Based on record reviews and interviews the facility failed to ensure residents and/or residents' RP (Responsible Party) were informed of the risks, benefits and side effects of psychotropic/antipsychotic medications for 3 (#4, #5 and #7) of 5 (#3, #4, #5, #7 and #160) residents reviewed for unnecessary medications. Findings: Resident #4 Review of Resident #4's medical record revealed an admission date of 03/28/2025 with diagnoses which included metabolic encephalopathy and anxiety disorder. Review of Resident #4's physician orders revealed Resident #4 received the psychotropic medication Vistaril 25 mg (milligram) po (by mouth) q (every) 6 hours prn (as needed) for anxiety. Further review of Resident #4's medical record failed to reveal documentation of a consent for the use of psychotropic medication. During an interview on 06/18/2025 at10:40 a.m., S5Skilled Unit Manager acknowledged Resident #4 did not have a consent in place for the use of Vistaril and should have. Resident #5 Review of Resident 5's medical record revealed an admission date of 06/03/2025 with diagnoses which included unspecified dementia, major depressive disorder and anxiety disorder. Review of Resident #5's physician orders revealed Resident #5 received the antipsychotic medication Zyprexa 5 mg po q hs (hour of sleep). Further review of Resident #5's medical record failed to reveal documentation of a consent for the use of antipsychotic medication. During an interview on 06/17/2025 at 2:10 p.m., S2DON (Director of Nursing) acknowledged Resident #5 did not have a consent in place for the use of Zyprexa and should have. During an interview on 06/18/2025 at 8:43 a.m., S2DON confirmed Resident #5 and/or RP had not been provided education in advance on the risks and benefits of taking Zyprexa. Resident #7 Review of Resident 7's medical record revealed an admission date of 04/02/2025 with diagnoses which included type 2 diabetes and anxiety disorder. Review of Resident #7's physician orders revealed Resident #7 received the psychotropic medication Lexapro 10 mg po q day for anxiety disorder. Further review of Resident #7's medical record failed to reveal documentation of a consent for the use of psychotropic medication. During an interview on 06/18/2025 at 8:43 a.m., S2DON confirmed Resident #7 and/or RP had not been provided education in advance on the risks and benefits of taking Lexapro. S2DON further confirmed a consent had not been obtained upon admission to the skilled unit and should have been.

Based on record reviews and interview the facility failed to ensure residents were provided information regarding formulation of an Advance Directive upon their admission for 5 (#3, #4, #5, #7 and #60) of 6 initial pool residents. Findings: Resident #3 Review of Resident #3's medical record revealed an admission date of 03/27/2025. Review of Resident #3's medical record failed to reveal documentation that Resident #3 and/or Resident #3's representative received information regarding advance directives. Resident #4 Review of Resident #4's medical record revealed an admission date of 03/28/2025. Review of Resident #4's medical record failed to reveal documentation that Resident #4 and/or Resident #4's representative received information regarding advance directives. Resident #5 Review of Resident #5's medical record revealed an admission date of 06/23/2025. Review of Resident #5's medical record failed to reveal documentation that Resident #5 and/or Resident #5's representative received information regarding advance directives. Resident #7 Review of Resident #7's medical record revealed an admission date of 04/02/2025. Review of Resident #7's medical record failed to reveal documentation that Resident #7 and/or Resident #7's representative received information regarding advance directives. Resident #60 Review of Resident 60's medical record revealed an admission date of 06/07/2025. Review of Resident #60's medical record failed to reveal documentation that Resident #60 and/or Resident #60's representative received information regarding advance directives. During an interview on 06/17/2025 at 3:00 p.m., S4Assistant Administrator acknowledged Residents #3, #4, #5, #7 and #60 were not provided written information regarding the formulation of an Advance Directive and should have been.

Based on record review and interviews, the facility failed to ensure a resident with an order for psychotropic medication as needed (PRN) was not subjected to chemical restraints for 1 (#4) of 5 (#3, #4, #5, #7 and #160) residents reviewed for unnecessary medications. The facility failed to ensure Resident #4's PRN order for psychotropic medication was limited to 14 days. Findings: Review of Resident #4's medical record revealed an admission date of 03/28/2025 with diagnoses which included metabolic encephalopathy and anxiety disorder. Review of Resident #4's physician orders revealed an order dated 03/31/2025 for Vistaril (a medication used to treat the symptoms of anxiety) 25 mg (milligram) po (by mouth) q (every) 6 hours prn for anxiety without a stop date. Review of Resident #4's June 2025 MAR (Medication Administration Record) revealed in part, Resident #4 received Vistaril on 06/01/2025 at 7:57 a.m., 06/05/2025 at 7:51 a.m., 06/06/2025 at 3:50 p.m., 06/10/2025 at 5:57 p.m. and 06/14/2025 at 5:43 p.m. During an interview on 06/18/2025 at 9:00 a.m., S5Skilled Unit Manager acknowledged Resident #4 had an order in place for prn Vistaril which did not have a stop date. During an interview on 06/18/2025 at 9:30 a.m., S2DON (Director of Nursing) acknowledged Resident #4 had an order for prn Vistaril for anxiety greater than 14 days and did not have a stop date.

Based on record review, observations, and interview, the facility failed to ensure correct use and maintenance of bed rails by ensuring residents were assessed for the risk of entrapment from bed rails, and failing to obtain an informed consent from resident or resident representative prior to installation for 1 (#60) out of 1 (#60) resident reviewed for accidents. Findings: Review of the facility's Restraint Policy with a revision date of 06/2024 revealed the following: 3. Residents must be assessed for use of appropriate restraint/safety device to meet their particular needs. An assessment of the use of bed rails may also be needed if half, three-quarter, or full bedrails are being used. Enablers such as rails may be used for aiding in turning and repositioning, assisting with transfers and providing a feeling of comfort and security for the resident. The side rails should not limit the resident's movement in and out of bed. Review of Resident #60's medical record revealed an admit date of 06/07/2025 with diagnoses of but not limited to generalized anxiety disorder, muscle weakness, repeated falls, essential hypertension, gastric reflux disease, dementia, dysphagia, anemia, age-related physical debility, and history of fracture of right femur. Observation on 06/16/2025 at 8:30 a.m. revealed Resident #60 in bed with side rails raised at head of bed. Observation on 06/17/2025 at 1:00 p.m. revealed Resident #60 in bed with side rails up at the head of bed. Review of Resident #60's MDS (minimum data set) dated 06/06/2025 revealed Resident #60 had a BIMS (brief interview mental status) score of 5 indicating severely impaired cognition. Review of Resident #60's medical record failed to reveal an assessment for risk of entrapment from bed rails and a signed consent for bed rails prior to installation had been done. During an interview on 06/18/2025 at 10:00 a.m. S5 Skilled Unit Manager confirmed Resident #60 had side rails in use and did not have an assessment for risk of entrapment and a signed consent for side rail use prior to bed installation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure a Physician/Nurse Practitioner (NP) or Resident Representative was notified after a resident had an in-house code and was transferred to the emergency room (ER) for 1 (Resident #1) of 3 (Resident #1, #2, and #3) sampled residents. Findings: Review of the facility's LDVA (Louisiana Department of Veteran Affairs) Veteran and Resident Manual dated 10/07/2022 revealed in part: I. Notification of changes: i. facility management must immediately inform the veteran's/resident's legal representative or an interested family member when there is: b. a significant change in the veteran's/resident's physical, mental, or psychosocial status (e.g. (for example), a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications); d. a decision to transfer or discharge the veteran/resident from the facility. Review of Resident #1's Medical Record revealed an admit date of 01/22/2024 with the following diagnoses, in part: acute respiratory failure with hypoxia, type 2 diabetes, major depressive disorder, anxiety disorder, pancreatic mass, and other pulmonary embolism. Review of Resident #1's Medical Record failed to reveal a Physician/NP or Resident Representative had been notified of Resident #1's in-house code and transfer to ER on [DATE]. During a telephone interview on 04/09/2024 at 2:00 p.m., Resident #1's Representative reported family was not notified Resident #1 coded and was sent to ER on [DATE]. During an interview on 04/09/2024 at 4:45 p.m., S3ADON (Assistant Director of Nursing), acknowledged the facility had not notified Resident #1's Representative of the code and transfer to ER and should have. During an interview on 04/11/2024 at 8:00 a.m., S2DON (Director of Nursing) verified documentation of notification of change could not be located in Resident #1's Medical Record. S2DON acknowledged Resident #1's Representative and Physician/NP should have been notified. During an interview on 04/11/2024 at 9:00 a.m., S1Administrator acknowledged Resident #1's Representative or Physician had not been notified of the change in condition and should have been notified. During an interview on 04/11/2024 at 2:15 p.m., S5NP could not confirm she had been notified of Resident #1 having been transferred to the ER on [DATE].

Based on record reviews and interviews, the facility failed to ensure services provided by the facility met professional standards of quality. The facility failed to ensure Nursing staff accurately documented glucose checks for 1 (Resident #1) of 3 (Resident #1, #2, and #3) sampled residents. Findings: Review of the facility's Blood Glucose Monitoring policy with a revision date of 05/11/2023 revealed in part: I. Purpose: to provide a policy for accurate and timely monitoring of blood glucose levels. F. Blood Sugar Testing: Document results on the Medication Administration Record (MAR) . Review of Resident #1's Medical Record revealed an admit date of 01/22/2024 with the following diagnoses, in part: acute respiratory failure with hypoxia, type 2 diabetes, major depressive disorder, anxiety disorder, pancreatic mass, and other pulmonary embolism. Review of Resident #1's Physician orders revealed an order dated 01/23/2024, which read in part: Humulin R to house sliding scale bid (two times a day) - blood glucose finger stick: 200 - 250 = 2 units; 251 - 300 = 4 units; 301- 350 = 6 units; 351- 400 = 9 units . Review of Resident #1's MAR failed to reveal documentation of Resident #1's blood glucose levels ordered for 01/24/2024 at 4:00 p.m. and 01/25/2024 at 6:00 a.m. Review of Resident #1's Medical Record revealed a nurse's note by S3ADON (Assistant Director of Nursing) dated 01/25/2024 at 4:36 p.m., which read in part: S3ADON called to room for unresponsive resident (Resident #1). Respirations very shallow with agonal breathing and pulse very weak . Blood Sugar 404 . During an interview on 04/11/2024 at 2:15 p.m., S5NP (Nurse Practitioner) reported blood glucose levels should be documented on the resident's MAR each time the glucose is checked in order to track and trend a resident's blood sugar. During an interview on 04/11/2024 at 2:30 p.m., S2DON (Director of Nursing) confirmed she could not locate documentation of Resident #1's blood glucose levels ordered for 01/24/2024 at 4:00 p.m. and 01/25/2024 at 6:00 a.m. S2DON acknowledged blood sugar levels should be documented on the resident's MAR. S2DON confirmed if the blood sugar levels were not documented on the MAR there would be no way for the NP to evaluate Resident #1's blood sugars.