**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure a resident with a new identified mental health diagnoses was referred for a Pre-admission Screening and Resident Review (PASARR) Level II evaluation as required for 1 (Resident #60) of 2 (Resident #9 and Resident #60) sampled residents reviewed for PASARR. Findings: Review of Resident #60's electronic medical record (EMR) revealed, in part, Resident #60 was admitted to the facility on [DATE] with a Level I PASARR. Further review revealed Resident #60 was diagnosed with Major Depressive Disorder (MDD) on 11/15/2021 and Delusional Disorder on 02/10/2023. Review of Resident #60's EMR revealed there was no documented evidence, and the facility did not present any documented evidence, of a Level II PASARR being completed for Resident #60. In an interview on 10/15/2024 at 1:26 p.m., S4Social Worker indicated she had never completed an evaluation for a Level II PASARR. S4Social Worker further confirmed she had not completed an evaluation for Resident #60's Level II PASARR following his diagnoses of MDD and Delusional Disorder, as required. In an interview on 10/16/2024 at 10:51 a.m., S4Social Worker indicated she called the Office of Aging and Adult Services and they confirmed that an evaluation for a Level II PASARR was required for Resident #60, due to his diagnoses of MDD and Delusional Disorder.

Based on record reviews and interviews, the facility failed to ensure a Level II Pre-admission Screening and Resident Review (PASARR) was completed to reflect a resident's diagnosis of mental illness for 1 (Resident #9) of 2 (Resident #9 and Resident #60) sampled residents reviewed for PASARR. Findings: Review of Resident #9's medical records revealed, in part, an admit date of 12/28/2023 with the diagnoses of Major Depressive Disorder (MDD) and Post Traumatic Stress (PTSD). Review of Resident # 9's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/04/2024 revealed, in part, Resident #9 had diagnoses of MDD and PTSD. Review of Resident #9's Level 1 PASARR assessment completed on 06/12/2023 revealed, in part, Resident #9 had no documentation of a mental illness diagnosis. Review of Resident #9's medical records revealed, in part, no referral was made to the appropriate state-designated authority for Level II PASARR evaluation and determination based on Resident #9's diagnoses of MDD and PTSD. Further review revealed there was no documented evidence, and the facility did not present any documented evidence, of a completed Level II PASARR. In an interview on 10/09/2024 at 10:39 a.m., S4Social Worker confirmed that based on Resident #9's diagnoses of MDD and PTSD, a referral to the appropriate authority for a Level II PASARR should have been completed, as required.

Based on record review, observation, and interviews the facility failed to ensure privacy was provided for 1 (Resident #32) of 1 (Resident #32) residents observed during catheter (a medical device that drains urine from the bladder) care. Findings: Review of Resident #32's medical records revealed, in part, an admit date of 09/15/2021. Review of Resident #32's October 2024 physician's orders revealed, in part, an order to change the suprapubic catheter dressing daily and as needed. Observation on 10/15/2024 at 1:50 p.m. revealed S5Wound Care Nurse (WCN) entered Resident #32's room to perform catheter care. Further observation revealed Resident #32's door and bedside curtain remained opened, exposing Resident #32 to the hallway while Resident #32 received catheter care from S5WCN. In an interview on 10/15/2024 at 1:58 p.m., S5WCN indicated she did not pull the curtain or close the door prior to providing catheter care to Resident #32. S5WCN further indicated due to Resident #32's door and privacy curtain remaining open during catheter care Resident #32 was exposed to anyone that would have passed by in the hallway, and he should not have been. In an interview on 10/15/2024 at 4:14 p.m., S2Director of Nursing/Infection Preventionist indicated Resident #32's privacy should have been maintained when S5WCN provided Resident #32 catheter care.

Based on record reviews and interviews, the facility failed to ensure an alleged incident of resident to resident verbal and/or physical abuse was reported to the State Survey Agency for 2 (Resident #2 and Resident #440) of 3 (Resident #2, Resident #61, and Resident #440) sampled residents investigated for abuse. Findings: Review of the facility's policy titled Reporting of Resident Abuse or Neglect - Statewide Incident Management System Reporting dated 01/10/2024 revealed, in part, the facility's policy is to provide an environment free from abuse. Further review revealed the definition of verbal abuse was any use of oral language that included disparaging (an opinion of little worth) and derogatory terms to the resident. Further review revealed the definition of physical abuse included hitting, slapping, pinching, and kicking an individual. Further review revealed all incidents of alleged abuse must be reported immediately to the Administrator, the Director of Nursing and the respective Department Head. Further review revealed reports of abuse will be reported to Health Standard within 2 hours of receiving a report of abuse. Resident #2 Review of Resident #2's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/17/2024 revealed, in part, Resident #2 had a Brief Interview of Mental Status (BIMS) score of 12 which indicated moderate cognitive impairment. Review of the facility's accident/incident report log dated 04/15/2024 through 10/14/2025 revealed, in part, Resident #2 had a documented incident of physical aggression received on 07/21/2024. Review of Resident #2's Risk for Harm care plan initiated on 07/21/2024 revealed, in part, Resident #2 was the recipient of physical aggression on 07/21/2024. Review of the Daily Quality Assurance Meeting Agenda dated 07/22/2024 revealed, in part, Resident #440 and Resident #2 had verbal interactions in the dining room and then Resident #440 threw coffee at Resident #2. Further review revealed no injuries were noted and no further follow-up was initiated at that time. In an interview on 10/15/2024 at 2:35 p.m., S2Director of Nursing/Infection Preventionist (DON/IP) indicated Resident #2's incident on 07/21/2024 was discussed during morning meeting and it was determined the incident, was only an interaction between Resident #2 and Resident #440. In an interview on 10/15/2024 at 3:22 p.m., S1Administrator indicated on 07/21/2024 Resident #2 and Resident #440 did not have a physical interaction with each other, that it was a verbal disagreement and Resident #440 threw coffee on Resident #2. Resident #440 Review of Resident #440's medical records revealed, in part, Resident #440 had an admit date of 02/09/2023 with diagnoses, in part, Major Depressive Disorder, Anxiety, and Bipolar Disorder with Psychotic features. Review of Resident #440's MDS with an ARD of 07/10/2024 revealed, in part, Resident #440 had a BIMS score of 12 which indicated moderate cognitive impairment. Review of Resident #440's care plan revealed, in part, Resident #440 had the potential to be physically/verbally aggressive to others. Review of facility's incident/accident report log dated 04/15/2024 through 10/14/2025 revealed, in part, Resident #440 had a documented incident of behavior on 07/21/2024 and physical aggression received on 09/03/2024. Review of Resident #440's nurse's note dated 07/21/2024 revealed, in part, Resident #440 was observed throwing coffee on another resident and S2DON/IP was notified of the incident. Review of Resident #440's nurse's note dated 09/03/2024 revealed, in part, Resident #440 had a verbal and physical altercation with an unidentified resident. Further review revealed Resident #440 was observed yelling racial slurs and cursing at an unidentified resident. Resident #440 attempted to hit the unidentified resident and fell to the ground. Further review revealed the unidentified resident began to hit Resident #440 while Resident #440 was on the ground. Record review revealed no documented evidence, and the facility presented no documented evidence the above mentioned incidents were reported to the State Survey Agency as required. In an interview on 10/16/2024 at 3:58 p.m., S2DON/IP indicated Resident #440's incident on 07/21/2024 was not reported to the State Survey Agency because the incident was documented as a behavior on the accident/incident log, and no further action was needed. S2DON/IP further indicated Resident #440's incident on 09/03/2024 was not reported to the State Survey Agency because Resident #440 only had a fall and no further action was needed. In an interview on 10/16/2024 2:15 p.m., S1Administrator indicated the above mentioned incidents on 07/21/2024 and 09/03/2024 were altercations between residents; and because the incidents did not involve staff the incidents did not meet the definition of physical and/or verbal abuse. S1Administrator confirmed the above mentioned incidents were not reported to the State Survey Agency as required.

Based on record reviews and interviews, the facility failed to ensure an alleged incident of resident to resident verbal and/or physical abuse was thoroughly investigated for 2 (Resident #2 and Resident #440) of 3 (Resident #2, Resident #61, and Resident #440) sampled residents investigated for abuse. Findings: Review of the facility's Reporting of Resident Abuse or Neglect - Statewide Incident Management System Reporting policy dated 01/10/2024 revealed, in part, the facility's policy was to provide an environment free from abuse. Further review revealed the definition of verbal abuse was any use of oral language that included disparaging (an opinion of little worth) and derogatory terms to the resident. Further review revealed the definition of physical abuse included hitting, slapping, pinching, and kicking an individual. Further review also revealed all incidents of alleged abuse must be reported immediately to the Administrator, the Director of Nursing and the respective Department Head. Review revealed the facility's policy was to provide timely and thorough investigations of all reports and allegations of abuse. Resident #2 Review of Resident #2's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/17/2024 revealed, in part, Resident #2 had a Brief Interview of Mental Status (BIMS) score of 12, which indicated Resident #2 had moderate cognitive impairment. Review of the facility's Accident and Incident report log dated 04/15/2024 through 10/14/2025 revealed, in part, Resident #2 had a documented incident of physical aggression received on 07/21/2024. Review of Resident #2's nurse notes revealed no documented evidence an incident of physical aggression occurred on 07/21/2024. Review of Resident #2's Risk for Harm care plan initiated on 07/21/2024 revealed, in part, Resident #2 was the recipient of physical aggression on 07/21/2024. In an interview on 10/15/2024 at 2:35 p.m., S2Director of Nursing/Infection Preventionist (DON/IP) stated Resident #2's incident on 07/21/2024 was discussed during morning meeting, and it was determined Resident #2's incident was only an interaction between Resident #2 and Resident #440. Resident #440 Review of Resident #440's MDS with an ARD of 07/10/2024 revealed, in part, Resident #440 had a BIMS score of 12, which indicated Resident #440 had moderate cognitive impairment. Review of facility's Incident and Accident log dated 04/15/2024 through 10/14/2025 revealed, in part, Resident #440 had a documented behavior incident on 07/21/2024. Review of Resident #440's Potential for Physical Aggression care plan initiated on 07/04/2024 and revised on 07/22/2024 revealed, in part, on 07/21/2024 Resident #440 threw coffee on another resident. Review of Resident #440's Nurse's Note dated 07/21/2024 revealed, in part, Resident #440 was observed throwing coffee on another resident. Further review revealed S2DON/IP was notified that Resident #440 threw coffee on another resident. Review of the Daily Quality Assurance Meeting Agenda dated 07/22/2024 revealed, in part, Resident #440 and Resident #2 had verbal interactions in the dining room, and Resident #440 threw coffee on Resident #2. Further review revealed no injuries were noted and no further follow-up was initiated at that time. In an interview on 10/16/2024 at 9:49 a.m., S6MDS Nurse indicated staff reported Resident #440 threw coffee on Resident #2 on 07/21/2024. S6MDS Nurse further indicated she documented the incident on Resident #440's care plan. In an interview on 10/16/2024 at 3:58 p.m., S2DON/IP indicated the incident on 07/21/2024 involving Resident #2 and Resident #440 was not investigated as an allegation of resident to resident abuse because it was only Resident #440's behavior. S2DON/IP indicated after reviewing Resident #440's nurse's note dated 07/21/2024 with documentation of Resident #440 throwing coffee on another resident, staff decided no further action was needed. There was no documented evidence, and the provider did not present any documented evidence that an investigation was completed for 07/21/2024 incident where Resident #440 threw coffee onto Resident #2. Review of facility's Incident and Accident log dated 04/15/2024 through 10/14/2025 revealed, in part, Resident #440 had was the recipient of physical aggression on 09/03/2024. Review of Resident #440's Nurse's Note dated 09/03/2024 revealed, in part, Resident #440 had a verbal and physical altercation with an unidentified resident. Further review revealed Resident #440 was observed yelling racial slurs and cursing at the unidentified resident. Resident #440 fell to the ground while attempting to hit the unidentified resident. Further review revealed the unidentified resident then began to hit Resident #440 while still Resident #440 was still on the ground from the fall. Review revealed documentation that supervisors were notified of the alleged resident to resident verbal and physical abuse on 09/03/2024. In an interview on 10/16/2024 at 9:50 a.m., S6MDS Nurse confirmed Resident #440 had a verbal and physical altercation with unidentified resident on 09/03/2024. S6MDS Nurse indicated she documented the incident as an altercation with another resident on Resident #440's care plan. In an interview on 10/16/2024 at 3:58 p.m., S2DON/IP indicated Resident #440's incident on 09/03/2024 was just a fall. After reviewing Resident #440's above mentioned Nurse's Note from 09/03/2024, S2DON/IP denied Resident #440's incident on 09/03/2024 involved verbal and/or physical abuse. In an interview on 10/16/2024 2:15 p.m., S1Administrator indicated the above mentioned incidents on 07/21/2024 and 09/03/2024 were altercations between residents. S1Administrator further indicated because the above mentioned incidents did not involve staff, the above mentioned incidents did not meet the definition of physical and/or verbal abuse. S1Administrator indicated the facility had no other documentation for the above mentioned incidents to present to the survey team. S1Administrator further indicated the facility did not have any documentation of an investigation having been completed such as written statements or interviews with staff for the above mentioned incidents as required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to maintain an effective infection control program in order to prevent the transmission of communicable diseases and infections as evidence by failing to ensure: 1. a resident's infection causing organism was included as part of the facility's infection control surveillance; 2. a Certified Nursing Assistant (CNA) did not use gloves stored in her pockets for catheter (a medical device that drains the bladder) care for 1 (Resident #32) of 1 (Resident #32) residents observed for catheter care; and, 3. staff provided wound care in a sanitary manner for 1 (Resident #12) of 1(Resident #12) residents observed for wound care. Findings: 1. Review of the facility's June 2024 infection tracking and trending documentation revealed no documented evidence that the infection causing organism was included in the facility's infection surveillance. Review of the facility's July 2024 infection tracking and trending documentation revealed no documented evidence that the infection causing organism was included in the facility's infection surveillance. Review of the facility's August 2024 infection tracking and trending documentation revealed no documented evidence that the infection causing organism was included in the facility's infection surveillance. Review of the facility's September 2024 infection tracking and trending documentation revealed no documented evidence that the infection causing organism was included in the facility's infection surveillance. In an interview on 10/15/2024 at 2:48 p.m., S2Director of Nursing/Infection Preventionist (DON/IP) confirmed the facility's infection tracking and trending did not include the infection causing organism in each resident's infection when applicable. In an interview on 10/15/2024 at 3:18 p.m., S2DON/IP indicated a resident's infection causing organism would be located in the resident's chart, but it was not part of the facility's infection surveillance. 2. Review of Resident #32's Electronic Medical Record (EMR) revealed, in part, he was admitted to the facility on [DATE] with a diagnoses of tubule-interstitial nephritis (inflammation of the kidney tubes). Review of Resident #32's MDS (Minimum Data Sheet) with an ARD (Assessment Reference Date) of 09/27/2024 revealed, in part, he required substantial/maximal assistance for personal hygiene. Review of Resident #32's October 2024 physician's orders revealed, in part, an order for catheter care every shift. Further review revealed Resident #32 had an order for Macrobid (a medication used to treat urinary tract infections) 100 mg capsule, give 1 capsule daily as a prophylactic for urinary tract infection (UTI). Review of Resident #32's care plan revealed, in part, Resident #32 had a UTI related to the use of an indwelling catheter that was initiated on 09/24/2024. Further review revealed Resident #32 had a goal to have the UTI resolved without complications, with an intervention for suprapubic catheter care every shift, by the target date of 12/31/2024. Observation on 10/15/2024 at 1:36 p.m., revealed S7CNA washed her hands with soap and water and then put on a gown. Observation further revealed S7CNA pulled one pair of gloves out of her uniform pocket and put the gloves on her hands. Observation further revealed S7CNA cleansed Resident #32's suprapubic catheter insertion site while wearing the gloves she removed from her uniform pocket. In an interview on 10/15/2024 at 1:42 p.m., S7CNA confirmed she used the gloves in her pocket to perform catheter care, and she should not have. In an interview on 10/15/2024 at 4:12 p.m., S2DON/IP indicated she did not see a problem with using gloves that were in your pockets. 3. Review of Resident #12's Electronic Medical Record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses, in part, of Pressure Ulcer of the Sacral Region, Stage 4. Review of October 2024's physician's orders revealed, in part, to cleanse Resident #12's sacral wound with wound cleanser, pat dry, apply zinc oxide, then apply calcium alginate, and apply a clean dry dressing every day and as needed. Observation on 10/15/2024 at 10:10 a.m. revealed S5LPN's put on a clean pair of gloves and her waist length hair touched her wrist and touched her gloves. Further observation revealed S5LPN performed wound care to Resident #12's wound while wearing the above mentioned gloves. In an interview on 10/15/2024 at 10:11 a.m., S5LPN acknowledged her long hair should have been contained or pulled back prior to performing wound care.

Based on record review and interview, the facility failed to maintain a system for the provision of feedback reports on antibiotic usage, antibiotic resistance patterns based on laboratory data, and antibiotic prescribing practices for practitioners. Findings: Review of the facility's Infection Control documentation revealed no documented evidence, and the facility did not present any documented evidence that the facility had a system for the provision of feedback reports on the facility's antibiotic usage and antibiotic resistance patterns based on laboratory data. In an interview on 10/15/2024 at 2:48 p.m., S2Director of Nursing/Infection Preventionist confirmed she had no documented evidence regarding the usage of antibiotics or antibiotic resistance patterns in the facility.

Based on record review, observations, and interviews, the facility failed to ensure a Certified Nursing Assistant (CNA) performed hand hygiene during incontinence care for 2 (S3CNA and S4CNA) of 2 (S3CNA and S4CNA) CNAs observed during incontinence care for 1 sampled (Resident #2) and one random resident (Resident #R4). Findings: Review of the facility's policy titled, Handwashing/Hand Hygiene, last revised on 08/30/2023, revealed, in part, staff must perform hand hygiene before and after direct contact with residents, after contact with body fluids, and after removing gloves. Observation on 07/15/2024 at 1:48 p.m., revealed after S3CNA finished performing incontinence care for Resident #R4, S3CNA removed her gloves and touched Resident #R4's fall mat, door handle, and call bell without performing hand hygiene. In an interview on 07/16/2024 at 1:52 p.m., S3CNA indicated she had not performed hand hygiene after completing Resident #R4's incontinence care and after removing her gloves, before touching the above mentioned items and should have. Observation on 07/16/2024 at 2:00 p.m., revealed S4CNA performed incontinence care for Resident #2. Further observation revealed, after cleaning Resident #2's vaginal area with gloved hands, S4CNA opened Resident #2's cabinet with the handle, without removing her gloves or performing hand hygiene. Further observation revealed S4CNA then removed her gloves and reached into her pocket to pull out barrier cream (a cream used to protect the skin from irritants) without performing hand hygiene. In an interview on 07/16/2024 at 2:06 p.m., S4CNA indicated she did not remove her gloves after cleaning Resident #2, and before opening Resident #2 cabinet. S4CNA further indicated she did not perform hand hygiene after removing her gloves, before reaching into her pocket. In an interview on 07/17/2024 at 8:58 a.m., S2Director of Nursing (DON) indicated S3CNA should have performed hand hygiene after removing her gloves. S2DON further indicated S4CNA should have removed her gloves after cleaning Resident #2, before going into Resident #2's cabinet, and should have performed hand hygiene after removing her gloves, before reaching into her pocket for barrier cream.

Based on observations, interviews, and record reviews, the facility failed to ensure the medication error rate was not greater than 5% by having a medication error rate of 7.69%. This deficient practice was identified for 2 (Resident #15 and Resident #19) of 9 (Resident #2, Resident #6, Resident #10, Resident #19, Resident #35, Resident #43, Resident #51, Resident #62, and Resident #71) residents observed during medication administration. Findings: Resident #15 Observation on 12/05/2023 at 9:25 a.m. revealed S4Licensed Practical Nurse (LPN) administered one Calcium Carbonate (a medication used to treat kidney disease) 500 milligrams (mg) chewable tablet by mouth to Resident #15. Review of Resident #15's December 2023 Physician Orders revealed, in part, an order for Calcium Carbonate 600 mg tablet one tablet by mouth daily. In an interview on 12/06/2023 at 12:29 p.m., S4LPN confirmed the Calcium Carbonate tablet administered to Resident #15 was the wrong dose and should have been 600 mg. In an interview on 12/06/2023 at 1:58pm, S2Director of Nursing (DON) stated S4LPN should have administered Resident #15's proper Calcium Carbonate dose per the physician's orders. Resident #19 Observation on 12/05/2023 at 11:03 a.m. revealed S5LPN administered one Methocarbamol 500 mg tablet by mouth to Resident #19. Review of Resident #19's December 2023 Physician's Orders revealed, in part, Methocarbamol (medication used for muscle spasms) 500 milligrams (mg) one tablet by mouth three times a day. Review of Resident #19's electronic medication administration record (eMAR) for December 2023 revealed, in part, Resident #19's Methocarbamol 500 mg tablet was scheduled to be administered by mouth three times a day at 9:00 a.m., 2:00 p.m., and 9:00 p.m. In an interview on 12/06/2023 at 1:52 p.m., S5LPN stated she had not administered Resident #19's Methocarbamol at 9:00 a.m., and therefore the administered dose observed on 12/05/2023 at 11:03 a.m. would have been the first dose of Methocarbamol administered to Resident #19 on 12/05/2023. S5LPN further stated the Methocarbamol would have been administered 2 hours after the scheduled administration time. In an interview on 12/06/2023 at 1:58 p.m., S2DON stated S5LPN should have only administered Resident #19's medications one hour before or one hour after Resident #19's scheduled medication administration time. There were 26 opportunities for medication administration with 2 medication errors which resulted in a 7.69% medication error rate.

Based on observation, record reviews, and interviews, the facility to: 1.Ensure a Licensed Practical Nurse (LPN) documented medication administration when the medication was administered and store medications in a secure manner for 1 (Resident #13) of 18 sampled residents reviewed during investigations and for 1 (Resident #19) of 9 (Resident #2, Resident #6, Resident #10, Resident #19, Resident #35, Resident #43, Resident #51, Resident #62, and Resident #71) residents observed during medication administration; and, 2. Store medications in a secure manner Findings: Resident #13 Review of the May 2023 Louisiana Administrative Code, Title 46, Part XLVII revealed, in part: the registered nurse retained the accountability for the total nursing care of the individual, and was responsible for and accountable to each consumer of nursing care for the quality of nursing care he or she received, regardless of whether the care was provided solely by the registered nurse or by the registered nurse in conjunction with other licensed or unlicensed assistive personnel. Further review revealed, in part, the plan for nursing care is implemented according to the following criteria: Nursing actions are consistent with the plan for nursing care, interventions are implemented in a safe and appropriate manner, and nursing actions are documented by written records, observation of nursing performance, report of nursing action by the individual and/or pertinent others, and documentation includes, but is not limited to, written records that attest to the care provided to patients based on assessment data and the patient's response to the intervention. Review of Resident #13's December 2023 Physician's Orders revealed, in part, the following: 1. Albuterol Sulfate HFA inhalation aerosol solution, inhale two puffs orally every six hours as needed for wheezing; 2. Oxycodone Hydrochloride oral tablet 10 milligram (mg) four times a day (QID) for pain; 3. Ambien oral tablet 5mg by mouth at bedtime for insomnia; and, 4. Apixaban 5mg twice a day for blood clots. Review of Resident #13's Care Plan revealed, in part, administer medications as ordered. Review of Resident #13's electronic health record revealed, in part, no documented evidence Resident #13 was assessed and approved to self-administer medications. Observation on 12/05/2023 at 10:05 a.m. revealed Resident #13's Albuterol inhalant aerosol solution was on the bedside table. Observation on 12/05/2023 at 12:20 p.m. revealed Resident #13's Albuterol inhalant aerosol solution was on the bedside table. In an interview on 12/05/2023 at 1:03 p.m., S4Licensed Practical Nurse (LPN) stated she administered albuterol inhalant aerosol solution. S4LPN stated the albuterol inhalant aerosol solution was stored in the medication cart. S4LPN unlocked medication cart Z and was unable to locate the albuterol inhalant aerosol solution. S4LPN stated she must have left Resident #13's albuterol inhalant aerosol solution on his bedside table on 12/04/2023 when she last administered the medication. S4LPN stated medication should not be left at Resident #13's bedside and confirmed Resident #13's albuterol inhalant aerosol solution had been at his bedside since 12/04/2023. In an interview on 12/06/2023 at 10:00 a.m., S2Director of Nursing (DON) stated Resident #13 had not been assessed for self-administration of medications and his albuterol inhalant aerosol solution should not have been left at the bedside. On 12/06/2023 at 9:56 a.m., Resident #13's November 2023 electronic Medication Administration Record (eMAR) revealed, in part, the following: Ambien 5mg was not documented as administered on the following dates: 11/04/2023, 11/05/2023, 11/06/2023, 11/10/2023, 11/12/2023, 11/14/2023, 11/15/2023, 11/16/2023, 11/17/2023, and 11/22/2023 at 2100; Apixaban 5mg was not documented as administered on the following dates: 11/15/2023 and 11/17/2023 at 0900 and 11/04/2023, 11/05/2023, 11/06/2023, 11/10/2023, 11/12/2023, 11/14/2023, 11/15/2023, 11/16/2023, 11/17/2023, 11/22/2023 at 1800, and Oxycodone hydrochloride oral tablet 10mg was not documented as administered on the following dates: 11/27/2023 at 0000; 11/27/2023 at 0600; 11/17/2023 and 11/18/2023 at 1200; and 11/04/2023, 11/05/2023, 11/06/2023, 11/10/2023, 11/12/2023, 11/14/2023, 11/15/2023, 11/16/2023, 11/17/2023 and 11/22/2023 at 1800. On 12/06/2023 at 9:56 a.m., Resident #13's December 2023 eMAR revealed, in part, the following: Ambien 5mg was not documented as administered on the following dates: 12/02/2023, 12/03/2023, 12/04/2023 and 12/05/2023 at 2100; Apixaban 5mg was not documented as administered on the following dates: 12/02/2023, 12/03/2023, 12/04/2023, and 12/05/2023 at 1800; and Oxycodone hydrochloride oral tablet 10mg was not documented as administered on the following dates: 12/06/2023 at 1200; and, 12/02/2023, 12/03/2023, 12/04/2023, and 12/05/2023 at 1800. On 12/07/2023 S1Administrator presented the surveyor with printed copies of Resident #13's November 2023 eMAR and December 2023 eMAR. Review of Resident #13's November 2023 electronic Medication Administration Record (eMAR) revealed, in part, the following: Ambien 5mg was not documented as administered on the following dates: 11/04/2023 and 11/05/2023; Apixaban 5mg was not documented as administered on the following dates: 11/04/2023 and 11/05/2023 at 1800; and Oxycodone hydrochloride oral tablet 10mg was not documented as administered on the following dates: 11/27/2023 at 0000; 11/27/2023 at 0600; and 11/04/2023 and 11/05/2023 at 1800. Review of Resident #13's December 2023 electronic Medication Administration Record (eMAR) revealed, in part, all medications were documented as administered. In an interview on 12/07/2023 at 9:45 a.m., S4LPN stated she was aware of the omissions on Resident #13's November 2023 eMAR and Resident #13's December 2023 eMAR for ambien, apixaban and oxycodone. S4LPN stated she had administered medications for Resident #13 in November 2023 and December 2023 and had not documented the eMAR when she administered the medications. S4LPN stated she corrected the omissions on 12/06/2023. S4LPN stated she had worked many hours in November 2023 and she should have signed medications as administered immediately after administration but she did not. S4LPN stated she had played catch up but things continued to snowball. S4LPN stated S2DON and S3Assistant Director of Nursing (ADON) had talked to her about time management. In an interview on 12/07/2023 at 9:50 a.m., S3ADON stated she was aware S4LPN had worked a lot of shift and had omissions on the eMAR. S3ADON stated medications should be documented as administered at the time of administration. In an interview on 12/07/2023 at 9:54 a.m., S2DON confirmed medications should be documented on the eMAR when they are administered. S2DON further stated S3ADON was responsible to ensure nursing staff perform their job duties and she was the direct supervisor of S3ADON. Resident #19 Review of the facility's Administering Medications Policy and Procedure revealed, in part, if a medication was given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. Review of Resident #19's Physician's Orders for December 2023 revealed, in part, Methocarbamol (medication used for muscle spasms) 500 milligrams (mg) one tablet by mouth three times a day. Review of Resident #19's eMAR for December 2023 revealed, in part, Methocarbamol 500 mg one tablet by mouth three times a day with scheduled administration times of 9:00 a.m., 2:00 p.m., and 9:00 p.m. Observation on 12/05/2023 at 11:03 a.m. revealed S5LPN administered, in part, Methocarbamol 500mg one tablet by mouth to Resident #19. Review of Resident #19's Medication Audit Report for 12/05/2023 revealed, in part, Methocarbamol 500mg was documented as being administered on 12/05/2023 at 10:29 a.m. and 1:39 p.m. Further review revealed no documented evidence and the facility presented no documented evidence S5LPN had documented administering Resident #19's Methocarbamol at 11:03 a.m. In an interview on 12/06/2023 at 1:52 p.m., S5LPN stated she had not given the Methocarbamol at 9 a.m. administration time, and therefore the dose observed at 11:03 a.m. would have been the first dose of Methocarbamol administered on 12/05/2023. S5LPN further stated she had started signing the medication out at 10:30 a.m., and had to stop prior to preparing the medication, therefore the dose documented as 10:30 a.m., was really administered at 11:03 a.m. S5LPN further stated she was not signing out medication when administered. In an interview on 12/06/2023 at 1:58 p.m., S2DON (Director of Nursing) stated the nurses should only sign out medications at time of administration.

Based on observation and interview, the facility failed to ensure water accessible to residents did not exceed 120 degrees Fahrenheit for 4 bathrooms (Bathroom A, Bathroom B, Bathroom C, and Bathroom D) of 7 (Bathroom H, Bathroom I, and Bathroom J) bathrooms observed for water temperature. Findings: Observation on 12/04/2023 at 9:39 a.m. revealed the water from the sink in Bathroom B was hot to touch, and surveyor was unable to maintain their hand in the flow of water for more than 5 seconds due to the high temperature. Observation on 12/04/2023 at 9:43 a.m. revealed the water from the sink in Bathroom D was hot to touch, and surveyor was unable to maintain their hand in the flow of water for more than 5 seconds due to the high temperature. Observation on 12/04/2023 at 9:47 a.m. revealed the water from the sink in Bathroom C was hot to touch, and surveyor was unable to maintain their hand in the flow of water for more than 5 seconds due to the high temperature. Observation on 12/04/2023 at 9:50 a.m. revealed the water from the sink in Bathroom A was hot to touch, and surveyor was unable to maintain their hand in the flow of water for more than 5 seconds due to the high temperature. Observations on 12/04/2023 at 2:05 p.m. revealed S9Maintenance Supervisor (MS) measured the temperature of the water from the sink in Bathroom D, and obtained a reading of 100 degrees Fahrenheit. In an interview on 12/04/2023 at 2:07 p. m., S9MS stated his thermometer was not calibrated because the water temperature was obviously above the 100 degree Fahrenheit reading. S9MS stated the water was hot to touch and higher than 120 degrees Fahrenheit. S9MS further stated he was aware of potential harm to residents with temperatures above 120 degrees Fahrenheit. S9MS stated he would get his other thermometer. Observations on 12/04/2023 at 2:50 p.m. revealed S9MS measured the temperature of the water from the sink in Bathroom A, and obtained a reading of 125 degrees Fahrenheit. Observations on 12/04/2023 at 2:53 p.m. revealed S9MS measured the temperature of the water from the sink in Bathroom C, and obtained a reading of 127 degrees Fahrenheit. Observations on 12/04/2023 at 2:56 p.m. revealed S9MS measured the temperature of the water from the sink in Bathroom D, and obtained a reading of 127 degrees Fahrenheit. Observations on 12/04/2023 at 2:59 p.m. revealed S9MS measured the temperature of the water from the sink in Bathroom B, and obtained a reading of 126 degrees Fahrenheit. In an interview on 12/04/2023 at 2:59 p.m., S9MS stated the bathroom sink water temperatures were too high and should have been below 120 degrees Fahrenheit. S9MS he was aware In an interview on 12/07/2023 at 1:32 p.m., S1Administrator acknowledged the bathroom sink temperatures should not have been that hot. S1Administrator stated he was aware of the potential for harm with hot water temperatures.

Based on observation and interviews, the facility failed to ensure medications were maintained in a secure manner. Findings: Observation on 12/07/2023 at 12:22 p.m. revealed there was no staff present at nursing station N and the door to nursing station N was open. Further review revealed medication cart Y was stored in nursing station N and medication cart Y was unlocked. On 12/07/2023 at 12:24 p.m., S4Licensed Practical Nurse (LPN) acknowledged nursing station N was open and unattended. S4LPN confirmed medication cart Y was unlocked. In an interview on 12/07/2023 at 12:50 p.m., S3Assistant Director of Nursing (ADON) stated the medication cart should be locked at all times.

Based on interviews and record review, the facility failed to ensure food was palatable to residents in taste, temperature and consistency. This deficient practice had the potential to affect any of the 89 residents that receive food from the facility's kitchen. Findings: Review of the resident council meeting minutes dated 11/21/2023 revealed, in part, Resident #23 reported food that was served cold. Further review revealed, Resident #23 reported that the bell pepper served on 11/21/2023 was not good, the rice was hard, and the meat tasted burnt. During the Resident Council meeting held on 12/05/2023 at 9:33 a.m., Resident #63 stated the food served by the facility was served cold and did not taste good. During the Resident Council meeting held on 12/05/2023 at 9:33 a.m., Resident #2 stated the food served by the facility was served cold. In an interview on 12/06/2023 at 8:48 a.m., Resident #28 stated the pancakes he had for breakfast this morning were too hard to eat. Resident #28 further stated his breakfast today was not warm. In an interview on 12/06/2023 at 2:10 p.m., Resident #80 stated he was served cold food for dinner last night and is often served cold food by the facility. On 12/05/2023 at 11:45 a.m., a test tray was pulled by the survey team from Food Cart E. The food tray contained meatloaf, gravy, rice, and mixed vegetables. Four surveyors tasted the food, and found the food to be lukewarm to room temperature. In an interview on 12/07/2023 at 9:17 a.m., S6Dietary Manager acknowledged he received complaints about the food temperature from Resident #23 and Resident #85. S6Dietary Manager further stated he did not ask any other residents if they had complaints regarding the temperature of the food. S6Dietary Manager further stated he followed up with Resident #23 and Resident #85 about food being cold and has warmed those two residents' foods in the microwave.

Based on observations and interviews, the facility failed to: 1. Ensure cooking and serving items were clean, dry and did not contain residue (steam table pans) before being available for use in food service; 2. Ensure oven was clean and did not contain residue; and 3. Ensure Glucerna (a nutritional supplement) and fruit juices were not expired and available for resident consumption for 2 (Medication Cart X and Medication Cart Y) of 3 (Medication Cart X, Medication Cart Y, and Medication Cart Z) medication carts and 1 medication room observed. Findings: 1. Observation of the facility's kitchen on 12/05/2023 at 1:30 p.m., revealed sixteen steam table pans were stacked on a storage rack and had water dripping from them. Further observation revealed eight of the sixteen steam table pans had built up brown residue on their surfaces and were available to use for food preparation. In an interview on 12/05/2023 at 1:35 p.m., S6Dietary Manager acknowledged the clean steam table pans should only be stored when dry, and confirmed the steam table pans were stored wet. S6Dietary Manager acknowledged none of the 16 steam table pans should have been available for use. Observation of the facility's kitchen with S6Dietary Manager on 12/07/2023 at 9:17 a.m., revealed 12/07/2023 at 9:17 a.m., the facility's oven had a buildup of an unknown reside on the bottom surface of the oven, an unknown brown residue in a drip pattern between the double glass of the oven's door, and a buildup of an unknown black residue on the oven stand's brake pedals. In an interview on 12/07/2023 at 9:17 a.m., S6Dietary Manager acknowledged that the oven was not as clean as it should be. 2. Observation on 12/06/2023 at 2:07 p.m. revealed Medication Cart Y contained: -2 cartons of Glucerna with expiration dates of 07/01/2023; -1 carton of Glucerna with an expiration date of 08/01/2023; -1 carton of Glucerna with an expiration date of 10/01/2023; and, -3 cartons of Glucerna with expiration dates of 12/01/2023. In an interview on 12/06/2023 at 2:14 p.m., S8LPN confirmed the above mentioned cartons of Glucerna on Medication Cart Y were expired. In an interview on 12/07/2023 at 12:18 p.m., S2DON confirmed the above mentioned cartons of Glucerna present on Medication Cart Y on 12/06/2023 were expired and should not have been available for resident consumption. 3. Observation on 12/07/2023 at 1:08 p.m. of Medication Cart X revealed 1 carton of Glucerna with an expiration date of 07/01/2023. In an interview on 12/07/2023 at 1:09 p.m., S5LPN stated the Glucerna was expired and should not be on Medication Cart X and available for resident consumption. Observation on 12/07/2023 at 1:11 p.m. of the medication storage room revealed 3 cartons of apple juice with expiration dates of 11/10/2023, 08/29/2023, and 08/29/2023. Further observation revealed 2 cartons of orange juice with expiration dates of 09/28/2023 and 11/15/2023, and 2 cartons of cranberry juice with expiration dates of 08/12/2023 and 08/11/2023. In an interview on 12/07/2023 at 1:12 p.m., S5LPN stated the above mentioned juices were expired and should not be available for resident consumption. In an interview on 12/07/2023 at 1:17 p.m., S2DON stated S3Assistant Director of Nursing (ADON) should have disposed of the expired nutritional supplements and juices on the medication carts and in the medication room. In an interview on 12/07/2023 at 1:26 p.m., S3ADON stated she had no explanation as to why there were still expired nutritional supplements and juices present on the medication carts and in the medication room.

Based on record review and interview the facility failed to ensure: 1. The resident's treatment administration record was completed for antipsychotic side effects monitoring and the behaviors monitoring for 1 (Resident #6) of 5 (Resident #6, Resident #13, Resident #17, Resident #28, and Resident #88) sampled residents reviewed for unnecessary medication; 2. The resident's electronic medication administration (eMAR) was completed for medications administered for 2 (Resident #28, Resident #88) of 5 (Resident #6, Resident #13, Resident #17, Resident #28, and Resident #88) sampled residents reviewed for unnecessary medication; and 3. The resident's eMAR was completed for supplements administered as ordered for 1 (Resident #47) of 2 (Resident #47 and Resident #75) sampled residents reviewed for pressure ulcers. Findings: 1. Resident #6 Review of Resident #6's November and December Physician Orders revealed, in part, an order for Seroquel (antipsychotic medication) 100 milligram (mg), 1 tablet by mouth at bedtime. Review of Resident #6's care plan revealed Resident #6 had behavior problem verbal and physical aggression towards others with interventions to include in part, administer medications as ordered, monitor for medication side effects, monitor behavior episodes, and attempt to determine underlying causes. Review of Resident #6's November 2023 and December 2023 Treatment Administration Record revealed, in part: - Behaviors- monitor for the following: Itching, picking at skin, restlessness, agitation, yelling at staff, increase in complaints, biting, spitting, cussing, elopement, stealing, delusions, hallucinations, psychosis, aggression, refusing care. Document: N if monitored and none of the above observed. Y' if monitored and any of the above observed, select chart see other / see nurses notes and progress note finding. Documentation on the following days were omitted: 11/6/2023 day and evening shifts, 11/7/2023 evening shift, 11/10/2023 day shift, 11/11/2023 day shift, 11/12/2023 day and evening shift, 11/13/2023 -11/16/2023 evening shift, 11/17/2023 day and evening shift, 11/18/2023 day shift, 12/1/2023 evening shift, 12/2/2023 day shift, 12/4/2023 evening shift, 12/5/2023 day and evening shift and 12/6/2023 day shift. - Antipsychotic Medication - monitor for dry mouth, constipation, blurred vision, orientation/confusion, difficulty urinating, hypotension, dark urine, nausea and vomiting, lethargy, drooling, extrapyramidal symptoms, tremors, disturbed gait, increased agitation, restlessness, involuntary movement of mouth or tongue. Document N if monitored and none of the above observed. Y if monitored and any of the above was observed, select chart code other / see nurses notes and progress note finding. Documentation on the following days were omitted: 11/6/2023 day and evening shifts, 11/7/2023 evening shift, 11/10/2023 day shift, 11/11/2023 day shift, 11/12/2023 day and evening shift, 11/13/2023 -11/16/2023 evening shift, 11/17/2023 day and evening shift, 11/18/2023 day shift, 12/1/2023 evening shift, 12/2/2023 day shift, 12/4/2023 evening shift, 12/5/2023 day and evening shift and 12/6/2023 day shift. In an interview on 12/07/2023 at 12:31 a.m. S2Director of Nursing (DON) stated behaviors and antipsychotics should be monitored every shift and acknowledged there was gaps in Resident #6's documentation. 2. Resident #88 Review of Resident #88's November 2023 Physician Orders revealed orders, in part, Amlodipine 5 milligrams (mg) by mouth once a day (medication used for blood pressure); Aspirin 81 mg by mouth once a day (medication used for circulation); Atorvastatin Calcium 40 mg by mouth at bedtime (medication used for cholesterol); Losartan Potassium-HCTZ 100-25 mg by mouth once a day (medication used for blood pressure); Trazadone 50 mg at bedtime (medication used for sleep); Docusate Sodium 100mg by mouth two times a day (medication used for constipation); and Quetiapine Fumarate 50mg by mouth two times a day (medication used for mood). Review of Resident #88's November 2023 eMAR revealed, in part, for November 2023 the following medications had no documented evidence the doses had been administered on the medication administration record: Amlodipine 5 mg by mouth at 09:00 a.m. dose on 11/17/2023. Aspirin 5 mg by mouth at 09:00 a.m. dose on 11/17/2023. Atorvastatin Calcium 40 mg at 9:00 p.m. dose on 11/22/2023. Losartan Potassium-HCTZ 100-25 mg at 9:00 a.m. doses on 11/17/2023 and 11/18/2023. Trazadone 50 mg at 9:00 p.m. dose on 11/22/2023. Docusate Sodium 100mg at 9:00 p.m. doses on 11/16/2023, 11/22/2023 and at 9:00 a.m. on 11/17/2023. Quetiapine Fumarate 50mg at 9:00 a.m. doses on 11/17/2023 and 11/18/2023 and 9:00 p.m., doses on 11/16/2023 and 11/22/2023. Resident #28 Review of Resident #28's November 2023 Physician Orders revealed orders, in part, Ambien 5mg by mouth a bedtime (medication used for insomnia; Aripiprazole 15 mg one tablet at bedtime (medication used for psychosis); Atorvastatin Calcium 80 mg one tablet by mouth a bedtime (medication used for cholesterol); Levermir 100 units/milliliter inject 12 units into skin in the evening (medication used for high blood sugar); Tamsulosin HCL 0.4 mg one tablet at bedtime (medication used for urinary); Entresto 49-51 mg one tablet twice a day (medication used for high blood pressure); Pantoprazole 40 mg one tablet twice a day (medication used for stomach ulcer); and Cyclobenzaprine 5mg one tablet three times a day (medication used to treat muscle spasms). Review of Resident #28's November 2023 eMAR revealed, in part, for November 2023 the following medications had no documented evidence the doses had been administered on the medication administration record: Ambien 5mg at 9:00 p.m. dose on 11/05/2023. Aripiprazole 15 mg 9:00 p.m. dose on 11/05/2023. Atorvastatin Calcium 80 mg 9:00 p.m. dose on 11/05/2023. Levermir 100 units/milliliter inject 12 units 6:00 p.m. dose on 11/05/2023. Tamsulosin HCL 0.4 mg 9:00 p.m. dose on 11/05/2023. Entresto 49-51 mg 6:00 p.m. dose on 11/05/2023. Pantoprazole 40 mg 6:00 p.m. dose on 11/05/2023. Cyclobenzaprine 5mg 9:00 p.m. dose on 11/05/2023. In an interview on 12/07/2023 at 11:25 a.m., S4Licensed Practical Nurse (S4LPN) acknowledged she did not document the above medications as given on the eMAR's for Resident #28 and Resident #88. S4LPN further stated the medications were given to the residents but was not documented because she was probably too busy. In an interview on 12/07/2023 at 11:22 a.m., S1Administrator stated he was aware of the missing documentation on some of the Residents eMAR's. 3. Review of Resident #47's November 2023 and December 2023 Physician Orders revealed orders for, in part, Juven (nutritional supplement) oral packet administer one packet per gastrostomy tube (artificial tube to provide nutrition) two times a day; and Promod (nutritional supplement) oral liquid give 30 milliliters (ml) by mouth two times a day. Review of Resident #47's November 2023 and December 2023 eMAR revealed, in part: -No documented evidence of Juven had been administered for the 8:00 a.m. dose on 11/10/2023, and no doc umented evidence the 6:00pm dose had been administered on 11/14/2023 through 11/17/2023, 11/22/2023, and 12/01/2023; -No documented evidence of Promod had been administered for 9:00 a.m. dose on 11/10/2023, and no documented evidence the 6:00 p.m. dose had been administered on 11/09/2023, 11/10/2023, 11/13/2023 through 11/17/2023, 11/22/2023, and 12/01/2023. In an interview on 12/07/2023 at 10:43 a.m., S4LPN stated she was administering the nutritional supplements as ordered but she had issues with her time management skills, and therefore was not documenting supplements when the supplements were administered. In an interview on 12/07/2023 at 10:43 a.m., S2Director of Nursing (DON) acknowledged the missing documentation and stated the supplements should be documented when administered.

Based on observations and interviews the facility failed to ensure: 1. The resident's ice supply was maintained according to infection control practices for 1 ice chest (Ice Chest F) of 2 ice chests (Ice Chest F and Ice Chest G) observed for infection control practices; and, 2. The Licensed Practical Nurse (LPN) performed hand hygiene between administering medication to separate residents for 1 (S4LPN) of 3 (S4LPN, S5LPN, and S11LPN) LPNs observed during medication administration observations. Findings: 1. Observation on 12/04/2023 at 10:00 a.m. revealed the top of the ice scoop was sitting in clear liquid inside the ice scoop holder on Ice Chest F. Observation on 12/04/2023 at 12:00 p.m. revealed the top of the ice scoop was sitting in clear liquid inside the ice scoop holder on Ice Chest F. Observation on 12/05/2023 at 9:32 a.m. revealed the top of the ice scoop was sitting in clear liquid inside the ice scoop holder on Ice Chest F. Observation on 12/06/2023 at 10:10 a.m. revealed the top of the ice scoop was sitting in clear liquid inside the ice scoop holder on Ice Chest F. In an interview on 12/06/2023 at 10:15 a.m., S10Certified Nursing Assistant (CNA) confirmed the ice scoop was sitting in clear liquid inside the ice scoop holder and stated it should not be like that. When asked how it is supposed to be, S10CNA stated, the ice scoop holder should be cleaned out and not have water in it. In an interview on 12/06/023 at 10:20 a.m., S2Director of Nursing stated an ice scoop should not be sitting in an ice scoop holder with standing water in it and that the ice scoop holder should be cleaned periodically and after each shift. 2. Observation on 12/05/2023 at 9:25 a.m. revealed S4LPN did not perform hand hygiene and proceeded to prepare medication for Resident #51. S4LPN then entered Resident #51's room, administered Resident #51's medication, grabbed Resident #51's water cup by the area Resident #51 had drank from, and left Resident #51's room without performing hand hygiene. Further observation revealed S4LPN then proceeded to the medication cart and started to prepare Resident #35's medication without performing hand hygiene. Observation on 12/05/2023 at 9:30 a.m. revealed S4LPN did not perform hand hygiene and proceeded to administer medication to Resident #35. In an interview on 12/06/2023 at 12:29 p.m., S4LPN stated she should have performed hand hygiene between administering medications to residents. In an interview on 12/06/2023 at 1:58 p.m., S2Director of Nursing (DON) stated S4LPN should have performed hand hygiene between administering medication to residents.

Based on record review, observations and interviews, the facility failed to allow residents unrestricted visitation. This deficient practice was identified for 2 of 5 sampled residents (Resident #1 and Resident #2) and for 5 of 5 random residents (Resident #R6, Resident #R7, Resident #R8, Resident #R9 and Resident #R10) reviewed for family visitation. This deficient practice had the potential to affect any of the 90 residents who reside in the facility as documented on the facility's census. Findings: Review of the Centers for Medicare and Medicaid Services Memorandum QSO 20-39-NH revised 05/08/2023 revealed, in part, facilities must allow indoor visitation at all times and for all residents as permitted under the regulations. While previously acceptable during the PHE, facilities can no longer limit the frequency and length of visits for residents, the number of visitors or require advance scheduling of visits. Observation on 07/31/2023 at 8:30 a.m. and on 08/01/2023 at 9:00 a.m. revealed at the main front entrance to the facility, a notice posted by S1Administrator dated 03/07/2023. Further review of the notice revealed, in part, to our residents and family members, unfortunately our communities continue to experience additional cases of COVID 19 as reported by the Louisiana Department of Health and parish officials. Because of the reported high rate of potential for infection, our facility will continue with our current plan of limiting visitation to our protocol where family members may make an appointment to visit, however, this will require the residents to remain indoors while the visitors remain outside at our East and [NAME] Lobby areas, or outside visitation in our bayside Park. Review of the Visitation Policy revised June 14, 2023 revealed, in part, the intent was to provide the residents of Bayside Healthcare Center with the appropriate protection from the impact of a pandemic event, and necessary measures initiated to prevent the spread of infection. Visitation will be allowed during a pandemic response according to the Core Principles of Covid-19 Infection Prevention. Bayside Healthcare Center will accommodate and support indoor and outdoor visitation, including visits for reasons beyond Compassionate Care situations, based on the following guidelines, in part: the facility will request to limit visitation to (2) visitors per resident at one time and it is recommended that all visitation will be for 30 minutes per visit. In an interview on 07/31/2023 at 9:33 a.m., S7Receptionist stated visitation starts at 9:30 a.m. daily. In an interview on 07/31/2023 at 10:28 a.m., S7Receptionist stated visitation ends at 6:00 p.m. daily. In an interview on 07/31/2023 at 1:55 p.m., S3Certified Nursing Assistant (CNA) Supervisor stated residents are allowed to have visitors but they have to call and make appointments or families have to call to let facility know they are coming. In an interview on 07/31/2023 at 2:32 p.m., S4Certified Nursing Assistant stated visitors for residents located on the west side of the building have to visit in the dining area, front lobby or East Hall. S4Certified Nursing Assistant stated visits are for 30 minutes to an hour. She stated visitation ends at approximately 7pm. In an interview on 07/31/2023 at 2:35 p.m., S5CNA stated family members and visitors have to have an appointment to visit the residents in the facility. S5CNA indicated if a family member shows up in the evening without an appointment, the family or visitors are not allowed to visit with the resident if they are in a double occupancy room. In an interview on 07/31/2023 at 2:35 p.m., S2Registered Nurse Supervisor stated residents in double occupancy rooms visit in East Hall, front lobby or dining area. S2Registered Nurse Supervisor stated visitation starts at approximately 9am and ends between 6pm and 8pm when S7Receptionist leaves. S2Registered Nurse Supervisor stated visits usually last one hour but can be longer based on the number of visitors coming in the facility at that time. S2Registered Nurse Supervisor stated we ask families to make an appointment to visit residents. S2Registered Nurse Supervisor stated visitors are notified about visitation when the resident is admitted to the facility. In an interview on 08/01/2023 at 9:25 a.m., S6Licensed Practical Nurse (LPN) stated she is not sure about the visitation policy and what times visitors can visit. Resident #1 In an interview on 07/31/2023 at 11:18 a.m., Resident #1 stated her brother visits her every week and her brother has to make an appointment to visit her because the facility is locked up due to the pandemic. Resident #2 In an interview on 07/31/2023 at 11:25 a.m., Resident #2 stated the she cannot have visitors in the middle of the night because the facility does not allow visits during that time. In an interview on 08/01/2023 at 12:50 p.m., Resident #2's daughter stated she has not been able to visit her mom in a year because she had not been able to get an appointment. Resident #2's daughter stated she was told to visit her mother she would have to make an appointment. Resident #R6 In an interview on 07/31/2023 at 11:05 am, Resident #R6 stated he could only have visitors from 7:00 a.m. till 10:30 p.m. Resident #R6 stated his family had to call and make an appointment when they wanted to visit. Resident #R6 further stated that he was not allowed to have anyone visit late at night. In an interview on 07/31/2023 at 1:07 p.m., Resident #R6's wife stated she has to make an appointment to visit her husband. Resident #R6's wife stated she was never informed by the facility she could visit at any time without an appointment. Resident #R7 In an interview on 08/01/2023 at 10:55 a.m., Resident #R7's son stated his father is on the secured unit and he has to make an appointment when he wants to come visit him. Resident #R7's son stated that the front desk person told him that visiting hours were 8 a.m. to 8 p.m. Resident #R7's son indicated he is only allowed to visit for about an hour. Resident #R8 In an interview on 08/01/2023 at 11:10 a.m., Resident #R8's daughter stated she was told if her mother was moved to a room with a roommate she would have to make an appointment for visitation. Resident #R8's daughter stated she heard that visiting hours ended at 5:30 p.m. during the week and Resident #R8's daughter further stated on the weekend they do not like you visiting past 3:00 p.m. because there is no one at the front door to let you in. Resident #R9 In an interview on 07/31/2023 at 1:15 p.m., Resident #R9's wife stated the facility told her visitation hours are between 9am-5pm Mondays- Fridays and 9am-3pm Saturdays and Sundays. She stated the facility never informed her she could visit at any time without an appointment. Resident #R10 In an interview on 08/02/2023 at 11:01 a.m., Resident #R10's daughter stated she has scheduled appointment times at the facility. Resident #R10's daughter stated if she could not make an appointment in the past and wanted to come later she had to call and reschedule the visit, she cannot just show up at the facility unannounced. Resident #R10's daughter stated she called to reschedule in the past for 3pm and was told she could come for 4pm because there were other visitors scheduled at that time. Resident #R10's daughter stated she has been in the process of feeding her mother and had to stop feeding her because another visitor came to the visitation area and she had to leave so the other visitor could visit a resident. Resident #R10's daughter stated she was never informed that she could visit the facility at any time without an appointment. In an interview on 08/02/2023 at 9:42 a.m., S1Administrator stated all staff do not know the visitation rules only staff that deal with visitation. S1Administrator stated he does not have a specific list of staff that are knowledgeable of the visitation rules. S1Administrator stated all staff members don't need to know about the visitation rules because all staff don't engage with visitors. S1Administrator stated families are notified about visitation rules via email, word of mouth and signs on the door.

Based on record review and interview the facility failed to revise and place new interventions on a care plan after a fall for 1 (Resident #3) of 2 sampled residents reviewed for accidents. This deficient practice had the potential to affect any of the 80 residents that resided in the facility as documented on the Residents Census and Conditions form (CMS-672) Census List. Findings: Review of Resident #3's nurses notes revealed, in part, Resident #3 had a fall on the following dates: 05/04/2022, 05/12/2022, 07/01/2022, 08/24/2022, 09/03/2022, 10/13/2022, and 11/11/2022. Review of Resident #3 care plan revealed, in part, no new interventions placed after a fall on the following dates: 05/04/2022, 05/12/2022, 07/01/2022, 08/24/2022, 09/03/2022, 10/13/2022, and 11/11/2022. In an interview on 12/15/2022 at 1:20 p.m., S5Care Coordinator stated no revisions or interventions were added after falls for the following dates: 05/04/2022, 05/12/2022, 07/01/2022, 08/24/2022, 09/03/2022, 10/13/2022, and 11/11/2022. In an interview on 12/15/2022 at 1:25 p.m., S2Director of Nursing stated Resident #3's care plan was not revised and new interventions placed after each fall previously discussed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and interviews, the facility failed to identify a significant weight loss and implement interventions for 1 (Resident #45) of 2 (Resident #45 and Resident #33) sampled residents investigated for nutrition in an total investigative sample of 18. Findings: Review of the facility's Weight Assessment and Management Policy revealed, in part, any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation, and the nursing department will notify the dietician if the weight loss is confirmed. Review also revealed the threshold for significant unplanned and undesired weight loss will be based on the following criteria 1 month- 5% weight loss is significant; greater than 5% is severe, 3 months-7.5% weight loss is significant; greater than 7.5 % is severe, 6 months- 10% weight loss is significant; greater than 10 % severe. Further review revealed careplanning for weight loss or impaired nutrition will be a multidisciplinary effort, individualized care plans shall address, to the extent possible, the identified causes of weight loss, goals and benchmarks for improvement, and time frames and parameters for monitoring and reassessment. Review of Resident #45's medical record revealed, in part, Resident #45 was admitted to the facility on [DATE] with a diagnosis of Huntington's disease and muscle wasting and atrophy. A review of Resident #45's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 09/29/2022 revealed, in part, Resident #45 required one person physical assistance when eating, and Resident #45 weighed 98 pounds and received a mechanically altered therapeutic diet. Review of Resident #45's care plan revealed, in part, Resident #45 was at risk for weight loss and required the dietician to complete an evaluation and provide diet recommendations. Review of Resident #45's record revealed the following documentation: On 05/11/2022, Resident #45 weighed 100 pounds; On 11/08/2022, Resident #45 weighed 78 pounds; and, On 12/14/2022, Resident #45 weighed 74 pounds, which was a 26% weight loss in 6 months. Review of Resident #45's Physician Orders from September 2022 through December 2022 revealed, revealed no new orders related to Resident #45's weight loss. Review of Resident #45's progress notes from September 2022 through December 2022 revealed, no documented evidence, and the facility was unable to provide any documented evidence that Resident #45's weight loss was identified or addressed by the facility. Observation on 12/13/2022 at 11:40 a.m. revealed Resident #45 appeared thin and cachectic in appearance. Observation on 12/14/2022 at 10:00 a.m. revealed S3Assistant Director of Nursing (ADON) and S10Ward Clerk weighed Resident #45 with a wheelchair scale. Observation further revealed Resident #45 and her wheelchair weighed 109.4 pounds, and the wheelchair's weight was 35.6 pounds. In an interview on 12/14/2022 at 10:15 a.m., S3ADON stated Resident #45's weight was 73.8 pounds. S3ADON further stated she weighed Resident #45 earlier this morning and her weight was 74 pounds. S3ADON also stated Resident #45 was at risk for weight loss, but she was not being seen by the dietician. S3ADON stated Resident #45's physician was not notified of the weight loss, and Resident #45 did not have any interventions in place to prevent further weight loss. In an interview on 12/14/2022 at 10:25 a.m., S2Director of Nursing (DON) stated the facility failed to identify Resident #45's weight loss and put proper interventions into place. S2DON stated the dietician and the physician were not notified of Resident #45's weight loss, but they should have been. In an interview on 12/14/2022 at 10:50 a.m., S4Registered Nurse Supervisor (RN Supervisor) stated she was responsible for the facility's Weight Program, and Resident #45's weight loss was not identified or addressed by the facility prior to 12/14/2022 and no interventions were put into place. In a telephone interview on 12/14/2022 at 1:03 p.m., S20Dietician stated she was never notified by the facility of a significant weight loss for Resident #45, nor did she make any recommendations for Resident #45.

Based on record review and interview, the facility failed to complete quarterly assessments for 3 (Resident #1, Resident #4, and Resident #38) of 3 (Resident #1, Resident #4, and Resident #38) residents reviewed for resident assessment. Findings: Review of Resident #1's most recent Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/07/2022 revealed a completion date of 12/09/2022. Further review revealed the completion date was more than 14 days after the ARD. Review of Resident #4's most recent Quarterly MDS with an ARD of 11/08/2022 revealed a completion date of 12/09/2022. Further review revealed the completion date was more than 14 days after the ARD. Review of Resident #38's most recent Quarterly MDS with an ARD of 11/01/2022 revealed a completion date of 11/25/2022. Further review revealed the completion date was more than 14 days after the ARD. Review of the facility's transmission report revealed, in part, the quarterly assessments for Resident #1, Resident #4, and Resident #38 were completed late. In an interview on 12/15/2022 at 9:40 a.m., S5Care Coordinator verified that Quarterly MDS assessments were being completed late due to shortage of staff. In an interview on 12/15/2022 at 10:00 a.m., S2Director of Nursing reviewed the transmission reports and verified the Quarterly MDS assessments for Resident #1, Resident #4, and Resident #38 were completed late.

Based on record reviews, observations, and interviews, the facility failed to ensure expired medications and dressings were not available for residents use; and have a system in place to ensure the accurate dispensation of controlled medications for 2 (Resident #4 and Resident #9) of 16 residents who received controlled medications from the facility. This failed practice had the potential to affect any of the 80 residents residing in the facility who receive medications as documented on the facility's Resident Census and Conditions of Residents form (CMS-672). Observation on 12/13/2022 at 2:30 p.m., of medication storage room c revealed the following expired medications: Four bottles of Gericare brand Coated Aspirin 325 milligrams (mg) with an expiration date of 07/2022; Three bottles of Gericare brand Aspirin 325 mg with an expiration date of 07/2022; Four bottles of Rugby brand Meclizine 12.5 mg with an expiration date of 08/2022; and One 16 oz bottle of Docusate Sodium 50mg/5 milliliter (ml) with an expiration date of 10/2022. In an interview on 12/12/2022 at 2:56 p.m., S4Registered Nurse Supervisor (RN Supervisor) stated that medications in the medication storage room c were for resident use. S4RN Supervisor stated that Four bottles of Gericare brand Coated Aspirin 325 mg with an expiration date of 07/2022, Three bottles of Gericare brand Aspirin 325 mg with an expiration date of 07/2022, Four bottles of Rugby brand Meclizine 12.5 mg with an expiration date of 08/2022, and One 16 ounce (oz) bottle of Docusate Sodium 50mg/5ml with an expiration date of 10/2022, were expired and should not be in medication storage room c and available for resident use. Observation on 12/12/2022 at 12:00 p.m. of treatment cart b revealed, in part, Calcium Alginate Ag Rope 12 dressings had an expiration date of 07/26/2022. In an interview on 12/12/2022 at 12:05 p.m., S6Treatment Nurse (TN) stated that the 12 Calcium Alginate Ag Rope dressings, were expired, and should have been removed from cart. On 12/13/2022 at 12:11 p.m., a reconciliation was completed of controlled substances on medication cart a, and the controlled substance binder for medication cart a revealed the following: Review of Resident #4's medication card for Oxycodone 5 mg tablets had 66 pills in the blister pack and the documentation in the individual narcotic record count was 67. Review of Resident #9's medication card for Oxycodone/APAP 10-325 mg tablet had 40 pills in the blister pack and the documentation in the individual narcotic record count was 8. Review of Resident #9's medication card for Oxycodone HCL 15 mg tablet had 7 pills and the individual narcotic record count was 8. In an interview on 12/13/2022 at 12:11 p.m., S12Licensed Practical Nurse (LPN) stated that she did not count the narcotics on 12/13/2022 when she arrive at shift change with the departing nurse. S12LPN confirmed the medication count and the number on the individual narcotic record were not the same. In an interview on 12/13/2022 at 12:12 p.m., S3Assistant Director of Nursing (ADON) stated that nurses should perform a narcotic count every shift change, and confirmed the medication count and the number on the individual narcotic record were not the same In an interview on 12/13/2022 at 3:35 p.m., S2Director of Nursing (DON) stated the number of narcotic tablets in the medication blister packs and the number indicated on the individual narcotic sheet should be the same. S2DON further stated that expired medications and expired dressings should not be in the medication storage room c and treatment cart b where medications are kept for resident use.