Based on interviews and record reviews, the facility failed to ensure a resident (Resident #71) with a new diagnoses of Bipolar Disorder was referred to the appropriate state agency for a Preadmission Screening and Resident Review (PASARR) Level II evaluation as required. Findings: Review of the facility's policy titled PASARR Preadmission Screening and Coordination with an effective date of 01/18/2018 revealed, in part, the preadmission screening and resident review process requires that all applicants to the Medicaid certified nursing facility are screened for possible serious mental disorders or intellectual disabilities and related conditions. Further, the policy review revealed the facility must notify the state designated mental health or intellectual disability authority when a resident with a mental disorder (MD) or an intellectual disorder (ID) experiences a significant change in mental or physical condition. This must occur promptly to ensure that the resident continues to receive the care and services they need in the most appropriate setting. Review of Resident #71's clinical record revealed Resident #71 was diagnosed with Bipolar Disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) on 11/18/2024. Further review revealed there was no evidence a Level II PASARR had been completed as required. Review of Resident #71's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/22/2025 revealed, in part, a Brief Interview of Mental Status (BIMS) score of 6, which indicated moderate cognitive impairment. Further review revealed Resident #71 was diagnosed with Bipolar Disorder. In an interview on 04/03/2025 at 9:50AM, S8Social Worker indicated a Level II PASARR was not completed on Resident #71 after a new diagnosis of Bipolar Disorder and should have been. In an interview on 04/03/2025 at 3:42PM, S1Administrator indicated a Level II PASARR should have been requested on Resident #71 after a new diagnosis of Bipolar Disorder on 11/18/2024. S1Administrator confirmed Resident #71 did not have a Level II PASARR completed as required.

Based on observations, interviews and record reviews, the facility failed to conduct an accurate comprehensive assessment for 4 (Resident #4, Resident #22, Resident #46, Resident #64) of 34 (Resident #4 Resident #5, Resident #14, Resident #19, Resident #20, Resident #22, Resident #23, Resident #24, Resident #32, Resident #34, Resident #38, Resident #40, Resident #41, Resident #45, Resident #46, Resident #51, Resident #61, Resident #64, Resident #70, Resident #71, Resident #75, Resident #76, Resident #78, Resident #88, Resident #93, Resident #94, Resident #96, Resident #99, Resident #100, Resident #102, Resident #104, Resident #108, Resident #109, Resident #411) sampled residents reviewed for comprehensive assessments. Findings: Resident #4 Review of Resident #4's quarterly MDS with an ARD of 02/24/2025 revealed, in part, Section GG Functional Abilities - Omnibus Budget Reconciliation Act (OBRA)/Interim, questions GG0130 B-I and GG0170 A-FF were not completed as required. Resident #22 Review of Resident #22's clinical record revealed, in part, Resident #22 had a diagnosis of dysphagia (medical term used to describe difficulty swallowing) with an onset date of 07/03/2024. Review of Resident #22's quarterly, Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/13/2025 revealed, in part, Section K, titled, Swallowing/ Nutritional Status read no loss of liquids, no holding food in mouth/cheeks, no residual food in mouth after meals, no coughing or choking during meals or when swallowing medications, and no complaints of difficulty or pain when swallowing. Further review revealed Section K titled Swallowing/ Nutritional Status, also read no mechanically altered diet. Review of Resident #22's March 2025 and April 2025 Physician Orders revealed, in part, Resident #22 was ordered a puree mechanically altered diet, and thickened liquids since 08/15/2024. Review of Resident #22's Progress Notes revealed, in part, on 07/5/2024, the Registered Dietitian recommended a pureed diet with nectar-thickened Liquids. Review of Resident #22's Care Plan revealed, in part, Resident #22 had a swallowing problem, coughing and choking during meals, and swallowing medications that was initiated on 01/13/2025. Observation on 03/31/2025 at 9:51AM of Resident #22's room revealed a sign posted in his room on the wall indicating Resident #22 was on a nectar-thickened liquid diet. In an interview on 04/02/2025 at 9:25AM, S5Licsensed Practical Nurse (LPN) indicated Resident #22 had a prescribed diet of puree texture with nectar-thickened liquids. S5LPN further indicated dietary staff served Resident #22 a pureed textured diet with nectar-thickened liquids. Observation on 04/02/2025 at 12:38PM revealed Resident #22 was served a pureed textured meal with nectar-thickened liquids. Further observation revealed the meal ticket on his tray read nectar-thickened liquid, regular/puree. In an interview on 04/03/2025 at 10:25AM, S3Medicare Case Manager (MCM) confirmed that section K on Resident #22's quarterly MDS with an ARD of 01/13/2025, indicated Resident #22 did not have any swallowing issues and Resident #22 did not receive a mechanically altered diet. Resident #46 Review of Resident #46's quarterly MDS with an ARD of 01/14/2025 revealed, in part, Section GG Functional Abilities- OBRA/Interim, questions GG0130 B-I and GG0170 A-K were not completed as required. Resident #64 Review of Resident #64's annual MDS with an ARD of 02/05/2025 revealed, in part, Section GG Functional Abilities- OBRA/Interim Questions GG0130 B-I and GG0170 A-K were not completed as required. In an interview on 04/03/2025 at 9:45AM, S3MCM indicated Section GG - Functional Abilities Questions GG0130 A-I and GG0170 A-K are assessed and completed on the admission, annual and quarterly MDS assessments. S3MCM confirmed Resident # 4's section GG Functional Abilities- OBRA/Interim Questions GG0130 B-I and GG0170 A-FF were not completed and should have been completed with Resident #4's 2/24/2025 quarterly MDS assessment; Resident #46's section GG Functional Abilities- OBRA/Interim, questions GG0130 B-I and GG0170 A-K were not completed and should have been completed with Resident #46's 1/14/2025 quarterly MDS assessment; and Resident #64's section GG Functional Abilities- OBRA/Interim Questions GG0130 B-I and GG0170 A-K were not completed and should have been completed with Resident #64's 2/5/2025 annual MDS assessment.

Based on observations, interviews, and record reviews, the facility failed to: 1. implement identified interventions for residents at risk for injuries related to falls (Resident #93, Resident #94); and, 2. ensure thin liquids were not accessible to a resident who required thickened liquids (Resident #22). This deficient practice was identified for 3 (Resident #22, Resident #93, and Resident #94) of 5 (Resident #22, Resident #23, Resident #64, Resident #93, Resident #94) sampled residents reviewed for accident hazards. Findings: 1. Resident #93 Review of Resident #93's clinical record revealed, in part, diagnoses of arthropathy, physical debility, muscle weakness, abnormal gait and mobility, lack of coordination, and repeated falls. Review of Resident #93's care plan revealed, in part, Resident #93 was at risk for falls with an intervention to have a fall mat on the floor next to the bed when Resident #93 was in bed. Review of Resident #93's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/12/2025 revealed, in part, a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #93 was cognitively intact. Observation on 03/31/2025 at 11:00AM revealed Resident #93 was in bed, and the fall floor mat was rolled up and placed between the wall and the dresser. Further observation revealed Resident #93 had a sign in his room, which indicated a floor mat should be on the floor next to the bed while Resident #93 was in bed. In an interview on 04/02/2025 at 9:25AM, S7Certified Nursing Assistant (CNA) indicated Resident #93 was on fall precautions, and a fall mat should have been placed on the floor next to Resident #93's bed. In an interview on 04/02/2025 at 11:42AM, Resident #93 indicated the staff forgot to place the fall mat on the floor next to Resident #93's bed at times. Observation on 04/02/2025 at 3:04PM revealed Resident #93 was in bed, and the fall floor mat was rolled up between the wall and the dresser. Observation on 04/02/2025 at 4:15PM revealed Resident #93 was in bed, and the fall floor mat was rolled up between the wall and the dresser. Observation on 04/03/2025 at 8:25AM revealed Resident #93 was in bed, and the fall floor mat was rolled up between the wall and the dresser. In an interview on 04/03/2025 at 8:30AM, S2Director of Nursing (DON) indicated Resident #93 should have had a fall floor mat on the floor next to the bed while Resident #93 was in the bed. Resident #94 Review of Resident #94's MDS with an ARD of 02/13/2025 revealed, in part, Resident #94 had a BIMS score of 04, which indicated severely impaired cognition. Review of Resident #94's April 2025 Physician Orders revealed, in part, an order dated 02/13/2025 for Resident #94 to have a fall mat placed at the bedside while in bed. Review of Resident #94's care plan revealed, in part, Resident #94 was at risk for falls due to mobility impairments. Further review revealed Resident #94 had an intervention for a fall mat to be placed at the bedside while in bed. Observation on 03/31/2025 at 10:20AM revealed Resident #94 was sitting upright on the side of his bed and there was no fall mat at Resident #94's bedside. Further observation of Resident #94's room revealed a fall mat was leaning against the wall. Observation on 04/02/2025 at 9:58AM revealed Resident #94 was sitting upright on the side of his bed and there was no fall mat at Resident #94's bedside. Further observation of Resident #94's room revealed a fall mat was leaning against the wall. Observation on 04/02/2025 at 10:47AM revealed Resident #94 was sitting upright on the side of his bed and there was no fall mat at Resident #94's bedside. Further observation of Resident #94's room revealed a fall mat was leaning against the wall. In an interview on 04/03/2025 at 2:09PM, S6CNA indicated a fall mat should have been placed next to Resident #94's bed while Resident #94 was in bed. In an interview on 04/03/2025 at 2:47PM, S2DON confirmed Resident #94 should have had a fall mat placed at his bedside while in bed as a fall intervention. 2. Resident #22 Review of Resident #22's clinical records revealed, in part, diagnoses of dysphasia (difficulty swallowing foods or liquids), hemiplegia, and hemiparesis to the right side. Review of Resident #22's care plan revealed, in part, Resident #22 had a swallowing problem with an intervention to follow the prescribed diet (Puree texture nectar- thickened liquids). Review of Resident #22's March and April 2025 Physician Orders revealed, in part, Resident #22 was prescribed nectar-thickened liquids (modified consistency for liquids that is thicker than water to prevent aspiration). Review of Resident #22's MDS with an ARD of 03/12/2025 revealed, in part, Resident #22 had a BIMS score of 3, which indicated severely impaired cognition. Review of Resident #22's progress note dated 01/13/2025 revealed, in part, Resident #22 required set-up assistance with eating. Observation on 03/31/2025 at 9:51AM of Resident #22's room revealed that Resident #22 had a sign in his room which indicated Resident #22 was prescribed nectar-thickened liquids. Further observation revealed a water bottle on Resident #22's nightstand containing a thin consistency liquid that Resident #22 could access and consume. Observation on 04/02/2025 at 9:20AM, revealed a water bottle full of thin consistency liquids was on Resident #22's nightstand, where Resident #22 could access and consume the thin liquids. In an interview on 04/02/2025 at 9:25AM, S5Licensed Practical Nurse (LPN) indicated Resident #22 was prescribed thickened-liquids. Observation on 04/02/2025 at 9:28AM with S5LPN revealed a water bottle on Resident #22's nightstand containing a thin consistency liquid that Resident #22 could access and consume. In an interview on 04/02/2025 at 9:29AM, S5LPN confirmed that the water bottle contained thin liquids and should not be accessible to Resident #22 in his room. In an interview on 04/03/2025 at 8:30AM, S2DON confirmed thin liquids should not have been accessible to Resident #22 in his room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure a reportable incident of injury of unknown source was reported to the State Agency for 1 (Resident #34) of 5 (Resident #22, Resident #34, Resident #39, Resident #63 and Resident #76) sampled residents investigated for accidents. The facility failed to report Resident #34 had a displaced left femur fracture to the left hip without a known source of injury. Findings: Review of a policy and procedure titled, Abuse Components Plan/Elder Justice Act and Affordable Care Act, with a revision date of 10/24/2022 revealed, in part, applicable governing standards for the policy are 42 CFR 483.12 F609, Louisiana Department of Health Nursing Facilities - Licensing, Standards LAC 48:I. Chapter 97-99 (page1), an injury is classified as an injury of unknown source when the source of the injury was not observed by anyone, when the source of the injury could not be explained by the resident, and the injury is suspicious because of the extent of the injury or the location of the injury (page 3); all alleged violations including injuries of unknown source will be reported to the appropriate State Agency (page 9); injuries of unknown source may include but is not limited to fractures, sprains, dislocations; and allegations must not be dismissed on the basis of a resident's cognitive impairment or mental disorder (page 12). Review of Resident #34's medical record revealed Resident #34 was admitted to the facility on [DATE] with diagnoses in part, Alzheimer's disease, dementia, and malnutrition. A diagnosis of a displaced fracture of left femur was added to the diagnosis list on 03/20/2024. Review of Resident #34's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/12/2024 revealed Resident #34 was severely cognitively impaired and could not make needs known. Further review revealed Resident #34 was dependent on staff for all care and received hospice services. Review of the facility's incident log revealed Resident #34 had an incident on 03/20/2024 listed as other type. Review of Resident #34's nursing note dated 03/20/2024 at 7:45 a.m. completed by S5Licensed Practical Nurse (LPN) revealed, in part, Resident #34 had swelling to the anterior left pelvis and left lateral thigh with pain noted upon movement as evidenced by grimacing. Further review revealed an order was obtained for an immediate x-ray of the left hip. In an interview on 04/03/2024 at 9:15 a.m., S5Licensed Practical Nurse (LPN) indicated on 03/20/2024 she was called to Resident #34's room by S11Hospice Aide because Resident #34's left hip was swollen. S5LPN stated upon assessment, Resident #34 grimaced in pain with movement to the left leg, the physician was notified and an order was obtained for stat (immediate) x-ray which revealed a left femur fracture. S5LPN stated the facility was not aware of how the injury occurred to Resident #34 and further stated there were no reported incidents of a fall or other incidents. Review of Resident #34's left hip x-ray results dated 03/20/2024 at 12:32 p.m. revealed, in part, an oblique fracture of the sub trochanteric left proximal femoral diaphysis was identified with 1/4 shaft with posterior displacement, severe demineralization, soft tissue swelling, the fracture poorly visualized, and additional imaging recommended if possible. During the entrance conference interview on 04/01/2024 at 9:33 a.m. S1Administrator stated the facility did not have any reportable incidents deemed reportable to the State Agency within the last 2 to 3 years. In an interview on 04/03/2024 at 2:00 p.m., S2Director of Nursing (DON) stated Resident #34's injury of unknown source was not reported to the State Agency when the injury was discovered on 03/20/2024. Review of witness statement documented by S11HospiceAide revealed, in part, on the morning of 03/20/2024 before providing morning care to Resident #34, it was noted Resident #34's left thigh was swollen and the nurse was immediately notified before proceeding with care. Review of Resident #34's skilled nursing note documented by S12HospiceNurse on 03/20/2024 at 1:15 p.m. revealed, in part, Resident #34 left hip was swollen, and resident was guarding, had facial grimaces, and was in apparent pain. Further review revealed Resident #34 was nonverbal and could not make needs known. Upon assessment the resident's left hip was edematous from the thigh to hip. Further review revealed the facility staff indicated something must have happen overnight to Resident #34, Resident #34 did not fall, and the cause for Resident #34 injury was unknown. Review of the physician's progress note dated 03/21/2024 revealed Resident #34 had pain and swelling on 03/20/2024 and the x-ray showed an acute left proximal femur fracture with posterior dislocation and severe demineralization. Further review revealed Resident #34 was bed bound with no reported falls or injuries and had a fracture suspected secondary to repositioning. In an interview on 04/03/2024 at 2:33 p.m., S1Adminisrator stated Resident #34's injury was not reported to the State Agency because he did not see the injury as suspicious and he did not feel the injury was the result of abuse because the physician stated the injury could have occurred due to severe demineralization (loss of minerals from bone which increases risk of fracture). S1Administrator further stated after reviewing the regulation guidance Resident #34's injury should have been reported to the State Agency when discovered.

Based on observations, interviews, and record reviews, the facility failed to ensure a resident's behaviors were addressed for 1 (Resident #22) of 1(Resident #22) sampled residents investigated for behavioral healthcare needs. Findings: Review of Resident #22's clinical record revealed, in part, Resident #22 had diagnoses, which included unspecified dementia, major depressive disorder, and bipolar disorder. Review of Resident #22's physician's progress note dated 03/28/2024 revealed, in part, Resident #22 was wandering around the facility and claimed she was missing things from her room. Further review revealed, Resident #22 indicated everybody thought she was crazy. Further review revealed, Resident #22 was mistrusting of all staff members and residents in the building. Further review revealed Resident #5 had a diagnosis of hording behaviors and staff members were to continue to remind Resident #22 not to collect the utensils. In an interview 04/01/2024 at 12:10 p.m., Resident #22 indicated Resident #76 accused her of going into her room and stealing from her. Resident #22 further indicated Resident #76 screamed at her. In an interview on 04/01/2024 at 1:01 p.m., Resident #76 indicated Resident #22 had been coming in her room for the last week and stealing her belongings. Observation on 04/01/2024 at 2:15 p.m., revealed Resident #22 was trying to come into Resident #39's room. Observation on 04/01/2024 at 12:15 p.m., revealed Resident #22 opened the door and looked into Resident #361's room. In an interview on 04/03/2024 at 3:15 p.m., S9Activities Director indicated Resident #22 does take things she finds that may belong to other residents or facility. In an interview on 04/03/2024 at 3:16 p.m., S13CNA indicated she had witnessed Resident #22 go into other resident's rooms. S13CNA further indicated she does not think it was safe for Resident #22 to have gone into other resident's rooms. In an interview on 04/03/2024 at 3:18 p.m., S7CNA indicated she had witnessed Resident #22 go into Resident #5's room and take candy. S7CNA further stated she does not feel that it is safe for Resident #5 to have gone into other resident's rooms. In an interview on 04/04/2024 at 9:59 a.m., S4LPN further indicated Resident #22 had asked her to heat up a can of soup, and later that same day, she found out the soup was actually for Resident #76. S4LPN further indicated she had not put a nursing note in Resident #22's clinical record regarding this incident and should have. S4LPN further stated, based on her nursing judgement, it was unsafe for Resident #22 to have gone into other resident's rooms. In an interview on 04/04/2024 at 11:43 a.m., Resident #7 indicated Resident #22 had stolen her shirt and tried to give it back to her. Resident #7 further indicated she had reported this incident to S9Activities Director. In an interview on 04/04/2024 at 11:42 a.m., Resident #5 indicated Resident #22 had gone into her room and taken her candy and her fortune cookie. Resident #5 further indicated she had told S7CNA and S9Activities Director about the incident. In an interview on 04/04/2024 at 12:50 p.m., S9Activities Director indicated Resident #5 and Resident #7 had told her about Resident #22 taking their belongings. S9Activities Director further indicated she did not report this to S1Administrator or S2Director of Nursing (DON). In an interview on 04/04/2024 at 9:37 a.m., S14Social Services (SS) indicated she was unaware of the allegations of Resident #22 going into resident's rooms and taking their belongings until yesterday. S14SS further indicated when the behavioral health provider comes to see Resident #22 for a visit, she uses a verbal report from her (S14SS) and the nurse's notes to aide in determining Resident #22's behaviors. S14SS further indicated it could be an issue if Resident #22's behaviors were not reported to her by the facility's staff and/or her behaviors were not documented in Resident #22's nurse's notes. Review of Resident #22's nurse's notes from 12/01/2023 to 04/03/2024 revealed, in part, no evidence of documentation regarding Resident #5's behaviors of wandering and/or taking other resident's belongings. Review of Resident #22's plan of care revealed no evidence of goals or interventions related to Resident's behaviors of wandering, hoarding, and/r taking other resident's belongings In an interview on 04/04/2024 at 11:12 a.m., S2DON indicated if the facility's nurses and CNAs were aware Resident #22 was having behaviors, they should have been reporting it to upper management and documenting nursing notes regarding behaviors. S2DON further indicated Resident #22's plan of care should have addressed her behaviors and diagnoses and it did not.

Based on observation, interview, and record review, the facility failed to: 1. Store food meant for resident consumption in a manner to prevent contamination; and, 2. Ensure the facility's kitchen was maintained in a sanitary manner. Findings: 1. Review of the facility's policy titled Foods brought by Family/Visitors, last revised on 07/21/2014 revealed, in part, resident's perishable foods must be stored in re-sealable containers with tightly fitting lids in the resident's refrigerator. Further review revealed containers will be labeled with the resident's name, the name of the item, and the use by date. Observation of the facility's kitchen on 04/01/2024 at 9:40 a.m., revealed two cartons of Ready Care Chocolate Shakes were present in Refrigerator #5. Review of the side of the two cartons revealed instructions that once the chocolate shakes were thawed, they should be refrigerated up to 14 days. Further observation revealed no date noted on either carton that indicated the day they were first thawed and/or opened. Observation of the facility's kitchen on 04/01/2024 at 9:39 a.m., revealed Resident #11's name on personal food that was being stored in Refrigerator #3. Further observation revealed a pan with Resident #11's name on it was undated, the name of the item it contained was not present, and the cover was not secure. Observation of the facility's kitchen on 04/03/2024 at 11:25 a.m., revealed a pan with Resident #11's name on it was located in Refrigerator #3. Further observation revealed the pan with Resident #11's name on it did not contain the name of the food item it contained. Further observation revealed a plastic bag with Resident #11's name on it, contained raw meat patties. Further observation revealed the above mentioned raw meat patties were stored on a shelf above a container of potato salad. Observation of the kitchen on 04/03/2024 at 11:26 a.m., revealed one carton of Ready Care Chocolate Shake located in Refrigerator #5 with no date noted on the carton that indicated the day it was first thawed. In an interview on 04/03/2024 at 11:45 a.m., S10Food Service Manager confirmed both the plastic bag and pan of food in Refrigerator #3 were for Resident #11, and indicated per the facility's policy, Resident #11's personal food should not be in the facility's refrigerator. S10Food Service Manager further indicated raw meat should not be stored above other food items due to possible contamination of lower food items. S10Food Service Manager further indicated the Ready Care Chocolate Shakes should have a date that indicated the day they were first thawed and/or opened, if the instructions were for them to be refrigerated up to 14 days. 2. Observation of the facility's kitchen on 04/03/2024 at11:23 a.m., revealed an unknown dry brown substance, in a splattered pattern, was noted on the walls next to the mixer stand. Further observation revealed an unknown sticky brown liquid substance was on the floor between mixer stand and the stand for a tea maker. Observation of the facility's kitchen on 04/03/2024 at 11:30 a.m., revealed the drain to the rinse compartment of the facility's three compartment sink was drained and water poured onto the floor. Further observation revealed, water and food debris were noted to be in a standing puddle on the floor where a piece of tile was missing near the floor drain. In an interview on 04/03/2024 at 11:45 a.m., S10Food Service Manager indicated the unknown dry brown substance should not be on the walls next to the stand mixer and the unknown sticky brown substance should not be pooled on the floor between the stand mixer and the stand for the tea maker. S10Food Service Manager further indicated the rinse compartment of the facility's three compartment sink should not be draining onto the floor, the tile of the floor should not be missing, and water and food debris should not be pooled where the piece of tile was missing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to implement a comprehensive care plan for a special diet and aspiration precautions for 1 (#68) of 28 sampled residents. Findings: Record review revealed, Resident #68 was readmitted to facility on 11/15/2022 with a diagnosis, in part, dysphagia of the oropharyngeal phase following cerebral infarction. Resident #68 Physician orders for April 2023 revealed an order on 01/13/2022 for a regular diet, mechanical soft texture, regular -thin liquids. Review of Resident #68's care plan revealed, in part, a problem onset date of 12/14/2020 with a revision date of 04/18/2023 - I have difficulty swallowing (dysphagia), coughing or choking during meals or swallowing med, aspiration precautions, and, 1:1 supervision during oral intake. A goal date of 05/31/2023. Interventions included: all staff will be informed of my special dietary and safety needs, 1:1 supervision during oral intake, and diet to be followed as prescribed. Review of Resident #68's Speech Therapy Discharge summary dated [DATE] indicated resident with mild difficulty with thin liquids by cup and distant supervision with swallowing abilities. Interventions provided included instructing and training patient in compensatory strategies and safe swallow strategies in order to increase safety and consumption with meals and decrease aspiration risk. Discharge recommendations included mechanical soft chopped texture, all liquids, occasional supervision with oral intake, general swallow techniques and precautions, alternation of liquid/solids, rate modification, and chin tuck method Observation on 04/17/2023 at 12:10 p.m. revealed Resident #68 dietary ticket on tray indicated mechanical soft with puree meats, no added salt, and ice cream with all meals. Observed on tray, [NAME] beans with rice and greens with no ice cream. Further observation revealed Resident #68 coughed while eating Observation on 04/18/2023 at 12:17 p.m. revealed Resident #68 lying sideways in his bed with the head of bed elevated 45 degrees and his with lunch tray on a bed side table in front of him. Dietary ticket revealed regular mechanical soft with puree meets no added salt diet. Further observation revealed S7Certified Nurse Assistant (CNA) while assisting resident with meal and instructed Resident #68 to move over in bed which he slightly did with difficulty. Further observation revealed S7CNA continued to feed the Resident #68. In an interview on 04/18/2023 at 12:25 p.m., S7CNA stated that she was not aware that Resident #68 required staff to sit with him while he ate and assist as needed. In an interview on 04/18/2023 at 12:30 p.m., S4LPN (Licensed Practical Nurse) confirmed the diet slip for Resident #68 did not match the ordered diet Regular Mechanical Soft. Observation on 04/19/2023 at 8:40 a.m. revealed Resident #68 was seated upright in bed with his breakfast tray on bed side table in front of him and feeding himself with no staff in the room. In an interview on 04/19/2023 at 9:27 a.m., S6Speech Therapist stated Resident #68 needed to be seated upright and use chin tuck method when he ate. S6Speech Therapist further stated staff should alternate liquids and solids and follow aspiration precautions. In an interview on 04/19/2023 at 10:06 a.m., S4LPN stated she was not aware Resident #68 had aspiration precautions on his care plan. S4LPN stated when a resident is on aspiration precautions the over bed signage on wall in resident's room will indicate this and it is usually in the physician's orders. S4LPN acknowledged and confirmed that it is not indicated on the over bed signage on wall in Resident #68's room and it is not in the physician's orders. In an interview on 04/19/2023 at 12:20 p.m., S8CNA stated she was not aware of the assistance or strategies required when she provided feeding assistance for Resident #68. In an interview on 04/20/2023 at 8:37 a.m. S9CNA stated she was not aware of the assistance or strategies required when she provided feeding assistance for Resident #68. S9CNA stated she referenced the Over Bed Signage on wall for information on resident. S9CNA confirmed that Over Bed signage did not have any swallowing problems or strategies noted on it. In an interview on 04/20/2023 at 9:26 a.m., S5MDS (Minimum Data Set) Nurse stated the MDS department was responsible for updating the over bed signage when there was a change in condition in resident's status. S5MDS Nurse confirmed if there are swallowing issues or strategies it is indicated on over bed signage on wall. In an interview on 04/20/2023 at 11:30 a.m., S2DON (Director of Nursing) acknowledges the staff was unaware of Resident #68's need for aspiration precautions.

**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 by failing to ensure a Licensed Practical Nurse (LPN) completed hand hygiene during wound care for 1 (Resident #43) of 3(Residents #43, #18, #88) residents observed for pressure ulcers. Findings: Review of the facility's policy and procedure titled, Wound Care revealed, in part, the following Steps in the procedure: Reposition patient to expose area to be dressed. Avoid exposing the resident unnecessarily; Remove soiled dressing, place in trash bag; Remove gloves, perform hand hygiene, reapply gloves; Clean wound with prescribed cleanser; Assess wound characteristics to determine appropriate interventions; Remove gloves, perform hand hygiene, apply new gloves; Apply prescribed topical agent to wound; Apply prescribed wound dressing, which should cover entire wound; Apply tape as applicable; Reposition resident, place call light within reach; Discard gloves and all used supplies in trash bag. Remove equipment; and Perform hand hygiene. Review of Resident # 43 clinical record revealed, in part, Resident #43 was re-admitted to the facility on [DATE] with diagnoses in part; Pressure ulcer of the sacral region, Type 2 Diabetes Mellitus without complications, Hemiplegia, and muscle wasting. Review of Resident #43's April/2023 Physician's Orders, in part, revealed the following: Wound care: Stage III; Cleanse wound to Sacrum with Normal saline pat dry, apply honey alginate cover with dry dressing three times a week and as needed (prn) until resolved. Observation on 04/18/23 01:45 p.m. revealed S3Licensed Practical Nurse (LPN) provided wound care to Resident #43's pressure ulcer. Further observation revealed S3LPN cleaned Resident #43's wound with normal saline and gauze then removed the soiled gloves. Observation revealed S3LPN did not perform hand hygiene after she removed the soiled gloves. Observation then revealed S3LPN applied another pair of gloves then applied honey alginate and applied a dressing to Resident #43's wound. Observation revealed S3LPN removed the soiled gloves. Observation revealed S3LPN did not perform hand hygiene then proceeded to assist Resident #43 with positioning, touching residents bed and covers and applying her heel protectors. In an interview on 4/18/2023 at 1:57p.m., S3LPN acknowledged she failed to perform hand hygiene after she cleaned Resident #43's sacral wound. S3LPN further acknowledged that she should have performed hand hygiene before she applied new gloves to place the resident's clean dressing and after she provided wound care. In an interview on 04/19/203 at 8:57a.m., S2Director of Nursing (DON) stated S3LPN informed her she did not perform hand hygiene after she cleaned Resident #43's sacral wound. S2DON further stated that S3LPN informed her that she only changed gloves before she applied a clean dressing on Resident #43's wound. S2DON was also informed that S3LPN did not perform hand hygiene after the dressing change and touched multiple surfaces in the resident's room. S2DON acknowledged S3LPN should have performed hand hygiene after she cleaned Resident #43's sacral wound and after providing wound care.