St Joseph of Harahan

Based on observations, interviews, and record review, the facility failed to maintain adequate dietary staffing levels to ensure the timely preparation and delivery of resident meals by failing to ensure: 1. breakfast was served in a timely manner; and 2. lunch was served at an appropriate palatable temperature. Findings: 1. Review of the facility's posted undated Meal Times form revealed the following, in part: Dining Room II: Breakfast 7:00AM, Lunch 12 noon, and Supper 5:00PM Dining Room I: Breakfast 7:00AM, Lunch 12 noon, and Supper 5:30PM West I : Breakfast 7:45AM, Lunch 12 noon, and Supper 5:45PM Observations in the kitchen on 3/24/25 at 8:40AM, revealed 2 staff preparing meals for hallway carts. In an interview on 03/24/2025 at 8:40AM, S7Assistant Dietary Manager indicated one staff member called in, the Dietary Manager was on her way back from an appointment, and the kitchen was already short staffed. Observations during dining facility task on 3/24/25 starting at 12:50PM, revealed some residents had not been served in both dining areas. Further observations revealed meal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record reviews, the facility failed to ensure an allegation of abuse was reported to the State Survey Agency within the required two hour timeframe for 2 (Resident #105, Resident #115 ) of 4 (Resident #51, Resident #105, Resident #115, Resident #187) sampled residents investigated for abuse. Findings: Review of the facility's Abuse Prevention and Prohibition Policy and Procedure dated 03/25/2023 revealed, in part, the administrator shall immediately initiate a Statewide Incident Management System (SIMS) report to the Louisiana Department of Health, but not less than 2 hours after forming a suspicion of a crime if the alleged violation involves abuse (physical abuse) or results in serious bodily injury. Review of the Louisiana Department of Health (LDH) Health Standards Incident Report #272956 revealed, in part, an allegation of physical abuse involving Resident #115 and Resident #105: -Occurred on 03/05/2025 at 11:14 PM; -Was entered into the SIMS reporting system on 03/10/2025 at 4:40PM. In an interview on 03/25/2025 at 10:48AM, S1Administrator confirmed the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to: 1. Ensure Resident #47's care planned fall interventions were implemented; and 2. Ensure Resident #115 a known wanderer, had a care plan developed for wandering. This deficient practice was identified 2 (Resident #47, Resident #115) of 5 (Resident #30, Resident #47, Resident #51, Resident #115, Resident #187) sampled residents reviewed for accidents. Findings: 1. Resident #47 Review of Resident #47's medical record revealed, in part, Resident #47 had an unwitnessed fall on 03/05/2025 while transferring from her bed to her wheelchair unassisted. Further review revealed Resident #47's fall on 03/05/2025 resulted in a left hip fracture. Review of Resident #47's Significant Change Minimum Data Set (MDS) and State Optional Assessment with an Assessment Reference Date (ARD) of 03/18/2025 revealed, in part, Resident #47 had a Brief Interview of Mental Status (BIMS) score of 13, which indicated Resident #47 was cognitively intact, required…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record reviews and interviews, the facility failed to administer a medication as ordered by the physician for 1 (Resident #116) of 4 (Resident #97, Resident #116, Resident #177, Resident #204) sampled residents reviewed for hospitalization. Findings: Review of the facility's policy and procedure on Medication Administration with an effective date of 10/04/2024, revealed, in part, nursing personnel shall ensure the safe and effective administration of medications. Further review revealed, prior to administration, the nursing staff member administering the medication shall ensure medications match the physician's orders and label, and that the proper dose was administered. Review of Resident #116's medical record revealed he had the following diagnoses, in part, of Congestive Heart Failure, Hypertensive Heart Disease with Atrial Fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). Review of Resident #116's physician orders dated 11/12/2024, revealed, in part, to increase Digoxin (medication used to treat congestive heart failure) to 250…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews, the facility failed to ensure maintenance staff secured electrical wall sockets in 3 (Room a, Room b, and Room c) of 4 (Room a, Room b, Room c, and Room d) rooms; and 2 (Hall X and Hall Y) of 4 (Hall W, Hall X, Hall Y, and Hall Z) halls observed for physical environment. Findings: Observation on 10/28/2024 at 9:15 a.m., revealed an electrical wall socket located in Room a was not secured to the wall. Observation on 10//28/2024 at 10:15 a.m. of the Hall W, Hall X, Hall Y, and Hall Z revealed the following: - Hall X had one electrical wall socket not secured to the wall; and - Hall Y had three electrical wall sockets not secured to the wall. Observation of Room b on 10/28/2024 at 10:15 a.m., revealed the electrical wall socket located at the head of the bed was not secured to the wall. Further observation revealed there were two electrical plugs which were plugged into the electrical socket. Observation on 10/28/2024 at 10:25 a.m. of Room c revealed the electrical wall socket located at the head of the bed was not secured to the wall. Further…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure a resident received care and services to prevent falls as much as possible by failing to develop new individualized interventions after a resident sustained a fall. This deficient practice was identified for 3 (Resident #1, Resident #2, and Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents reviewed for falls. Findings: A review of the facility's incident reports for the past 60 days revealed, in part, a fall by Resident #1 on 08/06/2024; falls by Resident #2 on 08/12/2024, 08/22/2024, and 08/30/2024; and falls by Resident #3 on 07/26/2024, 08/02/2024, and 09/01/2024. Review of the facility's Fall Prevention Program Policy and Procedure (10/22/2014) revealed, in part, the fall prevention program is an individualized daily plan to promote safety of residents who have been identified as high risk for Falls via interdisciplinary team determination. All residents will be assessed upon readmit, quarterly, annually, if…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a resident was free from verbal abuse for 1 (Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) sampled Residents. Findings: Review of the facility's Abuse - Prevention and Prohibition Policy and Procedure revealed, in part, each resident has the right to be free from abuse. Further review revealed verbal abuse was defined as the use of oral, written or gestural language that willfully includes disparaging and derogatory terms to residents or their families or within their hearing distance or sight, regardless of the resident's age, ability to comprehend, or disability and examples included name calling, cursing, or yelling at a resident in anger. Review of Resident #3's record revealed he was admitted to the facility on [DATE] with diagnosis, in part of Alzheimer's Dementia. Review of Resident #3's Minimum Data Set with an Assessment Reference Date of 06/12/2024 revealed, in part, he had a Brief Interview Mental Status Score of 7…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure staff performed hand hygiene prior to providing catheter care for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. Findings: Review of the facility's Catheter Care, Indwelling Catheter Policy and Procedure dated 08/24/2016 revealed, in part, hand hygiene should be performed and gloves put on prior to the procedure. Further review the next step was to inspect the catheter at the urinary meatus and not any problems, then cleanse the perineal area with soap and water or a perineal wipe taking care to wash from front to back. Cleanse the area well at the insertion site and remove all debris form the insertion site. Further review revealed to then rinse well with warm water and pat dry. Further review revealed to then empty, clean and store bedpan or measuring device properly and then ensure the catheter is secured to the resident's thigh as appropriate. Further review revealed to then remove gloves…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure a resident was provided with restorative services for 1 (Resident #5) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents. Findings: Review of Resident #5's Physical Therapy Discharge summary dated [DATE] revealed, in part, Resident #5 was discharged from physical therapy with restorative nurse program to facilitate Resident #5 maintaining current level of performance and in order to prevent a decline with ambulation, bed mobility, and transfers. Review of Resident #5's Occupational Therapy Discharge summary dated [DATE] revealed a discharge recommendation for 24 hour care and participation in the restorative nurse program. In an interview on 05/16/2024 at 11:26 a.m., S7Restorative CNA indicated Resident #5 was not on the restorative CNA program at this time, and had not been since admit. In an interview on 05/16/2024 at 12:19 p.m., S2DON confirmed Resident #5 was not provided restorative series as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview the facility failed to identify and/or implement interventions to prevent falls. This deficient practice was identified for 2 (Resident #4 and Resident #5) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents reviewed for falls. Findings: Resident #4 Review of the facility's Incident/Accident Log for the last 3 months revealed, in part, Resident #4 had an unobserved fall on 03/18/2024 in Resident #4's room with no injury apparent upon assessment. Review of Resident #4's Nurses Notes dated 03/18/2024 at 5:00 p.m. revealed Resident #4 was screaming out, and when the Certified Nursing Assistant (CNA) entered the room, found Resident #4 on the floor. Further review revealed Resident #4 indicated he was trying to get out of the bed by himself and fell. Review of Resident #4's Care Plan revealed problems of, in part, Resident #4 was assessed as being at risk for falls related to impaired mobility and weakness with falls on 03/17/2024 and 04/29/2024. Further review revealed no documented evidence and the facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observations, and interviews, the facility failed to ensure a dependent resident was provided incontinence care as needed for 1(Resident #2) of 4(Resident #1, Resident #2, Resident #3, and Resident #4) residents reviewed for incontinence care. Findings: Review of Resident #2's MDS (Minimum Data Set) with ARD (Assessment Reference Date) dated 03/20/2024 revealed, in part: Resident #2 had a BIMS (Brief Interview for Mental Status) score of 06 (which indicated severe cognitive impairment), was always incontinent of bowel and bladder, and substantial/maximum assistance for toileting. Review of Resident #2's Potential for Bowel and Bladder Retraining assessment dated [DATE] revealed, in part, Resident #2 was incontinent of bladder and staff were to provide pericare after each one of Resident #2's incontinent episodes. Review of the facility's camera footage on 04/24/2024 at 4:51 a.m. through 04/24/2024 at 8:41 a.m. revealed, S8CNA exited Resident #2's room at approximately 4:55 a.m. with a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to ensure: 1. A resident had a physician's order to maintain an indwelling urinary catheter; 2. A resident was assessed every shift for adverse signs and symptoms related to an indwelling urinary catheter; and, 3. A resident with an indwelling urinary catheter received catheter care every shift. This deficient practice was identified for 1 (Resident #69) of 3 (Resident #68, Resident #69, and Resident #91) sampled residents investigated for urinary catheters. Findings: Observation on 03/10/2024 at 1:22 p.m. revealed Resident #69 had a urinary catheter drainage bag attached to his wheelchair with rust colored urine in the drainage tubing. Review of Resident #69's hospital discharge records revealed, in part, Resident #69 had an emergency room visit on 03/08/2024 and was diagnosed with hematuria (blood in the urine), urinary retention (the inability to pass urine), and a urinary tract infection. Further review revealed Resident #69 was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record reviews, observations, and interviews, the facility failed to administer a resident's oxygen per physician's orders for 2 (Resident #67 and Resident #129) of 4 (Resident #34, Resident #67, Resident #112, and Resident #129) sampled residents investigated for respiratory care. Findings: Resident #67 Review of Resident #67's record revealed diagnoses, in part, of Respiratory Failure and Hypoxia (low levels of oxygen in the blood). Review of Resident #67's physician's orders for March 2024 revealed, in part, an order for Oxygen 2 liters per nasal cannula for low oxygen saturation. Observation on 03/10/24 at 10:24 a.m. revealed Resident #67 receiving oxygen at 3 liters per nasal cannula via an oxygen concentrator. Observation on 03/11/2024 at 1:00 p.m. revealed Resident #67 receiving oxygen at 3 liters per nasal cannula via an oxygen concentrator. In an interview on 03/12/2024 at 1:45 p.m., S17LPN acknowledged Resident #67's orders indicated Resident #67 should have received oxygen at 2 liters per nasal cannula. Resident #129 Review of Resident #129's record revealed, in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews, the facility failed to ensure expired medications and dressings were not available for resident use for 3 (Medication Cart V, Medication cart X, Medication Cart Z) of 5 (Medication Cart V, Medication cart W, Medication Cart X Medication Cart Y, and Medication Cart Z) medication carts and 1 (Medication Room C), of 2 (Medication Room B and Medication Room C) medication rooms observed for medication storage. Findings: Observation on 03/13/2024 at 11:30 a.m. with S10Licensed Practical Nurse (LPN) of Medication Cart Z revealed a bottle of Fish Oil 500 milligram (mg) caplets with an expiration date of 07/2023. Further observation revealed one 30 ounce (oz) bottle of Uti-stat (a supplement to aid in the prevention of bladder infections) with an expiration date of 02/28/2024. Observation on 03/13/2024 of Medication Room C at 11:40 a.m. with S10LPN revealed two 30 ounce bottles of Uti-stat with expiration dates of 2/28/2024. In an interview on 03/13/2024 at 11:31 a.m., S10LPN stated the expired bottle of Fish Oil 500 mg caplets and the three 30 oz…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observations and interviews, the facility failed to: 1. Ensure a nurse did not administer a contaminated supplement to a resident for 1 (Resident #583) of 5 (Resident #79, Resident #180, Resident #583, Resident #584, and Resident #600) residents observed during medication administration; 2. Ensure a resident's continuous positive airway pressure (a machine that delivers a constant stream of air pressure to prevent airway closure during sleep) mask was contained in a sanitary manner for 1 (Resident #34) of 4 (Resident #34, Resident #67, Resident #112, and Resident #129) sampled residents reviewed for respiratory care; and, 3. Ensure the nurse completed hand hygiene during medication administration for 1 (S10Licensed Practical Nurse) of 2 (S6Licensed Practical Nurse and S10Licensed Practical Nurse) Licensed Practical Nurses observed during medication administration. Findings: 1. Observation on 03/12/2024 at 8:41 a.m. revealed S10Licensed Practical Nurse (LPN) poured 30 milliliters of Pro-Stat (a supplement to promote wound healing) in a medication cup. Further…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to implement protocols and processes to identify the types of organisms/bacteria which caused infections, and/or the types of antibiotics those organisms were susceptible and resistant to. Findings: Review of the facility's Surveillance: Infection Prevention and Control Program with reviewed date of 08/16/2023 revealed, in part, outcome surveillance included reviewed of relevant data which may include laboratory antibiograms (antibiotic susceptibility profiles). Review of the facility's Antibiotic Stewardship Program Policy and Procedure revealed, in part, the Director of Nursing (DON)/designee would maintain a facility Antibiotic Stewardship Program to promote commitment to safe and appropriate antibiotic use. Further review revealed the DON/designee would monitor the antibiotic resistance based on laboratory data as appropriate. Further review revealed the DON/designee would utilize the Laboratory Vendor Antibiogram report or the Facility Antibiogram Form. In an interview on 03/13/2024 at 1:08 p.m., S14Infection…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observation, and interview the facility failed to ensure medications were not left unattended on a resident's bedside table for 1(Resident #481) of 34 (Resident #1, Resident #4, Resident #34, Resident #67, Resident #68, Resident #69, Resident #72, Resident #78, Resident #82, Resident #91, Resident #92, Resident #95, Resident #103, Resident #105, Resident #112, Resident #129, Resident #139, Resident #158, Resident #160, Resident #164, Resident #165, Resident #174, Resident #184, Resident #191 Resident #203, Resident #221, Resident #223, Resident #477, Resident #478, Resident #479, Resident #480, Resident #481, Resident #579, and Resident #581) sampled resident included in the initial pool. Findings: Review of Resident #481's March 2024 Physician's Orders revealed, in part, no evidence of an order for Ultra Lubricating eye drops. Review of Resident #481's record revealed no documentation of an assessment that Resident #481 could self-administer medications. Observation on 03/10/2024 at 9:45 revealed, Resident #481 had a bottle of Ultra Lubricating eye drops on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, observations, and record review the facility failed to allow a resident who is their own responsible party a choice to leave the facility on pass/leave for 1 resident (Resident #180) of 4 residents (Resident #103, Resident #95, and Resident #72) investigated for choices. Findings: Review of facility policy and procedure titled Pass/Leave of Absence with an effective date of 11/17/2015 revealed, in part facility residents may leave out on pass. Further review revealed a physician's order is needed if the facility resident is on skilled services at the time of pass/leave request and should include reason for leave, if resident can go on pass/leave alone and/or with a responsible party. Review of Resident #180's face sheet revealed, in part an admit date of 02/12/2024. Further review revealed Resident #180 is her own responsible party. In a phone interview on 03/12/2024 at 8:22 a.m., Resident #180's son stated he made a pass/leave request to S4Assistant Director of Nursing (ADON) to take his mother, Resident #180 out of the facility for pass/leave and was denied his…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure a resident's code status was consistent with the resident's wishes for 1 (Resident #478) of 34 (Resident #1, Resident #4, Resident #34, Resident #67, Resident #68, Resident #69, Resident #72, Resident #78, Resident #82, Resident #91, Resident #92, Resident #95, Resident #103, Resident #105, Resident #112, Resident #129, Resident #139, Resident #158, Resident #160, Resident #164, Resident #165, Resident #174, Resident #184, Resident #191 Resident #203, Resident #221, Resident #223, Resident #477, Resident #478, Resident #479, Resident #480, Resident #481, Resident #579, and Resident #581) sampled resident included in the initial pool. Findings: Review of Resident #478's electronic medical record revealed, in part, Resident #478 was admitted to the facility on [DATE]. Review of Resident #478's March 2024 Physician's Orders revealed, in part, an order dated 02/29/2024 which indicated Resident #478 was a Full Code (which indicated in the event he…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interviews the facility failed to notify the provider (Physician or Nurse Practitioner) a resident refused blood collection as ordered by Nurse Practitioner for 1 (Resident #182) of 5 (Resident #72, Resident #182, Resident #184, Resident #203, Resident #478 ) sampled residents investigated for unnecessary medication. Findings: Review of Resident #182's record revealed, in part, a physician's telephone order dated 02/16/2024 to obtain blood samples for a complete blood count (a blood test that counts the cells that make up your blood), comprehensive metabolic panel (a blood test is used to measure liver and kidney functions and nutrient levels), lipid panel (a blood test that measures fat molecules called lipids in your blood), thyroid stimulating hormone (a blood test used to diagnosis and monitor thyroid disorders) and a glycated hemoglobin (a blood test used to measure average blood sugar levels over the past 3 months). Review of Resident #182's record revealed, in part, an Advanced Laboratory order sheet dated 2/20/2024 indicating Resident #182 refused…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observations, and interviews, the facility failed to report an injury of unknown origin following the discovery of a resident's unexplainable wrist fracture for 1 (Resident #69) of 3 (Resident #69, Resident #92, Resident #481) sampled residents investigated for accidents. Findings: Review of the facility's Abuse Prevention and Prohibition Policy and Procedure revealed, in part, the facility employee who becomes aware of an injury of unknown source shall immediately report the matter to the facility administrator. Further review revealed the injury of unknown origin shall be reported not less than 2 hours if the incident involves serious bodily injury. Review of Resident #69's Minimum Data Set with an Assessment Reference Date of 12/20/2023 revealed, in part, Resident #69 had a Brief Interview for Mental Status score of 6, which indicated Resident #69 had severe cognitive impairment. Further review revealed Resident #69 had a diagnosis of cognitive communication deficit Review of Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record reviews, observations, and interviews, the facility failed to investigate an injury of unknown origin following the discovery of a resident's unexplained wrist fracture for 1 (Resident #69) of 3 (Resident #69, Resident #92, Resident #481) sampled residents investigated for accidents. Findings: Review of the facility's Abuse Prevention and Prohibition Policy and Procedure revealed, in part, an injury of unknown origin must be thoroughly investigated, including interviews of employees who were working in resident's room during the time in question and obtaining signed statements from these employees. Review of Resident #69's Minimum Data Set with an Assessment Reference Date of 12/20/2023 revealed, in part, Resident #69 had a Brief Interview for Mental Status score of 6, which indicated Resident #69 had severe cognitive impairment. Further review revealed Resident #69 had a diagnosis of cognitive communication deficit Observation on 03/10/2024 at 1:22 p.m. revealed Resident #69 had a blue cast on his left upper extremity. In an interview on 03/10/2024 at 1:23 p.m.,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interview, and record review, the facility failed to develop a plan of care that addressed a resident's pain for 1 (Resident #165) of 1 (Resident #165) sampled residents investigated for pain. Finding; Review of Resident #165's Plan of Care revealed, in part, no documented evidence of measurable goals or interventions for the management of Resident #165's pain. Further review revealed no documented evidence of timeframes or approaches for monitoring the effectiveness of interventions managing Resident #165's pain. In an interview on 03/10/2024 at 9:30 a.m., Resident #165 complained of pain to the left knee rated a 10 on a scale of 0 to 10 with 0 being no pain and 10 being the worse pain. Observation on 03/11/2024 at 9:43 a.m. revealed Resident #165 was not participating in his physical therapy exercises. In an interview on 03/11/2024 at 9:53 a.m., Resident #165 indicated that the pain to his left knee was keeping him from participating in physical therapy. In an interview on 03/11/2024 at 10:21 a.m., Resident #165 stated he was experiencing pain in his left…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure: 1. A resident that required dialysis had an order for hemodialysis (a procedure that filters waste and fluid from the blood in people whose kidneys can no longer function) frequency for 1 (Resident #477) of 1 (Resident #477) sampled residents investigated for dialysis services; 2. Ongoing communication regarding a resident's condition was completed with the dialysis facility for 1 (Resident #477) of 1 (Resident #477) sampled residents investigated for dialysis services; and 3. A dialysis resident's condition was assessed upon return from dialysis for 1 (Resident #477) of 1 (Resident #477) sampled residents investigated for dialysis services. Findings: Review of the facility's policy titled Dialysis Resident's Care Policy and Procedure, most recently revised on 10/09/2014, revealed, in part, the facility must obtain a physician's order for dialysis services that specified the days the resident was to go to dialysis. Further review revealed, the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record reviews, the facility failed to ensure the medication error rate was not greater than 5%. This deficient practice was identified for 2 (Resident #583 and Resident #584) of 4 (Resident #180, Resident #583, Resident #584, and Resident #600) residents observed during medication administration. Findings: Observation on 03/12/2024 at 8:41 a.m. revealed S10Licensed Practical Nurse (LPN) administered one tablet of Metoprolol Succinate Extended Release (a medication to lower blood pressure) 100 milligrams (mg) 1 tablet by mouth to Resident #583. Further observation on 03/12/2024 at 9:04 a.m. revealed S10LPN administered Vitamin B12 (a vitamin required for metabolism) 500 micrograms (mcg) 1 tablet by mouth to Resident #584. Review of Resident #583's March 2024 Physician's orders revealed, in part, an order dated 02/29/2024 to administer 1 tablet of Toprol XL (a medication used to lower blood pressure) 50 mg by mouth twice daily. Review of Resident #584's March 2024 Physician's orders revealed, in part, an order dated 03/07/2024 to administer 1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to ensure food available for use was properly stored, dated, and labeled in the dry food pantry and walk-in kitchen refrigerator. Findings: Review of the facility's Food Storage Labeling Policy dated October 2018 revealed, in part, the facility will store and label all foods to ensure safety and quality. Further review of the policy revealed food is routinely monitored in storage to identify and discard foods that have passed the expiration or use by date. Observation on 03/10/2024 at 9:15 a.m. of the kitchen's dry food pantry revealed an undated box with 7 bunches of overripe bananas that were black with brown bruises. Observation on 03/10/2024 at 9:20 a.m. revealed, in the facility's walk-in refrigerator 8 chef salads in plastic containers with soggy brown lettuce. Further observation revealed the containers were dated 03/04/2024. In an interview on 03/10/2024 at 9:16 a.m., S16Culinary [NAME] stated the bananas were for resident use.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure: 1. Documentation of a resident's wound assessment and treatment for 1 (Resident #477) of 4 (Resident #92, Resident #184, Resident #191, and Resident #477) sampled residents investigated for wound care; and 2. Documentation of a resident's antibiotic administration was recorded for 1 (Resident #91) of 3 (Resident #68, Resident #69, and Resident #91) sampled residents investigated for urinary tract infections. Findings: #1 Review of Resident #477's Electronic Medical Record (EMR) revealed, in part, Resident #477 was admitted to the facility on [DATE]. Review of Resident #477's admission Order Sheet dated 03/07/2024 revealed, in part, orders for Resident #477's right lower leg wound and right heel wound were noted. Review of Resident #477's March 2024's Physician's Orders revealed, in part, no documentation of a wound care order for Resident #477's right lateral shin wound or right heel wound on 03/07/2024 and/or 03/08/2024. Review of Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to report an allegation of neglect timely to the State Survey Agency and Certification Agency as required for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. Findings: Review of the facility's Abuse - Prevention and Prohibition Policy and Procedure, effective 03/25/2023, revealed, in part, neglect means the failure of the facility, its employees or service provider to provide adequate medical care or goods and services to a resident to avoid physical harm, pain, mental anguish, or emotional distress. Further review revealed, in part, the administrator shall immediately initiate a SIMS (Statewide Incident Management System) report to the Louisiana Department of Health no later than 24 hours after forming the suspicion if the alleged violation involves neglect and does not result in serious bodily harm. Review of Resident #1 record revealed he was admitted to the facility on [DATE]. Review of Resident #1's baseline care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, the facility failed to ensure the facility staff treated a resident with respect and dignity by failing to respond to residents' request for a bedpan and was told to urinate in a diaper for 1(Resident #2) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) residents sampled. Findings: In an interview on 08/28/2023 at 10:33 a.m., Resident #2 stated she was usually continent of her bowel and bladder, but had to go in a diaper a couple of times because facility staff could not find a bed pan. In an interview on 08/29/2023 at 8:35 a.m., Resident #2 stated she asked for the bed pan this morning, but the staff took too long to bring her the bedpan and she wetted on herself. In an interview on 08/30/2023 at 8:45 a.m., Resident #2 stated she did not have a good night last night. Resident #2 stated she asked to use the bedpan around 11:30 p.m. last night and S5Certified Nursing Assistant (CNA) told her to pee in the bed. In an interview on 08/30/2023 at 9:42 a.m., S4CNA Supervisor stated S5CNA was the CNA taking care of Resident #2. S4CNA Supervisor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview the facility failed to notify a resident representative of a change in tube feeding formula and new medication orders. This deficient practice was identified for 2 (Resident #1 and Resident #4) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) residents sampled for failure to notify. Findings: Resident #1 Review of Resident #1's physician orders revealed, in part, a telephone order dated 06/25/2023 stating it was okay to use Isosource (a nutritional formula) 1.5 until Peptemen (a nutritional formula) comes in. In an interview on 08/29/2023 at 11:40 a.m., Resident #1's husband stated Resident #1's tube feeding was changed on 06/25/2023 from Peptamen to Isosource and facility did not notify him of the change in tube feeding. In an interview on 08/30/2023 at 1:42 p.m., S2Director of Nursing (DON) confirmed there was no documentation to indicate Resident #1's husband was made aware of the tube feeding change on 06/25/2023. S2DON stated staff should have documented they notified Resident #1's family representative of tube…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure pain medication was available for resident use as ordered by the Physician for 1 (Resident #2) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) residents. Findings: Review of Resident #2's August 2023 physician orders revealed Oxycodone 15 milligrams (mg) by mouth every 6 hours as needed for pain. In an interview on 08/28/2023 at 10:33 a.m., Resident #2 stated she had been having pain but had not been able to receive her pain medication since last Thursday. Resident #2 stated she received her pain medication the first two days she was in the facility, but has not had it over the weekend because staff stated the medication was not available. In an interview on 08/28/2023 at 1:15 p.m., Resident #2 stated she was in pain and her pain level was a 12 (pain scale of 8 or more indicated severe pain). Resident #2 stated she had to go through the weekend without her pain medication because the facility did not have her pain medication in stock. In an interview on 08/28/2023 at 1:20 p.m., S7Licensed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview the facility failed to ensure adequate monitoring was completed after the initiation of new medications. This deficient practice was identified for 2 (Resident #4 and Resident #5) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) residents sampled. Findings: Resident #4 Review of Resident #4's physician orders revealed, in part, new physician orders written on 06/09/2023 for Flonase Allergy RLF 50 microgram/spray use in both nostrils daily for 7 days and Mucinex extended release 600 mg by mouth twice daily for 7 days. Review of Resident #4's Nurses notes dated 06/01/2023 through 08/27/2023 revealed, in part, no adequate monitoring for efficacy and adverse consequences while these medication were being administered. Resident #5 Review of Resident #5's physician orders revealed, in part, new physician orders written on 06/09/2023 for Potassium extended release 10 milliequivalent (mEq) 1 tablet by mouth every day and on 07/01/2023 Pataday 0.2% once daily 1 drop to each eye every morning indefinitely. Review of Resident #5's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview the facility failed to ensure a medication administration error rate was not equal to or greater than 5 percent. The facility had a medication administration error rate of 24%. This deficient practice was identified for 1 (S6 License Practical Nurse) of 1 nurse observed during medication administration for 2 (Resident #3 and Resident #4) of 2 (Resident #3 and Resident #4) sampled residents with 25 administration opportunities observed. Findings: Resident #3 Review of Resident #3's active physician orders revealed orders for Lexapro 5 milligrams (mg) give 1 tablet by mouth once daily; Hydrocortisone 1% cream - chest/trunk lesion - apply mixture of Bactroban and 1% hydrocortisone daily until resolved; Calcium +D soft chewable tablet give one tablet by mouth once daily; Oxybutynin 5 mg take 1 tablet by mouth once daily; and Potassium Chloride 20 milliequivalent (mEq) tablet give one tablet by mouth once daily. Observation on 08/29/2023 at 9:05 a.m. revealed S6Licensed Practical Nurse did not administer Calcium +D soft chewable tablet,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to accurately document administration of medications for 2 (Resident #3 and Resident #4) of 3 (Resident #3, Resident #4, and Resident #5) residents reviewed for medication administration task. Findings: Resident #3 Review of Resident #3 active physician orders revealed, in part, medication orders for Hydrocortisone 1% cream, chest/trunk lesion, apply mixture of Bactroban and 1% hydrocortisone daily until resolved; Calcium +D soft chewable tablet give one tablet by mouth once daily; Oxybutynin 5 milligram (mg) TR24 take 1 tablet by mouth once daily; Potassium Chloride extended release 20 milliequivalent (mEq) tablet give one tablet by mouth once daily. Observation of medication administration on 08/29/2023 at 9:05 a.m. revealed, in part, S6LPN did not administer Resident #3's Calcium +D soft chewable tab, Oxybutynin 5mg tablet, and Potassium CL ER 20mEq tablet as ordered; however, S6Licensed Practical Nurse (S6LPN) signed off medication as administered. In an interview on 08/29/2023 at 1:25 p.m., S6LPN confirmed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.