Based on record review and interviews the facility failed to ensure a resident's plan of care was implemented for 1 (#1) of 5 (#1, #5, #6, #53, #109) residents who were reviewed for unnecessary medications. The facility failed to ensure resident #1's insulin was given as ordered by a physician. Findings: Review of the facility's Insulin Guidelines policy revealed the following; 1. Insulin is administered following doctors orders with an insulin syringe. Review of resident #1's medical record revealed an admit date of 06/27/2018 with a diagnosis of but not limited to Type 2 Diabetes Mellitus and long term use of insulin. Review of resident #1's July 2023 Physicians Orders revealed an order for Novolin N 100 units/ml (millimeter) vial, inject 30 units subcutaneously every morning. Review of resident #1's Comprehensive plan of care revealed a problem of Potential for altered nutrition with the approach of administer insulin as ordered. Review of resident #1's July 2023's MAR (medication administration record) revealed Novolin N 30 units was documented as not given at 6:30 a.m. on 07/10/2023 and 07/11/2023. During an interview on 08/02/2023 at 9:00 a.m. S4 Corporate Nurse and S3 DON (Director of Nurses) confirmed resident #1 was not administered insulin as ordered on 07/10/2023 and 07/11/2023. During an interview on 08/02/2023 at 10:37 a.m. S2 Administrator in Training confirmed resident #1 was not administered insulin on 07/10/2023 and 07/11/2023 as ordered because it was not in stock at the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure a resident's medical record reflected the resident's advance directive choices for 1 (#109) of 29 sampled residents. The facility failed to ensure each of Resident #109's code status documentation was in agreement. Findings: Review of Code Blue-Licensed Nursing Staff document provided by S3 DON (Director of Nursing), who reported the document was used for staff training revealed: This procedure is to be followed when any resident is found unresponsive, no breathing or no normal breathing (gasping). . 3. Licensed Nursing Staff to establish code status: Review the resident's medical record, this is the most reliable way to know the resident's code status. The chart review is critical and is to be done quickly while the resident is being assessed, prior to initiating CPR (Cardiopulmonary Resuscitation). Review of Resident #109's medical record revealed an admission date of [DATE] with diagnoses that included, in part, type 2 diabetes mellitus, essential hypertension, metabolic encephalopathy, atherosclerotic heart disease of native coronary artery without angina pectoris, chronic viral hepatitis C, major depressive disorder, nicotine dependence and vascular dementia. Review of Resident #109's current physician orders revealed a [DATE] order for Initiate CPR (cardiopulmonary resuscitation). Review of document titled Declaration Competent Resident signed by resident on [DATE] revealed: -Declaration made this May day of 2023 (month, year). I, [NAME] being of sound mind, willfully and voluntarily make known my desire that my dying shall not be artificially prolonged under the circumstances set forth below, do here by declare: . __check mark__Do use CPR In the absence of my ability to give directions regarding the use of such life-sustaining procedure, it is my intention that this declaration shall be honored by my family and physician as the final expression of my legal right to refuse medical and surgical treatment and accept the consequences from such refusal. Review of Resident #109's paper chart binder revealed an orange sticker on the spine that read DNR, indicating Resident #109 was a DNR. During an interview on [DATE] at 2:40 p.m. S5 LPN (Licensed Practical Nurse) reported if a resident's code status was needed quickly she would look at either the DNR list on back of door at the nurse's station, the spine of the resident's paper chart binder or the code status list on the medication cart. S5 LPN observed the DNR list and the spine of Resident #109's paper chart binder and reported they did not agree and should have. During an interview on [DATE] at 2:55 p.m. S2 AIT (Administrator in Training) reported Resident #109 had never been a DNR and the DNR sticker should not have been on the spine of the paper chart binder.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure a resident with an indwelling catheter received appropriate care and services to prevent urinary tract infections for 1 (#73) of 2 (#54, #73) residents reviewed for urinary catheter or UTI (urinary tract infection). The facility failed to ensure Resident #73's indwelling catheter was changed as ordered. Findings: Review of Resident #73's medical record revealed Resident #73 had an admission date of 06/27/2018, with a readmission on [DATE], and had diagnoses that included, in part, benign prostatic hyperplasia with lower urinary tract symptoms, other obstructive and reflux uropathy, other retention of urine, unspecified kidney failure, type 2 diabetes mellitus, atherosclerotic heart disease, vascular dementia, and essential hypertension. Review of Resident #73's physician orders revealed: -07/23/2023 order for Change 24Fr (French)/30cc (cubic centimeters) foley catheter monthly. -06/22/2023 Foley catheter at all times for urine collection related to retention Review of Resident #73's June, July and August 2023 MAR (medication administration record) failed to reveal Resident #73's catheter had been changed since Resident #73's readmission on [DATE] when Resident #73 had a catheter. Review of June and July 2023 progress notes failed to reveal Resident #73's foley catheter had been changed. Review of Resident #73's MDS (minimum data set) with assessment reference date of 06/27/2023 revealed Resident #73 had a BIMS (brief interview mental status) score of 9, indicating Resident #73 was moderately impaired cognitively. Resident #73's 06/27/2023 MDS further revealed Resident #73 had an indwelling catheter. During an interview on 08/02/2023 at 7:54 a.m. Resident #73 responded yes when asked if he had a catheter and a bag that hung on his leg. Resident #73 further reported he had the catheter about a month and the catheter had not been changed since it was put in. During an interview on 08/02/2023 at 9:12 a.m. S5 LPN (Licensed Practical Nurse) reported Resident #73's catheter was put in outside the facility about 2 months ago. S5 LPN further reviewed Resident #73's medical record and confirmed Resident #73's foley catheter had not been changed since 06/22/2023 and should have been changed monthly.

Based on record reviews and interview the facility failed to ensure there was a sufficient number of skilled licensed nurses, nurse aides, and other nursing personnel to provide care and respond to each resident's basic needs. The facility failed to provide the minimum required staffing hours for 14 of 25 weekend days. Findings: Review of the facility's PBJ (Payroll Based Journal) Staffing Data Report for FY (Fiscal Year) Quarter 2 2023 (January 1-March 31) revealed the submitted weekend staffing data was excessively low. Review of the facility's Staffing Pattern forms for weekends from Fiscal Year Quarter 2 revealed the facility: Provided 210.8 hours on 01/01/2023 and were required to provide 260.8 hours. Provided 262.5 hours on 01/22/2023 and were required to provide 265.5 hours. Provided 220 hours on 02/05/2023 and were required to provide 267.9 hours. Provided 259 hours on 02/11/2023 and were required to provide 267.9 hours. Provided 244.5 hours on 02/12/2023 and were required to provide 265.5 hours. Provided 247.5 hours on 02/18/2023 and were required to provide 267.9 hours. Provided 225 hours on 02/19/2023 and were required to provide 267.9 hours. Provided 265.7 hours on 02/25/2023 and were required to provide 267.9 hours. Provided 249 hours on 02/26/2023 and were required to provide 267.9 hours. Provided 248.75 hours on 03/04/2023 and were required to provide 267.9 hours. Provided 247.5 hours on 03/05/2023 and were required to provide 267.9 hours. Provided 251.2 hours on 03/12/2023 and were required to provide 265.5 hours. Provided 266.5 hours on 03/19/2023 and were required to provide 267.9 hours. Provided 256.2 hours on 03/26/2023 and were required to provide 267.9 hours. During an interview on 08/01/2023 at 9:15 a.m. S2 Administrator In Training and S1 Administrator confirmed the facility did not provide the minimum required hours on 01/01/2023, 01/22/2023, 02/05/2023, 02/11/2023, 02/12/2023, 02/18/2023, 02/19/2023, 02/25/2023, 02/26/2023, 03/04/2023, 03/05/2023, 03/12/2023, 03/19/2023, 03/26/2023 and should have.

Based on record reviews and interview, the facility failed to ensure individuals with convictions barring employment were not employed by the facility for 1 (S2 CNA [Certified Nursing Assistant] Student) of 5 (S2 CNA Student, S3 CNA, S4 CNA, S5 CNA, S6 CNA) personnel records reviewed. Findings: Review of the facility's Screening: Criminal Background Checks policy revealed in part: It is the responsibility of all employers that employ non-licensed persons or ambulance personnel to know which convictions bar employment. Louisiana Revised Statute 40:1203.3 covers criminal convictions that bar an employer from hiring a non-licensed person or ambulance personnel. Those criminal convictions are listed in the following table .14:67 Theft-Felony .*if results of the Criminal Background Check reveal that a non-licensed person or any licensed ambulance personnel hired on a temporary basis or any other person who is an employee has been convicted of any of the offenses listed above, the employer shall immediately terminate the person's employment. Review of S2 CNA Student's personnel file revealed a hire date 09/09/2022, and a criminal background check completed on 08/23/2022. Further review revealed S2 CNA Student was a felon with a conviction of charge R.S. 14:67 Theft of goods over $500. Further review revealed no documentation the charge had been reduced. During an interview on 01/10/2023 at 4:15 p.m., S1 Administrator verified S2 CNA Student's background check showed a conviction that would be deemed a conviction barring employment, and the employee should not have been hired to work at the facility.