Wynhoven Community Care Center

Based on interviews, observations, and record reviews, the facility failed to ensure a resident's enabler bar was not an accident hazard for 1 (Resident #1) of 3 sampled residents reviewed for accident hazards. This deficient practice resulted in actual harm on 02/28/2026 at 7:33PM for Resident #1, when S3Certified Nursing Assistant (CNA) transferred Resident #1 from her wheelchair to the bed. Resident #1's left leg hit the enabler bar, with a missing end cap, which resulted in a laceration to Resident #1's left lower leg. Resident #1 was then transported to a local Emergency Department (ED) where she was assessed as having a large stellate (a star-shaped or irregular, multi-angled tear in the skin) laceration to the left lower leg, received 6 interior sutures, 27 exterior sutures, a tetanus shot, and pain medication. Resident #1 required daily wound care and 14 days of antibiotics. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a past noncompliance citation.Findings:Review of the facility's Bed and Side Rails policy and procedure, dated 11/28/2017, revealed, in part, a facility designee shall inspect all bed frames, mattresses, and bed rails as part of a regular maintenance program. Further review revealed examples of bed rails included but were not limited to, grab bars and assist bars.Review of the facility's undated Maintenance Supervisor (MS) job description revealed, in part, the MS should identify and correct hazardous facility conditions. Further review revealed the MS should tour the property daily to look for needed maintenance and liability hazards and report to the administrator.Review of Resident #1's medical record revealed an admission date of 12/05/2024, and diagnoses which included, in part, Peripheral Vascular Disease, Malnutrition, Chronic Kidney Disease, Depression, and Alzheimer's Disease.Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/15/2026 revealed, in part, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 5. A score of 5 indicated Resident #1 had severe cognitive impairment. Further review of Resident #1's MDS revealed Resident #1 received hospice services.Review of Resident #1's care plan revised on 03/02/2026 revealed, in part, Resident #1 required extensive assistance of 1 staff person with transfers.Review of Resident #1's nurses notes dated 02/28/2026 at 7:33PM revealed, in part, S3CNA called S4Licensed Practical Nurse (LPN) to Resident #1's room. S4LPN observed Resident #1 with a large laceration to her left lower leg with bleeding. Further review revealed S3CNA indicated the laceration occurred during transfer. Further review revealed S4LPN provided first aide and called Emergency Medical Services (EMS). Further review revealed Resident #1 was transferred to the local ED on 02/28/2026 at 7:47PM for evaluation and treatment of a left lower leg laceration.Review of Resident #1's ED records, dated 02/28/2026, revealed, in part, Resident #1 arrived to the ED on 02/28/2026 at 8:13PM via EMS. Further review revealed Resident #1 had a very large stellate laceration to the lateral left lower leg which measured 25.5 centimeters (cm). Resident #1's laceration required an extensive amount of cleaning. Further review revealed the laceration was deep to the fascia (a thin sheath of connective tissue which surrounds and supports muscle) and required a complicated repair of 6 internal and 27 external sutures. Further review revealed Resident #1 required a tetanus vaccination update. Further review revealed Resident #1 had a history of multidrug resistant pseudomonas which had previously caused cellulitis of the same leg; therefore, Resident #1 would require close monitoring. Further review revealed Resident #1 was discharged to the nursing facility on 02/28/2026 at 10:59PM.Review of Resident #1's Physician Orders dated 03/07/2026 revealed an order for Bactrim Double Strength (DS) (an antibiotic) tablet 800-160 milligram (mg), take 1 tablet by mouth every 12 hours for 7 days.Review of Resident #1's March 2026 electronic Medication Administration Record (eMAR) revealed Bactrim DS 800-160mg was administered every 12 hours as ordered from 03/07/2026 through 03/13/2026.Review of Resident #1's Physician's Progress Note dated 03/13/2026 revealed, in part, on 02/28/2026 Resident #1 suffered an injury to her left leg which resulted in a large laceration and required repair in the ED. Further reviewed revealed Resident #1 was placed on antibiotics for prophylactic treatment of the wound due to the extent and depth of the laceration. Further review revealed Resident #1's wound was assessed 10 days post injury, but was not adequately healed. Further review revealed half of Resident #1's sutures were removed on this day, due to the delayed healing of the wound with some surrounding erythema (superficial reddening of the skin) which was mildly increased from the last inspection 3 days prior. Further review revealed scant discharge was observed from the central non healed portion of Resident #1's wound. Further review revealed Resident #1's Physician ordered Bactrim DS for 7 additional days. Review of Resident #1's Physician Orders dated 03/13/2026 revealed an order for Bactrim DS tablet 800-160mg take 1 tablet by mouth every 12 hours for 7 days.Review of Resident #1's March 2026 electronic Medication Administration Record (eMAR) revealed Bactrim DS Tablets 800-160mg were administered every 12 hours as ordered as ordered from 03/13/2026 through 03/20/2026.Review of Resident #1's record revealed on 03/16/2026 Resident #1's physician removed 7 additional sutures.Review of Resident #1's Nurse's Notes dated 03/25/2026 at 7:04PM revealed Resident #1's remaining sutures were removed by Resident #1's physician.In a telephone interview on 03/30/2026 at 9:13AM, S4LPN indicated she Resident #1's nurse when Resident #1 sustained the laceration to her left lower leg. S4LPN indicated she observed Resident #1's enabler bar had a missing end cap which caused the enabler bar to have a sharp edge. S4LPN further indicated during Resident #1's transfer her left lower leg rubbed on the enabler bar which caused the left lower leg laceration. In a telephone interview on 03/30/2026 at 10:00AM, S3CNA indicated she was Resident #1's CNA on 02/28/2026. S3CNA indicated when she assisted Resident #1 with a transfer from her wheelchair to her bed, Resident #1's left leg rubbed against the enabler bar which resulted in a laceration to Resident #1's left lower leg. S3CNA indicated S4LPN observed Resident #1's enabler bar had a missing end cap. In an interview on 03/30/2026 at 2:07PM, S5Treatment Nurse indicated Resident #1's left lower leg laceration required daily wound care.In an interview on 03/30/2026 at 3:22PM, S1Administrator indicated at the time of Resident #1's incident S1Administrator was not aware Resident #1's enabler bar had a missing end cap, and she should have been.Review of the facility's corrective action response revealed, in part, S3CNA was suspended pending an investigation.Review of the facility's corrective action response revealed S6Maintenance Supervisor assessed Resident #1's bed on 03/01/2026 and noted the enabler bars were missing the end caps and corrected the issue. S6MS assessed all resident enabler bars in the building for missing caps and all beds found to have a defect were immediately corrected.Review of the facility's corrective action response revealed all facility enabler bars were reviewed to ensure no other residents were affected because all the residents who used enabler bars had the potential to be affected. Record review revealed all residents had a side rail/bed mobility/lift assessment completed on 03/03/2026, care plans and over-bed signage were verified for accuracy.Review of the facility's corrective action response revealed on 03/03/2026 nursing staff were in-serviced on the transfer/lift policy and procedure and the bed side rail policy and procedure.Review of the facility's corrective action response revealed the maintenance department was educated. Further review revealed on 03/05/2026 padding was added to all enablers in the facility.A monitoring tool was implemented to monitor transfer status to ensure ongoing alignment with the MDS, care plan and over-bed signage.The above was confirmed by the surveyor through observations, record review, and interviews which verified the corrective action was put into place and the noncompliance was corrected before the surveyor entered the facility.Throughout the survey from 03/26/2026 to 03/27/2026 observations revealed all enablers were intact and accident hazards related to enablers were not observed. Record reviews revealed staff received training on the facility's repositioning, transfer, bed side rail, and lift policies and procedures. Interview conducted while onsite on 03/26/2026 and 03/27/2026 revealed nurses and CNAs confirmed trainings were completed. Nurses and CNAs were knowledgeable of the need to assess enabler bars and beds for accident hazards prior to a transfer, ensuring transfers were completed properly, not proceeding with a transfer if was deemed unsafe, and reporting any accident hazard to the maintenance department. The facility has implemented the following actions to correct the deficient practice:Action was obtained for the resident identified:Resident #1 was assessed on 02/28/2026 for injuries and bruising, and S4LPN noted a laceration to the left lower lateral leg;Pressure was applied to Resident #1's leg, vital signs were obtained, Resident #1's Responsible Person, Resident #1's physician and Resident #1's hospice provider were notified;Resident #1 was transferred to the hospital for evaluation and treatment;On 02/28/2026 S4LPN padded Resident #1's enabler bar with foam prior to Resident #1's return; and,Wound care and pain monitoring were initiated per Physician Orders. Other residents who had the potential to be affected:Any resident who resided in the facility and used an enabler bar had the potential to be affected.No other residents were found to be affected by this incident.The facility placed the following actions in place to ensure the incident does not recur:S6MS assessed Resident #1's bed and put a new end cap on Resident #1's enabler bar;S6MS assessed all resident enabler bars on 03/01/2026. Audit results revealed no missing end caps;On 03/03/2026 side rail/bed mobility/lift assessments were completed on all residents;All residents' care plans and over bed signage were verified on 03/03/2026;The maintenance department re-inspected structural integrity and proper function of all resident beds on 03/03/2026;S2Director of Nursing (DON) and the therapy department in-serviced licensed nurses and CNAs on repositioning, transfer, bed side rail, and lift policy and procedure; and,On 03/05/2026 all enabler bars were padded.The plan the facility has implemented to ensure the incident does not reoccur:S6MS or designee would monitor all enabler bars daily for 1 week starting on 03/03/2026;S2DON or designee would audit 10 random resident transfers for 1 week starting on 03/03/2026;Audit findings would be reviewed in Quality Assurance Performance Improvement (QAPI), and corrective action would be implemented immediately if non-compliance was identified; and,Any non-compliance would result in immediate correction, re-education, and/or progressive discipline.The facility was in compliance on 03/08/2026.The facility conducted on going monitoring for a total of 1 week.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure an effective system was in place to ensure the resident record accurately reflected a resident's wishes for a code status of Do Not Resuscitate (DNR) if an emergency occurred for 1 (Resident #103) of 46 (Resident #1, Resident #4, Resident #5, Resident #10, Resident #11, Resident #14, Resident #19, Resident #20, Resident #23, Resident #24, Resident #25, Resident #28, Resident #29, Resident #33, Resident #35, Resident #36, Resident #37, Resident #39, Resident #40, Resident #41, Resident #46, Resident #52, Resident #53, Resident #60, Resident #61, Resident #68, Resident #71, Resident #72, Resident #76, Resident #77, Resident #80, Resident #82, Resident #83, Resident #85, Resident #86, Resident #87, Resident #88, Resident #92, Resident #93, Resident #94, Resident #97, Resident #99, Resident #102, Resident #103, Resident #154, Resident #354) sampled residents reviewed for advanced directives.
This deficient practice resulted in an Immediate Jeopardy situation on [DATE] at 2:06PM, when Resident #103, whose code status was to be a DNR, became pulseless and a code was called by S5Licensed Practical Nurse (LPN). Cardiopulmonary Resuscitation (CPR) was initiated and performed by facility staff. Chest compressions were started and epinephrine was administered. The Immediate Jeopardy ended for Resident #103 at 2:50PM when chest compressions ended. The facility failed to update Resident #103's record to reflect the resident's wishes of DNR.
This deficient practice had the likelihood to cause serious injury, serious harm, serious impairment or death to the remaining105 residents who reside in the facility and may need to receive emergency care.
S1Administrator was notified of the Immediate Jeopardy on [DATE] at 3:42PM.
The Immediate Jeopardy was removed on [DATE] at 11:39AM, after it was verified through interviews and record reviews the facility implemented an acceptable Plan of Removal, prior to the survey exit.
Findings:
Review of the facility's undated Advanced Directive policy and procedure revealed, in part, the plan of care for each resident will be consistent with his or her documented treatment preferences and/or advanced directives, information about whether or not the resident has executed an advanced directive shall be displayed prominently in the medical record.
Review of Resident #103's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed, in part, Resident #103 had a Brief Interview Mental Status (BIMS) score of 15 which indicated Resident #103 was cognitively intact.
Review of Resident #103's EMR revealed, in part, a physician's order dated [DATE] which documented CPR as Resident #103's Code Status.
Review of Resident #103's Care Plan meeting on [DATE] revealed, in part, Resident #103 wanted his Code Status to a DNR.
Review of Resident #103's Care Plan created on [DATE], revealed Resident #103 elected to be a Full Code with an intervention to have staff review his code status on a quarterly basis and as needed with changes and require staff to have knowledge of Resident #103's Full Code Status.
There was no documented evidence and the facility did not present any documented evidence that a DNR order was placed into Resident #103's electronic medical record to reflect the change in code status from a full code to a DNR.
Review of Resident #103's LaPost revealed, in part, Resident #103 signed his LaPost for his code status to be a DNR on [DATE], and S8Physician signed the above mentioned LaPost related to Resident #103's request for DNR code status on [DATE].
In an interview on [DATE] at 11:38AM, S5LPN indicated she looked in Resident #103's Electronic Medical Record (EMR) to verify his code status and according to his EMR, Resident #103 was a full code.
In an interview on [DATE] at 11:48AM, S4Assistant Director of Nursing/Infection Preventionist indicated Resident #103's EMR documented Resident #103 as a full code.
There was no documented evidence and the facility did not present any documented evidence that a DNR order was placed into Resident #103's EMR to reflect the change in code status from a full code to a DNR.
There was no documented evidence and the facility did not present any documented evidence that Resident #103's care plan was updated to reflect Resident #103's DNR code status.
Review of Resident #103's EMR revealed, in part, a note dated [DATE] by S5LPN indicating Resident #103 was found pulseless and not breathing at 2:05PM. A code was called by S5LPN at 2:06PM and CPR was initiated and performed by facility staff. Chest compressions ended at 2:50PM and Resident #103 expired.
In an interview on [DATE] at 12:12PM, S3Social Services indicated a resident's code status was reviewed and discussed at care plan meetings, and the Clinical Care Coordinator/MDS Nurse would handle physician's orders that arose from a care plan meeting.
In an interview on [DATE] at 2:31PM, S2Diretor of Nursing (DON) indicated if a Resident changed their Code Status the Clinical Care Coordinator and the DON were supposed to ensure the EMR and care plan were updated.
In an interview on [DATE] at 2:40PM, S3Social Services indicated once she gets the signatures of the LaPOST she would give the signed copy to the DON to update in the resident's EMR.
In an interview on [DATE] at 1:36PM, S7Quality Management Nurse indicated the facility did not have a policy and procedure in place related to transcribing LaPOST orders into a resident's EMR.
In an interview on [DATE] at 1:42PM, S7Quality Management Nurse indicated she did not recall why Resident #103's DNR Code Status order was not transcribed into the EMR. S7Quality Management Nurse confirmed CPR should not have been performed on Resident #103.
A Plan of Removal was accepted on [DATE] at 11:39AM, which included the following actions to correct the deficient practice:
1.
All 105 residents residing in the facility had the potential to be affected by this deficient practice.
a.
The facility failed to update Resident #103's physician order after a change in code status.
b.
On [DATE], an audit was conducted of all resident's codes status in the building to ensure the code status in the electronic health record matched the physician order, signed, consent, LaPOST if applicable and the care plan. No other residents were identified.
2.
As of [DATE] all nursing staff currently working were educated. The remaining staff will be educated prior to returning to work on the DNR policy and Medication treatment order policy processes by the DON or designee.
a.
The nurse receiving the order will be responsible for transcribing orders into the EMR and notify the DON at the time the order is received.
b.
DON/ADON will oversee contacting the Medical Director and ensuring that all signatures are obtained immediately for advanced directives.
c.
The medical record nurse and clinical care coordinator assigned to the unit will be notified of any codes status changes immediately. All code status changes in the EMR will be adjusted instantly by the clinical care coordinator.
d.
The following policies were reviewed on [DATE], and no updates were made.
a.
Do not resuscitate policy.
b.
Nurses will be educated on the Medication Treatment Order Policy.
a.
Nurses will also be educated on updating the EMR and notifying the DON immediately upon receiving a code status order. If the DON is unavailable, the Administrator will be the next point of contact.
3.
The facility will monitor its performance to ensure this solution was sustained by the following:
a.
On [DATE] the DON or designee started monitoring changes in code status physician orders, care plans, and progress notes to ensure the order was entered into the EMR.
b.
Monitoring will occur 5x a week for 8 weeks and then as deemed necessary by the QAPI committee.
c.
The results of monitoring will be reviewed weekly by the Quality Assurance committee. Any identified issues will be addressed by the Administrator/DON with reeducation and progressive discipline.
4.
The facility asserts the likelihood for serious harm to any resident no longer exists as of [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure a resident's care plan was revised to update his code status (a term used to describe what type of interventions, if any, a healthcare team could perform if an individual's heart stopped beating or they stopped breathing).
This deficient practice was identified for 1 (Resident #103) of 23 (Resident #5, Resident #23, Resident #25, Resident #29, Resident #33, Resident #35, Resident #39, Resident #40, Resident #41, Resident #46, Resident #68, Resident #71, Resident #72, Resident #76, Resident #80, Resident #82, Resident # 83, Resident #92, Resident #93, Resident #94, Resident #99, Resident #102, and Resident #103) sampled residents.
Findings:
Review of Resident #103's clinical record revealed, in part, Resident #103 was admitted to the facility on [DATE].
Review of Resident #103's Minimum Data Set with an Assessment Reference Date of 01/02/2025 revealed, in part, Resident #103 had a Brief Interview Mental Status score of 15, which indicated Resident #103 was cognitively intact.
Review of Resident #103's Care Plan created on 01/15/2025, revealed, in part, Resident #103 elected to be a Full Code (life saving measures, cardiopulmonary resuscitation, could be performed) with interventions for staff to have knowledge of Resident #103's Full Code Status and to review Resident #103's code status quarterly and as needed.
Review of Resident #103's clinical record revealed, in part, a care plan meeting was conducted on 12/30/2024 revealed, and Resident #103 requested his Code Status to be a Do Not Resuscitate (DNR) (no life saving measures should be performed).
Review of Resident #103's Louisiana Physician Orders for Scope of Treatment (LaPOST) revealed, in part, Resident #103 wished for his code status to be a DNR. Further review revealed the LaPOST was signed by Resident #103 on 12/30/2024, and signed by S8Physician s on 01/03/2025.
Review of Resident #103's clinical record revealed there was no documented evidence, and the facility did not present any documented evidence, Resident #103's care plan was updated to reflect his wish to be a DNR as mentioned above on the LaPOST.
In an interview on 04/16/2025 at 10:30AM, S6Interim Clinical Care Coordinator confirmed Resident #103's care plan and code status were not updated per LaPOST.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure a Registered Nurse adhered to professional standards of practice when a Registered Nurse (S6Interim Clinical Care Coordinator [S6ICCC]) falsified a resident's medical record. This deficient practice was identified for 1 (S6ICCC) of 2 (S6ICCC, and S7Quality Management Nurse) Registered Nurses identified as having revised Resident #103's care plan.
Findings:
Review of the facility's Code of Conduct, with a revision date of 09/2016, revealed, in part, falsification of records was a violation that was grounds for disciplinary action up to and including termination.
Review of the Louisiana Title 46 Professional and Occupational Standards, Part XLVII 3915 Standard Number 7: Professional Performance revealed, in part, a registered nurse should demonstrate professional nursing practice behaviors by making nursing decisions and actions that are determined in an ethical manner.
Review of Resident #103's physician orders revealed, in part, Resident #103 had an order for Full Code status (life saving measures, cardiopulmonary resuscitation) dated [DATE].
Review of Resident #103's care plan, presented to the survey team on [DATE] by S6ICCC revealed, in part, Resident #103 had a code status care plan indicating Resident #103 was a Full Code.
Review of Resident #103's electronic medical record (EMR) revealed, in part, Resident #103's Louisiana Physisican Orders for Scope of Treatment (LaPOST), updated on [DATE], revealed Resident #103 elected a Do Not Resuscitate (DNR) code status (in the event a person was found pulseless or not breathing CPR would not be completed).Further review revealed the LAPOST was signed by Resident #103 on [DATE] and signed by the physician on [DATE].
Review of Resident #103's care plan presented by S6ICCC to the survey team on [DATE] at 3:30PM revealed, in part, S6ICCC falsified Resident 103's care plan by, discontinuing the Full Code status care plan on [DATE], creating a new DNR code status care plan on [DATE], discontinuing the new DNR code status care plan on [DATE], and resuming the Full Code status care plan on [DATE].
In an interview on [DATE] at 4:30PM, S6ICCC was presented with documentation which demonstrated that 6ICCC had falsified Resident #103's care plan record. S6ICCC denied altering Resident 103's care plan and attempted to mislead the surveyor, indicating that the care plan creation date was [DATE] because she had opened the care plan earlier that day.
In an interview on [DATE] at 10:30AM, S6ICCC indicated she altered Resident #103's care plan on [DATE] because she realized Resident #103's care plan and code status were not updated per Resident #103's LAPOST updated on [DATE]. S6ICCC further indicated that no one asked her to alter Resident #103's care plan. S6ICCC further indicated she falsified Resident #103's care plan to prevent the facility from receiving a deficiency.
In an interview on [DATE] at 10:30AM, S6ICCC indicated she initially lied to the surveyor and denied falsifying Resident #103's medical record because she was afraid she would get into trouble. S6ICCC further indicated she was not aware of the potential implications of altering medical records, such as a person's code status and care plan. S6ICCC further indicated when she falsely revised Resident #103's care plan and misrepresented the facts when questioned by the surveyor, she went against professional nursing standards.

Based on observations, interviews, and record reviews, the facility failed to ensure a resident's pressure ulcer treatment plan was carried out in accordance with physician's orders for 1 (Resident #94) of 2 (Resident #94, Resident #99) sampled residents investigated for pressure ulcer care.
Findings:
Review of the facility's Wound Care policy and procedure dated 01/09/2022 revealed, in part, pressure relieving devices should be adhered to as part of the resident's wound care plan.
Review of Resident #94's medical record revealed, in part, Resident #94 had diagnoses which included hemiplegia (loss of movement on one side of the body) following a stroke affecting the left side and symptoms involving cognitive functions.
Review of Resident #94's Minimum Data Set with an Assessment Reference Date of 01/08/2025 revealed, in part, Resident #94 had a Brief Interview for Mental Status (BIMS) score of 0 which indicated severe cognitive impairment. Further review revealed Resident #94 had an unhealed Stage 4 left lateral foot pressure injury.
Review of Resident #94's care plan with a start date of 03/13/2025 and a review date of 05/06/2025 revealed, in part, a plan of care for a Stage 4 pressure injury to the left lateral foot with care approaches that included heel protectors applied to resident while in bed and treatment should be administered as ordered.
Review of Resident #94's April 2025 physician's orders revealed, in part, an order dated 03/14/2025 for heel protectors to bilateral feet to aid in wound healing and prevention every shift as tolerated.
Review of Resident #94's wound care provider progress note written by S13Wound Nurse Practitioner dated 04/08/2025 at 2:14 p.m. revealed, in part, Resident #94's left lateral foot pressure injury treatment recommendations included wearing heel protectors.
Observation on 04/15/2025 at 11:00AM revealed Resident 94's heels were in direct contact with the surface of the bed and Resident #94 was not wearing bilateral heel protectors.
Observation on 04/15/2025 at 2:00PM revealed Resident 94's heels were in direct contact with the surface of the bed and Resident #94 was not wearing bilateral heel protectors.
In an interview on 04/15/2025 at 2:30PM, S15Certified Nursing Assistant (CNA) indicated Resident #94 was not wearing heel protection boots.
Observation on 04/16/2025 at 9:15AM revealed Resident #94 was asleep in his bed with his heels in direct contact with the surface of the bed. Further observation revealed Resident #94 was not wearing bilateral heel protectors.
In an interview on 04/16/2025 at 11:08AM, S14Licensed Practical Nurse (LPN) confirmed Resident #94 was not wearing bilateral heel protectors when she started her shift at 7:00AM and should have been.
The facility could not provide any documented evidence Resident #94 was unable to tolerate the application of bilateral heel protectors as ordered.
In an interview on 04/16/2025 at 3:24PM, S2Director of Nursing confirmed Resident #94 should have been wearing bilateral heel protectors as ordered.

Based observations, interviews, and record reviews, the facility failed to:
1. Ensure the facility's infectious waste storage room was locked and not accessible to residents prone to wandering for 1 (Storage Room a) of 1 (Storage Room a) infectious waste storage rooms observed;
2. Ensure disposable razors were not accessible for 2 (Shower Room a, Shower Room b) of 3 (Shower Room a, Shower Room b, Shower Room c) observed; and,
3. Ensure shower rooms were secured for 3 (Shower Room a, Shower Room b, and Shower Room c) of 3 (Shower Room a, Shower Room b, Shower Room c) shower rooms observed; and,
4. Ensure whirlpool rooms were secured for 3 (Whirlpool Room a, Whirlpool Room b, Whirlpool Room c) of 3 (Whirlpool Room a, Whirlpool Room b, Whirlpool Room c) whirlpool rooms observed.
Findings:
1.
Review of the facility's wanderguard resident's list revealed, in part, 14 residents were identified as residents who wander and require monitoring.
Observation on 04/15/2025 at 11:23AM revealed Storage Room a door found unlocked and unattended, with the key left in the doorknob.
In an interview on 04/15/2025 at 11:30AM, S9CNA/WC indicated Storage Room a contained biohazardous materials including sharps containers with used needles. S9CNA/WC further indicated Storage Room a was left unlocked and unlocked and unattended, and should not have been.
In an interview on 04/16/2025 at 11:52AM, S2Director of Nursing (DON) indicated the above mentioned 14 residents were capable ofwere capable of self-mobility either in a wheelchair or by ambulation.
In an interview on 04/16/2025 at 3:24PM, S2DON confirmed Storage Room a contained biohazardous materials including used sharps containers and should be locked at all times to ensure resident safety.
2.
Observation on 04/16/2025 at 10:39AM of Shower Room a revealed there was 4 disposable razors accessible inside a plastic cup of an unlocked cabinet.
Observation on 04/16/2025 at 11:00AM of Shower Room b revealed there was 3 disposable razors accessible in an unsecured 3 compartment container.
In an interview on 04/16/2025 at 3:20PM, S4Assistant Director of Nursing/Infection Preventionist confirmed the disposable razors should not have been left in an unlocked cabinet and/or accessible.
In an interview on 04/16/2025 at 3:24PM, S1Administrator confirmed the above deficient findings and confirmed the disposable razor blades should not be accessible to wandering residents.
3.
Observation on 04/16/2025 at 10:30AM of Whirlpool Room a revealed Whirlpool Room a door was not locked.
Observation on 04/16/2025 at 10:39AM of Shower Room a revealed Shower Room a door was not locked.
Observation on 04/16/2025 at 10:45AM of Whirlpool Room c revealed Whirlpool Room c door was not locked.
Observation on 04/16/2025 at 10:46AM of Shower Room c revealed Shower Room c door was not locked.
Observation on 04/16/2025 at 10:59AMe of Shower Room b revealed Shower Room b door was not locked.
Observation on 04/16/2025 at 11:00AM of Whirlpool Room b revealed Whirlpool Room b door was not locked.
In an interview on 04/16/2025 at 3:20PM, S4Assistant Director of Nursing (ADON)/Infection Preventionist confirmed above mentioned shower rooms and whirlpool rooms' doors were not locked at this time.
In an interview on 04/16/2025 at 3:24PM, S1Administrator confirmed the disposable razors should not be accessible and confirmed the above mentioned shower rooms and whirlpool rooms were not locked and should have been.

Based on interview and record reviews, the facility failed to implement their controlled substance policy to ensure controlled drugs were reconciled for 1 (Medication Cart b) of 3 (Medication Cart a, Medication Cart b, Medication Cart c) medication carts reviewed for reconciliation of controlled substances.
Findings:
Review of the facility's Controlled Substances Policy and Procedure, revised on 10/06/2023, revealed, in part, nursing staff must count controlled medications at the end of each shift. Further review revealed the nurse coming on duty and the nurse going off duty must make the count together and discrepancies must be documented and reported to the Director of Nursing.
Review of the March 2025 Daily Narcotic Sheet Count for Medication Cart b revealed the narcotic count was not signed off by both the coming on duty and the going off duty nurse on the following dates and shifts:
03/01/2025 for the Morning and Evening shift;
03/02/2025 for the Morning shift; and,
03/04/2025 for the Morning shift.
Review of the April 2025 Daily Narcotic Sheet Count for Medication Cart b revealed the narcotic count was not signed off by both the coming on duty and the going off duty nurse on the following dates and shifts:
04/02/2025 for the Morning shift;
04/05/2925 for the Evening shift;
04/06/2025 for the Morning shift;
04/08/2025 for the Morning shift and Evening shift;
04/11/2025 for the Evening shift;
04/12/2025 for the Morning shift and Evening shift;
04/13/2025 for the Evening shift; and,
04/14/2025 for the Morning shift.
In an interview on 04/16/2025 at 3:50PM, S2Director of Nursing had nothing to present to dispute the above mentioned deficient practice and indicated the Daily Narcotic Sheet Counts should be signed by both the coming on duty and the going off duty nurse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews, the facility failed to maintain an accurate medical record for a resident's code status (a term used to describe what type of interventions, if any, a healthcare team could perform if an individual's heart stopped beating or they stopped breathing).
This deficient practice was identified for 1 (Resident #103) of 23 (Resident #5, Resident #23, Resident #25, Resident #29, Resident #33, Resident #35, Resident #39, Resident #40, Resident #41, Resident #46, Resident #68, Resident #71, Resident #72, Resident #76, Resident #80, Resident #82, Resident #83, Resident #92, Resident #93, Resident #94, Resident #99, Resident #102, and Resident #103) sampled residents reviewed for accurate records.
Findings:
Review of Resident #103's physician orders revealed, in part, Resident #103 had an order for Full Code status (life saving measures, cardiopulmonary resuscitation) dated [DATE].
Review of Resident #103's care plan, presented to the survey team on [DATE] by S6ICCC revealed, in part, Resident #103 had a code status care plan indicating Resident #103 was a Full Code.
Resident #103's Louisiana Physician Orders for Scope of Treatment (LaPOST), updated on [DATE] revealed, in part, Resident #103 elected a Do Not Resuscitate (DNR) code status (in the event a person was found pulseless or not breathing CPR would not be completed).
In an interview on [DATE] at 1:08PM, S7Quality Management Nurse confirmed Resident #103's code status order was not updated in Resident #103's electronic record and should have been.

Based on observations, interviews, and record reviews, the facility failed to ensure staff wore proper personal protective equipment (PPE) for a resident on Enhanced Barrier Precautions (EBP) during a resident transfer and linen change for 3 (S10Certified Nursing Assistant [CNA], S11CNA, S12CNA) of 4 (S10CNA, S11CNA, S12CNA, S15CNA) CNAs observed while providing care to residents on EBP.
Findings:
Review of the facility's Enhanced Barrier Precautions policy and procedure dated 2001 and revised on 04/2024, revealed, in part, EBP should be followed when working with residents when close physical contact would occur during transfer and mobility. Further review revealed personnel should use gowns and gloves if they were changing the linens of residents on EBP.
Review of Resident #99's April 2025 physician's orders revealed, in part, an order dated 03/19/2025 for EBP.
Observation on 04/14/2025 at 12:15PM revealed an EBP sign on Resident 99's room door indicating staff must wear a gown and gloves when performing high contact resident care activities including transferring and changing linens.
Observation on 04/16/2025 at 9:28AM revealed S10CNA and S11CNA performed a transfer of Resident #99 from the bed to a wheelchair using a mechanical lift without wearing a gown or gloves. Further observation revealed S10CNA and S11CNA rolled Resident #99 to his side, placed a lift pad under Resident #99, transferred Resident #99 into a wheelchair, and then repositioned Resident #99 in the wheelchair without wearing a gown or gloves. Further observation revealed S12CNA helped to reposition Resident #99 in his wheelchair without wearing a gown.
Observation on 04/16/2025 at 9:30AM revealed S12CNA removed the dirty linen from Resident #99's bed without wearing a gown. Further observation revealed S12CNA placed clean linen on Resident #99's bed without changing her gloves in between removing the dirty linen and placing the clean linen on Resident #99's bed.
In an interview on 04/16/2025 at 9:35AM, S11CNA indicated she did not know what high contact resident care activities required staff to wear a gown and gloves for a resident on EBP.
In an interview on 04/16/2025 at 9:37AM, S12CNA indicated she did not know why Resident #99 was on EBP. S12CNA further indicated she did not know what high contact resident care activities required staff to wear a gown and gloves for a resident on EBP.
In an interview on 04/16/2025 at 3:24PM, S2Director of Nursing confirmed the above mentioned personnel should have worn gloves and gowns while transferring and changing Resident #99's linen because he was on EBP.

Based on observations, interviews, and record reviews, the facility failed to assess a resident for self-administration of medications for 1 (Resident #29) of 1 (Resident #29) sampled residents observed with medications left at the bed side for self-administration.
Findings:
Review of the facility's Self-Administration of Medications policy and procedure revised on 11/2024 revealed, in part, the interdisciplinary team would assess each resident's cognitive and physical abilities to determine whether self-administration of medications were safe and clinically appropriate for the resident. Further review revealed if a resident was deemed safe for self-administration of medications, this was to be documented in the resident's medical record and care plan. Further review revealed self-administered medications should be stored in a safe and secure place and any medications found at bedside that were not authorized for self-administration were turned over to the nurse in charge for return to the family or responsible party.
Review of Resident #29's Quarterly Minimum Data Set with an Assessment Reference Date of 03/14/2025 revealed, in part, Resident #29 had a Brief Interview of Mental Status score of 12, which indicated Resident #29 had moderate cognitive impairment.
Review of Resident #29's April 2025 Physician's Orders revealed, in part, no evidence Resident #29 had an order for Vitamin B12 2,500 micrograms (mcg) (a vitamin supplement vital in many bodily functions). Further review revealed no evidence Residents #29 had an order to self-administer Vitamin B12 2,500 mcg.
Review of Resident #29's clinical record revealed no documented evidence, and the facility did not present any documented evidence Resident #29 was assessed and/or care planned to self-administer medications.
Observation on 04/14/2025 at 10:12AM revealed a bottle of Vitamin B12 2,500 mcg tablets was on resident #29's bedside table.
Observation on 04/15/2025 at 10:31AM revealed a bottle of Vitamin B12 2,500 mcg tablets was on Resident #29's bedside table.
Observation on 04/15/2025 at 1:04PM revealed a bottle of Vitamin B12 2,500 mcg tablets was on Resident #29's bedside table.
In an interview on 04/15/2025 at 1:04PM, with S21Licensed Practical Nurse (LPN) present, Resident #29 indicated she self-administered one tablet of Vitamin B12 2,500 mcg every day.
In an interview on 04/15/2025 at 1:10PM, S21LPN indicated Resident #29 should not have had a bottle of Vitamin B12 2,500 mcg tablets at her bedside to self-administer.
In an interview on 04/15/2025 at 3:57PM, S6Interim Clinical Care Coordinator (CCC) indicated Resident #29 should not have been self-administering Vitamin B12 2,500 mcg daily without being assessed and care planned for self-administration. S6Interim CCC further indicated self-administration of medications required a physician's order.
In an interview on 04/16/2025 at 2:56PM, S2Director of Nursing (DON) indicated Resident #29 should not have been self-administering Vitamin B12 2,500 mcg tablets daily. S2DON further indicated nursing staff should have identified Resident #29 was not authorized to self-administer Vitamin B12 2,500 mcg tablets and removed the bottle of Vitamin B12 from Resident #29's possession.

Based on observations and interviews, the facility failed to ensure facility whirlpool rooms were maintained in a sanitary manner for 3 (Whirlpool Room a, Whirlpool Room b, Whirlpool Room c) of 3 (Whirlpool Room a, Whirlpool Room b, Whirlpool Room c) whirlpool rooms observed for cleanliness.
Observation on 04/16/2025 at 10:30AM, of Whirlpool Room a, revealed there was an unidentified pink residue noted on the bottom of the whirlpool bathtub.
Observation on 04/16/2025 at 10:45AM, of Whirlpool Room c, revealed there was an unidentified yellow residue and a piece of used paper noted on the bottom of the whirlpool bathtub.
Observation on 04/16/2025 at 11:00AM, of Whirlpool Room b, revealed there was an unidentified pink residue noted on the bottom of the whirlpool bathtub.
Observation on 04/16/2025 at 3:10PM, of Whirlpool Room c, with S4Assistant Director of Nursing/Infection Preventionist present, revealed there was an unidentified yellow residue and a piece of used paper noted on the bottom of the whirlpool bathtub.
Observation on 04/16/2025 at 3:12PM, of Whirlpool Room b, with S4Assistant Director of Nursing/Infection Preventionist present, revealed there was an unidentified pink residue noted on the bottom of the whirlpool bathtub.
Observation on 04/16/2025 at 3:17PM, of Whirlpool Room a, with S4Assistant Director of Nursing/Infection Preventionist present, revealed there was an unidentified pink residue noted on the bottom of the whirlpool bathtub.
In an interview on 04/16/2025 at 3:20PM, S4Assistant Director of Nursing/Infection Preventionist confirmed the whirlpool bathtubs in Whirlpool Room a, Whirlpool Room b and Whirlpool Room c were unsanitary.
In an interview on 04/16/2025 at 3:24PM, S1Administrator had nothing to present to dispute the above mentioned deficient practice and confirmed the whirlpool bathtubs were unsanitary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to communicate and/or document the required information when a resident was transferred to the hospital for 1 (Resident #103) of 3 (Resident #83, Resident #102, Resident #103) sampled residents reviewed for transfer requirements.
Findings:
Resident #103 was transferred to the hospital on [DATE].
There was no documented evidence and the facility failed to present any documented evidence that nursing staff communicated and/or provided the hospital with Resident #103's face sheet/contact information, diagnosis list, LAPOST, medication list and a copy of the transfer order for the above mentioned transfer to the hospital.
There was no documented evidence and the facility failed to present any documented evidence a discharge transfer summary was provided to the receiving hospital when Resident #103 was transferred to the hospital on [DATE].
In an interview on 04/16/2025 at 9:36AM, S14Licensed Practical Nurse indicated a discharge transfer summary should include a resident's current code status and should be completed for any resident sent to the hospital.
In an interview on 04/17/2025 at 9:42AM, S7Quality Management Nurse confirmed the facility could not provide any documented evidence Resident #103 was sent to the hospital on [DATE] with a discharge transfer summary as required.

Based on interview, and record reviews the facility failed to develop a person-centered care plan for a resident with a Urinary Tract Infection (UTI) receiving Intravenous (IV) Antibiotics via a Midline Intravenous Catheter. This deficient practice was identified for 1 (Resident #46) of 1 (Resident #46) residents investigated for intravenous antibiotic usage.
Findings:
Review of Resident #46's electronic medical record (EMR) revealed, in part, Resident #46 had diagnoses, which included, in part, Urinary Tract Infection (UTI) and Non- Alzheimer's Dementia.
Review of Resident #46's April 2025 Physician's orders revealed, in part, an order dated 04/04/2025, for Resident #46 to receive intravenous antibiotics via a midline intravenous catheter.
There was no documented evidence and the facility did not present any documented evidence that a care plan was developed for Resident #46 receiving Intravenous (IV) Antibiotics for a UTI via a Midline Intravenous Catheter prior to when the surveyor brought it to the attention to facility staff.
In an interview on 04/15/2025 at 2:00PM, S22Licensed Practical Nurse indicated facility staff should have developed a care plan to administer IV antibiotics via a midline intravenous catheter for Resident #46, and they did not.
In an interview on 04/15/2025 at 4:50PM, S2Director of Nursing acknowledged staff should have developed a care plan to administer (IV) antibiotics via a midline intravenous catheter for Resident #46's UTI, and they did not.

Based on record review and interviews, the facility failed to ensure a resident was referred for dental services within 3 days of a resident's dentures being missing for 1 (Resident #1) of 1 (Resident #1) sampled residents with missing dentures in a total sample of 3.
Findings:
Review of the facility's undated Dental Services policy and procedure revealed, in part, the facility will promptly, within 3 days, refer residents with lost or damaged dentures for dental services.
In an interview on 07/02/2024 at 3:46 p.m., S2Social Service Director indicated she was notified of Resident #1's missing dentures on either the Tuesday or Wednesday after Memorial Day (05/28/2024 or 05/29/2024) by a staff member. S2Social Services Director indicated she did not have any documented evidence she attempted to arrange dental services for Resident #1's missing dentures until 06/12/2024.
In an interview on 07/02/2024 at 4:08pm, S1Administrator indicated once the facility was aware of Resident #1's missing dentures, services should have been arranged for replacement of the missing dentures within 3 days.

Based on record review and interview, the facility failed to obtain the resident's most recent documentation of services provided for 2 (Resident #53 and Resident #104) of 2 (Resident #53 and Resident #104) sampled residents reviewed for hospice.
Findings:
Review of the facility's Hospice Program Policy Statement last reviewed on 01/02/2024 revealed, in part, staff must have communication with the hospice provider (and documented such communication) to ensure the needs of the resident are addressed and met 24 hours a day.
Resident #53
Review of Resident #53's hospice binder revealed Resident #53 was admitted to hospice on 7/29/22. Further review of Resident #53's hospice binder revealed the last Aide Care Visit documentation was dated 02/21/2024 and the last Registered Nurse Skilled Nursing Visit documentation was dated 02/20/2024.
Resident #104
Review of Resident #104's hospice binder revealed Resident #104 was admitted to hospice on 11/20/2023. Further review of Resident #104's hospice binder revealed the last Aide Care Visit documentation was dated 02/17/2024 and the last Registered Nurse Skilled Nursing Visit documentation was dated 02/20/2024.
In an interview on 04/11/2024 at 1:21 p.m., S7Clinical Coordinator indicated the hospice binders should have had documentation of recent visit notes from March 2024 and April 2024.
In an interview on 04/11/2024 at 1:28 p.m., S2Director of Nursing confirmed the hospice binders should have had more documentation of recent visit notes from March 2024 and April 2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and interviews, the facility failed to ensure a resident's pain level was reassessed and managed for 1(Resident #40) of 1(Resident #40) residents reviewed for pain management.
Findings:
Review of the facility's undated policy titled Administering Pain Medications revealed, in part, staff should prepare by reviewing the resident's care plan to assess for any special needs of the resident. Further review revealed all nursing, therapy, and ancillary staff would utilize the verbal descriptive scale, and/or Numeric Pain Intensity Scale (0-10) to facilitate consistent pain assessments.
Review of the facility's undated policy titled Pain Assessment and Management revealed, in part, pain management was defined as the process of alleviating the resident's pain to a level that was acceptable to the resident. Further review revealed the facility should implement the resident's medication regimen as ordered and document the results of the intervention.
Review of the National Institutes of Health defined the numeric rating scale (NRS) as a pain screening tool, commonly used to assess pain severity using a 0-10 scale, with zero meaning no pain and 10 meaning the worst pain imaginable.
Review of the Resident #40's EMR (electronic medical record) revealed Resident #40 was admitted to the facility on [DATE] with diagnoses which included, in part, Osteoarthritis, Neuropathy, and Unspecified Pain.
Review of Resident #40's Plan of Care with a target completion date of 05/17/2024 revealed, in part, a goal of Resident #40 would have potential for pain related to her diagnosis of Neuropathy and Osteoarthritis, Further review revealed Resident #40 should be assessed for signs and symptoms of pain every 2 hours and as needed and the facility should evaluate and document the effectiveness of Resident #40's pain medication.
Review of Resident #40's April 2024 Pail Scale Assessments revealed, in part, Resident #40 had a pain level of 10 on 04/11/2024. Further review revealed there was no documented evidence and the facility did not present any documented evidence of Resident #40's pain level was reassessed after pain intervention was provided.
Review of Resident #40's April 2024 electronic Medication Administration Record (eMAR) revealed there was no documented evidence and the facility did not present any documented evidence Resident #40's pain level was reassessed after pain intervention was provided.
In an interview on 04/09/2024 at 9:18 a.m., Resident #40 stated the facility staff give her pain medications, but they never return to ask her if the pain medications were effective. Resident #40 further stated her acceptable pain level would be to have a pain level of a 1 or less.
In an interview on 04/11/2024 at 9:10 a.m., Resident #40 stated on a scale of 1-10, she would describe her pain today as a level of a 10.
In an interview on 04/11/2024 at 11:30 a.m., Resident #40 stated her pain cream administered around 9:00 a.m. this morning was ineffective.
In an interview on 04/11/2024 at 3:17 p.m., S9Licensed Practical Nurse stated she should have assessed Resident #40's pain level within 2 hours of administering her pain medication and she did not.
In an interview on 04/11/2024 at 3:56 p.m., S2Director of Nursing(DON) stated the expectation of nursing staff was to assess the effectiveness of all pain interventions provided to a resident including, scheduled pain medication. S2DON further stated Resident #40's pain rating should have been assessed within 2 hours after a pain intervention was provided and it was not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and interviews, the facility failed to ensure a resident who no longer resided on a locked memory care unit's careplan was updated for 2 (Resident #9 and Resident #71) of 2 residents reviewed for Dementia Care.
Findings:
Review of the facility's undated document titled, Memory Care Unit Transition to Wander Guard System document revealed, in part, all residents transitioning from the memory care unit to a wander guard would have their careplan updated.
Resident #9
Review of Resident #9's electronic medical record (EMR) revealed, in part, Resident #9 was admitted to the facility on [DATE] with a diagnosis of Dementia and Alzheimer's Disease.
Review of Resident #9's Comprehensive Careplan with a target revision date of 06/20/2024, revealed, in part, Resident #9 resided on the facility's locked memory care unit.
Resident #71
Review of Resident #71's electronic medical record (EMR) revealed, in part, Resident #71 was admitted to the facility on [DATE] with a diagnosis of Dementia.
Review of Resident #71's Comprehensive Careplan with a target revision date of 06/25/2024, revealed, in part, Resident #71 resided on the facility's memory care unit.
In an interview on 04/11/2024 at 12:15 p.m., S1Adminsitrator stated the facility no longer had a locked memory care unit.
In an interview on 04/11/2024 at 3:12 p.m., S5Unit Coordinator/Minimal Data Set stated Resident #9 and Resident #71's careplan should have been updated to reflect both residents were no longer on a locked memory care unit and it was not.
In an interview on 04/11/2024 at 3:16 p.m., S2Director of Nursing stated Resident #9 and Resident #71's careplan should have been updated to reflect both residents were no longer on a locked memory care unit and it was not.

Based on record review, observation, and interview, the facility ensure staff used Personal Protective Equipment (PPE) with 1 COVID-19 positive resident (Resident R1). This deficient practice had the potential to affect 82 non-positive COVID-19 residents residing in the facility who were at risk for contracting COVID-19.
Findings:
Review of the facility's Infection Control Interim Policy for Coronavirus revealed, in part, residents, visitors, and others at the facility must wear appropriate source control, in accordance with national standards. Personal Protection Equipment should be discarded after resident care, prior to leaving a resident room, and followed by hand hygiene.
Review of the facility COVID test results log dated 08/2023 revealed, in part, Resident #R1 tested positive for COVID-19 on 08/05/2023. Record review revealed in part, Resident #R1 was placed on contact and droplet isolation precautions after testing positive for COVID-19.
An observation on 08/09/2023 at 9:55 a.m. into the open doorway of Resident #R1's isolation room revealed Resident #R1 was sitting in her wheelchair by her bed having her oxygen saturation assessed by S4Licensed Practical Nurse. Further observation revealed S4LPN did not don a gown, goggles or face shield while performing care for a COVID-19 positive resident (Resident #R1) Further observation revealed S4LPN exited Resident #R1's room, removed her gloves and did not perform hand hygiene.
An observation on 08/09/2023 at 10:05 a.m. revealed with soiled hands S4LPN touched the medication cart and touched the top of her cart, the computer key board, and keys to unlock the cart. Further observation revealed S4LPN did not perform hand hygiene to obtain Resident #R2's (a non-positive COVID-19 resident) medications out of the medication drawer and dispensed them into a medication cup. Further observation revealed S4LPN then walked to Resident #R2, who was not COVID-19 positive and administered his medications without performing hand hygiene.
An observation on 08/09/2023 at 10:15 a.m. revealed S4LPN performed hand hygiene then opened the medication cart and obtained Resident R3's (a non- COVID-19 positive resident) oral medications, eye drops and nasal spray. Further observation revealed S4LPN also obtain a wrist blood pressure monitor and digital forehead thermometer from the left top drawer of her cart and placed the wrist blood pressure monitor and digital forehead thermometer in her front shirt pocket. Observation revealed S4LPN entered Resident R3's room and obtained a blood pressure and temperature and proceeded to place both instruments back into her front shirt pocket. Further observation revealed S4LPN instilled Resident R3's eye drops, administered Resident R3's nasal spray and placed Resident R3's medication cup on her bedside table. Observation revealed S4LPN returned to her medication cart, placed the wrist blood pressure monitor and digital forehead thermometer on the top of the medication cart without disinfecting them. Further observation revealed S4LPN performed hand hygiene.
An observation on 08/09/2023 at 10: 30 a.m. revealed S4LPN obtained a glucometer, glucometer strips out of the left top drawer of the medication cart. Further observation revealed S4LPN entered Resident #R4's (a non-COVID-19 resident) room. Further observation revealed S4LPN obtained a blood glucose reading by finger stick. Further observation revealed S4LPN returned to the medication cart, placed the glucometer on the top of the cart, removed her gloves and did not perform hand hygiene. Further observation revealed S4LPN open the medication drawer, touched several insulin pens until she found Resident R4's insulin pen which S4LPN placed on the top of the medication cart. Further observation revealed S4LPN then put on gloves and pick up Resident #R4's insulin off the top of the medication cart. Further observation revealed without performing hand hygiene S4LPN administered insulin into Resident R4's upper left arm.
An observation on 08/09/2023 at 10:50 a.m. revealed S4LPN returned to her medication cart, did not perform hand hygiene and proceeded to push the medication cart to the nurse's station.
In an interview on 08/09/2023 at 11:00 a.m., S1Administrator stated S4LPN should have put on proper PPE prior to going into Resident R1's room. S1Administrator further stated S4LPN should not have provided resident care to non-COVID-19 residents after contact with a positive COVID-19 resident without proper PPE on and not using proper hand hygiene.
In an interview 08/10/2023 at 11:43 a.m. S4LPN stated she did not don proper PPE before entering Resident R1's room, and S4LPN further stated she did not sanitize her hands after exiting Resident R1's room. S4LPN further stated she should not have had contact with non COVID-19 residents after entering Resident R1's room without proper PPE on.

Based on observations, record reviews, and interviews the facility failed to ensure all oral medications remained under the direct visual supervision of S4Licensed Practical Nurse (LPN) for 1 (Resident #R3) or 3 (Resident #R1, Resident #R2, Resident #R3) residents observed during a medication pass.
Findings:
Review of the facility's Administering Oral Medications Policy and Procedure revealed, in part, staff were to remain with the resident until all medications were taken.
Review of Resident #3's August 2023 physician's orders revealed, in part, the following:
Zoloft (a medication for depression) 100 milligram (mg) tablet, 1 tablet by mouth each day;
Namzaric (a medication to treat moderate to severe Alzheimer's disease) 14 mg-10 mg capsule, 1 capsule by mouth each day,
Ranolazine ER (a medication to treat chest pain) 500 mg tablet, 1 tablet by mouth twice a day;
Metoprolol Succinate ER (a medication used to treat chest pain, heart failure, or high blood pressure) 50 mg tablet, 1 tablet by mouth twice a day;
Furosemide (a medication used to fluid retention) 20 mg tablet, 1 tablet by mouth each day;
Entresto (a medication used to treat chronic heart failure) 24 mg-26mg tablet 1 tablet by mouth twice a day;
Buspirone HCL (a medication used to treat anxiety) 5 mg tablet, 1 tablet by mouth twice a day;
Fish oil (supplement) 1000 mg capsule, 1 capsule by mouth each day;
Biotin (supplement) 5000 mg tablet, 1 tablet by mouth each day;
CertaVite (multi vitamin) tablet, 1 tablet by mouth each day; and
Magnesium Oxide 400 mg tablet, 1 tablet by mouth each day.
Observation on 08/09/2023 at 10:26 a.m. revealed, S4LPN dispensed Zoloft 100 mg 1 tablet, Namzaric 14mg-10mg 1 capsule, Ranolazine ER 500 mg 1 tablet, Metoprolol Succinate ER 50 mg 1 tablet, Furosemide 20 mg 1 tablet, Entresto 24 mg-26mg 1 tablet, Buspirone HCL 5 mg 1 tablet, Fish oil 1000mg 1 capsule, Biotin 5000mg 1 tablet, CertaVite 1 tablet, and Magnesium Oxide 400 mg 1 tablet into a medication cup. Further observation revealed, S4LPN entered Resident #3's room and left the medication listed above in a medication cup on the bedside table of Resident #R3. Further observation revealed S4LPN administered eye drops to Resident #3 and exited the resident's room without administering or observing Resident #3 complete her oral medications.
In an interview on 08/09/2023 at 10:40 a.m., S4LPN confirmed she left Resident #R3's oral medications on her bedside table without verifying that Resident #R3 took the medications.
In an interview on 08/09/2023 at 11:23 a.m., S3Director of Nursing stated S4LPN should not have left Resident #R3's room without ensuring that all of her oral medications were taken.
In an interview on 08/09/2023 at 11:23 p.m., S1Administrator stated S4LPN should not have left oral medications on Resident #R3's bedside table. S1Administrator further stated S4LPN should have observed Resident #R3 take all her oral medications before exiting Resident #R3's room.

Based on record review and interview the facility failed to ensure the Responsible Party received notification of a change in condition for an injury or fall in a timely manner for 2 (Resident #1 and Resident #2) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents reviewed for timely notification to the Responsible Party.
Findings:
Resident #1
Review of Incident Report for Resident#1's dated Tuesday, 04/25/2023, revealed Resident#1 had an unwitnessed fall. Resident#1 was found in assigned room in a sitting position next to the sink by nursing students. Incident reported to S8License Practical Nurse (LPN) at 8:30 a.m. on 04/25/2023. Resident#1's Responsible Party was not notified until 04/25/2023 at 8:07 p.m.
Review of Resident#1's clinical chart revealed in part, no documented evidence of an attempt to notify Resident#1's Responsible Party of the incident that occurred on 04/25/2023.
In an interview on 06/20/2023 at 1:50 p.m., S3LPN stated she worked 7 p.m. to 7 a.m. shift on 04/25/2023 and upon making rounds at the beginning of her shift, Resident#1's Responsible Party was visiting with Resident#1 and Resident#1 stated she had a fall. S3LPN Further stated when she returned to the desk she questioned S8LPN about Resident#1's fall, and S8LPN stated she informed Resident#1's Responsible Party of the fall during the 7 p.m. to 7 a.m. shift.
In an interview on 06/20/2023 at 2:05 p.m., S2Director of Nursing (DON) stated she is the interim DON and was recently hired. S2DON Further stated she was not aware of Resident#1's fall and the Fall policy should be followed.
Surveyor attempted to call S8LPN on 06/20/2023 at 2:10 p.m., without success.
In an interview on 06/20/2023 at 2:20 p.m., S1Administrator stated Resident's the Responsible Party should be made aware of any changes in condition or falls in a timely manner as well as the DON and nursing supervisor. S1Administrator stated 12 hours is not considered timely notification. S1Administrator further stated S8LPN is no longer employed with the organization.
Resident #2
Review of Resident #2 Nursing Progress Notes dated 06/07/20238:00 a.m. revealed in part, Resident #2 was observed by several employees screaming and yelling and was enraged and combative. Resident #2 was heard stating, Get your hands off me, they are trying to beat me up. These black people want to get back at me for the way they were treated. S4License Practical Nurse(LPN) was able to get the situation under control and re-directed Resident#2 back to their personal room. Further review of Nursing Progress Notes dated 06/07/2023 by S5LPN revealed an observation of a skin tear to Resident #2 right arm, skin torn with scant bleeding noted. The area was immediately cleaned and dressed by S5LPN per protocol. Resident #2 tolerated well. S9Certified Nursing Assistant(CNA) reported that Resident#2 had received her shower and became irritated and combative, and had to hold Resident #2 to avoid Resident #2 hitting her until help could arrive. Resident #2 was kicking and tried to bite nursing assistant. Due to the loud outbursts by Resident #2, staff was able to hear the commotion in the shower and came to intervene.
Review of Resident #2 Nursing Progress Notes dated 06/07/2023 5:52 p.m. revealed in part, S5LPN doing Med Pass and observed several staff trying to re-direct Resident #2 who was enraged and combative. Upon getting the details of what took place, S5LPN observed a skin tear to Resident #2 right arm, skin torn with scant bleeding noted. Area immediately cleaned and dressed by S5LPN.
In an interview on 06/20/2023 at 8:45 a.m., S4LPN stated was alerted from the loud screaming and yelling coming from the shower room. S4LPN went to the shower room and found Resident#2 combative, kicking, and attempting to bite S10CNA. S4LPN embraced Resident#2 from behind until Resident#2 calmed down and escorted back to room, and reported the incident to the S4Licensed Practical Nurse, who was caring for Resident #2.
In an interview on 06/20/2023 at 12:30 p.m., S5LPN stated that on 06/07/2023, Resident #2 was combative and had aggressive behavior while in the shower room and was reported to attempt to kick and bite staff. Upon receiving Resident #2 in their room, the right arm was noted to have a skin tear and scant bleeding from the arm. Immediately a dressing was applied to the right arm. Resident #2 was calm and placed in bed with no further distress noted. The incident occurred approximately at 8:00 a.m. on 06/07/2023, during medication pass. Resident #2 family member arrived to visit approximately 10:00 a.m. on 06/07/2023, and noticed the bandage on the right arm of Resident #2 and questioned the staff about the bandage. S5LPN stated that the incident was explained to family member and the family member was upset that they were not notified of the incident and it was only discovered because the family member had taken the sweater off of Resident #2 to lotion the arms. Resident #2 could not explain what happened. S5LPN stated that the responsible party was not called at that time because it happened during medication pass and S5LPN had to finish giving the other residents the medications.
In an interview on 06/20/2023 at 2:45 p.m., S1Administrator stated the Responsible Party should have been notified immediately when the incident occurred.