**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain personal hygiene for 1 (#3) of 3 (#3, #4, and #56) residents reviews for activities of daily living. Findings: Review of the medical record revealed resident #3 was admitted to the facility on [DATE] with diagnoses including in part, acute metabolic encephalopathy, cerebral infarction, and psychosis and delusion. Review of the admission Minimum Data Set, dated [DATE] revealed resident #3 had a brief mental Score of 08 which indicated that resident #3 had moderate cognitive impairment with his daily decision making skills. Review of resident #1's record revealed care planning for bathing/hygiene deficit dated 01/03/2025. The approaches included in part, total care for resident #3. Shower/clean and check fingernails. On 03/03/25 09:50 a.m., an observation revealed resident #3 lying in bed. Further observation revealed a buildup of dirt and grime observed underneath the nail beds of both his hands. On 03/03/2025 at 11:30 a.m., an observation revealed resident #3 sitting up in bed eating his lunch meal. Further observation revealed a buildup of dirt and grime under the nail beds of both of his hands. 03/03/2025 at 11:45 a.m., S2Director of Nursing was notified of the observations the buildup of dirt and grime underneath resident #3's nail beds. S2Director of Nursing observed the resident eating his lunch with the dirty fingernails. She confirmed that resident #3's fingernail beds needed cleaning. On 03/06/2025 at 11:30 a.m., S1Administrator was notified of the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #56 Review of the medical record revealed resident #56 was admitted to the facility on [DATE] with diagnoses that include type 2 diabetes mellitus, depression, restless leg syndrome, insomnia, hypertension, heart failure, chronic kidney disease, history of falls, edema and Non Hodgkin's lymphoma. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed it had not been completed at this time, due to the resident being admitted on [DATE]. On 03/05/2025 at 1:25 p.m., an observation revealed resident #56 lying in bed with a ¼ bed rail raised on the left side of the resident's bed. Review of resident #56's record revealed no documented evidence of the following: a physician's order for bed rails, informed consent from the resident or resident's representative for bed rail use, or an assessment for the risk of entrapment prior to installation of bed rails on resident #56's bed. On 03/05/2025 at 1:15 p.m., S2DON was notified of the above findings. She confirmed resident #56's record revealed no documented evidence of the following: a physician's order for bed rails, informed consent from the resident or resident's representative for bed rail use, or an assessment for the risk of entrapment prior to installation of bed rails on resident #56's bed. On 03/06/2025 at approximately 11:30 a.m., S1Administrator was notified of the findings regarding resident #56. Based on observations, record reviews, and interviews, the facility failed to 1) ensure residents had a physician's order for bed rails, 2) obtain consent from the resident or resident's representative for bed rail use, and 3) assess residents for the risk of entrapment from bed rails prior to the installation of bed rails for 3 (#3, #4, and #56) of 3 (#3, #4, and #56) residents reviewed for bed rails. Findings: Resident #3 Review of the medical record revealed resident #3 was admitted to the facility on [DATE] with diagnoses including, acute metabolic encephalopathy, cerebral infarction, psychosis and delusion. Review of the admission minimum data set (MDS) dated [DATE] revealed resident #3 had a brief interview of mental status (BIMS) score of 08 which indicated that resident #3 had moderate cognitive impairment with his daily decision making skills. Further review revealed that resident #3 was independent with rolling left and right, sit-to-lying, lying to sitting on the side of bed, supervision or touching with sit to stand, and chair/chair transfer. On 03/03/2025 at 11:18 a.m. and on 03/05/2025 at 9:50 a.m., observations revealed resident #3 was lying in bed with a ¼ bed rail raised on the left side of the resident's bed. The observations also revealed a second ¼ bed rail that was lowered on the right side. The lowered bed rail on the right side remained attached to the bed. Review of resident #3's record revealed no documented evidence of the following: a physician's order for bed rails, informed consent by the resident or resident's representative for bed rail use, or an assessment for the risk of entrapment prior to installation of bed rails on resident #3's bed. On 03/05/2025 at 1:25 p.m., S2Director of Nursing was notified of the above findings. She confirmed resident #3's record revealed no documented evidence of the following: a physician's order for bed rails, informed consent from the resident or resident's representative for bed rail use, or an assessment for the risk of entrapment prior to installation of bed rails on resident #3's bed. On 03/06/2025 at approximately 11:30 a.m., S1Administrator was notified of the findings related to the use of bed rails for resident #3. Resident #4 Review of the medical record revealed resident #4 was admitted to the facility on [DATE] with diagnoses that included psychosis and delusion. Review of the admission Minimum Data Set, dated [DATE] revealed resident #4 had a BIMS score of 04 which indicated that resident #4 had severe cognitive impairment with her daily decision making skills. Further review revealed that resident #4 required assistance with activities of daily living. On 03/03/2025 at 9:35 a.m. and 03/05/2025 at 8:45 a.m., observations revealed resident #4 was in bed with ¼ bed rails raised on both sides of the resident's bed. Further observation revealed the left bed was loose and wobbly. Review of resident #4's record revealed no documented evidence of the following: a physician's order for bed rails, informed consent from the resident or resident's representative for bed rail use, or an assessment for the risk of entrapment prior to installation of bed rails on resident #4's bed. On 03/05/2025 at 1:25 p.m., S2Director of Nursing was notified of the above findings. She confirmed resident #4's record revealed no documented evidence of the following: a physician's order for bed rails, informed consent from the resident or resident's representative for bed rail use, or an assessment for the risk of entrapment prior to installation of bed rails on resident #4's bed. On 03/06/2025 at approximately 11:30 a.m., S1Administrator was notified of the findings regarding resident #4.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to maintain a sanitary environment to help prevent the development and transmission of communicable diseases and infection by, 1) having dirty and expired items inside of the medication cart, 2) having nail clippers and employee personal belongings inside of the wound care cart, and 3) having non-medication items inside of the medication storage room. Findings: On [DATE] at 9:40 a.m., observation of the medication cart with S5Licensed Practical Nurse (LPN) revealed one large medication cup holding tray that had multiple areas of an old, dried, unknown crusty substance and particles scattered throughout the tray and one box that contained multiple individualized packages of Povidone-Iodine that expired on 12/2019. S5LPN confirmed the medication cup holding tray was dirty and needed to be cleaned and the expired packages of Povidone-Iodine should not have been stored inside of the medication cart and available for resident use. On [DATE] at 10:00 a.m., observation of the wound care cart with S3LPN revealed a box that contained one tube of Silver Sulfadiazine cream 1%, two tubes of Mupirocin ointment, one non-woven dressing, one piece of Dr. Scholl's Corn Cushion, and one large pair of nail clippers. The nail clippers were in direct contact with the items inside of the box. Further observation revealed a small Ziploc bag that contained multiple pieces of Halls cough drops and Jolly Ranchers hard candy. S3LPN confirmed the bag of cough drops and hard candy belonged to her (S3LPN). On [DATE] at 10:51 a.m., S2Director of Nursing (DON) was notified of the above findings regarding the observations of the medication and wound care carts. S2DON confirmed that expired items should not be stored inside of the medication cart and available for resident use. S2DON further confirmed the pair of nail clippers should not have been stored in direct contact with the wound care supplies and S3LPN should not have stored her personal belongings inside of the wound care cart due to cross contamination. On [DATE] at 9:45 a.m., an observation of the medication storage room with S4Licensed Practical Nurse (LPN) revealed there was one large tote bag that contained two boxes of insulin syringes, one large black swivel/rolling chair, one large Christmas Tree box, one medium sized box of artificial flowers, seven Christmas stockings, one 8.4 ounce of Scope mouth wash, one 5.7 ounce of Crest tooth paste, one large book titled Mutts Comic Art of [NAME], one door hanger, one large item grabber, one New Testament Bible, and two medium sized blue therapy type floor mats. S4LPN confirmed the items should not have stored inside of the medication storage room. On [DATE] at 10:20 a.m., S2Director of Nursing was notified of the above findings from the observation in the medication storage room. She confirmed the items should not have been stored inside of the medication storage room due to cross contamination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #106 Record review revealed resident #106 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia, altered mental status unspecified, type 2 diabetes mellitus without complications, dementia, essential hypertension, morbid severe obesity, cardiomegaly, acute embolism and thrombosis of unspecified deep veins of unspecified lower extremity, and pulmonary embolism. Review of resident #106's active March 2024 physician orders revealed an order for Oxygen (O2) at 3 liters per minute (LPM) via nasal cannula (NC). Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 14 which represents resident #106 was cognitively intact. Review of resident #106's active care plan revealed impaired breathing patterns. Further review of the care plan revealed the following approaches: Will receive Oxygen via nasal cannula as ordered. Uses O2/Nebulizer, if not in use place cannula/nebulizer tubing /mask in plastic bag. On 03/25/2024 at 08:05 a.m. an observation of resident #106's room revealed the humidification bottle that was dated 03/20/2024. The nasal cannula was uncovered and lying on the bedside dresser. Further observation revealed there was no plastic bag to store the nasal cannula. Resident #106 reported he receives oxygen at 3 LPM as needed. On 03/26/2024 at 07:38 a.m. an observation of resident #106 revealed he was eating breakfast in the dining room area. Resident #106's respirations were even and unlabored. On 03/26/2024 at 07:40 a.m. an observation of resident #106's room revealed the nasal cannula was uncovered and lying on the edge of his bed. On 03/26/24 08:00 a.m. an interview and observation with S2DON in resident #106's room revealed the nasal cannula was uncovered and lying on the edge of the bed. S2DON confirmed resident #106's nasal cannula should be stored in a plastic bag when not in use. Based on observations, record reviews, and interviews, the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for 2 (#105 and #106) of 2 (#105, and #106) residents reviewed for respiratory care. Findings: Resident #105 Review of the facility's Oxygen Therapy Policy with an effective date of 10/2008 and a revised date of 10/12/2022 revealed: I. Purpose To furnish a therapeutic concentration of oxygen in the treatment of disease involving anoxia. A. Nasal Cannula 11. Store nasal cannula in a plastic bag when not in use. Review of the medical record for sampled resident #105 revealed an admission date of 03/13/2024 with diagnoses including congested heart failure, edema, hypertension, cerebral infarction, thoracic aortic aneurysm, chronic respiratory failure with hypoxia, and vascular dementia. Review of the physician's orders dated 03/11/2024 revealed and order for oxygen at 3 liters per nasal cannula continuously. Review of the care plan revealed the resident's breathing patterns were impaired related to chronic respiratory failure and the resident was to receive oxygen via nasal cannula as ordered. On 03/25/2024 at 12:20 p.m. observation of resident #105 revealed the resident's portable oxygen tank was observed on the wheelchair and the oxygen nasal cannula was uncovered, rolled up and hanging from the oxygen tank flow meter. On 03/26/2024 at 7:40 a.m. observation of resident #105's room revealed the oxygen nasal cannula was on the side of the bed. Further observation of the cannula revealed it was not stored properly in a bag when not in use. On 03/26/2024 at 8:00 a.m., an observation and interview with S2Director of Nursing (DON) in resident #105's room revealed the oxygen nasal cannula was observed on the side of the bed uncovered. S2DON confirmed the nasal cannula should have been stored in a plastic bag when not in use.

Based on record reviews and interview the facility failed to implement their written policies and procedures for screening new employees for criminal history background checks for 2 Certified Nursing Assistants (CNA) (S4CNA and S5CNA) of 8 (S4CNA, S5CNA, S6CNA, S7CNA, S8CNA, S9CNA, S10CNA, S11CNA) personnel records reviewed for criminal history background checks. Findings: Review of the facility's Employee Policy Handbook with a revision date of April 2017 revealed B. Individuals employed by the Louisiana Department of Veterans Affair (LDVA) may occupy-security sensitive positions or handle confidential or sensitive information. Therefore, a criminal history check may be conducted on all new hires as well as employees changing positions including promotions, demotions, details, reassignments, and transfers, with some exceptions. Review of the personnel record for S4CNA revealed a hire date of 02/17/2019. Review of the personnel record for S5CNA revealed a hire date of 01/09/2020. Further review of the personnel records for S4CNA and S5CNA revealed there was no documented evidence of the status of the criminal history backgrounds checks obtained on the CNAs. On 03/26/2024 at 1:00 p.m., an interview with S1Administrator revealed they were unable to locate the background checks for S4CNA and S5CNA. On 03/26/2024 at 3:00 p.m., an interview with S3Human Resources Specialist revealed they are to obtain background checks on all employees.

Based on interview and record review, the facility failed to electronically submit accurate payroll information for the time frames of 10/01/2023 through 12/31/2023 for direct care staffing hours as required. Findings: Review of the 10/01/2023 through 12/31/2023 Payroll Based Journal (PBJ) report for the facility revealed three areas triggered; they were excessively low weekend staff, no Registered Nurse hours, and failed to have Licensed Nursing coverage 24 hours per day. On 03/25/2024 at 2:00 p.m., an interview with S1Administrator revealed she was responsible for submitting the data for the payroll based journal quarterly. S1Administrator revealed the Human Resources department had to change the personnel codes several times last year. The personnel codes were changed to ensure the staff were disclosed on the PBJ report. When the codes were changed it caused all of the staff to be entered on the report including those that did not provide patient care. Further interview with S1Administrator revealed they changed the codes again and no personnel were listed on the report. On 03/25/2024 at 3:35 p.m. S1Administrator confirmed the information submitted on the PBJ report from 10/01/2023 through 12/31/2023 was not accurate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to maintain an infection prevention and control program designed to provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections for 1 (#157) of 1 (#157) residents observed during pericare by failing to ensure staff performs hand hygiene after providing resident care. Findings: Review of the medical record revealed resident #157 was admitted to the facility on [DATE]. Resident #157's diagnoses included, in part, dementia, benign prostatic hyperplasia with urinary tract symptoms, and pressure ulcer. On 06/05/2023 at 11:05 a.m., an observation revealed S3CNA (Certified Nursing Assistant) preparing to perform pericare for resident #157, with the assistance of S4CNA. After S3CNA had completed the procedure, she retrieved a bottle of perineal cleanser from the resident's bedside table and placed the bottle inside of resident #157's dresser drawer. Further observation revealed S3CNA touching the resident's clothing, bed sheets, television remote control, blanket, pillows, and brushing off the bed several times with her soiled and contaminated right gloved hand. S3CNA did not remove the dirty and contaminated gloves, wash her hands, and /or apply hand sanitizer after she had completed performing pericare. On 06/05/2023 at 12:10 p.m., S3CNA was notified of the observations during the pericare procedure. She confirmed she had not removed her soiled and contaminated gloves, washed her hands, and had not applied hand sanitizer after providing pericare for resident #157. On 06/06/2023 at 3:50 p.m., S2DON (Director of Nursing) was notified of the findings observed during the pericare procedure. S2DON confirmed S3CNA should have removed her soiled and contaminated gloves, wash her hands, and /or applied hand sanitizer after providing pericare for resident #157 due to cross contamination.