F 0552 Review of the Medicare 5 day MDS assessment dated [DATE REDACTED] revealed a BIMS score of 14 which indicated that Resident #36 was cognitively intact. The MDS also indicated that Resident #3 was prescribed a/an: Level of Harm - Minimal harm or antipsychotic, antidepressant, opioid, antiplatelet, hypoglycemic, and anticonvulsant. potential for actual harm

Review of the May 2025 MAR revealed that Resident #36 received Seroquel for the treatment of Residents Affected - Some schizoaffective disorder, Sertraline for the treatment of bipolar disorder, Depakote for the treatment of schizoaffective disorder, Clonazepam for the treatment of generalized anxiety disorder, and Geodon for the treatment of mood.

Review of the medical record revealed that there was no consent by Resident #36 for the psychotropic medications.

On 05/21/2025 at 12:06 p.m., S7Regional Director of Clinical confirmed that there was no consent for the psychotropic medications: Seroquel, Sertraline, Depakote, Clonazepam, and Geodon.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 39 195585 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 195585 B. Wing 05/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cypress at Lake Providence 5976 US-65 North Lake Providence, LA 71254

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0559 Honor the resident's right to share a room with spouse or roommate of choice and receive written notice

before a change is made. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 18118

Residents Affected - Few Based on record review and interview, the facility failed to ensure the rights of Residents to receive written notice, including the reason for the change, before the Resident's room in the facility is changed for 1 (#41) of 1 Residents reviewed for rights.

Findings:

Review of the facility's Resident Rights - Right to Share a Room with Person of Choice Policy dated 02/2023 revealed in part:

Purpose: Clarify the Resident's rights regarding sharing a room with a roommate of choice.

4. When a Resident is being moved at the request of the facility, the Resident, or family and/or Resident representative receives an explanation in writing as to why the room change is required.

Review of the medical record for Resident #41 revealed an admitted [DATE REDACTED]. Resident #41 had diagnoses including diabetes mellitus, chronic venous hypertension, pain, cognitive communication deficit, reduced mobility, lack of coordination, hypertension, lymphedema, depression and obesity.

Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed Resident #41 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition for daily decision making.

On 05/19/2025 at 11:05 a.m. interview with Resident #41 revealed she was moved to her current room from another room and she was not happy.

Review of the nurses notes dated 12/26/2024 at 11:10 a.m. revealed Resident #41 was being moved to a different room.

Review of the nurses notes dated 12/25/2024 at 9:00 a.m. revealed Resident #41 was observed to curse and holler at her roommate. Further review of the nurses notes revealed Resident #41 was informed that since

she was causing the problem then she will have to be moved to another room.

On 05/20/2025 at 5:00 p.m. interview with S2Director of Nursing (DON) revealed she told Resident #41 she had to move to another room due to she was being rude to her previous roommate. S2DON revealed she verbally informed Resident #41 of the room change. S2DON confirmed she did not give Resident #41 or her Responsible Party a written notice of the room change as stated in the facility's policy.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 39 195585 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 195585 B. Wing 05/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cypress at Lake Providence 5976 US-65 North Lake Providence, LA 71254

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0577 Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Level of Harm - Minimal harm or 13974 potential for actual harm Based on observation and interview, the facility failed to ensure it posted the results of the most recent Residents Affected - Some surveys of the facility by failing to post the results of 3 surveys that occurred after the facility's last annual survey on 05/08/2024.

Findings:

On 05/21/2025 at 11:35 a.m., observation of the facility posted surveys revealed the results of the annual survey dated 05/08/2024 were accessible to residents in a survey results binder.

The facility was also surveyed on 09/26/2024 resulting in 2 deficiencies, on 04/01/2025 resulting in 2 deficiencies and on 04/23/2025 resulting in 3 deficiencies. The results of the 3 surveys were not posted. On 05/21/2025 at 1:45p.m., interview with S1Administrator confirmed the results of the 3 surveys conducted

after the annual survey of 05/08/2025 were not posted.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 39 195585 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 195585 B. Wing 05/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cypress at Lake Providence 5976 US-65 North Lake Providence, LA 71254

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Level of Harm - Minimal harm or 41829 potential for actual harm Based on record review and interview, the facility failed to ensure a Resident with a facility initiated discharge Residents Affected - Few with Medicare Part A skilled service with days remaining was provided with a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage from Centers for Medicare and Medicaid Services CMS-10055 and Notice of Medicare Non-coverage (NOMNC) form CMS-10123 for 1 (#16) of 3 (#8, #16, #322) Residents reviewed for termination of Medicare Part A services.

Findings:

Record review revealed Resident #16's Medicare Part A skilled services episode start date was 01/05/2025.

The last covered day of Part A services was 02/03/2025. The facility initiated the discharge from Medicare Part A services when benefit days were not exhausted. Resident #16 remained in the facility. Further review revealed no documented evidence Resident #16 was provided CMS-10055 and CMS-10123 prior to being discharged from Medicare Part A Services.

On 05/20/2025 at 11:02 a.m. an interview with S14Clinical Reimbursement Specialist confirmed she was not able to locate the completed forms CMS-10055 and CMS-10123 for Resident #16.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 39 195585 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 195585 B. Wing 05/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cypress at Lake Providence 5976 US-65 North Lake Providence, LA 71254

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Level of Harm - Minimal harm or potential for actual harm 18118

Residents Affected - Few Based on observations and interviews, the facility failed to maintain a safe, clean, comfortable and homelike environment for 3 (#35, #41 and #63) of 8 (#15, #20, #35, #41, #52, #61, #63, #321) Residents reviewed for environment.

Findings:

Resident #41

On 05/19/2025 at 9:47 a.m., and 05/21/2025 at 8:30 a.m., observations of Resident #41's room revealed the air/heating unit had grime and debris on the air vents.

Resident #63

On 05/19/2025 at 8:45 a.m., and 05/20/2025 at 11:00 a.m., observations of Resident #63's room revealed

the air/heating unit had grime and dust on the air vents.

On 05/21/2025 at 8:40 a.m. an interview with S2Director of Nursing (DON) confirmed the air/heating units in Residents #41 and #63's room needed to be cleaned.

On 05/21/2025 at 8:30 a.m. an interview with S16Maintenance Director confirmed the air/heating units in Residents #41 and #63's room needed to be cleaned.

43405

Resident #35

Observations of Resident #35's room on 05/19/2025 at 7:43 a.m. and 05/21/2025 at 8:40 a.m. revealed numerous dead flying insects noted stuck to the bathroom walls, heavy lint buildup to the ceiling vent in the Resident's bathroom, the lid on top of the toilet was ajar with the inside part of the toilet visible, and black buildup noted to the inside of the air conditioner unit in the resident's room.

Observation/interview on 05/21/2025 at 12:45 p.m. of Resident #35's room with S2DON and S1Administrator confirmed that Resident #35's air conditioner unit, ceiling vent in bathroom, and bathroom walls needed to be cleaned and lid to commode needed to be adjusted.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 39 195585 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 195585 B. Wing 05/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cypress at Lake Providence 5976 US-65 North Lake Providence, LA 71254

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0605 An interview on 05/21/2025 at 12:10 p.m. with S7Regional Director of Clinical confirmed no documented evidence of monitoring for side effects and behaviors every shift associated with the use of antipsychotics Level of Harm - Minimal harm or and antianxiety medications for Resident #61 from 04/17/2025 through 04/30/2025, and from 05/04/2025 potential for actual harm through 05/20/2025.

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 39 195585 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 195585 B. Wing 05/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cypress at Lake Providence 5976 US-65 North Lake Providence, LA 71254

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 On 05/21/2025 at 10:06 a.m. interview with S15LPN/MDS revealed the MDS should have had the number one on the MDS for injury (not major) when Resident #19 received stitches to his forehead on 04/19/2025. Level of Harm - Minimal harm or potential for actual harm On 05/21/2025 at 11:15 a.m. S2DON was notified of the inaccurate assessment for falls on the MDS.

Residents Affected - Some 51983

Resident #62

Review of Resident #62's medical record revealed an admitted [DATE REDACTED] and diagnoses which include in part: osteomyelitis, diffuse traumatic brain injury, unspecified intracranial brain injury with loss of consciousness, depression, nontraumatic subarachnoid hemorrhage, other reduced mobility, and encephalopathy.

Review of quarterly MDS assessment dated [DATE REDACTED] revealed Resident #62 had a BIMS score of 10 which indicated moderate cognitive impairment. Further review of section M of the MDS assessment reveals that Resident #62 did not have a pressure ulcer/injury over a bony prominence and no unhealed pressure ulcers/injuries.

On 05/19/2025 at 7:45 a.m., interview with Resident #62 revealed that he had a wound on his right hip.

On 05/20/2025 at 10:12 a.m., Resident #62 observed laying in his bed on his left side watching television. A dressing dated 05/19/2025 was noted to his right hip.

On 05/20/2025 at 3:24 p.m., interview with S13 LPN/Treatment Nurse revealed that an outpatient wound consultant currently comes to facility to treat Resident #62's right hip and sacral wounds every Monday and Thursday.

On 05/20/2025 at 3:24 p.m., record review revealed Resident #62 had the pressure ulcers to his right hip and sacrum on admission.

On 05/21/2025 at 10:00 a.m., an interview conducted with S15LPN/MDS confirmed that Resident #62 did not have an accurate MDS skin assessment on quarterly MDS assessment dated [DATE REDACTED].

On 05/21/2025 at 10:21 a.m., interview with S2DON confirmed that Resident #62 did not have any wounds documented on the quarterly MDS assessment dated [DATE REDACTED].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 39 195585 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 195585 B. Wing 05/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cypress at Lake Providence 5976 US-65 North Lake Providence, LA 71254

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 On 05/20/2025 at 5:20 p.m. S1Administrator and S2Director of Nursing (DON) were notified of Resident #13 smoking and not wearing a smoke apron as stated in the care plan. Level of Harm - Minimal harm or potential for actual harm 51983

Residents Affected - Few Resident #62

Review of Resident #62's medical record revealed an admitted [DATE REDACTED] and diagnoses which include in part: osteomyelitis, diffuse traumatic brain injury, unspecified intracranial brain injury with loss of consciousness, depression, nontraumatic subarachnoid hemorrhage, other reduced mobility, and encephalopathy.

Review of quarterly MDS assessment dated [DATE REDACTED] revealed Resident #62 had a BIMS score of 10 which indicates moderate cognitive impairment.

On 05/19/2025 at 12:44 p.m., a fall mat was observed in Resident #62's room propped against wall away from the Resident's bed. Resident #62 did not have a fall mat on floor next to his bed.

On 05/20/2025 at 10:12 a.m., observation of Resident #62's room revealed that the fall mat was still propped up against the wall away from the Resident's bed. There was no fall mat on the floor next to Resident #62's bed.

On 05/20/2025 at 3:50 p.m., review of Resident #62's medical records revealed that Resident #62 fell from his bed on 02/26/2025 and on 05/08/2025. Further review of Resident #62's fall risk care plan revealed that a fall mat should be utilized.

On 05/21/2025 at 8:15 a.m., observation of Resident #62's room revealed that there was no floor mat next to

the Resident's bed and that the floor mat was still propped against the wall in the corner of the room.

On 05/21/2025 at 8:15 a.m., an interview with S4Licensed Practical Nurse (LPN) confirmed that Resident #62 did not have a fall mat next to his bed.

On 05/21/2025 at 8:25 a.m., Interview conducted with S2DON at Resident #62's bedside. S2DON confirmed that Resident #62's fall mat was propped against the wall and not at his bedside as care planned. Further

review of Resident #62's care plan with S2DON confirmed that Resident #62's plan of care had not been individualized to the Resident's needs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 39 195585 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 195585 B. Wing 05/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cypress at Lake Providence 5976 US-65 North Lake Providence, LA 71254

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 On 05/19/2025 at 1:35 p.m. it was noted that Resident #3 had lengthy facial hair below the nose and on the chin. Level of Harm - Minimal harm or potential for actual harm On 05/20/2025 at 11:30 a.m., Resident #3 was observed in her room with lengthy facial hair below the nose and on the chin. Residents Affected - Some

On 05/20/2025 at 11:52 a.m. an interview with S5Certified Nursing Assistant (CNA) revealed that Resident #3 should receive baths on Monday, Wednesday, and Friday.

Review of the April and May 2025 Documentation Survey Report v2 revealed Resident #3's bath days were scheduled for Tuesday, Thursday, and Saturday. Further review of the report revealed the only documentation of bathing was completed on 04/07/2025, 05/05/2025, and 05/19/2025 for the months of April and May 2025.

On 05/21/2025 at 12:06 p.m., S2DON confirmed that Resident #3 did not have baths documented.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 39 195585 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 195585 B. Wing 05/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cypress at Lake Providence 5976 US-65 North Lake Providence, LA 71254

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Review of the Quarterly MDS assessment dated [DATE REDACTED] revealed Resident #13 had a BIMS score of 14 which indicated the resident had intact cognition for daily decision making and required partial to moderate Level of Harm - Minimal harm or assistance with toileting and bathing. potential for actual harm

Review of the Fall Risk assessment dated [DATE REDACTED] revealed Resident #13 was at risk for falls. Residents Affected - Some

Review of the Incident/Accident report dated 04/22/2025 at 9:10 a.m. revealed Resident #13 was found sitting on the floor in front of his wheelchair alert and oriented.

Review of the current care plan revealed the Resident had limited physical mobility. Further review of the care plan revealed the fall on 04/22/2025 was not addressed on the care plan.

Review of the medical record revealed no documented evidence of an intervention attempted after Resident #13 was found on the floor on 04/22/2025.

On 05/21/2025 at 11:55 a.m. S2DON confirmed no new interventions were attempted after Resident #13 had

a fall on 04/22/2025 and also confirmed the fall on 04/22/2025 was not addressed on the care plan.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 39 195585 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 195585 B. Wing 05/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cypress at Lake Providence 5976 US-65 North Lake Providence, LA 71254

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Record review revealed Resident #27 was admitted to the facility on [DATE REDACTED] with diagnoses that included morbid (severe) obesity, type 2 diabetes mellitus, chronic obstructive pulmonary disease, obstructive sleep Level of Harm - Minimal harm or apnea, primary pulmonary hypertension, atrial fibrillation, and shortness of breath. potential for actual harm

Review of active May 2025 Physician orders revealed Oxygen at 2 Liters Per Minute (LPM) via Nasal Residents Affected - Few Cannula (NC) continuous to maintain saturation greater than or equal to 93%.

Review of the May 2025 Electronic Medication Administration Record (EMAR) revealed documentation Resident #27 received Oxygen at 2 LPM via NC as ordered.

On 05/19/2025 at 08:30 a.m. and 05/20/2025 at 10:10 a.m., observations of Resident #27 revealed she was receiving oxygen at 2 LPM via NC. Further observation revealed there was no signage posted outside Resident #27's room indicating no smoking oxygen in use.

On 05/20/2025 at 12:10 p.m., an observation and interview conducted with S2Director of Nursing (DON) in Resident #27's room revealed Resident #27 was receiving Oxygen at 2 LPM via NC. Further observation revealed there was no signage posted outside Resident #27's door indicating no smoking oxygen in use. S2DON confirmed there should have been signage posted outside of Resident #27's door indicating no smoking/oxygen in use.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 39 195585 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 195585 B. Wing 05/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cypress at Lake Providence 5976 US-65 North Lake Providence, LA 71254

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 On 05/21/2025 at 9:45 a.m. an interview with S7Regional Director of Clinical confirmed Resident #18 had not been assessed for bed rails, assessed for entrapment prior to the installation of bed rail, obtained an Level of Harm - Minimal harm or informed consent for bed rails, obtained an order for bed rails, or added bed rail to the care plan. potential for actual harm 51983 Residents Affected - Some Resident #321

Review of Resident #321's medical record revealed an admitted [DATE REDACTED] with diagnosis which included in part: anemia, syncope and collapse, adult failure to thrive, and subluxation of cervical vertebrae.

Review of admission Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed Resident #321 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated that Resident #321 was cognitively intact. Further review of MDS revealed that Resident #321 was able to transfer self with standby assist.

Observations on 05/19/2025 at 7:30 a.m., 05/20/2025 at 10:10 a.m., and 05/21/2025 at 8:12 a.m. of Resident #321's right upper quarter bedrail was observed on bed in the up position while the Resident was laying in it.

On 05/20/2025 at 11:08 a.m., record review reveals that Resident #321's record did not have a physician's order for bed rail use, care plan, or bed rail assessment.

On 05/21/2025 at 9:45 a.m., interview with S7Regional Director of Clinical confirmed that the facility did not assess Resident #321 for bed rails or risks of entrapment prior to the installation of bed rail. S7Regional Director of Clinical also confirmed that Resident #321 did not have a physician's order, consent, or care plans for bed rails.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 39 195585 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 195585 B. Wing 05/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cypress at Lake Providence 5976 US-65 North Lake Providence, LA 71254

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 13974

Residents Affected - Some Based on record review and interviews, the facility failed to ensure it had sufficient nursing staff with appropriate competencies and skills to provide nursing services to maintain the highest practicable physical, mental, and psychosocial well-being of each Resident by having staff fail to follow physician orders for 1 (#32) of 5 (#32, #3, #36, #63, #61) reviewed for unnecessary medications.

Findings:

Review of the medical records revealed Resident #32 was admitted to the facility on [DATE REDACTED] with a diagnosis of diabetes. Review of the physician orders revealed Resident #32 was to receive accu-checks four times daily. If the results were 401 or greater, staff were to administer 10 units of insulin and call the physician.

Review of the accu-check results revealed the following:

On 05/02/2025 at 10:00 a.m., Resident #32 had an accu-check of 434. There was no documentation that the physician was notified.

On 05/03/2025 at 10:00 a.m., Resident #32 had an accu-check of 407. There was no documentation that the physician was notified.

On 05/11/2025 at 10:00 a.m., Resident #32 had an accu-check of 455. There was no documentation that the physician was notified.

On 05/16/2025 at 10:00 a.m., Resident #32 had an accu-check of 410. There was no documentation that the physician was notified.

On 05/17/2025 at 10:00 a.m., Resident #32 had an accu-check of 423. There was no documentation that the physician was notified.

On 05/20/2025 at 3:15 p.m., interview with S2Director of Nursing (DON) confirmed there was no documentation that the staff notified the physician when Resident #32 had an accu-check of 401 or greater.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 39 195585 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 195585 B. Wing 05/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cypress at Lake Providence 5976 US-65 North Lake Providence, LA 71254

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0732 Post nurse staffing information every day.

Level of Harm - Potential for 52271 minimal harm Based on observation and interview, the facility failed to ensure nurse staffing data requirements were Residents Affected - Some posted daily in a prominent location and readily accessible to residents and visitors. This deficient practice had the potential to affect any of the 68 residents who resided in the facility.

Findings:

On 05/19/2025 at 8:00 a.m., the daily staffing for 05/19/2025 was unable to be located.

On 05/20/2025 at 10:05 a.m., the daily staffing for 05/20/2025 was unable to be located.

On 05/20/2025 at 10:10 a.m., an interview and observation were conducted with S2Director of Nursing (DON). S2DON confirmed that the daily staffing had not been posted.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 39 195585 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 195585 B. Wing 05/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cypress at Lake Providence 5976 US-65 North Lake Providence, LA 71254

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm 13974

Residents Affected - Few Based on observation, record reviews and interviews, the facility failed to ensure it provided pharmaceutical services to meet the needs of the Residents by failing to have medications available for administration for 2 (#33, #8) of 3 (#33, #8, #30) Residents observed for a medication pass.

Findings:

Resident #33

On 05/19/2025 at 7:35 a.m., a medication pass was observed for Resident #33 with S3Licensed Practical Nurse (LPN). During the medication pass, S3LPN reported Vitamin D-2 400 units was not on the cart.

Review of the physician's orders revealed Resident #33 was to receive Vitamin D-2 400 units daily.

On 05/19/2025 at 9:10 a.m., S3LPN reported that the medication was not available in the facility for administration.

On 05/19/2025 at 12:50 p.m. observation of the medication room revealed Resident #33's Vitamin D-2 was not in the medication room.

On 05/19/2025 at 1:00 p.m., interview with S2Director of Nursing (DON) confirmed Resident #33's Vitamin D-2 was not available in the facility for administration.

Resident #8

On 05/19/2025 at 7:40 a.m., a medication pass was observed for Resident #8 with S3LPN. During the medication pass, S3LPN reported Farxiga 10 milligrams (mg) was not on the cart.

Review of the physician's orders revealed Resident #8 was to receive Farxiga 10 mg daily.

On 05/19/2025 at 9:10 a.m., S3LPN reported that the medication was not available in the facility for administration.

On 05/19/2025 at 12:50 p.m. observation of the medication room revealed #8's Farxiga was not in the medication room.

On 05/19/2025 at 1:00 p.m., interview with S2DON confirmed Resident #8's Farxiga was not available in the facility for administration.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 39 195585 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 195585 B. Wing 05/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cypress at Lake Providence 5976 US-65 North Lake Providence, LA 71254

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Review of the medical record for Resident #3 revealed an admitted [DATE REDACTED] with diagnoses that included cerebral infarction, diabetes mellitus with diabetic neuropathy, chronic obstructive pulmonary disease, Level of Harm - Minimal harm or malignant neoplasm of pancreas, psychosis, schizophrenia, and major depressive disorder. potential for actual harm

Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed a Brief Interview of Residents Affected - Some Mental Status (BIMS) score of 14 which indicated that Resident #3 was cognitively intact.

Review of the May 2025 Medication Administration Record (MAR) revealed that Resident #3 was prescribed Levothyroxine daily.

Review of the monthly drug regimen review revealed that the pharmacist failed to report irregularities related to the need for Resident #3's thyroid level to be monitored.

On 05/21/2025 at 1:40 p.m., S7Regional Director of Clinical confirmed that the pharmacist did not identify the irregularity related to monitoring lab work.

Resident #36

Review of the medical record for Resident #36 revealed an admitted [DATE REDACTED] with diagnoses that included Parkinson's disease, dysphagia, type 2 diabetes mellitus, chronic obstructive pulmonary disease, bipolar disorder, generalized anxiety disorder, major depressive disorder, schizoaffective disorder, and seizures.

Review of the Medicare 5 day MDS assessment dated [DATE REDACTED] revealed a BIMS score of 14 which indicated that resident #36 was cognitively intact.

Review of the May 2025 MAR revealed that Resident #36 was prescribed Atorvastatin Calcium nightly.

Review of the monthly drug regimen review revealed that the pharmacist failed to report irregularities related to the need for Resident #36's lipid panel to be monitored.

On 05/21/2025 at 1:40 p.m., S7Regional Director of Clinical confirmed that the pharmacist did not identify the irregularity related to monitoring lab work.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 39 195585 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 195585 B. Wing 05/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cypress at Lake Providence 5976 US-65 North Lake Providence, LA 71254

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43405 potential for actual harm Based on record review and interview, the facility failed to ensure each resident's medication regimen was Residents Affected - Few free from unnecessary medications by failing to monitor for edema while resident was on a diuretic for 1 (#61) of 5 (#3, #32, #36, #61, and #63) residents reviewed for unnecessary medications.

Findings:

Review of Resident #61's record revealed an admitted [DATE REDACTED] with diagnoses including chronic obstructive pulmonary disease, acute/chronic combined systolic and diastolic heart failure, acute kidney failure, unspecified dementia unspecified severity with other behavioral disturbance, cellulitis, hypokalemia, cocaine abuse, hypertension, hyperlipidemia, myocardial infarction, chronic kidney disease.

Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed a Brief Interview of Mental Status (BIMS) score of 3 indicating severe cognitive impairment. Further review of the MDS revealed resident required assistance with activities of daily living.

Review of the May 2025 Physician's Orders revealed an order dated 04/18/2025 for Hydrochlorothiazide (diuretic) Oral Tablet 25 milligrams (mg) give 1 tablet by mouth one time a day.

Review of the April 2025 Medication Administration Record (MAR) revealed no documented evidence of monitoring for edema for 13 times in April 2025.

Review of the May 2025 MAR revealed no documented evidence of monitoring for edema for 16 times in May 2025.

An interview on 05/21/2025 at 11:45 a.m. with S2Director of Nursing (DON) and S7Regional Director of Clinical confirmed the facility should have been monitoring Resident #61 for edema while she was taking a diuretic. S2DON and S7Regional Director of Clinical confirmed there was no documented evidence of monitoring for edema on Resident #61 while on a diuretic for 13 times in April 2025 and 16 times in May 2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 39 195585 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 195585 B. Wing 05/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cypress at Lake Providence 5976 US-65 North Lake Providence, LA 71254

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or 13974 potential for actual harm Based on observations, interview, and record reviews, the facility failed to ensure it did not have a Residents Affected - Few medication error rate of 5 percent or greater by having 2 errors in 27 opportunities resulting in a medication error rate of 7%.

Findings:

Resident #33

On 05/19/2025 at 7:35 a.m., a medication pass was observed for Resident #33 with S3Licensed Practical Nurse (LPN). During the medication pass, S3LPN reported Vitamin D-2 400 units was not on the cart.

Review of the physician's orders revealed Resident #33 was to receive Vitamin D-2 400 units daily.

On 05/19/2025 at 9:10 a.m., S3LPN reported that the medication was not available in the facility for administration. This resulted in an error by omission.

Resident #8

On 05/19/2025 at 7:40 a.m., a medication pass was observed for Resident #8 with S3LPN. During the medication pass, S3LPN reported Farxiga 10 milligrams (mg) was not on the cart.

Review of the physician's orders revealed Resident #8 was to receive Farxiga 10 mg daily.

On 05/19/2025 at 9:10 a.m., S3LPN reported that the medication was not available in the facility for administration. This resulted in an error by omission.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 39 195585 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 195585 B. Wing 05/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cypress at Lake Providence 5976 US-65 North Lake Providence, LA 71254

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Review of Resident #55's medical record revealed an admitted [DATE REDACTED] and diagnoses which include in part: monoplegia of lower limb affecting unspecified side, unspecified psychosis not due to substance or known Level of Harm - Minimal harm or physiological condition, human immunodeficiency virus (HIV) disease, other seizures, and constipation. potential for actual harm

Review of quarterly MDS assessment dated [DATE REDACTED] revealed Resident #55 had a BIMS score 11 which Residents Affected - Few indicated moderate cognitive impairment.

On 05/19/2025 at 7:55 a.m., Resident #55 was observed lying in bed with his bedside table positioned next to his bed within his reach. Observed on the bedside table was a medication administration cup that contained two tablets.

On 05/19/2025 a.m., interview with S4Licensed Practical Nurse (LPN) confirmed that there were medications

on Resident #55's bedside table. S4LPN identified the medications as Levetiracetam and a stool softener. S4LPN also confirmed that the two medications were Resident #55's night medications and should have been administered the prior night.

On 05/20/2025 at 11:20 a.m., review of Resident #55's Medication Administration Record (MAR) revealed there were no documented refusals of medication by Resident #55 on 05/18/2025.

On 05/20/2025 at 12:55 p.m., S2DON was notified that on 05/19/2025 Resident #55 had medications left on his bedside table from the prior night and that S4LPN confirmed the medications were left on his bedside table.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 39 195585 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 195585 B. Wing 05/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cypress at Lake Providence 5976 US-65 North Lake Providence, LA 71254

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Level of Harm - Minimal harm or 51983 potential for actual harm Based on record review and interview the facility failed to have quarterly Quality Assessment and Assurance Residents Affected - Few (QAA) meetings with required members of the QAA committee present. The failed practice was evidenced by

the facility`s lack of documentation of QAA meetings being held since the previous annual survey.

Findings:

On 05/22/2025 at 2:40 p.m., an interview with S1Administrator revealed the facility was unable to locate documentation of any quarterly QAA meetings held since the prior annual survey.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 39 195585 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 195585 B. Wing 05/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cypress at Lake Providence 5976 US-65 North Lake Providence, LA 71254

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 13974 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure it maintained an infection Residents Affected - Few control program designed to provide a sanitary environment by having staff store used tube feeding syringes improperly for 1 (#44) of 1 (#44) residents reviewed for tube feeding.

Findings:

Resident #44

Review of the medical record revealed Resident #44 was admitted to the facility on [DATE REDACTED] with diagnoses which included cerebral infarction and dysphasia.

Review of the physician orders revealed an order to crush crushable medications and to flush with 30 cubic centimeters (cc) of water before and after medications.

On 05/20/2025 at 10:11 a.m., observation revealed the tip of the syringe used to administer medications was filled with an orange colored liquid and the plunger of the syringe was in the plunger.

On 05/20/2025 at 10:45 a.m., interview with S2Director of Nursing (DON) revealed the syringe should have been rinsed and disassembled before being stored for later use.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 39 195585 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 195585 B. Wing 05/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cypress at Lake Providence 5976 US-65 North Lake Providence, LA 71254

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Level of Harm - Minimal harm or 13974 potential for actual harm Based on observations and interviews, the facility failed to ensure it maintained an effective pest control so Residents Affected - Some that the facility was free of pests by having flies throughout the facility on all days of the survey, and by observing flies in Resident #52, #15 and #20's room.

Findings:

On all days of the survey flies were observed throughout the facility.

Resident #52

On 05/19/2025 at 10:16 a.m., Resident #52 reported he had to constantly shoo flies away from his food when he ate. Several flies were observed in the resident's room at that time.

On 05/20/2025 at 7:50 a.m., Resident #52 was in his room eating breakfast. Resident #52 was observed swatting flies away as he ate. Resident #52 also reported flies remained a problem in his room.

Resident #15

On 05/19/2025 at 9:25 a.m., Resident #15 voiced concerns that flies are bad in his room and throughout the facility. Several flies observed in his room at that time.

On 05/20/2025 at 7:45 a.m., Resident #15 was in his room. Resident #15 reported flies remained a problem

in his room and several flies were observed in his room.

41829

Resident #20

On 05/19/2025 at 11:30 a.m., observation of Resident #20's room revealed numerous flies.

On 05/19/2025 at 11:32 a.m., an interview with Resident #20 revealed the flies were bad in his room and in

the hallways.

On 05/20/2025 at 10:03 a.m., observation of Resident #20's room revealed there were multiple flies.

On 05/21/2025 at 01:07 p.m., S1Administrator was informed of the numerous amount of flies in resident rooms and throughout the facility observed during each day the survey. S1Administrator confirmed he had also observed flies within throughout the building.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 39 195585 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 195585 B. Wing 05/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cypress at Lake Providence 5976 US-65 North Lake Providence, LA 71254

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0947 Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Level of Harm - Minimal harm or potential for actual harm 52271

Residents Affected - Some Based on observation and interview, the facility failed to ensure that required dementia management and abuse prevention training was completed for 2 (S11Certified Nursing Assistant [CNA], S12CNA) of 5 (S8CNA, S9CNA, S10CNA, S11CNA, S12CNA) personnel records reviewed. Additionally, the facility failed to ensure that competencies and skills training was provided for 4 (S8CNA, S9CNA, S10CNA, S12CNA) of 5 (S8CNA, S9CNA, S10CNA, S11CNA, S12CNA) personnel records reviewed.

Findings:

Review of S11CNA's personnel record revealed no documented evidence of required dementia management, abuse prevention training, or competencies and skills training.

Review of S12CNA's personnel record revealed no documented evidence of required dementia management and abuse prevention training.

Review of S8CNA's personnel record revealed no documented evidence of competencies and skills training.

Review of S9CNA's personnel record revealed no documented evidence of competencies and skills training.

Review of S10CNA's personnel record revealed no documented evidence of competencies and skills training.

On 05/21/2025 at 2:07 p.m., S2Director of Nursing confirmed that there was no documented evidence of dementia management, abuse prevention, and competencies/skills training.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 39 195585