**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to correctly implement Physician's Orders to meet professional standards of quality for 1 (#3) of 16 sampled residents' reviewed for medication administration records. Findings: Review of the facility's policy titled Medication Administration, dated 07/02/2024, revealed the following, in part: Policy: Medications are administered .as ordered by the physician and in accordance with professional standards of practice. Policy explanation and compliance guidelines: 8. Obtain and record vital signs, when applicable or per Physician's Orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. Review of Resident #3's Clinical Record revealed he was admitted to the facility on [DATE] with medical diagnoses, which included Unspecified Atrial Fibrillation, Chronic Combined Systolic (Congestive) and Diastolic (Congestive) Heart Failure, Peripheral Vascular Disease, and Acute Pulmonary Edema. Review of Resident #3's current Physician's Orders revealed the following, in part: Amlodipine Besylate oral tablet, give 10 milligrams by mouth in the morning for blood pressure greater than 140/90 mmHg. Blood pressure parameters: Obtain blood pressure/pulse before giving as needed beta blockers/antihypertensive medications. Hold medication with a systolic blood pressure of 100 mmHg or less. If systolic blood pressure is above 180 mmHg, give medication and call medical doctor to review plan. Hold if pulse is 50 BPM or less and call medical doctor to review plan. Review of Resident #3's December 2024 Medication Administration Record (MAR) revealed the following documentation for the Amlodipine Besylate medication, in part: 12/02/2024- blood pressure 128/62 mmHg, check mark, which indicated medication was administered, S2LPN's initials. 12/03/2024- blood pressure 138/67 mmHg, check mark, which indicated medication was administered, S2LPN's initials. 12/04/2024- blood pressure 134/61 mmHg, check mark, which indicated medication was administered and S2LPN's initials. 12/05/2024- blood pressure 135/62 mmHg, check mark, which indicated medication was administered and S2LPN's initials. An interview was conducted on 12/18/2024 at 1:45 p.m. with S2LPN. S2LPN reviewed Resident #3's December 2024 MAR and confirmed she administered Amlodipine Besylate medication, as indicated by the check marks, to Resident #3 every morning on 12/02/2024 through 12/05/2024. After further review, S2LPN confirmed the blood pressure results dated 12/02/2024 through 12/05/2024 were all less than 140/90 mmHg. S2LPN reviewed Resident #3's current Physician's Order blood pressure parameters, and December 2024 MAR blood pressure parameters for Amlodipine Besylate medication and confirmed Amlodipine Besylate medication should not have been given to Resident #3 every morning on 12/02/2024 through 12/05/2024 with blood pressures less than 140/90 mmHg. She stated when she administered Amlodipine Besylate medication on the previously mentioned dates, she did not notice on Resident #3's December 2024 MAR the parameters to give medication for blood pressure greater than 140/90mmHg. She stated for Resident #3 she was only aware of one order with parameters to hold blood pressure medication for systolic blood pressure less than 100 mmHg, which was the reason she did not hold the medication. An interview was conducted on 12/18/2024 at 2:15 p.m. with S1DON. S1DON reviewed Resident #3's aforementioned December 2024 MAR and current Physician's Orders and confirmed S2LPN gave Amlodipine Besylate medication with blood pressure results less than 140/90 mmHg and should not have. S1DON stated she expected the S2LPN to correctly follow the Resident #3's current physician orders and hold blood pressure medication per physician's parameters.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to follow Enhanced Barrier Precautions (EBP) and proper hand hygiene procedures to prevent the development and transmission of infections by staff for 1 (#7) of 4 (#7, #10, #12, and #15) residents observed for EBP. Findings: Review of the facility's policy titled Enhanced Barrier Precautions, dated 06/06/2024, revealed the following, in part: Policy: It is the policy of this facility to implement EBP for the prevention of transmission of multidrug-resistant organisms. 3. Implementation of EBP b. PPE for EBP is only necessary when performing high-contact care activities . 4. High-contact resident care activities include: g. Device care or use: urinary catheters . Review of Resident #7's clinical record revealed he was admitted to the facility on [DATE] with medical diagnoses which included Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms and Obstructive and Reflux Uropathy. Review of Resident #7's current physician orders revealed the following, in part: Start date: 11/06/2024 Suprapubic Catheter: daily care and cleaning of insertion site with soap and water, apply split gauze dressing. An observation was made on 12/17/2024 at 4:30 p.m. of Resident #7's room. There was a sign on the wall by the door that stated the following, in part: EBP Providers and staff must also: Wear gloves and a gown for the following high-contact resident care activities: Device care An observation was made on 12/17/2024 at 4:31 p.m. of S3LPN providing suprapubic catheter care for Resident #7. S3LPN did not put on a gown prior to providing suprapubic catheter care. After providing catheter care to Resident #7, S3LPN removed her gloves, and with bare hands, she picked up the soiled linens used for the catheter care and placed them in a pile on the resident's chair. S3LPN then removed the wash basin from the bedside table and emptied it into the bathroom sink. S3LPN walked back towards the resident with bare hands and without performing hand hygiene. S3LPN touched the resident's water pitcher, newspapers and pen, and then placed the items on the bedside table, and pushed the bedside table towards the resident. S3LPN grabbed the soiled linens from the chair with her bare hands and placed them in the bathroom soiled linen basket. She then washed her hands with soap and water and exited Resident #7's room. An interview was conducted on 12/17/2024 at 5:01 p.m. with S3LPN. S3LPN confirmed the observations above. She stated she should not have touched the soiled linens with her bare hands after she performed suprapubic catheter care. She confirmed she should have performed hand hygiene after touching the soiled linens and before touching Resident #7's personal belongings. S3LPN further confirmed she was unaware Resident #7 was on EBP and, after reviewing the EBP sign on the wall, stated she should have worn a gown and did not. An interview was conducted on 12/18/2024 at 3:45 p.m. with S1DON. S1DON stated S3LPN told her she did not wear a gown during suprapubic catheter care. She confirmed all nurses had been educated on the EBP policy and she expected them to follow the policy. She further confirmed S3LPN did not use proper hand hygiene after suprapubic catheter care, and should have.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to maintain medical records on each resident that are complete and/or accurately documented. The facility failed to ensure: 1) Suprapubic catheter care and intake and output documentation were completed for 1 (#7) of 1 (#7) residents reviewed for catheter care. 2) Side effects monitored for antidepressant, antianxiety and anticoagulation medication documentation were completed for 1 (#3) of 5 (#3, #6, #13, #15 and #124) residents reviewed for unnecessary medication and medication regimen. Findings: Review of the facility's policy titled Documentation in Medical Record, dated 02/06/2024, revealed the following, in part: Policy Explanation of Compliance Guidelines: 1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. 2. Documentation should be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred. 4. Principles of documentation include, but are not limited to: B. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care. 1. Review of Resident #7's clinical record revealed he was admitted to the facility on [DATE] with medical diagnoses which included Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms and Obstructive and Reflux Uropathy. Review of Resident #7's current physician orders revealed the following, in part: Monitor daily intake and output two times a day. Suprapubic Catheter: daily care and cleaning of insertion site with soap and water, apply split gauze dressing and monitor for pain and skin redness, burning, excoriation, rash, and excoriation in the evening for suprapubic catheter care. Review of Resident #7's November 2024 Treatment Administration Record (TAR) revealed the following documentation, in part: Suprapubic catheter daily care and cleaning of insertion site with soap and water, apply split gauze dressing and monitor for pain and skin redness, burning, excoriation, rash, and excoriation, in the evening for suprapubic catheter care. The boxes for the dates 11/07/2024 and 11/12/2024 were blank. Review of Resident #7's December 2024 Medical Administration Record (MAR) revealed the following documentation, in part: Start Date: 12/04/2024. Monitor daily intake and output every shift. The boxes for the dates 12/04/2024 (night), 12/07/2024 (night), 12/11/2024 (day) and 12/14/2024 (day) were blank. Start Date: 12/14/2024. Monitor daily intake and output 2 times a day. The boxes for the dates 12/15/2024 (night) and 12/17/2024 (night) were blank. Review of Resident #7's November and December 2024 Progress/Nurse's Notes revealed no documentation of suprapubic catheter care or intake and output results. An interview was conducted on 12/17/2024 at 3:40 p.m. with S3LPN. S3LPN stated she worked 11/07/2024 and 11/12/2024 on the night shift and cared for Resident #7. She stated when suprapubic catheter care is completed for residents, the task was expected to be documented on the TAR. After review of Resident #7's November 2024 TAR, S3LPN confirmed the box was blank, which indicated she did not complete suprapubic catheter care documentation on 11/07/2024 and 11/12/2024 and should have. An interview was conducted on 12/18/2024 at 11:22 a.m. with S4LPN via telephone. S4LPN stated she was working the day shift 12/11/2024 and was taking care of Resident #7. She stated resident's intake and output was expected to be documented on the MAR each shift. After S4LPN was notified of Resident #7's December 2024 MAR related to intake and output boxes dated 12/11/2024 were blank on the day shift, she confirmed she forgot to document the intake and output results and should have. She stated she could have documented the intake and output results in the progress notes. An interview was conducted on 12/18/2024 at 11:27 a.m. with S5LPN via telephone. S5LPN stated she was working the night shift on 12/04/2024 and taking care of Resident #7. She stated resident's intake and output was expected to be documented on the MAR each shift. After S5LPN was notified of Resident #7's December 2024 MAR related to intake and output boxes dated 12/04/2024 were blank on the night shift, she confirmed she forgot to document the intake and output results and should have. An interview was conducted on 12/18/2024 at 2:15 p.m. S1DON. S1DON reviewed Resident #7's November 2024 TAR related to suprapubic catheter care dated 11/07/2024 and 11/12/2024 and confirmed the boxes were blank, which indicated no documentation. She further reviewed December 2024 MAR related to intake and output dated 12/04/2024 (night), 12/07/2024 (night), 12/11/2024 (day) and 12/14/2024 (day), 12/15/2024 (night) and 12/17/2024 (night) and she confirmed the boxes were blank, which indicated no documentation. S1DON confirmed she expected the nurses to correctly complete documentation for suprapubic catheter care once every shift and intake and output each shift and they did not. S1DON reviewed Resident #7's November and December 2024 Progress/Nursing notes and confirmed there was no evidence of documentation for suprapubic catheter or intake and output and should have been. 2. Review of Resident #3's clinical record revealed he was admitted to the facility on [DATE] with medical diagnoses which included Depression, Unspecified, Anxiety Disorder, Unspecified and Unspecified Atrial Fibrillation. Review of Resident #3's current physician orders revealed the following, in part: Eliquis Oral Tablet 2.5mg, give 1 tablet by mouth two times a day for Anticoagulant. Buspirone HCl Oral Tablet, give 7.5mg by mouth three times a day for Anxiety. Xanax oral tablet 0.5mg, give 0.5mg by mouth every 6 hours as needed for Anxiety. Zoloft oral tablet (sertraline HCI), give 25mg by mouth in the morning for Depression. Review of Resident #3's September 2024 Treatment Administration Record (TAR) revealed the following, in part: Monitor for Side effects of antidepressant (N/V, Headache, dizziness, restlessness, insomnia, and constipation) two times a day 'Y' if no side effects noted, 'N' if side effects noted make progress note notify MD. The dates 09/16/2024, 09/25/2024 and 09/26/2024 for the evening shift boxes were blank. Anticoagulant medication- monitor for discolored urine, black tarry stools, sudden severe headache, nausea and vomiting, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status and or vital signs, sob, nose bleeds. Document: 'Y' if monitored and none of the above observed. 'N' if monitored and any of the above was observed, select chart code 'Other/See Nurses Notes' and progress notes findings every shift. The dates 09/16/2024, 09/25/2024 and 09/26/2024 for the evening shift boxes were blank. Antianxiety medication- monitor for drowsiness, slurred speech, dizziness, nausea, aggressive/impulsive behavior. Document: 'Y' if monitored and none of the above observed. 'N' if monitored and any of the above was observed, select chart code 'Other/See Nurses Notes' and progress note findings two times a day Y if not side effects, N if side effects noted, make progress note notify MD. The dates 09/16/2024, 09/25/2024 and 09/26/2024 for the evening shift boxes were blank. Review of Resident #3's September 2024 Progress/Nurse's Notes revealed no documentation of side effects monitored for antidepressant, antianxiety and anticoagulation medication. An interview was conducted on 12/17/2024 at 3:40 p.m. with S3LPN. S3LPN stated she worked 09/16/2024 on the night shift and cared for Resident #3. She stated Resident #3 was monitored for side effects related to antidepressant, antianxiety and anticoagulation medication and was expected to be documented on the TAR. After review of the September 2024 TAR, S3LPN confirmed she did not complete side effect documentation on 09/16/2024 and should have. An interview was conducted on 12/18/2024 at 1:45 p.m. with S2LPN. S2LPN stated she worked 09/26/2024 on the night shift and cared for Resident #3. She stated Resident #3 was monitored for side effects related to antidepressant, antianxiety and anticoagulation medication and was expected to be documented on the TAR. After review of the September 2024 TAR, S2LPN confirmed she did not complete side effect documentation on 09/26/2024 and should have. An interview was conducted on 12/18/2024 at 2:15 p.m. S1DON. S1DON reviewed the September 2024 MAR side effects monitored for antidepressant, antianxiety and anticoagulation medication and confirmed the boxes on 09/16/2024, 09/25/2024 and 09/26/2024 were blank, which indicated no documentation. She confirmed she expected the nurses to correctly complete documentation for the monitored side effects related to medication on each shift and did not. S1DON further reviewed the September 2024 Progress/Nursing notes and confirmed there was no evidence of side effect documentation related to antidepressant, antianxiety and anticoagulation medication.

Based on observations, record review, and interviews, the facility failed to ensure medications were properly stored in 1 (Med Cart 1) of 2 (Med Cart 1 and Med Cart 2) Medication Carts observed for medication storage. Findings: Review of the facility's policy titled, Medication Storage revealed in part, the following: 6. Refrigerated Products: a. All medications requiring refrigeration are stored in refrigerators located in the medication room. An observation was made on 12/18/2023 at 9:10 a.m. of Med Cart 1 with S4LPN. One bottle of Lorazepam Concentrate 2mg/mL for Resident #79 was observed in the narcotic lock box drawer of the medication cart at room temperature. The Lorazepam Concentrate bottle revealed a label which read Refrigerate. An interview was conducted on 12/18/2023 at 9:10 a.m. with S4LPN. S4LPN confirmed the label on Resident #79's bottle of Lorazepam Concentrate read Refrigerate and should have been placed back into the medication room refrigerator after administration. S4LPN confirmed the bottle of Lorazepam Concentrate was room temperature. S4LPN stated she was unsure how long the Lorazepam Concentrate was stored in the medication care, and Resident #79 last received a dose of Lorazepam Concentrate on 12/13/2023. An interview was conducted on 12/18/2023 at 1:20 p.m. with the facility's Pharmacist. He confirmed Lorazepam Concentrate should be stored in the medication room refrigerator after each use. He stated Lorazepam Concentrate should not be left out of the refrigerator for long periods of time. He stated if Lorazepam Concentrate remained at room temperature for long periods of time, the effectiveness of the medication greatly decreased. An interview was conducted on 12/18/2023 at 1:24 p.m. with S2DON. S2DON confirmed all medications requiring refrigeration, as indicated on the label of the medication, should be returned back into the medication room refrigerator after administration. S2DON provided a medication pamphlet for Lorazepam Concentrate which indicated the medication should have been stored at a cold temperature from 36 degrees Fahrenheit to 46 degrees Fahrenheit S2DON confirmed Resident #79's Lorazepam Concentrate was not stored at the proper temperature and should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure residents understood the binding arbitration agreement signed on admission for 3 (#21, #77, and #177) of 3 (#21, #77, and #177) residents reviewed for arbitration. All 24 residents who currently resided in the facility had binding arbitration agreement. Findings: Review of the facility's form titled admission Agreement on page 9 of 11 revealed an arbitration agreement was included in the admission Agreement with no option for declination. This agreement revealed in part, the following: Section 8.2 Arbitration. Any dispute, claim or controversy of any kind between you and us arising out of, in connection with, or relating to this Skilled Nursing Facility admission Agreement and any amendment hereof, or the breach hereof, which cannot be resolved by you or us to small claims court for disputes or claims within the scope of its jurisdiction or determined by arbitration in [NAME], LA in accordance with the then-current commercial arbitration rules of the Federal Arbitration Act, and the arbitrator will be required to render a decision adopting, in full, either one or the other of such proposed resolutions on a per issue basis, and no compromises or alternative resolutions shall be allowed or considered. Resident #21 Review of the clinical record revealed Resident #21 was admitted to the facility on [DATE]. Further review revealed Resident #21 was their own responsible party. Review of Resident #21's record revealed a form titled, admission Agreement. The admission Agreement form was dated and signed by Resident #21 and the S3AC on 09/03/2021. Further review revealed a binding arbitration agreement was included with no option for declination. An interview was conducted on 12/18/2023 at 12:28 p.m. with Resident #21. She stated she was not educated by the facility on what an arbitration agreement was prior to signing the admission agreement. She stated she would not have signed the arbitration agreement had she been educated on what it meant. Resident #77 Review of the clinical record revealed Resident #77 was admitted to the facility on [DATE]. Further review revealed Resident #77 was their own responsible party. Review of Resident #77's record revealed a form titled, admission Agreement. The admission Agreement form was dated and signed by Resident #77 and S3AC on 12/14/2023. Further review revealed a binding arbitration agreement was included with no option for declination. An interview was conducted on 12/18/2023 at 12:48 p.m. with Resident #77. Resident #77 was able to answer questions appropriately and was alert and oriented. She stated she was not educated by the facility on what an arbitration agreement was prior to signing the admission agreement. She stated she would not have signed the arbitration agreement had she been educated on what it meant. Resident #177 Review of the clinical record revealed Resident #177 was admitted to the facility on [DATE]. Further review revealed Resident #177 had a designated RP as their responsible party. Review of Resident #177's record revealed a form titled, admission Agreement. The admission Agreement form was dated and signed by Resident #177's RP and S3AC on 12/15/2023. Further review revealed a binding arbitration agreement was included with no option for declination. An interview was conducted on 12/18/2023 at 12:50 p.m. with Resident #177's RP. He stated he was not educated by the facility on what an arbitration agreement was prior to signing the admission agreement. He stated he would not have signed the arbitration agreement had he been educated on what it meant. An interview was conducted on 12/18/2023 at 12:09 p.m. with S3AC. She reviewed Resident #21, #77, and #177's signed admission Agreements and confirmed all 3 residents agreements included an arbitration agreement. She stated she did not know the admission Agreement included an arbitration agreement. S3AC reviewed all 24 residents' admission Agreement and confirmed all 24 had signed arbitration agreements included. She confirmed all 24 residents, who currently resided in the facility, had signed a binding arbitration agreement when they signed the admission Agreement. She confirmed none of the 24 residents or their RPs had been educated on what an arbitration agreement was. She stated she was responsible for educating the residents and RPs of the admission agreement upon admission. She stated she should have educated them on what an arbitration agreement was and did not. She confirmed the admission Agreement form had not been changed in many years and currently included arbitration agreements for new admissions. An interview was conducted on 12/18/2023 at 1:09 p.m. with S1ADM. He stated he did not know there was an arbitration agreement included in the admission Agreement form. He confirmed all 24 residents on the census had signed a binding arbitration agreement and were not educated on what an arbitration agreement was.