Based on observations, interviews and record review, the facility failed to ensure care plan interventions were implemented for a resident at risk for falls for 1 (Resident #8) of 1 (Resident #8) sampled residents investigated for accidents. Findings:Review of Resident #8's Care Plan, initiated on 05/19/2025, revealed, in part, Resident #8 was at risk for falls related to impaired mobility and impaired cognition. Further review revealed fall interventions included brake extenders with highlighted tape added to Resident #8's wheelchair. Observation on 07/28/2025 at 11:50AM revealed Resident #8's wheelchair did not have brake extenders with highlighted tape. Observation on 07/29/2025 at 2:15PM revealed Resident #8's wheelchair did not have brake extenders with highlighted tape. Observation on 07/30/2025 at 1:46PM revealed Resident #8's wheelchair did not have brake extenders with highlighted tape. Observation on 07/31/2025 at 12:14PM, with S10Licensed Practical Nurse (LPN) present revealed Resident #8's wheelchair did not have brake extenders with highlighted tape. In an interview on 07/31/2025 at 12:15PM, S10LPN confirmed Resident #14 did not have wheelchair brake extenders with highlighted tape. In an interview on 07/31/2025 at 2:00PM, S1Administrator was presented with the above mentioned findings and offered no further explanation to dispute the above mentioned deficient practice.

Based on observations, interviews, and record reviews, the facility failed to ensure a resident's indwelling urinary catheter collection bag was not touching the floor for 1 (Resident #67) of 1 (Resident #67) sampled residents investigated for urinary catheter care and Urinary Tract Infections (UTI). Findings: Review of Resident #67's Minimum Data Set with an Assessment Reference Date of 03/13/2025 revealed, in part, Resident #67 had an indwelling catheter and was dependent for all care. Review of Resident #67's July 2025 physician's orders revealed, in part, an order dated 10/17/2024 for an indwelling Foley catheter. Observation on 07/28/2025 at 11:04AM revealed Resident #67 had an indwelling catheter in place. Further observation revealed Resident #67's indwelling urinary catheter collection bag was hanging off the side of the bed touching the floor. Observation on 07/29/2025 at 12:00PM revealed Resident #67's indwelling urinary catheter collection bag was hanging off the side of the bed touching the floor. In an interview on 07/29/2025 at 2:16PM S4Certified Nursing Assistant (CNA) indicated Resident #67's indwelling urinary catheter collection bag was touching the floor and should not have been. In an interview on 07/31/2025 at 2:00PM, S1Administrator was presented with the above mentioned findings and offered no further explanation to dispute the above mentioned deficient practice.

Based on observation, interviews, and record reviews, the facility failed to:1. Ensure the correct enteral feeding (a type of liquid nutritional supplement that is typically given through a tube directly inserted into the stomach) formula was infused as ordered for 1 (Resident #13) of 1 (Resident #13) sampled residents investigated for enteral feeding maintenance. Findings:Review of the facility's Tube (Enteral) Feedings policy and procedure, dated 06/1994, with a revision date of 12/2015, revealed, in part, all enteral feedings will be administered in accordance with verified medical necessity and physician's orders. Review of Resident #13's July 2025 physician's orders revealed, in part, an order dated 07/23/2025 for Resident #13 to receive Nutren 2.0 (a type of enteral feeding) at 50 milliliters (mL) per hour for twenty-four hours per day. Observation on 07/30/2025 at 10:45AM revealed Resident #13 had Isosource 1.5 (a type of enteral feeding) infusing at a rate of 50 mL per hour. Further observation revealed the above mentioned Isosource 1.5 had an infusion start date and time of 07/30/2025 at 10:00PM labeled on the enteral feeding bag. In an interview on 07/30/2025 at 11:10AM, S10Licensed Practical Nurse (LPN) indicated Resident #13 had received the incorrect enteral feeding. S10LPN further indicated Resident #13 should have received Nutren 2.0 as ordered. In an interview on 07/30/2025 at 11:54AM, S2Director of Nursing (DON) confirmed Resident #13 had been administered the incorrect enteral feeding formula. In an interview on 07/31/2025 at 2:00PM, S1Administrator was presented with the above mentioned findings and offered no further explanation to dispute the above mentioned deficient practice.

Based on observations, interviews, and record reviews, the facility failed to ensure a resident's oxygen tubing was maintained in a sanitary manner per facility policy for 1 (Resident #14) of 1 (Resident #14) sampled residents reviewed for respiratory care. Findings:Review of the facility's Infection Control Oxygen Equipment Cleaning policy and procedure, dated 04/2006, with a revision date of 03/2018, revealed, in part, oxygen tubing and cannulas should be replaced every 7 days. Review of Resident #14's July 2025 Physician's orders revealed, in part, an order dated 06/27/2025 for Resident #14 to receive oxygen at 2 liters (L) by nasal cannula continuously. Observation on 07/28/2025 at 11:14AM revealed Resident #14's oxygen tubing had a date of 07/06 written on the tubing. Observation on 07/29/2025 at 2:30PM revealed Resident #14's oxygen tubing had a date of 07/06 written on the tubing. In an interview on 07/30/2025 at 11:01AM, S11Licensed Practical Nurse (LPN) indicated Resident #14's oxygen tubing should have been changed out weekly. In an interview on 07/31/2025 at 2:00PM, S1Administrator was informed of the above and offered no explanation to dispute the above mentioned deficient practice.

Based on observations, interviews and record reviews, the facility failed to ensure a resident's Electronic Medical Record (EMR) was accurately documented for 5 (Resident #8, Resident #13, Resident #14, Resident #53, Resident #110) of 46 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, Resident #14, Resident #16, Resident #18, Resident #19, Resident #23, Resident #26, Resident #32, Resident #39, Resident #42, Resident #53, Resident #55, Resident #56, Resident #60, Resident #62, Resident #63, Resident #67, Resident #68, Resident #69, Resident #74, Resident #80, Resident #81, Resident #85, Resident #87, Resident #89, Resident #93, Resident #95, Resident #108, Resident #110, Resident #114, Resident #115, Resident #118, Resident #119, Resident #120, and Resident #121) sampled residents reviewed for accurate medical record documentation. Findings:Resident #8 Review of Resident #8’s Care Plan, initiated on 07/15/2025, revealed, in part, Resident #8 should have brake extenders with highlighted tape added to her wheelchair due to recent falls. Review of Resident #8’s July 2025 Electronic Task Completion List revealed, in part, Resident #8 was documented as having had all of her safety devices and special equipment in place per the plan of care on the following dates: - 07/28/2025 at 10:58AM by S5Certified Nursing Assistant (CNA); - 07/28/2025 at 6:27PM by S9CNA; - 07/29/2025 at 5:06AM by S9CNA; - 07/29/2025 at 7:56AM by S5CNA; - 07/29/2025 at 2:53AM by S5CNA; - 07/30/2025 at 5:44AM by S8CNA; - 07/30/2025 at 8:11AM by S6CNA; - 07/30/2025 at 9:09PM by S7CNA; - 07/30/2025 at 10:13AM by S6CNA; and, - 07/31/2025 at 11:14AM by S4CNA. Observation on 07/28/2025 at 11:50AM revealed Resident #8’s wheelchair did not have brake extenders with highlighted tape. Observation on 07/29/2025 at 2:15PM revealed Resident #8’s wheelchair did not have brake extenders with highlighted tape. Observation on 07/30/2025 at 1:46PM revealed Resident #8’s wheelchair did not have brake extenders with highlighted tape. Observation on 07/31/2025 at 12:14PM, with S10Licensed Practical Nurse (LPN) present, revealed Resident #8’s wheelchair did not have brake extenders with highlighted tape. In an interview on 07/31/2025 at 12:08PM, S4CNA indicated she was assigned to care for Resident #8. S4CNA indicated she documented all safety precautions and/or interventions were in place for Resident #8 but did not know what all of the safety precautions were. In an interview on 07/31/2025 at 12:15PM, S10LPN confirmed Resident #8 did not have wheelchair brake extenders with highlighted tape on Resident #8’s wheelchair. In an interview on 07/31/2025 at 2:00PM, S1Administrator was presented with the above mentioned findings and offered no explanation or evidence to dispute the above mentioned deficient practice. Resident #13 Review of Resident #13’s Administration History Report revealed, in part, S3LPN documented on 07/30/2025 at 9:02AM that Resident #13 had received enteral feeding formula Nutren 2.0 as ordered. Observation on 07/30/2025 at 10:45AM revealed Resident #13 had Isosource 1.5 (a type of enteral feeding) infusing at a rate of 50 mL per hour. Further observation revealed the above mentioned Isosource 1.5 had an infusion start date and time of 07/30/2025 at 10:00PM labeled on the enteral feeding bag. In an interview on 07/30/20250at 11:10AM, S10LPN indicated her documentation that Resident #13 received Nutren 2.0 enteral feed on 07/30/2025 at 9:02AM was inaccurate and should not have been. In an interview on 07/30/2025 at 11:54AM, S2Director of Nursing (DON) confirmed Resident #13’s enteral feeding bag was labeled with the incorrect date. In an interview on 07/31/2025 at 2:00PM, S1Administrator was presented with the above mentioned findings and offered no explanation or evidence to dispute the above mentioned deficient practice. Resident #14 Review of Resident #14’s July 2025 Electronic Task Completion List revealed, in part, Resident #14’s oxygen tubing was documented as having been changed on the following dates: - 07/12/2025 at 6:27AM by S3LPN; - 07/19/2025 at 6:22AM by S3LPN; and, - 07/26/2025 at 6:36AM by S3LPN. Observation on 07/28/2025 at 11:14AM revealed Resident #14's oxygen tubing had a date 07/06 written on the tubing. Observation on 07/29/2025 at 2:30PM revealed Resident #14’s oxygen tubing had a date 07/06 written on the tubing. In an interview on 07/30/2025 at 11:01AM, S11LPN indicated Resident #14’s oxygen tubing should have been changed out weekly. S11LPN further indicated she did not know when the last time Resident #14’s oxygen tubing was changed out. In an interview on 07/31/2025 at 2:00PM, S1Administrator was presented with the above mentioned findings and offered no explanation or evidence to dispute the above mentioned deficient practice. Resident #53 Review of the facility’s Advance Directives policy and procedure, with a revision date of 07/2015, revealed, in part, if an Advance Directive has been completed, the admitting staff must obtain a copy of the Advance Directive so it may be placed in the medical record. Further observation revealed the admitting staff will document in the medical record and will notify the attending physician verbally and obtain a physician’s order if the resident has executed an Advance Directive. Review of Resident #53’s July 2025, electronic record revealed, in part, an order for Resident #53 to be a Full Code (which indicated in the event a resident presented with no pulse or no breath, medical interventions would take place). Review of Resident #53’s paper medical record revealed, in part, an Advanced Directive which indicated Resident #53’s code status was Do Not Resuscitate (DNR) (which indicated in the event a resident presented with no pulse and/or no breath, medical interventions would not take place). In an interview on 07/28/2025 12:29PM, Resident #53 indicated she wanted DNR to be her code status. In an interview on 07/28/2025 12:41PM, S1Administrator and S2Director of Nursing indicated when a code blue was called the actual chart and advance directive paper form was used. In an interview on 07/30/2025 9:45AM, S11Licensed Practical Nurse indicated the actual paper chart was used to determine a resident’s code status. In an interview on 07/30/2025 9:52AM, S18Licensed Practical Nurse indicated the actual paper chart was used to determine a resident’s code status. In an interview on 07/31/2025 11:15 AM S17Licensed Practical Nurse indicated the actual paper chart was used to determine as resident’s code status. In an interview on 07/31/2025 11:43 AM S11Licensed Practical Nurse indicated Resident #53’s Full Code status order in the July 2025, physician’s orders was incorrect. In an interview on 07/31/2025 12:07 PM S2(DON) indicated Resident #53's full code status in the computer was incorrect. In an interview on 07/31/2025 12:11 PM S1(NFA) indicated Resident #53's full code status in the computer was incorrect. Resident #110 Review of Resident #110’s Bathing Care Task log revealed, in part, no documented evidence, Resident #110 received and/or refused a bath/shower on 07/02/2025, 07/09/2025, 07/14/2025, 07/21/2025, and 07/28/2025. There was no documented evidence, and the facility did not present any documented evidence, staff documented if Resident #110 had received and/or refused a bath/shower on 07/02/2025, 07/09/2025, 07/14/2025, 07/21/2025, and 07/28/2025. In an interview on 07/30/2025 at 3:30PM, S2DON indicated Resident #110 was scheduled to have baths on Mondays, Wednesdays, and Fridays. S2DON further indicated S19CNA should have documented when Resident #110 received a bath/shower on the above mentioned dates.

Based on observations, interviews, and record reviews, the facility failed to:1. Post the appropriate signage for contact isolation on a resident's door (Resident #4, Resident #5);2. Ensure Certified Nursing Assistants (CNAs) wore proper personal protective equipment (PPE) while performing incontinence care on a resident on Enhanced Barrier Precautions (EBP) (Resident #67); and,3. Ensure CNAs completed hand hygiene during incontinence care (Resident #67).This deficient practice was identified for 3 (Resident #4, Resident #5, Resident #67) of 3 (Resident #4, Resident #5, Resident #67) sampled residents investigated for infection control surveillance. Findings:1. Review of the facility’s Procedure for Isolation: Isolation Precautions policy and procedure, dated 04/2006 and revised on 04/2014, revealed, in part, appropriate signage (isolation precaution signage) should be posted outside the resident’s door. Resident #4 Review of Resident #4’s July 2025 physician’s orders revealed, in part, an order for strict contact isolation precautions for Resident #4. Review of Resident #4’s Care Plan, initiated on 07/19/2025, revealed, in part, Resident #4 had a urinary tract infection (UTI) related to Extended-Spectrum Beta-Lactamases (ESBL) (a type of UTI that is caused by an ESBL bacteria, which is a bacteria resistant to many common antibiotics, making treatment more challenging). Observation on 07/28/2025 at 9:31AM revealed no contact isolation precaution signage was posted on Resident #4’s door. Resident #5 Review of Resident #5’s July 2025 physician’s orders revealed, in part, strict isolation for contact precautions. Review of Resident #5’s Care Plan, initiated on 07/26/2025, revealed, in part, Resident #5 was on contact isolation due to ESBL in her urine. Observation on 07/28/2025 at 9:28AM revealed no contact isolation precaution signage was posted on Resident #4’s door. In an interview on 07/28/2025 at 10:15AM, S2Director of Nursing (DON) confirmed Resident #4 and Resident #5 were on contact isolation due to ESBL in their urine. S2DON confirmed Resident #4 and Resident #5 should have had appropriate isolation signage posted on the outside of their door and they did not have the required signage posted. 2. Review of the facility’s Enhanced Barrier Precautions (EBP) policy and procedure, dated 01/2023, and revised on 03/2024, revealed, in part, EBP required the use of gown and gloves for high contact resident care activities such as urinary catheter care and incontinence care. Further review revealed EBP were indicated for residents with indwelling medical devices such as a urinary catheter. Review of Resident #67’s Care Plan, initiated on 09/16/2024 revealed, in part, Resident #67 was on EBP due to Resident #67’s indwelling urinary catheter. Observation on 07/29/2025 at 2:05PM revealed S4CNA entered Resident #67’s room to assist in performing catheter care and incontinence care. S4CNA did not put on a gown before she began to assist in the performance of Resident #67’s catheter care and incontinence care. S4CNA helped to remove Resident #67’s soiled brief, turned Resident #67, and placed a clean adult brief on Resident #67 without wearing a gown. In an interview on 07/29/2025 at 2:16PM, S4CNA indicated she did not think Resident #67 was on any barrier precautions. In an interview on 07/29/2025 at 2:30PM, S11Licensed Practical Nurse indicated Resident #67 was on EBP which included staff wearing gowns and gloves. In an interview on 07/31/2025 at 2:00PM, S1Administrator was presented with the above mentioned findings and offered no explanation to dispute the above mentioned deficient practice. 3. Review of the facility’s Hand Hygiene policy and procedure, dated 12/2011, and revised on 01/2024, revealed, in part, the purpose of hand hygiene was to cleanse hands to prevent transmission of infection or other conditions. Further review revealed hand hygiene should have been performed between all contact with residents and before and after applying gloves. Review of the Centers for Disease Control and Prevention (CDC)’s October 2022 Guidelines for Hand Hygiene in Health-Care Settings revealed, in part, staff should decontaminate their hands if moving from a contaminated body site to a clean body site during patient care. Observation on 07/29/2025 at 2:05PM revealed S5CNA entered Resident #67’s room to perform incontinence care. S5CNA then removed Resident #67's soiled adult brief, performed catheter care, cleaned Resident #21’s buttock area, and placed a clean adult brief on Resident #21 without changing gloves or performing hand hygiene. S5CNA then disposed of Resident #21's soiled adult brief into the trash. S5CNA then covered Resident #67 back up with her bedding while wearing the same gloves used to perform the above mentioned observation. In an interview on 01/14/2025 at 2:25PM, S5CNA confirmed she did not change gloves and perform hand hygiene after handling Resident #67’s soiled adult brief and/or after cleaning Resident #67’s soiled body and should have. In an interview on 07/31/2025 at 2:00PM, S1Administrator was presented with the above mentioned findings and offered no explanation to dispute the above mentioned deficient practice.

Based on observations, interviews, and record reviews, the facility failed to:1. Ensure staff wore hair restraints when preparing food in the facilities kitchen (S12Dietary Manager's Trainer, S13Dietary Aide, and S14Dietary Aide); 2. Ensure food stored in the facility's refrigerators were labeled as required (Refrigerator e, Freezer f);3. Ensure shelving in the facility's kitchen was kept in a sanitary manner;4. Ensure the facility's staff practiced appropriate hand hygiene (S15Dietary Aide and S12Dietary Manager's Trainer);5. Ensure chemicals were kept out of food service areas;6. Ensure utensils were stored in a sanitary manner when not in use; and,7. Ensure cartons of nutritional supplement was stored per a manufacturer's guideline and was not available for resident consumption (Medication Cart c, Medication cart d).The deficient practice was identified for 3 of 3 days observed for food preparation and storage requirements. Findings: 1. Review of the facility’s Employee Work Practices policy and procedure, last revised in 05/2018, revealed, in part, food service employees were to wear a clean hat or other hair restraint in the food production area; and or a beard restraint. Observation on 07/29/2025 at 11:15AM, revealed S12Dietary Manager’s Trainer had a section of hair to the left and right of her forehead styled and unrestrained from her hair net. Further observation revealed S13Dietary Aide had a mustache with no facial hair restraint in place. Observation on 07/29/2025 at 11:40AM, revealed S14Dietary Aide had a beard with no facial hair restraint in place, and S13Dietary Aide had a mustache with no facial hair restraint in place. In an interview on 07/29/2025 at 11:48AM, S12Dietary Manager’s Trainer indicated all hair should be restrained in a hair net. S12Dietary Manager’s Trainer confirmed anyone with facial hair should have a facial hair restraint. 2. Review of the facility's Food Storage Labeling policy and procedure, last revised on 05/2018, revealed, in part, all foods that are prepared in the facility should be labeled with the name of the food and the date of storage. Observation on 07/28/2025 at 09:01AM, revealed a three-fourths full container of Italian dressing was in Refrigerator “e” and was not labeled with an opened date. In an interview on 07/29/2025 2:56PM, S1Administrator indicated the above-mentioned finding was an oversight habit that should have not happened. Observation of Freezer “f” on 07/30/2025 at 10:39AM revealed a pitcher of an unknown light brown liquid was not labeled with the contents of the pitcher and/or the date of storage. In an interview on 07/30/2025 at 10:30AM, S2Director of Nursing indicated all items in Freezer “f” should be labeled and dated. In interview on 07/30/2025 at 10:34AM, S1Administrator indicated the above mentioned findings should not have been present. 3. Observation on 07/28/2025 at 09:01AM, revealed an unknown gray dusty-like substance was present on the shelf on top of the kitchen’s 3-compartment sink. Observation on 07/29/2025 at 11:38AM revealed the shelf next to the kitchen’s food prep sink had nine buckets and five metal containers sitting on a shelf. Further observation revealed the above mentioned shelf was covered with a grayish, dusty-like, slightly sticky substance. In an interview on 07/29/2025 at 11:40AM, S12Dietary Manager’s Trainer indicated the facility’s staff should clean all surfaces every week and the above mentioned shelves should have been clean. In an interview on 07/29/2025 2:56PM, S1Administrator indicated the above mentioned finding was an oversight habit that should have not happened. 4. Observation on 07/29/2025 at 11:20AM revealed, while checking food temperatures, S15Dietary Aide dropped the thermometer into the food. Further observation revealed, S15Dietary Aide then stuck her ungloved hand into the food to retrieve the thermometer. Observation on 07/29/2025 at 11:43AM, revealed S12Dietary Manager’s Trainer opened a trash can lid with her ungloved hands to throw a spatula away, opened the trash can lid again with her ungloved hands to throw away another item, did not perform hand hygiene, and then handed the dietary staff serving food to residents a stack of clean plates. In interview on 07/30/2025 at 10:34AM, S1Administrator indicated he had reviewed the surveillance footage from the kitchen and confirmed the surveyor’s observations of S12Dietary Manager Trainer, which were deficient practice. 5. Observation on 07/29/2025 at 11:23AM revealed a cleaning bucket with sanitizing solution was next to desserts and salads that were on the serving table behind the kitchen’s steam table. In an interview on 07/29/2025 at 11:36AM, S12Dietary Manager’s Trainer indicated the red bucket with the liquid and towel contained sanitizer. S12Dietary Manager’s Trainer further indicated she did not think this was a chemical. In an interview on 07/29/2025 2:56PM, S1Administrator indicated the above mentioned finding was an oversight habit that should have not happened. 6. Review of the Louisiana Administrative Code Title 51: Public Health-Sanitary Code, last revised in 02/2025 revealed, in part, during pauses in food preparation or dispensing, utensils shall be stored with their handles above the top of the food. Observation on 07/29/2025 at 11:28AM, S16Dietary Aide was using tongs to serve chicken with ungloves hands. Further observation revealed S16Dietary Aide then laid the tongs with the area she touched with her ungloved hands directly on top of the chicken. Observation on 07/29/2025 at 11:33AM, S15Dietary Aide was using tongs to serve biscuits with ungloved hands. Further observation revealed S15Dietary Aide then laid the tongs with the area she touched with her ungloved hands directly on top of the biscuits. In an interview on 07/29/2025 2:56PM, S1Administrator indicated the above mentioned findings were an oversight habit that should have not happened. 7. Review of Med Plus 2.0 nutritional supplement's directions revealed, in part, the product should be used within 4 hours of opening if not refrigerated. Observation on 07/31/2025 at 12:49PM revealed an opened unrefrigerated carton of Med Plus 2.0 nutritional supplement on Medication Cart “c”. Further observation revealed the above mentioned carton did not have an opened date and/or time written on it. Observation on 07/31/2025 at 12:51PM revealed an opened unrefrigerated carton of Med Plus 2.0 nutritional supplement on Medication Cart “d”. Further observation revealed the above mentioned carton did not have an opened date and/or time written on it. In an interview on 07/31/2025 at 1:04PM, S10Licensed Practical Nurse (LPN) confirmed she was assigned to Medication cart “c”. S10LPN further indicated the above mentioned supplement was opened on 07/31/2025 at 7:00AM, not refrigerated, and available for resident consumption. S10LPN further indicated she did not know the supplement should have been used within 4 hours of opening if not refrigerated. In an interview on 07/31/2025 at 1:05PM, S11LPN confirmed she was assigned to Medication cart “d”. S11LPN further indicated the above mentioned supplement was opened on 07/31/2025 at 6:00AM, not refrigerated, and available for resident consumption. In an interview on 07/31/2025 at 2:00PM, S1Administrator was presented with the above mentioned findings and offered no further explanation to dispute the above mentioned deficient practice.

Based on record reviews and interviews, the facility failed to ensure the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN), form Centers for Medicare and Medicaid Services (CMS)-10055, was completed prior to the discontinuation of Medicare Part A services (short term skilled nursing care and/or rehabilitation) for 2 (Resident #364 and Resident #365) of 3 (Resident #364, Resident #365, and Resident #366) sampled residents reviewed for termination of Medicare Part A services. Findings: Review of the facility's Traditional Medicare Beneficiary Notices for the Skilled Nursing Facility (SNF) policy, dated 03/2019, revealed, in part, the SNF was required to issue a SNFABN (CMS Form CMS-10055) before providing extended care items or services that Medicare was not expected to pay. The notice must be issued at least three days prior to terminating services, when the resident had days remaining in the benefit period and would remain in the facility under custodial care. Review of Resident #364's Skilled Nursing Facility Beneficiary Protection Notification Review, form CMS-20052, completed by the facility, revealed, in part, Resident #364's last day of Medicare Part A Services was on 01/11/2024. Review of Resident #364's record revealed, in part, a facility discharge date of 01/15/2024. There was no documented evidence, and the facility was unable to present any documented evidence, Resident #364 had a signed CMS-10055 form prior to Medicare Part A services being terminated by the facility on 01/11/2024. Review of Resident #365's Skilled Nursing Facility Beneficiary Protection Notification Review, form CMS-20052, completed by the facility revealed, in part, Resident #365's last day of Medicare Part A services was on 06/12/2024. Review of Resident #365's record revealed, in part, a facility discharge date of 06/26/2024. There was no documented evidence, and the facility was unable to present any documented evidence Resident #365 had a signed CMS-10055 form prior to Medicare Part A services being terminated by the facility on 06/12/2024. In an interview on 07/17/2024 at 2:20 p.m., S5AccountsManager confirmed Resident #364 and Resident #365 did not have form CMS-10055 completed prior to Medicare Part A services being terminated by the facility. In an interview on 07/18/2024 at 10:17 a.m., S1Administrator confirmed that Resident #364 and 365 did not have form CMS-10055 completed and should have.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to provide a bed-hold notice upon hospital transfer for 2 (Resident #46 and Resident #49) of 2 (Resident #46 and Resident #49) residents investigated for hospitalizations. Findings: Review of the facility's Bed Hold Policy last revised on 11/2023 revealed, in part, when a resident was transferred to the hospital, a copy of the completed form (notice) was to be provided to the resident, specifying the duration of the bed-hold according to the state plan and the facility's policy regarding bed-hold periods. Resident #46 Review of Resident #46's clinical record revealed Resident #46 had an emergency transfer to the hospital on [DATE]. Review of Resident #46's Bed Hold Agreement revealed it was signed and not dated. Resident #49 Review of Resident #49's clinical record revealed Resident #49 had an emergency transfer to the hospital on [DATE]. Review of Resident #49's Bed Hold Agreement revealed it was signed and not dated. In an interview on 07/17/2024 at 1:32 p.m., S5Accounts Manager (AM) indicated Resident #46 and Resident #49's Bed Hold Agreements were signed upon admission, but were not dated. S5AM further indicated when a resident was admitted to the hospital, she called the resident or the resident's representative on the seventh day following the hospitalization to review the bed hold policy. In an interview on 07/17/2024 at 2:22 p.m., S1Administrator indicated the bed hold policy was signed upon admission, and when it was possible a resident would re-sign the bed hold policy upon transfer to the hospital. S1Administrator further indicated if the resident was sent to the emergency room, the facility should call the resident representative in regards to the bed hold policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure a resident with a diagnosis of schizoaffective disorder was referred to the appropriate state agency for a Preadmission Screening and Resident Review (PASARR) Level II evaluation as required for 1 (Resident #57) of 1 (Resident #57) sampled residents reviewed for PASARR. Findings: Review of Resident #57's Electronic Medical Record (EMR) revealed, in part, Resident #57 was diagnosed on [DATE] with schizoaffective disorder. Further review of Resident #57's EMR revealed, in part, no evidence that a Level II evaluation was completed. There was no documented evidence and the facility did not present any documented evidence of completing a Level II PASARR evaluation as required for Resident #57. In an interview on 07/16/2024 2:05 p.m., S6Assistant Administrator confirmed that the facility did not have documentation that a Level II evaluation was completed for Resident #57 after a new mental disorder diagnosis. In an interview on 07/18/2024 at 10:20 a.m., S1Administrator confirmed the facility did not have documentation that a Level II evaluation was completed for Resident #57. S1Administrator further indicated Social Services should have referred Resident #57 for a Level II evaluation.

Based on record reviews and interviews, the facility failed to ensure a Level 1 Pre-admission Screening and Resident Review (PASARR) was accurately completed to reflect a resident's mental illness for 1 (Resident #57) of 1 (Resident #57) sampled residents reviewed for PASARR. Findings: Review of Resident #57's face sheet revealed, in part, an admit date of 07/18/2018 with a diagnoses of major depressive disorder. Review of Resident #57's Minimum Data Set with an Assessment Reference Date of 05/31/2024 revealed, in part, Resident #57 required daily antidepressant medications. Review of Resident #57's Level 1 PASARR assessment completed on 07/02/2018 revealed, in part, Resident #57 was documented to not have been diagnosed with a mental illness. Further review revealed no psychiatric diagnosis was selected/identified on the above mentioned assessment. In an interview on 07/17/2024 at 10:29 a.m., S7Admissions Coordinator indicated Resident #57's Level 1 PASARR was not verified for accuracy and should have been. In an interview on 07/17/2024 at 12:41 p.m., S6Assistant Administrator confirmed Resident #57's preadmission Level 1 PASARR was inaccurate and the accuracy was not verified upon admission. In an interview on 07/18/2024 at 10:20 a.m., S1Administrator confirmed Resident #57's Level I PASARR was not verified for accuracy and should have been.

Based on record reviews, observations, and interviews, the facility failed to ensure a resident was assisted for oral care as needed for 1 (Resident #7) of 1 (Resident #7) sampled residents reviewed for activities of daily living. Findings: Review of Minimum Data Set (MDS) Assessment Reference Date (ARD) 06/06/2024 revealed a Brief Interview for Mental Status (BIMS) score of 15 (score of 13-15 indicated the resident was cognitively intact). Further review revealed Resident #7 required setup or clean-up assistance with oral hygiene. Review of Resident #7's care plan with a goal date of 09/15/2024 revealed, in part, Resident #7 needed assistance with oral hygiene with an intervention to assist Resident #7 as needed with oral hygiene. Observation on 07/15/2024 at 10:29 a.m. revealed Resident # 7 had an unknown thick white and gray substance on her teeth. Observation on 07/16/2024 at 2:20 p.m. revealed Resident #7 had an unknown thick white and gray substance on her front teeth. Observation on 07/17/2024 at 1:35 p.m. revealed Resident #7 had an unknown thick white and gray substance on her teeth. Review of Resident #7's Personal Hygiene Activities of Daily Living documentation revealed no documented evidence, and the facility was unable to present any documented evidence, Resident #7 had oral care provided on the following dates: 06/18/2024, 06/22/2024, 06/21/2024, 06/23/2024 through 06/28/2024, 07/01/2024, 07/02/2024, 07/04/2024, 07/09/2024, 07/10/2024, 07/14/2024, and 07/15/2024. In an interview on 07/17/2024 at 1:35 p.m., Resident #7 indicated she only gets to brush her teeth when she complains to staff, and then the staff will set her up with the supplies to brush her teeth. Resident #7 further indicated she might get to brush her teeth twice a week at the most. In an interview on 07/17/2024 at 2:55 p.m., S10Certified Nursing Assistant (CNA) indicated the staff has to set Resident #7 up for oral care and monitor Resident #7 during oral care. S10CNA indicated oral care for Resident #7 should be completed on the morning shift and after supper on the evening shift. S10CNA further indicated care for Resident #7's teeth should be documented under oral care when completed. In an interview on 07/18/2024 at 9:21 a.m., S2Director of Nursing (DON) indicated the facility did not have any further documentation to present that Resident #7 had received oral care as required.

Based on observation and interviews, the facility failed to maintain the facility's ice machine in a sanitary manner for 1 (Ice Machine f) of 4 (Ice Machine c, Ice Machine d, Ice Machine e, and Ice Machine f) ice machines observed during kitchen observations. Findings: Observation on 07/16/2024 at 12:45 p.m. of Ice Machine f revealed the grate at the bottom of the ice machine had an unknown white and gray substance, and a thin shiny film under the grate. Further observation revealed the outlet, where the ice/water exited the machine, had a brown unknown substance in the outlet. In an interview on 07/16/2024 at 1:05 p.m., S9Dietary Manager indicated she was not aware of who was responsible for the cleaning of Ice Machine f. S9Dietary Manager further indicated Ice Machine f was not clean or sanitary, and was being used by residents and staff. In an interview on 07/16/2024 at 1:25 p.m., S8Maintenance indicated ice machines should be cleaned once a month; however, he had failed to clean the outlet or bottom grate of Ice Machine f for over a month and a half. S8Maintenance further indicated the grate and outlet of Ice Machine f needed to be cleaned and was not clean and sanitary at the present time. In an interview on 07/16/2024 at 2:05 p.m., S1Administrator indicated he had seen Ice Machine f and confirmed the machine was in need of a thorough cleaning and was not sanitary.

Based on record review, observations, and interviews, the facility failed to ensure staff cleaned the shower chairs between resident use with an approved disinfectant for 2 (Shower Room a and Shower Room b) of 2 (Shower Room a and Shower Room b) shower rooms observed for infection control practices. Findings: Review of the facility's Whirlpool and Tub Cleaning procedure dated 08/2021 revealed, in part, the shower chair should be sprayed with an approved disinfectant. Further review revealed the approved disinfectant should sit on the surface for 3 minutes, and the surface should be wiped with a clean damp cloth. Further review revealed the shower chair should be cleaned and disinfected between each use. In an interview on 07/15/2024 at 10:02 a.m., S4Certified Nursing Assistant (CNA), assigned to Shower Room b, indicated Virex was the approved disinfectant to be used to clean the shower chair between resident use. S4CNA presented the surveyor with a bottle of cleaner which was labeled as heavy duty floor cleaner which was identified as the cleaner that staff used to clean shower chairs. S4CNA indicated the bottle labeled as heavy duty floor cleaner was the cleaner she used to clean the shower chairs between resident use. In an interview on 07/15/2024 at 10:17 a.m., S3CNA, assigned to Shower Room a, indicated Virex was the approved disinfectant to be used to clean the shower chair between resident use, but Virex was not available in Shower Room a. S3CNA further indicated she had worked in all of the shower rooms in the facility, and the approved disinfectant had not been available. In an interview on 07/15/2024 at 12:15 p.m., S2Director of Nurses (DON) confirmed Virex was the approved disinfectant to be used to clean the shower chair between resident use. On 07/15/2024 at 12:15 p.m. S2DON accompanied the surveyor to Shower Room a and Shower Room b and confirmed Virex was not available in the shower rooms. S2DON confirmed the bottle of cleaner in Shower Room b was labeled as heavy duty floor cleaner. In an interview on 07/15/2024 at 12:17 p.m., S1Administrator confirmed Virex should be used to disinfect the shower chair between resident use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents received their medications according to the plan of care by: 1. Failing to have medications Acetaminophen - Codeine # 4 and Cosopt PF available for Resident #52. 2. Failing to have medication Tramadol 100 mg (milligrams) for Resident #55; and, 3. Failing to administer the correct dosage of the medication Tramadol 100 mg for Resident #55. There was a total of 24 total sampled residents. Findings: Resident # 52 Review of Resident #52's Physicians Order dated 08/20/2023 revealed, in part, Acetaminophen - Codeine #4 (pain medication) one by mouth two times a day and Cosopt PF (eye drop) one drop into both eyes twice a day. Review of Resident # 52's Individual Resident Narcotics Record revealed, in part, Acetaminophen - Codeine # 4 last dose was available on 08/16/2023 at 8:00 a.m. Further review revealed, in part, Resident #52's Individual Resident Narcotics Record Acetaminophen - Codeine # 4 became available 08/29/2023 at 8:00 a.m. Review of Resident #52's Electronic Medication Administration Record (eMAR) dated 08/2023 revealed, in part, Acetaminophen - Codeine #4 was documented as administered on the following dates when the medication was not available: 08/16/2023 at 8:00 p.m., 8/18/2023 at 8:00 a.m. and 8:00 p.m., 08/20/2023 at 8:00 p.m., 08/21/2023 at 8:00 a.m. and 8:00 p.m., 08/22/2023 at 8:00 a.m. and 8:00 p.m., 08/23/2023 at 8:00 a.m. and 8:00 p.m., 08/24/2023 at 8:00 a.m., 08/25/2023 at 8:00 a.m. and 8:00 p.m., 08/28/2023 at 8:00 a.m. and 8:00 p.m. Further review revealed Cosopt PF was not available to be administered on 08/18/2023 at 8:00 a.m. and 08/20/2023 at 8:00 a.m. In an interview on 08/30/23 at 11:37 a.m., S2 Director of Nursing (DON) confirmed Acetaminophen - Codeine #4 was not available for Resident #52 from 08/16/2023 to 08/28/23. S2DON further stated Cosopt PF was not available to be administered on 08/18/2023 at 8:00 a.m., and 08/20/2023 at 8:00 a.m. since it was also not available. Resident #55 Review of Resident #55's medical records revealed, in part, Resident #55 was admitted to the facility on [DATE]. Review of Resident #55's diagnosis list revealed, in part, Resident #55 has a diagnosis of multiple myeloma, malignant neoplasm of right and left lower lung, personal history of malignant neoplasm of bronchus, and bilateral osteoarthritis of hip. In an interview on 08/28/2023 at 10:00 a.m., Resident #55 stated she was in pain because she did not get her pain medication over the weekend because the facility ran out of her Tramadol (an opioid pain medication used to treat moderately severe pain). Review of Resident #55's August 2023 physician orders revealed, in part, an order to give Tramadol 100 mg by mouth three times daily. Review of Resident #55's August 2023 eMAR revealed, in part, Tramadol 100 mg was not given on, 08/26/2023 at 5:00 a.m., 1:00 p.m., and 9:00 p.m., 08/27/2023 at 5:00 a.m., 1:00 p.m., and 9:00 p.m., and 08/28/2023 at 5:00 a.m. In an interview on 08/30/2023 at 9:33 a.m., S2DON confirmed Resident #55 did not receive Tramadol 100 mg three times a day from 08/26/2023 to 08/28/2023 because the medication was not available. Review of Resident #55's medication label for Tramadol revealed, in part, Tramadol 50 mg tablet take two tablets by mouth three times daily. Review of Resident #55's individual resident narcotics record revealed, in part, Tramadol 50 mg was signed out to be given instead of Tramadol 100 mg on: -08/13/2023 at 9:00 p.m. -08/14/2023 at 6:00 a.m. -08/15/2023 at 5:30 a.m. -08/17/2023 at 5:00 a.m. -08/17/2023 at 8:00 p.m. -08/18/2023 at 5:30 a.m. -08/18/2023 at 8:00 p.m. -08/19/2023 at 4:00 a.m. -08/20/2023 at 5:00 a.m. -08/21/2023 at 8:00 p.m. -08/22/2023 at 4:35 a.m. -08/23/2023 at 4:00 a.m. -08/25/2023 at 1:00 p.m. In an interview on 08/30/2023 at 9:33 a.m., S2DON confirmed Tramadol 50 mg was signed out for administration and Tramadol 100 mg was ordered. S2DON acknowledged after review of Resident #55's individual narcotic inventory count sheet Resident #55 did not receive the correct dose of Tramadol on the above listed dates.

Based on record reviews and interviews the facility failed to maintain an accurate Individual Resident Narcotics Record by using correction tape/liquid and by not drawing a line through the error and by not having staff initial and witness. This deficient practice was identified for 2 (Resident #52 and Resident #55) of 2 (Resident #52 and Resident #55) residents reviewed for medication administration. Findings: Resident #52 Review of Resident #52's Individual Resident Narcotic record revealed, in part, on 08/29/2023 at 8:00 a.m. and 8:00 p.m. correction tape/liquid was used to correct the amount of medication given and on 08/29/2023 at 8:00 pm correction tape/liquid was used to correct the amount of medications remaining. In an interview on 08/30/23 at 10:23 a.m., S5LPN confirmed Resident #52's Individual Resident Narcotics Record revealed three areas on the form where correction tape/liquid was used. S5LPN stated an error should be corrected by drawing a line through the error on the Individual Resident Narcotics Record and have another nurse to witness and initial the correction. In an interview on 08/30/23 at 10:37 a.m., S2DON confirmed correction tape/liquid should not be used on the Individual Resident Narcotics Record and it was against professional standards. Resident #55 Review of Resident #55's Individual Resident Narcotics Record revealed, in part, correction tape/liquid was used to correct the amount of medication on hand and the amount of medication remaining three times on 08/28/2023, three times on 08/29/2023, and once on 08/28/2023. Further review of the Individual Resident Narcotics Record revealed corrections were made to the amount given by writing over the amount given (changing 1 to 2) without drawing a line through the error and without having a witness to initial the correction was made. In an interview on 08/30/2023 at 10:00 a.m., S5LPN stated she used correction tape/liquid to correct Resident #55's Individual Resident Narcotics record because the correct numbers of pills were not being given by staff. S5LPN further stated correction tape/liquid should have not been used to make corrections on Resident #55's Individual Resident Narcotics Record and corrections should be made by drawing a line through the error and initialed by a witness to verify the correction. In an interview on 08/30/2023 at 10:30 a.m., S2DON confirmed Resident #55's Individual Resident Narcotics Record was corrected using correction tape/liquid and it should not have been used. S2DON agreed it was difficult to determine if the reconciliation of the narcotics were correct due to the improper method of corrections.

Based on observations and interview, the facility failed to store food in a manner to prevent the possibility of food contamination. This deficient practice has the potential to effect a total of 116 residents who receive food from the kitchen. Findings: Observation of the facility's kitchen dry storage room on 08/28/2023 at 9:20 a.m. revealed, in part, two 5 pound containers of opened peanut butter with no open date, a 14 ounce container of opened coffee creamer with no open date, a 5 pound bag of opened chocolate cake mix with no open date, a 5 pound bag of opened yellow cake mix with no open date, and a 16 ounce box of opened powdered sugar with no open date. Observation of the facility's cooler on 08/28/2023 at 9:30 a.m. revealed, in part, a container with brown gravy and 6 ground beef patties with no label or date and two 24 ounce containers of sour cream with a best used date by of March 2023. Observation further revealed one container of sour cream was opened with no date and a grayish-black substance was noted around the rim of the container. In an interview on 08/28/2023 at 9:30 a.m., S6Assistant Dietary Manager (ADM) stated all the above listed items should have been dated when opened, and the items past the best used by date should have been discarded and not available for use. In an interview on 08/28/2023 at 3:30 p.m. S7Dietary Manager (DM) stated all items above found without dates and labels should have been dated and labeled when opened.

Based on record review and interview the facility failed to accurately document administration of medications by: 1. Failed to document Norco 5-325 mg (milligram) tablet was administered to Resident #1 on the electronic medication administration record (EMAR); and, 2. Failed to accurately document Acetaminophen - Codeine #4 when medication was not available for Resident # 52 of the 24 total sampled residents. Findings: Resident # 1 Review of Resident #1 Review of Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 08/03/2023 revealed, in part, Resident #1 has a Brief Interview Mental Status score of 15 which indicates Resident #1 was cognitively intact. In an interview on 08/29/2023 at 11:45 a.m., Resident #1 stated she had pain daily and required pain medication daily. Review of Resident #1's August 2023 physician orders revealed, in part, an order for Norco 5-325 mg tablet, take 1 tablet by mouth every 8 hours as needed for pain. Review of Resident #1's August 2023 EMAR revealed no documentation Norco 5-325 mg was given for pain in the month of August. Review of Resident #1's Individual Resident Narcotic Record revealed, in part, Norco 5-325 mg was signed out to be administered on 08/17/2023, 08/19/2023, 08/20/2023, 08/21/2023, 08/27/2023, 08/28/2023, and 08/29/2023. In an interview on 08/30/2023 at 9:00 a.m., S5Licensed Practical Nurse (LPN) stated she gave Resident #1 Norco 5-325 mg on 08/28/2023 and 08/29/2023 and failed to document the medication was given on the medication administration record. S5LPN furthered stated medications given should be signed as given on the medication administration record. In an interview on 08/31/2023 at 11:00 a.m., S2Director of Nursing (DON) confirmed Resident #1's EMAR did not accurately reflect administration of Norco 5-325 mg. S2DON further indicated medications administered should be documented on the EMAR. Resident #52 Review of Resident # 52's Physicians Order dated 08/20/2023 revealed, in part, Acetaminophen -Codeine #4 (pain medication) one by mouth two times a day. Review of Resident # 52's Individual Resident Narcotics Record revealed, in part, Acetaminophen - Codeine # 4 last dose was last available on 08/16/2023 at 8:00 a.m. Further review revealed, in part, Resident # 52's Individual Resident Narcotics Record Acetaminophen - Codeine # 4 became available 08/29/2023 at 8:00 a.m. Review of Resident # 52's EMAR dated 08/2023 revealed, in part, Acetaminophen - Codeine #4 was documented administered on the following dates: 08/16/2023 at 8:00 p.m., 8/18/2023 at 8:00 a.m. and 8:00 p.m., 08/20/2023 at 8:00 p.m., 08/21/2023 8:00 a.m. and 8:00 p.m., 08/22/2023 8:00 a.m. and 8:00 p.m., 08/23/2023 8:00 a.m. and 8:00 p.m., 08/24/2023 8:00 a.m., 08/25/2023 8:00 a.m. and 8:00 p.m., 08/28/2023 8:00 a.m. and 8:00 p.m. In an interview on 08/18/2023 at 2:45 p.m., S2DON confirmed Resident # 52's Acetaminophen - Codeine # 4 should not have been documented as administered after the date of 08/16/2023 per the Individual Resident Narcotics Record because it was not available.