Based on record review and interviews, the facility failed to ensure an alleged violation involving physical abuse witnessed by staff was reported immediately to the Administrator of the facility for 1 (#2) of 7 (#1, #2, #3, #4, #5, #6, #7) sampled residents. Findings: Review of the Abuse Reporting Policy dated 01/05/2024 revealed the following: Policy: All personnel must promptly report any incident or suspected incident of resident abuse, including injuries of unknown origin and misappropriation of resident property. Policy interpretation and implementation: 2. Any alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown origin and misappropriation of resident property, must be reported to the Administrator and Director of Nurses. Physical Abuse is defined as hitting, slapping, pinching, kicking, etc. It also includes controlling behavior through corporal punishment. 6. The person observing an incident of resident abuse, or suspecting resident abuse, must immediately report such incident(s) to their supervisor. The following information should be reported to the supervisor: The name of the resident(s) involved. The date and time that the incident occurred. Where the incident took place. The name(s) of the person(s) committing the alleged abuse, if known. Review of the record for resident #2 revealed an admit date of 06/14/2024 with following diagnoses: Alzheimer's disease, unspecified dementia, anxiety disorder and depression. Review of the Minimum Data Set (MDS) assessment for resident #2 dated 06/21/2024 revealed resident #2 had severely impaired cognitive skills for daily decision making. During an interview with resident #2 on 07/29/2024 at 3:30 p.m., resident #2 was confused and was unable to recall any incident of possible abuse. Observation at this time revealed the resident did not have any bruising. Review of the record for resident #7 revealed an admit date of 12/18/2021 with following diagnoses: major neurocognitive disorder due to probable vascular disease, unspecified, with mood disturbance. Review of the MDS assessment for resident #7 dated 07/17/2024 revealed resident #7 had severely impaired cognitive skills for daily decision making. During an interview with resident #7 on 07/30/2024 at 3:00 p.m., resident #7 was confused and was unable to recall any incident with another resident. Review of the care plan for resident #7 revealed problem of unease in dealing with others with onset on 11/01/2023. Further review revealed the following approaches: approach resident warmly and positively, convey acceptance of resident, provide consistent caregivers on all shifts, provide opportunity for resident to express fears/concerns related to socialization with others, listen in non-judgmental manner, monitor resident socialization behavior and document at least daily, and allow resident to select seating at planned activities and in dining room. Interview on 07/30/2024 at 8:29 a.m. with S7 Certified Nursing Assistant (CNA) revealed that she witnessed resident #7 slap resident #2 hard on the left side of her face on 07/13/2024 at approximately 2:00 p.m. S7CNA stated that resident #7 was agitated prior to the incident and was difficult to redirect. S7CNA further revealed she was approximately 40 yards from the residents; therefore, she was unaware of what precipitated resident #7 slapping resident #2. S7CNA stated she did not tell the nurse on duty that resident #7 hit resident #2. S7CNA reported that she has been trained on abuse and neglect reporting but confirmed she failed to report to nurse and/or administrator that she witnessed physical abuse. Interview on 07/30/2024 at 10:00 a.m. with S9Licensed Practical Nurse (LPN) revealed she worked on 07/13/2024 from 7:00 a.m. to 3:00 p.m. S9LPN stated that she was not made aware of any incident involving resident #2 and resident #7. Interview on 07/30/2024 at 11:00 a.m. with S1Adminsitrator revealed she was unaware of any incident involving resident #2 and resident #7. S1Administrator confirmed S7CNA should have reported the alleged abuse regarding resident #2 and resident #7 immediately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure the pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing for 3 (#32, #42, and #53) of 6 (#29, #32, #37, #42, #49, and #53) residents reviewed for unnecessary medications. The pharmacist failed to address no monitoring for side effects for residents #32, #42, and #53 while receiving antidepressant and antianxiety medications. Findings: Resident #32 Record of the record revealed an admission date of 03/15/2023 with diagnoses including schizophrenia unspecified, major depressive disorder, persistent insomnia, and bipolar disorder. Review of the September 2023 Physician's Orders revealed an order dated 03/15/2023 for Lorazepam (Antianxiety) 0.5 milligram tablet 3 times daily and Trazodone (Antidepressant) 100 milligram tablet by mouth at bedtime. Review of the August 2023 and September 2023 Medication Administration Record (MAR) for resident #32 revealed there was no documented evidence of monitoring for side effects of antidepressant and antianxiety medications. An interview on 09/26/2023 at 4:00 p.m. with S2DON revealed there was no documented evidence of monitoring for side effects of Lorazepam (Antianxiety) or Trazodone (Antidepressant) for resident #32 for August 2023 and September 2023. S2DON confirmed that resident #32 should have had monitoring for side effects of the psychotropic medications administered. Review of the monthly Medication Regimen Review dated 08/11/2023 for resident #32 revealed no documented evidence that pharmacist notified the physician, DON, and medical director regarding resident receiving Lorazepam (Antianxiety) or Trazodone (Antidepressant) and no documented evidence of side effect monitoring with administration of antidepressant and antianxiety medications. An interview on 09/27/2023 at 2:45 p.m. with S2DON confirmed that there was no documented evidence that the pharmacist addressed the facility not monitoring resident #32 for side effects of antianxiety and antidepressant medications. Resident #53 Review of the record revealed resident #53 was admitted on [DATE] with diagnoses including major depressive disorder recurrent, unspecified dementia, mild cognitive impairment, depression, post-traumatic stress disorder, and anxiety disorder. Review of the September 2023 Physician's Orders revealed an order dated 01/30/2023 for Sertraline (Antidepressant) 50 milligram tablet by mouth once daily and Buspirone (Antianxiety) 5 milligram tablet by mouth twice daily. Review of the August 2023 and September 2023 Medication Administration Record (MAR) revealed no documented evidence that resident #53 was monitored for side effects of Buspirone (Antianxiety) and Sertraline (Antidepressant) medications. An interview on 09/26/2023 at 4:00 p.m. with S2Director of Nursing (DON) revealed there was no documented evidence of monitoring for side effects of Sertraline (Antidepressant) or Buspirone (Antianxiety) for resident #53 for August 2023 and September 2023. S2DON confirmed that resident #53 should have had monitoring for side effects of the psychotropic medications administered. Review of the monthly Medication Regimen Review dated 08/11/2023 for resident #53 revealed no documented evidence that pharmacist notified the physician, DON, and medical director regarding resident receiving Sertraline (Antidepressant) and Buspirone (Antianxiety) and no documented evidence of side effect monitoring with administration of antidepressant and antianxiety medications. An interview on 09/27/2023 at 2:45 p.m. with S2DON confirmed that there was no documented evidence that the pharmacist identified the facility regarding not monitoring resident #53 for side effects while taking Sertraline and Buspirone for the August 2023 Medication Regimen Review. Resident 42 Review of the medical record for resident #42 revealed an admission date of 01/27/2020 with diagnoses including obsessive compulsive disorder, dementia, chronic pain, osteoporosis, degeneration of the nervous system, and depression. Review of the September 2023 Physician's orders revealed an order dated 04/29/2023 for Trazadone 50 milligrams (mg) by mouth at bedtime, and Celexa 20 mg to be given one time a day. Review of the August 2023 and September 2023 MAR revealed no documented evidence that resident #42 was monitored for side effects of Trazadone (Antidepressant) and Celexa (Antidepressant) medications. An interview on 09/26/2023 at 4:00 p.m. with S2DON revealed there was no documented evidence of monitoring for side effects of Trazadone (Antidepressant) or Celexa (Antidepressant) for resident #42 for August 2023 and September 2023. S2DON confirmed that resident #42 should have had monitoring for side effects of the psychotropic medications administered. Review of the monthly Medication Regimen Review dated 08/11/2023 for resident #42 revealed no documented evidence that pharmacist notified the physician, DON, and medical director regarding resident receiving Trazadone (Antidepressant) or Celexa (Antidepressant) and no documented evidence of side effect monitoring with administration of antidepressant and antianxiety medications. An interview on 09/27/2023 at 2:45 p.m. with S2DON confirmed that there was no documented evidence that the pharmacist identified the facility regarding not monitoring resident #42 for side effects while taking Trazadone and Celexa for the August 2023 Medication Regimen Review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to ensure that each resident was free from unnecessary medication use for 3 (#32, #42 and #53) of 6 (#29, #32, #37, #42, #49 and #53) residents reviewed for unnecessary medications. The facility failed to monitor side effects for residents #32, #42 and #53 that received psychotropic medications. Findings: Resident #32 Review of the facility's Depression/Anxiety-Clinical Protocol revealed in part the following: the staff and physician will monitor the resident carefully for side effects specific to each class of medication as well as interactions between antidepressants and anti-anxiety medications and other classes of medication. Record of the record revealed an admission date of 03/15/2023 with diagnoses including schizophrenia unspecified, major depressive disorder, persistent insomnia, and bipolar disorder. Review of the September 2023 Physician's Orders revealed an order dated 03/15/2023 for Lorazepam (Antianxiety) 0.5 milligram tablet 3 times daily and Trazodone (Antidepressant) 100 milligram tablet by mouth at bedtime. Review of the August 2023 and September 2023 Medication Administration Record (MAR) for resident #32 revealed there was no documented evidence of monitoring for side effects of antidepressant and antianxiety medications. An interview on 09/26/2023 at 4:00 p.m. with S2DON revealed there was no documented evidence of monitoring for side effects of Lorazepam (Antianxiety or Trazodone (Antidepressant) for resident #32 for August 2023 and September 2023. S2DON confirmed that resident #32 should have had monitoring for side effects of the psychotropic medications administered. Resident #53 Review of the record revealed resident #53 was admitted on [DATE] with diagnoses including major depressive disorder recurrent, unspecified dementia, mild cognitive impairment, depression, post-traumatic stress disorder, and anxiety disorder. Review of the September 2023 Physician's Orders revealed an order dated 01/30/2023 for Sertraline (Antidepressant) 50 milligram tablet by mouth once daily and Buspirone (Antianxiety) 5 milligram tablet by mouth twice daily. Review of the August 2023 and September 2023 Medication Administration Record (MAR) revealed no documented evidence that resident #53 was monitored for side effects of Buspirone (Antianxiety) and Sertraline (Antidepressant) medications. An interview on 09/26/2023 at 4:00 p.m. with S2Director of Nursing (DON) revealed there was no documented evidence of monitoring for side effects of Sertraline (Antidepressant) or Buspirone (Antianxiety) for resident #53 for August 2023 and September 2023. S2DON confirmed that resident #53 should have had monitoring for side effects of the psychotropic medications administered. Resident 42 Review of the medical record for resident #42 revealed an admission date of 01/27/2020 with diagnoses including obsessive compulsive disorder, dementia, chronic pain, osteoporosis, degeneration of the nervous system, and depression. Review of the September 2023 Physician's orders revealed an order dated 04/29/2023 for Trazadone 50 milligrams (mg) by mouth at bedtime, and Celexa 20 mg to be given one time a day. Review of the August 2023 and September 2023 MAR revealed no documented evidence that resident #42 was monitored for side effects of Trazadone (Antidepressant) and Celexa (Antidepressant) medications. An interview on 09/26/2023 at 4:00 p.m. with S2DON revealed there was no documented evidence of monitoring for side effects of Trazadone (Antidepressant) or Celexa (Antidepressant) for resident #42 for August 2023 and September 2023. S2DON confirmed that resident #42 should have had monitoring for side effects of the psychotropic medications administered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice by failing to ensure the RD (Registered Dietitian) was consulted for 1 (#1) of 5 (#1, #2, #3, #4, and #5) sampled residents, according to the physician's orders, Findings: Resident #1 was admitted to the facility on [DATE] with diagnoses of cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, unspecified convulsions, diabetic neuropathy, radiculopathy cervical region, intervertebral disc degeneration lumbar region, hemiplegia affecting right dominant side, aphasia following non-traumatic subarachnoid hemorrhage, dysarthria following non-traumatic subarachnoid hemorrhage, dysphagia following cerebral infarction, and cerebral infarction. Review of the October 2022 physician's orders revealed order dated 04/08/2022 for regular no added salt, no concentrated sweets, mechanical soft diet with chopped meats. Review of resident #1's April 2021 careplan revealed resident needed assistance with feeding and required mechanically altered diet. Staff are to supervise dining, monitor for choking, and provide verbal encouragement/cueing as needed. Staff to consult Registered Dietitian as needed. Review of resident #1's chart revealed a written Physician's Order dated 08/26/2022 and progress note dated 08/26/2022 revealed a swallow study and a consult to RD was ordered by nurse practitioner. An interview on 01/06/2023 at 10:00 a.m. with S4RD revealed she was not aware of an order dated 08/26/2022 for RD consult for resident #1. Review of Dietitian Notes revealed resident #1 was last seen by RD on 07/19/2022. An interview on 01/06/2023 at 2:45 p.m. with S2DON (Director of Nursing) confirmed that the RD should have been consulted for resident #1 based on the physician order dated 08/26/2022. On 01/06/2023 at 3:10PM, S1Administrator was notified of the deficient practice regarding RD not being consulted for resident #1 after consult was ordered on 08/26/2022.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to promptly notify the ordering physician/practitioner of diagnostic test results by not notifying physican/practioner of MBSS (Modified Barium Swallow Study) results for 1 (#1) of 5 (#1, #2, #3, #4, and #5) sampled residents. Findings: Resident #1 was admitted to the facility on [DATE] with diagnoses of cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, unspecified convulsions, diabetic neuropathy, radiculopathy cervical region, intervertebral disc degeneration lumbar region, hemiplegia affecting right dominant side, aphasia following non-traumatic subarachnoid hemorrhage, dysarthria following non-traumatic subarachnoid hemorrhage, dysphagia following cerebral infarction, and cerebral infarction. Review of the October 2022 physician's orders revealed order dated 04/08/2022 for regular no added salt, no concentrated sweets, mechanical soft diet with chopped meats. Review of resident #1's April 2021 careplan revealed the resident needed assistance with feeding and required mechanically altered diet. Staff to supervise dining, monitor for choking, and provide verbal encouragement/cueing as needed. Staff to consult Registered Dietitian as needed. Review of Quarterly MDS dated [DATE] revealed resident #1 required extensive assist with 1 person physical assist with eating. Review of Dietitian Progress Note dated 07/19/2022 revealed resident #1 was on a regular, no added salt/no concentrated sweets mechanical soft diet with chopped meats. Review of the medical record revealed resident #1 was on speech therapy for treatment of dysphagia from 08/24/2022 through 09/22/2022. Review of resident #1's chart revealed a written Physician's Order dated 08/26/2022 and progress note dated 08/26/2022 revealed a swallow study and a consult to Registered Dietitian was ordered by nurse practitioner. Review of MBSS results dated 09/06/2022 revealed resident #1 had aspiration observed during examination, decreased lingual strength, poor lingual control, oral residue, pharyngeal delay, no reflexive cough, ineffective cough, reduced laryngeal closure and elevation. Silent aspiration. Patient able to feed self per objective exam. Recommendation for nectar thick by cup teaspoon size sips for liquids. Recommended strategies included small bites and sips. Precautions recommended included the following: small bites, monitor oral pocketing, supervised po (By Mouth) feeding, position upright 90 for po, patient to be fed by trained staff, monitor patient for adequate nutrition and hydration, crush meds, consider an adjustable flow cup for smaller sips. ST (Speech Therapy) recommended and dietitian due to patient appears thin. An interview on 01/04/2023 at 11:35 a.m. with S3SLP (Speech Language Pathologist) revealed she had resident #1 multiple times for ST since he was admitted , resident had a dysphagia and frequently pocketed his food. S3SLP reported resident knew his swallow strategies and how to clear his mouth, no difficulty with liquids. She further stated resident was on regular mechanical soft diet with chopped meats, but was able to feed himself but needed to be monitored and fed by staff at times. S3SLP stated the most recent time resident #1 was on ST was 08/24/2022-09/22/2022. Review of facility's current Policy and Procedure for Lab and Diagnostic Test Results- Clinical Protocol revealed the nurse was responsible for notifying physician/nurse practitioner of results of lab and other diagnostic test results. An interview on 01/06/2023 at 12:30 p.m. with S3SLP revealed that she did not notify physician/practioner of results for MBSS on 09/06/2022 for resident #1. An interview on 01/06/2023 at 2:45 p.m. with S2DON (Director of Nursing) confirmed that physician/nurse practitioner should have been notified of MBSS results for resident #1 from 09/06/2022. On 01/06/2023 at 3:10PM, notified S1Administrator of deficient practice regarding facility not notifying physician/nurse practitioner of MBSS results from 09/06/2022 on resident #1.

Based on record review and interview the facility failed to ensure resident's care plans were reviewed and revised based on the residents' status after each assessment for 3 (#29, #35, #45) of the 29 sampled residents reviewed for care plans. The facility failed to revise the care plan for residents #29 and #45 and failed to address gastrostomy status for resident #35. Findings: Resident #29 Record review of Resident #29's MDS (Minimum Data Set) record revealed the following assessments were completed: an Entry assessment with an ARD (Assessment Reference Date) of 02/02/2022; an admission assessment with an ARD of 02/10/2022; and Quarterly assessment with an ARD of 05/12/2022. Review of Care Plan revealed Resident #29's care plan had no previous review or revision dates, and no date indicating when next review was required. Resident #35 Record Review of Resident #35's MDS record revealed the following assessments were completed: a Significant Change assessment with an ARD of 02/26/2022; a Quarterly assessment with an ARD of 05/28/2022; and a Significant Change assessment with an ARD of 06/30/2022. Review of Resident #35's Care Plan revealed the care plan had not been revised with the last 3 assessments and indicated the next review date of 02/07/2022. Review of Resident #35's diagnosis list revealed a diagnosis of gastrostomy status dated 02/19/2022. Review of Resident #35's Physician Orders revealed an order with a start date of 03/13/2022 for Nepro1.8 cal at 45 cubic centimeters/hour continuous per peg tube and an order to flush peg tube with 250 milliliters of water every 6 hours. Review of Nutrition Care Plan revealed Resident #35 had a care plan with an onset date of 03/20/2015 for Alteration in nutrition related to requires supervision and set up assistance with meals with a goal to maintain adequate nutritional status as evidence by weight remaining stable through the next review on 02/7/2022 with interventions to be fed by staff as needed. Resident #45 Record Review of Resident #45's MDS record revealed the following assessments were completed: a Quarterly with an ARD of 03/23/2022, and a Quarterly with an ARD of 06/08/2022. Review of Resident #45's Care Plan revealed the care plan had not been revised with the last two assessments and indicated the next review date was 03/28/2022. On 08/25/2022 at 2:00PM, during an interview S3MDS (Minimum Data Set) coordinator acknowledged Resident #35 did not have a care plan addressing her needs for a peg tube. S3MDS coordinator further acknowledged she did not review and/or revise Resident #29's, Resident #35's, or Resident #45's care plan per requirements with their quarterly and significant change assessments.

Based on observation, record review, and interview, the facility failed to ensure residents who were unable to carry out activities of daily living receive the necessary services to maintain good personal hygiene by failing to ensure resident's fingernails were trimmed in a timely manner for 1 (#33) of 4 (#19, #33, #40, and #45) residents reviewed for activities of daily living. Findings: Review of the medical record for sampled resident #33 revealed diagnosis of cerebral infarction, dementia with behavioral disturbance, unspecified convulsions, diabetic neuropathy, hemiplegia affecting non dominant side, aphasia and dysarthria following subarachnoid hemorrhage, radiculopathy cervical region, intervertebral disc degeneration lumbar region, and dysphagia following cerebral infarction. Review of the Quarterly MDS (Minimum Data Set) dated 05/31/2022 revealed the resident had severed cognitive impairment for daily decision making and required one person extensive assist for bed mobility, one person limited assist for eating, and one person total dependence for toileting and transfers. Further review of MDS revealed resident had impaired functional limitation on one side for upper and lower extremities. Review of the care plan dated 04/08/2021 revealed the resident required extensive assistance with activities of daily living. Staff are to assist resident with dressing, grooming, bathing and personal hygiene. On 08/22/2022 at 10:25AM, 08/23/2022 at 9:00AM, 08/24/2022 at 3:30PM, and 08/25/2022 at 12:30PM, observations of resident #33 revealed long fingernails to bilateral hands. An interview on 08/25/2022 at 12:20PM with S8LPN (Licensed Practical Nurse) revealed that resident #33's fingernails are trimmed by nurses on the hall due to resident being diabetic. An interview/observation on 08/25/2022 at 12:30PM with S3LPN, confirmed that resident #33's fingernails are too long and need to be trimmed. An interview on 08/25/2022 at 12:35PM with S2DON (Director of Nurses) confirmed that nurses on hall or Podiatrist are responsible for trimming resident #33's fingernails. S2DON confirmed that resident #33 needed his fingernails trimmed. On 08/25/2022 at 12:51PM S1Administrator was notified that resident #33 had long fingernails that needed to be trimmed and required extensive assist with activities of daily living.

Based on policy review, record review and interviews the facility failed to ensure a resident's medical records reflected the resident's wishes for Advanced Directives for 1 (#5) of 1 (#5) residents reviewed for Advance Directives. The facility failed to ensure the physician's orders and plan of care were consistent with the resident's wishes for Do Not Resuscitate (DNR). Findings: Review of the facility Advance Directives policy revised 12/2016 revealed in part: 20. The Director of Nursing Services or designee will notify the Attending Physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care. Review of resident #5's medical record revealed an admit date of 04/09/2022. Review of resident #5's current physician orders revealed an order dated 04/29/2022 for Full Code Status. Review of resident #5's comprehensive care plan dated 05/12/2022 revealed resident #5's Code status: Full Code. Present at admission. Review of resident #5's paper medical record binder revealed a full size red first page noting resident #5 was a DO NOT RESUSCITATE - (DNR). Further review revealed the medical record binder was flagged with bright colored stickers designating resident code status as DNR. The second page in resident #5's medical record binder was resident #5's (LA Post) Louisiana Physician Orders for Scope of Treatment for the code status signed 04/29/2022 reflecting resident #5's medical treatment wishes as DNR-Do not resuscitate/selective treatment. Review of resident #5's electronic medical record face sheet and Medication Administration Record (MAR) sheet revealed resident #5 code status as DNR. During an interview on 8/24/22 at 11:30 am S2DON (Director of Nursing) and S10LPN (Licensed Practical Nurse) reported if a resident was found unresponsive, S2DON would check the resident's paper medical record (chart) because the code status was on the first page in the front of the chart. S10LPN reported nurses look at the resident's electronic medical record or at the top of the resident's MAR for code status and acknowledged resident #5's MAR reflected a DNR code status. Further review of resident #5's LA Post, current physician orders and comprehensive care plan with S2DON and S10LPN, and they acknowledged a discrepancy in resident #5's code status. S2DON and S10LPN verified resident #5's code status should have been clarified with resident #5, resident #5's representative and physician and updated according to resident #5's wishes and was not done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice by failing to assess dialysis graft every shift for 1 (#39) of 1 (#39) residents reviewed for dialysis. Findings: Review of the record revealed resident #39 was admitted to the facility on [DATE] with diagnoses of morbid obesity, venous insufficiency chronic peripheral disease, chronic pain, and end stage renal disease. Review of the Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed resident #39 had a BIMS (Brief Interview of Mental Status) score of 10 indicating moderate cognitive impairment. Further review of the MDS confirmed the resident is receiving dialysis. On 08/23/2022 at 9:15AM, an interview with resident #39 reported she goes to dialysis 3 days per week on Monday, Wednesday, and Friday. Resident #39 reported she has a necklace graft to her upper chest wall, and staff do no monitor graft upon return from dialysis. Review of the facility's policy and procedure for Care of the Patient Receiving Hemodialysis revealed access site to be assessed for bruit and thrill every shift and notify the physician if not heard or felt. Further review of Care of the Patient Receiving Hemodialysis revealed access site to be monitored every shift and notify doctor with any sign and symptoms of infection, such as site being red, swollen, or hot to touch. Review of the June 2022, July 2022, and August 2022 MAR (Medication Administration Record) for resident #39 revealed no documentation for assessing dialysis access for bruit and thrill every shift, and no documentation for monitoring access site every shift for signs and symptoms of infection. On 08/24/2022 at 4:30PM, an interview with resident #39 revealed she went to dialysis today and returned to the facility about 4:00PM. She reported that the nurse had not monitored her dialysis access since she returned to the facility. On 08/25/2022 at 2:55PM, an interview with S7Corporate Administrator, confirmed that resident #39 should have had her dialysis access assessed for thrill and bruit and monitored dialysis access for signs and symptoms of infection each shift per facility's policy and procedure.

Based on interview and record review the facility failed to provide documentation that a resident or resident's representative were provided written Advance Directive information, and at the residents option, the right to decline or formulate and advance directive for 29 (#1, #2, #3, #4, #5, #6, #8, #10, #11, #12, #15, #18, #19, #28, #29, #33, #35, #38, #39, #40, #45, #49, #54, #58, #61, #62, #63, #161, #361) of 29 sampled residents. Findings: Review of the facility Advance Directives policy revised 12/2016 revealed in part: 6. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. 7. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. 8. If the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. a. The resident will be given the option to accept or decline the assistance. b. Nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline assistance. Review of residents #1, #2, #3, #4, #5, #6, #8, #10, #11, #12, #15, #18, #19, #28, #29, #33, #35, #38, #39, #40, #45, #49, #54, #58, #61, #62, #63, #161, and #361 records revealed no written documentation that the resident or his/her responsible party had been given information or offered the option to formulate an Advance Directive. During an interview on 08/23/2022 at 11:30AM S4Social Services reported the facility was instructed by the Feds advance directive information and statement of acknowledgment or declination form was no longer required so the facility had only been using the LA POST (Louisiana Physician Orders for Scope of Treatment) for instruction related to the resident's medical wishes. During an interview on 08/24/2022 at 10:00AM S1Administrator reported the facility had not been having residents or the resident's representative sign an acknowledgement/declination form to indicate whether they had received information or implemented advanced directives during admission and were using the resident's LA POST for the code status and to indicate the resident's advance directive wishes.

Based on record review and interview the facility failed to complete a quarterly assessment using the quarterly review instrument specified by the State and approved by CMS (Centers for Medicare and Medicaid Services) no later than 14 days after the Assessment Reference Date (ARD) for 2 (#6, and #11) of 7 (#1, #2, #3, #4, #6, #11, and #12) reviewed for Resident Assessment. Findings: Record review revealed the MDS (Minimum Data Set) quarterly assessments with an ARD date of 07/20/2022 were not completed for 2 (#6, and #11) residents. On 08/24/2022 at 11:33AM, an interview with S3MDS Coordinator confirmed Resident #6 and Resident #11's quarterly assessments with an ARD date of 07/20/2022 should have been completed by 08/03/2022.

Based on record review and interview, the facility failed to ensure resident assessments were electronically transmitted in a timely manner by failing to transmit the resident assessment within 14 days of completion for 5 (#1, #2, #3, #4, and #12) of 7 (#1, #2, #3, #4, #6, #11, and #12) sampled residents reviewed for resident assessments. Findings: Review of the records for residents #1, #2, #3, #4, and #12 revealed each resident had an MDS (Minimum Data Set) completed in March, April, and May in 2022 that was completed but not transmitted to the CMS (Centers for Medicare and Medicaid Services) system. Review of CMS Validation Reports dated 08/25/2022 indicated residents #1, #2, #3, #4, and #12's assessment records were submitted late. On 08/25/2022 at 2:00PM, an interview with S3MDS Coordinator revealed the MDS assessments for residents #1, #2, #3, #4 and #12 should have been submitted in a timely manner.

Based on observation and interview the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety by not ensuring 1) food storage containers were clean, 2) food was labeled, dated, and sealed appropriately, 3) the fryer and toaster oven were clean, and 4) the chemical sanitization levels in the 3 compartment sink was monitored appropriately. According to S5Dietary Manager (DM) 50 residents are served meals from the kitchen. Findings: Review of the facility's policy for 3 Sink Method revealed in part, use the third sink to soak dishes in chemical sanitizing solution per solution directions. Alternately, you can soak dishes for 30 seconds in hot water at 171 degrees Fahrenheit or hotter instead of sanitizing chemicals. Chlorine sanitizer should be maintained at 50-100ppm. On 08/22/2022 at 9:25AM, observation of the kitchen revealed the lids on the cereal bins contained grime and debris, and a package of dry noodles was stored in a plastic wrapper that contained grime and debris. Further observation revealed 5 plastic seasoning containers had grime and seasoning on the outside of the bottle, and a box of powdered sugar was not sealed and open to air. On 08/22/2022 at 9:30AM, observation of the freezer and refrigerator revealed a box of biscuits, corndogs, slices of Swiss cheese, sausage patties, a Ziploc bag containing strawberries, a Ziploc bag containing ham, and a plastic bag of salad not labeled or dated. On 08/22/2022 at 9:35AM observation of the fryer revealed food particles and grease buildup on the inside bottom of the fryer. The toaster oven contained an accumulation of burnt food particles covering the inside bottom and the trays of the toaster oven and needed to be cleaned. On 08/23/2022 at 8:32AM, an interview with S5Dietary Manager revealed the kitchen serves 50 residents from the kitchen. On 08/23/2022 at 1:00PM, S5Dietary Manager was notified of the issues in the kitchen. On 08/23/2022 at 1:40PM, observation of the 3 Compartment Sink revealed S6Dietary Worker performed a chemical sanitization strip reading. The test strip reading revealed multicolors yellow/blue/green and was not a clear reading. Further observation revealed the test strips used to test the sanitization level in the 3 compartment sink were expired as of July 2021. On 08/23/2022 at 1:40PM, an interview with S5Dietary Manger and S6Dietary Worker revealed they were not aware the test strips used to test the sanitization levels in the 3 compartment sink were expired. During the interview S5Dietary Worker revealed the facility did not have any other bottles of the chemical test strips to monitor sanitization levels of the 3 compartment sink. On 8/23/2022 at 1:50PM, S1Administrator was notified of the issues in the kitchen documented above.