Lourdes Rehabilitation and Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure wound treatments/interventions were completed for one resident (R21) of one resident reviewed for pressure ulcers. Findings include:On 8/26/2025 at approximately 8:38 a.m., R21 was observed in their room, laying in their bed. R21 was observed laying in the supine position in the middle of the bed without any wedges or pillows offloading pressure of their sacral area. On 8/27/25 at approximately 10:11 a.m., R21 was observed in their room, laying in their bed. R21 was observed laying in the supine position in the middle of the bed without any positing wedges or pillows offloading pressure of their sacral area. On 8/27/25 the medical record for R21 was reviewed and revealed the following: R21 was initially admitted to the facility on [DATE] and had diagnoses including Pressure Ulcer Sacral Region Stage 4 and Venous insufficiency. A review of R21's careplan revealed the following: A review of R21's careplan revealed the following: [R21]…

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, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen and failed to ensure dishware was properly sanitized. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 7/22/24 between 11:00 AM-11:30 AM, during a kitchen tour with Director of Dining E, the following was observed: In the dry storage room, there was a buildup of dust, trash and food debris on the floor under the racks. In addition, there was a box of bananas, with numerous bananas that were completely black, and several that were split open. There were fruit flies observed swarming inside the box. When queried, Director of Dining E stated, We usually freeze them for banana bread when they get ripe, but those need to get tossed. According to the 2017 FDA Food Code section 6-501.111 Controlling Pests, The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the PREMISES by: .4.…

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, interview, and record review, the facility failed to properly utilize personal protective equipment (PPE) for three (R20, R53, and R169) of three residents reviewed for transmission based precautions (TBP). Findings include: On 7/22/24 at 9:08 AM, staff were observed in R169's room wearing a gown and gloves. Signage was observed on the door that indicated R169 was on contact precautions (TBP intended to prevent transmission of infectious agents via contact with the person or their environment). The signage indicated a gown and gloves were to be donned when entering R169's room. Coat hooks were observed inside of R169's room labeled CNA (Certified Nursing Assistant) and Nurse. On 7/22/24 at 3:02 PM, R169 was observed sleeping in bed. Reusable gowns were observed hanging on hooks inside of the room. A family member was observed seated in a chair in the room without any PPE on. On 7/22/24 at 3:15 PM, an interview was conducted with Registered Nurse (RN) 'A'. When queried about why R169 was 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure non-pharmacological interventions were utilized prior to the use of an as needed anti-anxiety medication for one resident (R23) of five residents reviewed for unnecessary medications, resulting in the potential for inappropriate use of an anti-anxiety medication. Findings include: On 7/22/24 at 10:22 AM, a review of R23's clinical record revealed they admitted to the facility on [DATE] with diagnoses that included: dementia, major depressive disorder and adjustment disorder. R23's most recent completed Minimum Data Set assessment dated [DATE] revealed R23 had mild cognitive impairment and was independent with most activities of daily living. A review of R23's orders revealed an order dated 7/2/24 for Xanax (anti-anxiety medication) 0.25 milligrams every 12 hours as needed for 14 days. R23's medication administration record (MAR) revealed a dose of the medication was given on 7/10/24 at 1:05 PM. A Behavior Note dated 7/10/24 at 8:03 PM entered…

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 obtain labs in a timely matter for one resident, (R81) of one resident reviewed for labs, resulting in the potential for delayed treatment. Findings include: On 7/23/24 at 11:24 AM, a review of R81's physician's orders was conducted and revealed the following: An order dated 5/2/24 for a urinalysis and urine culture and sensitivity lab with a discontinuation date of 5/15/24. An order dated 5/8/24 for a urinalysis and urine culture and sensitivity lab with a discontinuation date of 5/15/24. An order dated 5/13/24 for a urinalysis and urine culture and sensitivity lab with a completed date of 5/14/24. A review of R81's lab results in the record did not reveal any results for the lab ordered 5/2/24. A review of R81's progress notes was conducted and did not reveal any information regarding the lab ordered on 5/2/24. Continued review of the notes revealed the following: A note dated 5/8/24 at 3:54 PM that read, .Resident complained of burning on urination and urinary frequency . NP (Nurse Practitioner) .notified. Order…

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, interview and record review, the facility failed to ensure two residents (R26 and R178) of four residents reviewed for medications were assessed for the safe self-administration of medication and to have medication kept at the bedside. Findings include: 08/22/23 at approximately 10:06 a.m., R26 was observed in their room, up in their bed. R26 was observed to have two bottles of eye drops and a cup full of cough drops on their bedside table. R26 was queried if they were using the eye drops and taking the cough drops and they reported that they were and that their eyes get dry in the facility along with their cough. R26 was queried if the facility Nursing staff knew they had the medications at the bedside and they reported that they did and they they have had them for a few weeks. On 8/22/23 at approximately 3:20 p.m., R26 was observed in their room, up in their bed. R26 was still observed to have a cup full of cough drops on their beside table along with the eye drops located in a tissue…

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, interview, and record review the facility failed to ensure a competency assessment was completed for one (R27) of five residents reviewed for advance directives, resulting in the facility to have allowed a family member to have signed medical consents and make health care decisions for R27 without the resident to have been deemed incompetent to make decisions regarding their care. Findings include: Review of the medical record revealed a family member of R27 had signed multiple medical consents and was allowed to make health care decisions for R27. Further review of the medical record revealed patient advocate papers on file, however no competency assessment was identified in the medical record. This indicated the patient advocate was signing consents and making decisions for R27 without the resident being deemed as incompetent to make their own decisions. Review of the medical record revealed R27 was readmitted to the facility on [DATE], with diagnoses that included: chronic pain and…

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, interview, and record reviews the facility failed to notify the physician of change of a resident's skin condition (R63), ensure a physician order was implemented for a treatment and proper storage of ointments for two (R's 43 & 63) of four residents reviewed for medications stored at the bedside. Findings include: R63 On 8/22/23 at 8:59 AM, R63 was observed sitting in their wheelchair next to their bed. An interview was conducted with the resident at that time. Observed on R63's nightstand was a medication cup filled with a thick ointment, placed behind a greeting card. When asked, R63 stated the staff applies it to their buttock area. At that time the assigned Infection Control Nurse (ICN) D (who was assigned to work the floor on the day of the observation) was asked to verify the medication in comparison with the resident's medication profile. The medication profile was reviewed with ICN D and revealed the resident did not have an order for an ointment to be applied to the resident. ICN D was asked to inform the surveyor of the next assistance to 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 observation, interview, and record review, the facility failed to appropriately prepare a PICC (peripherally inserted central catheter, used for infusion of intravenous fluids or medications) line prior to intravenous administration of antibiotics for one resident (R26) of one resident reviewed for PICC lines, resulting in the potential for infection. Findings include: On 8/23/23 at 9:34 AM, Nurse 'A' was observed preparing medications for administration to R26. Nurse 'A' prepared multiple medications including an intravenous (IV) antibiotic. Nurse 'A' entered the room, connected the IV tubing to the antibiotic bag and hung the bag on the IV pole. Nurse 'A' was then observed to flush R26's PICC line with 10 milliliters of normal saline. Nurse 'A' was not observed to scrub the PICC line connection port prior to flushing the line. After flushing the line, Nurse 'A' connected the IV tubing and began the infusion of the medication. On 8/23/23 at 9:49 AM, Nurse 'A' was asked about the process for preparing a PICC line for intravenous medication administration and admitted they…

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, interview, and record review, the facility failed to ensure a medication error rate less than five percent for one resident, (R26) of four residents reviewed for medication administration, resulting in a medication error rate of 9.09%. findings include: On 8/23/23 8:21 AM, Nurse 'A' was observed preparing R26's morning medications. Nurse 'A' prepared multiple medications including a Flonase (allergy treatment) nasal spray. After preparing the medications, Nurse 'A' entered R26's room and was observed to assist R26 with the nasal spray. Nurse 'A' administered one spray of the Flonase into R26's right nostril and one spray into their left nostril. At the conclusion of the medication administration, Nurse 'A' exited the room. Nurse 'A' was asked to confirm all of R26's medications due during the morning medication pass were given, and they said they were. On 8/23/23 at 10:24 AM, R26's physician's orders were reconciled (compared) with the observation of the medication administration at 8:21 AM. During the reconciliation it was discovered R26's order for Flonase…

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.