 p.m., S3Certified Nursing Assistant (CNA) indicated Resident #2 did not have a wheelchair cushion with a raised center section. In an interview on 01/14/2025 at 2:07 p.m., S2Licensed Practical Nurse (LPN) confirmed Resident #2 had a current order for a pommel cushion. On 01/14/2025 at 2:18 p.m., S4Physical Therapist observed Resident #2's wheelchair and indicated Resident #2's cushion was not a pommel cushion. In an interview on 01/14/2025 at 2:37 p.m., S1DON confirmed Resident #2 had a current physician's order for a pommel cushion. S1DON further indicated the pommel cushion was ordered as an intervention after a fall in an attempt to prevent further falls, and Resident #2 should have had a pommel cushion in his wheelchair. Resident #3 Review of Resident #3's fall scale evaluation dated 12/06/2024 revealed, in part, a score of 65. A score of 65 indicated Resident #3 was at a high risk for falls. Review of Resident #3's January 2025 Physician's Orders revealed, in part, on 12/10/2024 an order was received for a landing pad to be placed on the right side of Resident #3's recliner for safety. Review of Resident #3's Care Plan initiated on 12/10/2024 revealed, in part, Resident #3 was at risk for falls related to muscle weakness and lack of coordination with a documented intervention, in part, to follow the facility's fall protocol. Observation on 01/14/2025 at 10:42 a.m. revealed Resident #3's recliner did not have a landing pad placed on the right side of her recliner. Observation on 01/14/2025 at 4:05 p.m. revealed Resident #3's recliner did not have a landing pad placed on the right side of her recliner. Observation on 01/15/2025 at 8:30 a.m. revealed Resident #3's recliner did not have a landing pad placed on the right side of her recliner. In an interview on 01/15/2025 at 9:48 a.m., S5CNA indicated she was Resident #3's CNA for the current shift. Through visual observation, S5CNA confirmed Resident #3's recliner did not have a landing pad placed on the right side. In an interview on 01/15/2025 at 10:35 a.m., S2LPN confirmed Resident #3 had a current order for a landing pad to the right side of her recliner. In an interview on 01/15/2025 at 10:47 a.m., S1DON confirmed Resident #3 had a fall on 12/06/2024 and the intervention was to put a landing pad to the right side of the Resident #3's recliner. S1DON further indicated the nursing staff were responsible to ensure the landing pad was present in the room as ordered.

Based on observations, interviews, and record reviews, the facility failed to ensure to ensure staff maintained fluids within a resident's reach for a resident identified as being at risk for dehydration. This deficient practice was identified for 1 (Resident #2) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents reviewed for hydration. Findings: Review of the facility's Hydration Management policy and procedure dated January 2023 revealed, in part, residents identified with potential/actual dehydration would be evaluated for contributing risk factors/conditions. Further review revealed risk factors for dehydration may include diarrhea/vomiting and a plan of care for the resident would be developed to ensure provisions of adequate fluid intake. Further review revealed water pitchers would be placed at a resident's bedside unless otherwise indicated. Review of Resident #2's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/06/2024 revealed, in part, Resident #2 had a Brief Interview of Mental Status (BIMS) score of 5 which indicated severe cognitive impairment. Further review revealed Resident #2 had a diagnosis of dementia and malnutrition, was dependent on staff for transfers and mobility, and required supervision with setup assistance from staff for eating. Review of Resident #2's care plan with a revision date of 06/13/2024 revealed, in part, Resident #2 was identified as being at risk for dehydration or fluid deficit related to diarrhea. Further review revealed Resident #2 had interventions which included water was to be kept at bedside, and staff to encourage resident to drink fluids. Observation on 09/08/2024 at 8:32 a.m. revealed Resident #2 was in bed and her water pitcher was out of reach and across the room sitting on top of a large dresser. Further observation revealed Resident #2 had no water/fluids within reach at her bedside. In an interview on 09/08/2024 at 8:32 a.m., Resident #2 was unable to state if she was thirsty or how long it had been since she was offered fluids. Observation on 09/08/2024 at 10:16 a.m. revealed Resident #2 was in bed and her water pitcher was out of reach and across the room sitting on top of a large dresser. Further observation revealed Resident #2 had no water/fluids at her bedside. Observation on 09/08/2024 at 12:32 p.m. revealed Resident #2 was in bed and her water pitcher was out of reach and across the room on top of a large dresser. Further observation revealed Resident #2 had no water/fluids at her bedside. In an interview on 09/08/2024 at 12:55 p.m., S2Certified Nursing Assistant (CNA) indicated Resident #2 was able to eat and drink on her own after she was set up by staff. Observation on 09/08/2024 at 1:20 p.m. revealed Resident #2 was sitting upright in her bed with her lunch tray in front of her. Further observation revealed Resident #2 picked up a cup of red fluids and drank from the cup independently. Observations on 09/08/2024 of Hall D, where Resident #2 resided and was confirmed after facility staff confirmed with the review of surveillance camera footage, revealed no evidence ice and/or water was passed on the 6:00 am to 2:00 pm shift. In an interview on 09/09/2024 at 11:03 a.m., S1Director of Nursing (DON) indicated the CNAs were responsible to pass water and/or ice down the halls at least once a shift. In an interview on 09/09/2024 at 11:55 a.m., S1DON confirmed Resident #2 had a care plan for dehydration with an intervention which included to keep water at bedside. S1DON indicated the facility's camera footage for Hall D on 09/08/2024 for the 6:00 a.m. to 2:00 p.m. shift was reviewed, and the facility had no evidence the staff passed ice/water on Hall D at any time during the shift, and should have.

Based on record reviews, interviews, and observations, the facility failed to ensure privacy was maintained during showers for 4 (Resident #8, Resident #28, Resident #30, and Resident #215) of 4 sampled residents investigated for privacy. Findings: Resident #8 Review of Resident #8's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/01/2024 revealed, in part, a Brief Interview for Mental Status (BIMS) score of 15. A score of 15 indicated Resident #8 was cognitively intact. In an interview on 03/18/2024 at 11:22 a.m., Resident #8 indicated she did not have privacy during showers and she was embarrassed when other people saw her naked. In an interview on 03/19/2024 at 10:18 a.m., S11Certified Nursing Assistant (CNA) indicated 2 residents use shower room A at the same time. S11CNA indicated when there were 2 residents in the shower room it was very likely they would see each other naked. Observation of shower room A on 03/19/2024 at 3:41 p.m. revealed the ceiling between the shower and the open area of the shower room had tracks for a privacy curtain, and there was no privacy curtain suspended from the tracks. In an interview on 03/19/2024 at 3:41 p.m., S8Maintenance confirmed shower room A did not have a privacy curtain for the shower. Resident #28 Review of Resident #28's MDS with ARD of 02/14/2024 revealed, in part, a BIMS score of 13. A score of 13 indicated the resident was cognitively intact. Observation on 03/20/2024 at 10:08 a.m. revealed Resident #28 exited shower room A. In an interview on 03/20/2024 at 10:10 a.m., Resident #28 indicated she was in shower room A at the same time as Resident #8. Resident #28 further indicated she observed Resident #8 without clothes. Resident #30 Review of Resident #30's MDS with an ARD of 03/06/2024 revealed, in part, a BIMS score of 15. A score of 15 indicated Resident #30 was cognitively intact. Further review revealed Resident #30 was totally dependent on others for showering and bathing. In an interview on 03/20/2024 at 9:40 a.m., Resident #30 indicated the only privacy curtain in the shower room was around the toilet and the whirlpool. Resident #30 further explained when she showers the Certified Nursing Assistant would place her on a shower chair and take off her clothing and she would sit exposed while waiting for her turn in the shower stall. Resident #30 further added the Certified Nursing Assistant would take the other resident out the shower and then place her in the shower and they would be able to see each other naked at this time. Resident #30 further indicated if the door to the shower room would open, anyone who walked down the hall could see into the shower room. Resident #215 Review of Resident #215's MDS with an ARD of 03/13/2024 revealed a BIMS score of 15. A score of 15 indicated Resident #215 was cognitively intact. Observation on 03/20/2024 at 10:21 a.m. revealed Resident #215 sat on a shower chair unclothed in shower room A. Observation further revealed S11CNA transported Resident #8 out of the shower in the shower chair unclothed and Resident #215 and Resident #8 were able to see each other. In an interview on 03/20/2024 at 3:32 p.m., Resident #215 indicated she was self-conscious about her appearance. Resident #215 further indicated when she showered she was able to see other residents unclothed and they were able to see her. In an interview on 03/21/2024 at 10:01 a.m., S11CNA confirmed Resident #215 and Resident #8 were able to see each other unclothed in the shower room. S11CNA further indicated residents should not see each other unclothed. In an interview on 03/20/2024 at 2:41 p.m., S2Assistant Director of Nursing (ADON) indicated 2 residents use the shower room at the same time. S2ADON confirmed shower room A did not have a privacy curtain for the shower. S2ADON indicated privacy should be maintained at all times when a resident was in the shower room. 45877

Based on record review and interview, the facility failed to ensure a resident's meal intake and/or nutritional supplement intake was accurately documented in Resident #29's Electronic Medical Record for 1 (Resident #29) of 1 (Resident #29) sampled residents reviewed for nutrition. Findings: Review of Resident #29's March 2024's Physician's Orders revealed, in part, an order dated 12/01/2023 to administer a Magic Cup (a frozen nutritional supplement) two times a day, and an order dated 10/12/2023 to administer 6 ounces (oz) of Medpass Sugar Free (SF) (a supplemental nutritional drink) supplement four times a day. Review of Resident #29's March 2024 eMAR revealed, in part, Resident #29's Medpass SF supplement was to be administered to Resident #29 four times a day at 7:00 a.m., 11:00 a.m., 4:00 p.m., and 7:00 p.m. Further review revealed, the nurse was to indicate the amount the Medpass SF supplement Resident #29 drank with a notation of 1 for 25%, 2 for 50%, 3 for 75%, 4 for 100%, and R for refused. Further review revealed a notation of 0 for indicated for the administration of Resident #29's Medpass SF supplement at 7:00 a.m. on 03/17/2024, 03/18/2024, 03/19/2024, 03/20/2024, at 11:00 a.m. on 03/17/2024, 03/18/2024, 03/19/2024, 03/20/2024, at 4:00 p.m. on 03/17/2024, 03/18/2024, 03/19/2024, 03/20/2024, and at 7:00 p.m. on 03/17/2024, 03/18/2024, 03/19/2024, and 03/20/2024. Further review revealed Resident #29's Magic Cup supplement was to be administered to Resident #29 in the morning and the evening. Further review revealed the nurse was to indicate the amount of the Magic Cup supplement Resident #29 ate with a notation of 1 for 25%, 2 for 50%, 3 for 75%, 4 for 100%, and R for refused. Further review revealed a notation of 0 was indicated for the administration of Resident #29's Magic Cup supplement in the morning on 03/15/2024, 03/16/2024, 03/17/2024, and 03/20/2024, and in the evening on 03/15/2024, 03/16/2024, 03/17/2024, 03/18/2024, 03/19/20 and 03/20/2024. Review of Resident #29's February 2024 eMAR revealed, in part, Resident #29's Medpass SF supplement was to be administered to Resident #29 four times a day at 7:00 a.m., 11:00 a.m., 4:00 p.m., and 7:00 p.m. Further review the nurse was to indicate the amount of the Medpass SF supplement Resident #29 drank with a notation of 1 for 25%, 2 for 50%, 3 for 75%, 4 for 100%, and R for refused. Further review revealed a notation of 0 for indicated for the administration of Resident #29's Medpass SF supplement at 7:00 a.m., 11:00 a.m., 4:00 p.m., and 7:00 p.m. on 02/11/2024, 02/12/2024, 02/13/2024, 02/14/2024, 02/15/2024, 02/16/2024, 02/17/2024, 02/18/2024, and 02/19/2024. Review of Resident #29's Meal intake log from 02/21/2024 to 03/21/2024 revealed, in part. Resident #29's meal intake was not documented for breakfast and/or lunch on 02/24/2024, 02/25/2024, 03/09/2024, 03/12/2024, 03/17/2024, and 03/18/2024. In an interview on 03/20/2024 at 1:03 p.m., S10Certified Nursing Assistant (CNA) indicated a resident's meal intake was to be documented after breakfast, lunch, and dinner. In an interview on 03/21/2024 at 9:45 a.m., S9CNA indicated a resident's meal intake should be documented after every meal. In an interview on 03/21/2024 at 10:12 a.m., S12Licensed Practical Nurse indicated she had been documenting the consumption of Resident #29's Medpass SF supplement and Magic Cup supplement incorrectly in Resident #29's eMAR. In an interview on 03/21/2024 at 12:08 p.m., S2Assistant Director of Nursing (ADON) confirmed Resident #29's eMAR had inaccurate documentation to indicate the consumption of Resident #29's Medpass SF supplement and Magic Cup supplement. S2ADON further stated the nurse's should have been documenting a 1,2,3,4, or R to indicate the consumption of Resident #29's Medpass SF supplement and Magic Cup supplement. S2ADON further confirmed there was missing documentation of Resident #29's meal intake on the above mentioned dates and there should not have been.

Based on observation and interviews, the facility failed to dispose of garbage and refuse properly. Findings: Observation on 03/18/2024 at 9:24 a.m. revealed 2 dumpsters were located behind the facility. Observation revealed a grease drain was located to the left side of one of the dumpsters. The grease drain had a buildup of a black substance on the drain, and a buildup of the black substance on the ground between the dumpster and the grease drain. Observation revealed the area immediately behind the dumpster, located closest to the facility, had a buildup of used gloves, cardboard, paper plates, and a thick buildup of a black substance on the ground. In an interview on 03/18/2024 at 9:24 a.m., S5Dietary Manager confirmed the above documented findings and indicated S8Maintenance was responsible for maintaining the dumpster area. In an interview on 03/18/24 at 9:32 a.m., S8Maintenance confirmed the above documented findings, and indicated it was his responsibility to maintain the area. In an interview on 03/19/2024 at 8:20 a.m., S1Administrator indicated S8Maintenance was responsible for the maintenance of the area surrounding the dumpsters. S1Administrator reviewed pictures of the above documented areas and indicated the area was unsanitary and should not have litter on the ground surrounding the dumpsters.

Based on observation and interview the facility failed to ensure a staff member wore gloves when administering an insulin injection (a medication used to treat diabetes) to 1 (Resident #365) of 1(Resident #365) residents observed receiving insulin during the medication administration task. Findings: An observation on 03/19/2024 at 12:19 p.m. revealed S12Licensed Practical Nurse (LPN) administered an insulin injection without putting on gloves. In an interview on 03/19/2024 at 12:19 p.m., S12LPN confirmed she did not have gloves on when she administered Resident #365's insulin injection and should have worn gloves when she administered Resident #365's insulin injection. In an interview on 03/20/2024 at 1:40 p.m., S4Infection Preventionist confirmed gloves should have been worn when an injection was administered. In an interview on 03/20/2024 at 1:45 p.m., S3Corportate Nurse confirmed gloves should have been worn when a nurse administered a medication via an injection.

Based on record review and interviews, the facility failed to ensure a resident's code status was completed consistent with the resident's wishes for 1 (Resident #48) of 17 (Resident #2, Resident #8, Resident #10, Resident #11, Resident #14, Resident #16, Resident #20, Resident #22, Resident #27, Resident #29, Resident #30, Resident #32, Resident #43, Resident #46, Resident #48, Resident #58, and Resident #59) sampled residents reviewed for advanced directives in the initial pool. Findings: Review of Resident #48's Louisiana Physician Orders For Scope of Treatment (LaPOST) dated 02/29/2024 indicated Resident #48's request was for Do Not Resuscitate (DNR). Further review revealed Resident #48's LaPOST was not signed by a physician. In an interview on 03/18/2024 at 12:32 p.m., S2Assistant Director of Nursing (ADON) indicated Resident #48's LaPOST should have been signed by the physician. In an interview 03/19/2024 at 11:42 a.m., S7Medical Records indicated she was responsible for getting the LaPOSTs signed by the doctor. S7Medical Records indicated Resident #48's LaPOST slipped through the cracks, and was not signed by a physician.

Based on observation and interviews, the facility failed to have a means to dispose of garbage without touching the garbage receptacle for 1 of 2 hand wash sinks in the kitchen. Findings: Observation on 03/18/2024 at 9:10 a.m. during the brief kitchen tour, S5Dietary Manager identified two sinks as hand wash sinks. Observation of the hand wash sink, located in the food preparation area, revealed a garbage receptacle with a lid which had to be lifted manually in order to throw something away. Observation on 03/19/2024 at 11:31 a.m. revealed the hand wash sink, located in the food preparation area, had a garbage receptacle with a lid which had to be lifted manually in order to throw something away. In an interview on 03/19/2024 at 11:31 a.m., S13Dieatary Aide identified the sink located in the food preparation area as the sink dietary staff used to wash their hands. S13Dietary Aide indicated she disposed of soiled paper towels in the garbage receptacle and indicated she had to remove the lid of the garbage receptacle with her hands. In an interview on 03/19/2024 at 11:35 a.m., S5Dietary Manager indicated the garbage receptacle should not have a lid which needed to be lifted manually in order to throw something away.