**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations and interviews, the facility failed to provide services that met professional standards for 2 (#9 and #105) of 6 (#9, #22, #25, #52, #105, and #132) residents reviewed for accident hazards and supervision. The facility failed to ensure safe medication administration practices by leaving medication at the bedside.Findings:Review of the facility's undated Self-Administration of Medications policy revealed in part:3. To assess whether the resident is able to self-administer medications, the criteria on the Assessment for self-administration of medications form will be used. If the Interdisciplinary Team (IDT) determines that the resident is unable to self-administer medications, because this would be a danger to the resident or to others, then the Interdisciplinary Team may not grant the right to self-administer medications. If the right is granted, a specific order to self-administer must be obtained which includes how, when and for what reason the medication can be used.7. Self-administration of bedside medications must be care planned, including the specific order, granting of approval by IDT, and monitoring for compliance. Review of the facility's undated General Guidelines policy revealed in part:5. Residents are allowed to self-administer medications when specifically authorized by the IDT which includes the attending physician and in accordance with procedures for self-administration of medications. (See policy for self-administration of medications)Resident #9Review of Resident #9's medical record revealed an admission date of 08/16/2023 with diagnoses which included, in part, metabolic encephalopathy, personal history of transient ischemic attack (TIA) and cerebral infarction without residual deficits. Review of Resident #9's Quarterly MDS (minimum data set) assessment dated [DATE] revealed, in part, a BIMS (Brief Interview of Mental Status) score of 08/15, indicating moderate cognitive impairment).Review of Resident #9's medical record revealed a physician order dated 11/04/2024 Cleanse buttocks with soap and water pat dry apply zeasorb powder for preventative care leave open to air daily until resolved; every day shift and every 15 minutes as needed for preventative skin care. Further review of Resident #9's medical record failed to reveal a physician's order for self-administration of medication. Review Resident #9's care plan failed to reveal Resident #9 had been care planned for self-administration of medication.An observation on 07/28/2025 at 8:15 a.m. revealed one medication cup of powder with illegible/smeared label on Resident #9's bedside table. During an interview on 07/28/2025 at 9:25 a.m., with S4CNA (certified nursing assistant) and S5LPN (licensed practical nurse), S4CNA reported the medication in the cup on Resident #9's bedside table was for wound care on Resident #9's buttocks. S5LPN acknowledged medication was at the bedside. S5LPN reported she was unable to read the medication cup label. S5LPN reported medications of any kind should not be at the bedside. During an interview 07/28/2025 at 9:30 a.m., S5LPN reported the medication could be Zeasorb. Upon review of Resident #9's orders, S5LPN reported the powder in the medication cup was is Zeasorb and there was not an order for medication to be left at Resident #9's beside for self-administration. Resident #105Review of Resident #105's medical record revealed an admission date of 08/16/2023 with diagnoses which included, in part, dry eye syndrome of bilateral lacrimal glands, chronic obstructive pulmonary disease with (acute) exacerbation, chronic respiratory failure with hypoxia.Record of Quarterly MDS Assessment for Resident #105 dated 06/05/2025 revealed in a BIMS score of 15/15, indicating cognitively intact.Review of Resident #105's medical record revealed a physician's order dated 03/20/2025 refresh liquigel ophthalmic gel 1% (carboxymethylcellulose sodium [ophthalmic]); instill 2 drop in both eyes two times a day related to dry eye syndrome of bilateral lacrimal glands and instill 1 drop in both eyes every 2 hours as needed for dry eye. Further review of Resident #105's medical record failed to reveal a physician's order for self-administration of medication. Review of Resident #105's care plan failed to reveal Resident #105 had been care planned for self-administration of medication.An observation on 07/28/2025 at 9:05 a.m. revealed medication on Resident # 105's bedside table labeled Refresh Tears. During an interview on 07/28/2025 at 9:05 a.m., Resident #105 reported medication had been on the bedside table since last night, and she had just put the eye drops in her eyes. During an interview on 07/28/2025 at 9:15 a.m., S6LPN acknowledged Refresh Tears medication was at Resident #105's bedside and should not be in the room. S6LPN further acknowledged Resident #105 did not have an order for self-administration

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations and interviews, the facility failed to provide respiratory care consistent with professional standards of practice for 2 (#116 and #139) of 3 (#116, # 39, and #141) residents reviewed for respiratory services. The facility failed to ensure respiratory supplied were stored properly.Findings:Review of the facility's undated Oxygen Administration (Concentrator or Tank) policy revealed in part: Humidifier bottles, cannulas and 02 tubing will be changed at least once weekly and dated. Concentrator filter should be cleaned weekly or as needed as well. When not in use. Cannula or mask should be placed in a plastic bag.Resident #116Review of Resident #116's Quarterly MDS Assessment (minimum data sheet) dated 06/19/2025 revealed, in part, admission date to facility of 10/26/2023. Review of Resident #116's medical record diagnoses included, in part, other specified chronic obstructive pulmonary disease, history of falling, other specified anxiety disorders, muscle wasting and atrophy, not elsewhere classified, multiple sites, pain, unspecified and restless legs syndrome. Review of Resident #116's physician orders included an order dated 07/11/2025 Change O2 (oxygen) tubing, nasal cannula, humidifier bottle and clean filter; one time a day every Wednesday.An observation on 07/28/2025 at 7:55 a.m. revealed Resident #116's oxygen humidified water container and tubing were dated 07/18/2025. During an interview on 07/28/2025 at 8:00 a.m., S3DON (Director of Nursing) reported Resident #116's oxygen tubing was dated 07/18/2025 and should have been changed weekly.Resident #139Review of Resident #139's Quarterly MDS assessment dated [DATE] included an admission date to facility of 11/01/2024.Review of Resident #139's diagnoses included other specified chronic obstructive pulmonary disease and chronic systolic (congestive) heart failure. An observation on 07/28/2025 at 8:45 a.m. revealed Resident #139's nebulizing mask placed on top of nebulizing machine and was not stored in a bag.During an interview on 07/28/2025 at 9:30 a.m., S5LPN (licensed practical nurse) acknowledged Resident #139's nebulizing mask was undated, not stored a bag, and should have been.

Based on record reviews and interview, the facility failed to provide to the resident and/or the resident representative (RP) written notice which specified the reason for transfer, effective date, location and statement of the resident's appeal rights, and duration of the bed hold policy for 4 (#10, #52, #116 and #147) of 4 (#10, #52, #116 and #147) residents reviewed for transfer/discharge. Findings: Review of the facility’s “Bed-Hold and Readmission” undated policy revealed in part: Purpose: To explain and give written information to the resident and family member or legal representative of our bed-hold and readmission policy. General Information: Upon admission and when leaving the facility, the resident, family member or legal representative will be given instructions of the times allowed out of the facility for hospitalization and/or therapeutic leave… The policy states that a resident, family member or representative agrees that the facility holds the bed for specified number of days at a designated amount of charge. Note: If the resident wished to reserve the bed, there must be a signed agreement between the resident or responsible party and the nursing facility. Resident #10 Review of Resident #10's medical record revealed an admit date of 05/18/2022 with diagnoses of, but not limited to paraplegia, major depressive disorder and bipolar disorder. Review of Resident #10’s medical record revealed Resident #10 was sent to local ED (Emergency Department) on 04/21/2025 for wound evaluation. Further review of Resident #10’s medical record failed to reveal a written notice of transfer/discharge had been provided. Resident #52 Review of Resident #52's medical record revealed an admit date of 05/30/2023 with diagnoses of, but not limited to Parkinson’s disease with dyskinesia and age related osteoporosis without current pathological fracture. Review of Resident #52’s medical record revealed Resident #52 was sent to local ED on 02/20/2025 for evaluation after a fall. Further review of Resident #52’s medical record failed to reveal a written notice of transfer/discharge had been provided. Resident #116 Review of Resident #116's medical record revealed an admit date of 10/26/2023 with diagnoses of, but not limited to chronic obstructive pulmonary disease and other specified anxiety disorders. Review of Resident #116’s medical record revealed Resident #116 was sent to local ED on 06/01/2025 for altered mental status. Further review of Resident #116’s medical record failed to reveal a written notice of transfer/discharge had been provided. Resident #147 Review of Resident #147's medical record revealed an admit date of 04/24/2025 with diagnoses of, but not limited to metabolic encephalopathy and osteoarthritis. Review of Resident #147’s medical record revealed Resident #147 was sent to local ED on 04/30/2025 per RP’s request. Further review of Resident #147’s medical record failed to reveal a written notice of transfer/discharge had been provided. During an interview on 07/30/2025 at 1:00 p.m., S3DON (Director of Nursing) reported Residents #10, #52, #116, #147 and/or RPs had not been provided a written transfer/discharge notice upon transfer from the facility and should have been.

Based on record review and interview, the facility failed to refer a resident with newly evident or possible severe mental disorder, intellectual disability, or a related condition for a Level II PASARR (Pre-admission Screening and Resident Review) services for 1 (#3) of 6 (#3, #7, #13, #15, #34, and #135) residents reviewed for PASARR.This failure had the potential for residents to not be provided with specialized rehabilitation services, causing feelings of boredom, hopelessness and a diminished quality of life. Findings: Review of Resident #3's medical revealed an admit date of 06/28/2024 with a diagnosis of unspecified dementia, moderate without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of Resident #3's medical record revealed a diagnosis of Delusional Disorder was added on 07/02/2024. Review of Resident #3's Level I PASARR screen and determination record dated 06/21/2024 revealed Resident #3 was not suspected to have or had ever been diagnosed with a mental illness. Further review of Resident #3's medical record failed to reveal a new PASARR was completed after the new diagnosis of Delusional Disorder was added on 07/02/2024. During an interview on 07/30/2025 at 11:30 a.m., S2Corporate Nurse acknowledged a new PASARR had not been completed/submitted when Resident #3 was diagnosed with a new mental illness and should have been.

Based on observations and interviews, the facility failed to post address and telephone numbers of pertinent state agencies in a form and manner accessible and understandable to residents/resident representatives. Findings:Observation on 07/29/2025 at 9:55 a.m. revealed a framed document with state agency complaint address and phone number posted outside of the business office, at the end of a hallway, off of the facility's main hallway. The posting was on a letter size document and framed, with the bottom of the frame being 64 inches up from the floor. Observation further revealed the posting was not in a location easily noticeable from the main hallway. Further observation revealed only the business office and two staff bathrooms were on the hallway. Review of facility's admission packet revealed a document titled State Survey that included, in part, In accordance with LAC (Louisiana Administrative Code) Title 48:1 9715.F., and as required by R.S. (Revised Statute) 40: 2010.10, this facility is providing notification to the applicant that they may receive a copy of the annual licensing survey as well as the telephone number to report complaints. The telephone number is posted in the facility hallway in an accessible and visible location. During an interview on 07/30/2025 at 8:25 a.m., S1Administrator reported the posting was on the wall next to the business office and on the two televisions by the nursing stations. S1Administrator further acknowledged the print could be larger and the document could be positioned lower on the wall. Observation of television adjacent to a nursing station on 07/30/2025 from 9:31 a.m. to 9:41 a.m. failed to show information which indicated state agency complaint address/phone number to file a complaint. During an interview on 07/30/2025 at 9:45 a.m., S1Administrator was notified of the lack of state agency complaint address/phone number information on the television and reported he thought it was on there but maybe it was not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews the facility failed to ensure an appropriate intervention was utilized for 1 (Resident #23) of 2 (#23 and #56) residents reviewed for falls by failing to ensure landing strips were in place at Resident #23's bedside. Review of the facility's Fall Prevention Program policy (not dated) revealed in part: Policy: It is the policy of the facility to promote safety, dignity, and overall quality of life for residents. A safe and hazard free environment, as possible, will be provided as well. It is our goal to prevent falls by enabling staff to recognize those residents who have been identified as high risk for potential falls so appropriate interventions can be implemented. We also hope to decrease the risk of injury when falls cannot be prevented. g. Plan of Care: Based on the nursing assessment, preventive measures will be implemented and care planned for residents identified at high risk for falls. Review of Resident #23's medical record revealed in part, Resident #23 was initially admitted to the facility on [DATE] with re-entry on 11/29/2023. Diagnoses, included in part, fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing, anxiety disorder and dementia. Review of Resident #23's Quarterly MDS (Minimum Data Set) dated 03/07/2024 revealed in part, Resident #23 had a BIMS (Brief Interview of Mental Status) score of 11 out of 15 indicating moderately impaired cognition. Review of Resident #23's comprehensive care plan revealed in part, Resident #23 was high risk for falls with interventions including but not limited to, anticipate resident #23's needs, encourage to call for assistance, and ensure landing strips x (times) 2 to each side of bed at all times. Review of Resident #23's Physician's orders revealed an order dated 02/21/2024 which read, Landing strips x 2 to each side of bed at all times, every day. Observation on 06/25/2024 at 11:50 a.m. revealed Resident #23 lying in bed asleep with bed in low position. Further observation failed to reveal landing strips were in place to each side of Resident #23's bed. Observation on 06/26/2024 at 8:40 a.m. revealed Resident #23 asleep in bed with bed in low position. Further observation failed to reveal landing strips were in place to each side of Resident #23's bed. Observation on 06/26/2024 at 10:15 a.m. revealed Resident #23 awake in bed with bed in low position. Further observation revealed Resident #23's landing strips were folded up and sitting in the corner of Resident #23's room. During an interview on 06/26/2024 at 10:15 a.m., S4RN (Registered Nurse) acknowledged bilateral landing strips were not in place at Resident #23's bedside and should be. During an interview on 06/26/2024 at 10:40 a.m., Resident #23's Responsible Party reported upon arrival to Resident #23's room, fall mats were not in place at times and this concerned her.

Based on record reviews, observations, and interviews the facility failed to provide appropriate treatment and services for 3 (#1, #19 and #34) of 3 (#1, #19, and #34) residents reviewed for tube feeding. The facility failed to ensure the tube feeding container was labeled with the time it was started. Findings: Review of the facility's undated Nasogastric/Gastrostomy Tube Feedings policy revealed in part: Essential Points to Remember . 7. Labels should be completed with resident's name, date, start time, initials of nurse and rate. Resident #1 Review of Resident #1's medical record revealed an admit date of 05/10/2023 and diagnoses which included, in part, diffuse traumatic brain injury, dysphagia, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, encounter for attention to gastrostomy. Review of Resident #1's physician's orders revealed, in part: 06/03/2024 Isosource 1.5 at 45 ml (milliliters)/hr (hour) via peg tube continuously per feeding pump. An observation on 06/24/2024 at 9:22 a.m. revealed Resident #1 was receiving Isosource 1.5 at 45 ml/hr. Further observation revealed Resident #1's tube feeding formula label failed to include the time the feeding was started. During an interview on 06/24/2024 at 9:25 a.m. S3 LPN (Licensed Practical Nurse) confirmed Resident #1's tube feeding formula was not labeled with time it was started and should have been. Resident #19 Review of Resident #19's medical record revealed an admit date of 02/14/2014 and diagnoses which included, in part, aphasia, cognitive impairment, diffuse traumatic brain injury, persistent vegetative state, and encounter for attention to gastrostomy. Review of Resident #19's physician's orders revealed, in part: 06/03/2024 Promote with fiber 1.0 at 35ml/hr via peg tube continuously per feeding pump. An observation on 06/24/2024 at 9:13 a.m. revealed Resident #19 was receiving Promote with fiber 1.0 at 35 ml/hr. Further observation revealed Resident #19's tube feeding formula label failed to include the time the feeding was started. During an interview on 06/24/2024 at 9:24 a.m. S3 LPN confirmed Resident #19's tube feeding formula was not labeled with time it was started and should have been. Resident #34 Review of Resident #34's medical record revealed an admit date of 04/04/2022 and diagnoses which included, in part, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, dysphagia following cerebral infarction, and encounter for attention to gastrostomy. Review of Resident #34's physician's orders revealed, in part: 06/03/2024 Isosource 1.5 at 45ml/hr via peg tube continuously per feeding pump. An observation on 06/24/2024 at 9:05 a.m. revealed Resident #34 was receiving Isosource 1.5 at 45 ml/hr. Further observation revealed Resident #34's tube feeding formula label failed to include the time the feeding was started. During an interview on 06/24/2024 at 9:23 a.m. S3 LPN confirmed Resident #34's tube feeding formula was not labeled with time it was started and should have been.

Based on record reviews and interviews the facility failed to ensure 1 (# 62) of 1 resident reviewed for pain management received the treatment and care consistent with professional standards of practice and in accordance with the resident's Comprehensive Plan of Care. The facility failed to perform daily pain assessments including monitoring for worsening of pain symptoms. Findings: Review of resident #62's Comprehensive Plan of Care revealed a potential problem of altered comfort and pain. Intervention start date of 09/03/2021 and remain active for - Assess pain daily using 1-10 scale. Monitor for worsening of pain symptoms and notify physician of changes. Administer pain medication as ordered. Review of resident #62's clinical records revealed diagnoses that include other intervertebral disc degeneration lumbar region, poisoning by unspecified drugs, medicaments and biological substances, accidental (unintentional), initial encounter and chronic pain. Review of resident #62's June 2024 MAR (Medication Administration Record) revealed pain medications were administered on a routine basis, however, the record did not reflect the resident's response to the administration of the pain medication. Further review of resident #62's medical records failed to reveal daily pain assessments were done. Review of resident #62's June 2024 Physician Orders revealed the following orders: 03/15/2023 Hydrocodone-Acetaminophen (controlled drug) oral tablet 10-325 mg (milligram) Give 1 tablet by mouth every 8 hours as needed for pain related to chronic pain syndrome. Do not exceed 4,000 mg APAP (Acetaminophen) in 24 hours. 02/29/2024 Morphine Sulfate (controlled drug) ER (extended release) oral tablet 15 mg. Give 1 tablet by mouth two times a day related to chronic pain syndrome. 03/16/2023 Acetaminophen oral tablet 325 mg. Give 2 tablets by mouth every 4 hours as needed for pain/headache, dose alert (650mg). Do not exceed 4,000 mg APAP in 24 hours. During an interview on 06/24/2024 at 8:40 a.m., resident #62 complained of pain in both arms from exercises during therapy. Resident #62 reported she had been given her routine medications and she was still hurting. Resident #62 reported she would probably not be given anything else for pain and she would talk with her doctor whenever he visited. During an interview 06/26/2024 at 7:57 a.m. S3 LPN (License Practical Nurse) reported resident #62 receives routine pain meds but daily pain assessments were not being done.

Based on observation and interviews the facility failed to ensure the nurse staffing data was posted daily at the beginning of each shift. The facility failed to ensure the nurse staffing data was readily accessible to residents and visitors. The facility had a total census of 114 residents. Findings: Observations of the facility 06/26/2023 at 12:15 p. m. with S2 Corporate Nurse failed to reveal the nursing staffing data report was posted. During an interview on 06/26/2023 at 12:25 p.m. S2 Corporate Nurse reported the nursing staffing data should have been posted and it was not. During an interview on 06/26/2023 at 12:30 p.m. S3 [NAME] Clerk responsible for posting of the nurses staffing data reported she had not posted the nurse staffing data since the move to the new building. During an interview on 06/26/2023 at 12:30 p.m. S1 Assistant Administrator reported the nurse staffing report should have been completed and posted daily by S3 [NAME] Clerk and it was not.