Heritage Manor Of Baton Rouge I I

F-F609

Review of facility's policy titled, Elopement/Wandering, with revision date of 01/2023 revealed, in part the following:

Elopement occurs when a resident who is incapable of adequately protecting themselves leaves the premises without necessary supervision to do so.

1. All resident shall be observed and evaluated for demonstration of elopement risk by using Admission/Readmission Nursing screening on admission and Nurse Data Collection and Screening in the

observation period of each Minimal Data Set (MDS).

e. The following items shall be used to increase staff awareness of residents at risk to wander/elope.

i. A list of residents shall be available at the nurse's stations with residents at risk for wandering indicated.

ii. Orientation of all staff to potential wanderers will be performed on an ongoing basis.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 25 195389 Department of Health & Human Services Printed: 09/08/2025 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 195389 B. Wing 02/21/2025

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

Heritage Manor of Baton Rouge II 9301 Oxford Place Ave Baton Rouge, LA 70809

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 Resident #3's Clinical Record revealed an admitted [DATE REDACTED], with diagnoses which included Dementia, Encephalopathy, Altered Mental Status, and Housing Instability. Further review revealed a Level of Harm - Immediate protective order filed against Resident #3's Responsible Party (RP) on 01/13/2025 effective through 11:59 p. jeopardy to resident health or m. on 02/26/2025 for domestic abuse. safety

Review of Resident #3's local hospital Discharge Summary dated 01/31/2025, revealed the following, in part: Residents Affected - Few Housing Instability

Resident #3's Power of Attorney (POA) stated she had an open EPS case against two siblings.

POA's other siblings stated there was a protective order against POA.

EPS recommended placement, as there had been multiple reports and protective order between multiple parties in this situation.

Review of Resident #3's Nurse Data Collection and Screening dated 02/06/2025, Elopement risk section, revealed questions 1 through 3 were answered yes. Question 6, asked if the resident was at risk for elopement and indicated if any of the above questions (1-5) were answered yes, the resident was at risk. Question 6 was observed to be answered as No. Further review revealed the resident was not documented as using a wander guard.

Review of Resident #3's Current Comprehensive Plan of Care revealed, the following in part:

Onset date: 02/03/2025

Problem: The resident has impaired thought process related to encephalopathy: Risk for elopement

Interventions: Cue, reorient, and supervise as needed; and

On 02/04/2025 wander guard to right ankle.

Further review failed to reveal interventions to ensure staff were aware of Resident #3's current protective order and open Elderly Protective Services (EPS) case against three family members.

Review of Resident #3's Progress Noted dated 01/19/2025 to 02/19/2025 revealed, the following, in part:

On 02/04/2025 at 3:01p.m., notified Resident #3's Responsible Party (RP), resident would be placed on memory care unit due to wandering. Signed S11SW

Review of facility's Wanderers' Binder located at the nurse's station revealed a wander guard list dated 01/31/2025. Further review revealed a list of elopement risk residents which did not include Resident #3.

The facility had implemented the following actions to correct the deficient practice on 02/20/2025:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 25 195389 Department of Health & Human Services Printed: 09/08/2025 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 195389 B. Wing 02/21/2025

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

Heritage Manor of Baton Rouge II 9301 Oxford Place Ave Baton Rouge, LA 70809

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 Corrective actions for the alleged deficient practice of the facility failing to provide adequate supervision to prevent Resident #3 from eloping on 02/08/25. Level of Harm - Immediate jeopardy to resident health or o On 02/08/25 Resident #3 left from the facility and did not return. 02/08/25 Facility NFA contacted Elderly safety Protective Services to alert them resident #3 left the facility. 02/08/25 NFA alerted the facility Ombudsman that the resident's family removed her from the facility. Residents Affected - Few o All residents in the facility who have a risk for elopement have the potential to be affected by this alleged deficient practice. (Identified as two residents with secure care bracelets and 32 residents on the secure care unit).

o All resident electronic charts and hard copy charts were audited, by the DON and ADON to ensure that no other residents had an order for protection on 02/20/2025 at 7:50 pm. None were identified. If there were any additional protective orders with family dynamic/concerns this would have been communicated with the staff and care planned at this time.

o 02/21/25 all resident electronic charts and hard copy charts for residents considered an elopement risk were audited, by the facility DON, ADON and MDS Nurses to ensure this information was care planned appropriately so that this information could be communicated to staff via the care plan.

o Regional [NAME] President and NFA together reviewed the Long Term Care Survey manual for

F-F689. On 02/21/2025, Regional [NAME] in-serviced NFA and DON regarding these regulations and need to report to local police and LDH via the SIMS system.

Regional [NAME] President will review all SIMS reports submitted by the NFA to ensure they were reported appropriately and timely. Regional [NAME] President will review incident report list to ensure administrative staff are reporting appropriately.

Regional [NAME] President will oversee in-servicing/monitoring of the NFA and administrative staff to ensure all audits are completed appropriately and timely. Should monitoring/reporting not happen appropriately or timely staff will face progressive discipline up to and including termination.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 25 195389 Department of Health & Human Services Printed: 09/08/2025 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 195389 B. Wing 02/21/2025

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

Heritage Manor of Baton Rouge II 9301 Oxford Place Ave Baton Rouge, LA 70809

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 0835 An immediate in-service was initiated by the Director of Nurses on 02/20/2025 at 7:40 p.m. with staff present at the facility at the time. All staff that were not present will be in-serviced prior to their next shift. The staff Level of Harm - Immediate were in-serviced regarding: Residents with EPS cases. All residents with EPS cases will have a care plan jeopardy to resident health or and the information communicated to the staff immediately. All visits will be supervised. Should anyone try to safety leave with the resident the police will be called and it will be reported to the state. The Administrator and DON will be notified. Any resident classified as an elopement risk will be placed in the binder at the nurse's Residents Affected - Few station. In the instance of elopement, the police will be called and a report shall be made to the state. The in-servicing was be completed with present staff on 02/20/2025 and will be completed with all non-present staff prior to the first shift by the Director of Nursing or designee. A master list of all staff was generated by

the Human Resources Director. The DON and ADON used this list to retrain every staff member.

(Beginning 02/21/2025) To ensure continued compliance with the facility's plan of correction, the ADON Nurse, DON or designee will audit all paperwork for every new admission to ensure should the resident have

an open EPS case or is an elopement risk this will be entered into the care plan and communicated to the staff by the DON. This will be communicated to the staff via the Point Click Care task that fires to the kiosk and nurse laptop. These audits will continue for every new admission for the next 30 days. The DON, will audit 5 residents who are an elopement risk 3 X times a week for four weeks and routinely thereafter. The audit will consist of reviewing the care plan for residents who are an elopement risk to ensure this is properly care planned/ communicated to staff. Results of audits are to be captured on a special care form and discussed in the daily stand-up meeting with the interdisciplinary team. The Quality Assurance (QA) Committee is to meet weekly for no less than 4 weeks to promote compliance and gauge progress.

Beginning 02/21/25, the NFA or designee will interview 5 staff members 3 times x a week for the next 4 weeks to ensure they understand the need to supervise any visitation with residents with EPS protective orders and they know they need to alert the NFA, DON and authorities should the family attempt to leave with the resident.

An Emergency QA was held on 02/21/2025 with the facility Medical Director and QA Committee regarding residents who are an elopement risk and/or who have open EPS cases.

Should the above referenced QA measures not meet expectations, the QA/Audits/POC will be adjusted at that time. Staff found to be non-compliance will be re-educated and face progressive discipline up to and including termination.

Completion date - The likelihood for serious harm will no longer exist on 02/21/2025.

As of 02/21/2025, the facility asserts the likelihood for serious harm to any recipient no longer exists.

Throughout the survey from 02/20/2025 to 02/21/2025, observations, interviews, and record review revealed

the above listed actions were implemented. Random staff interviews revealed staff received training on the new process to ensure residents are properly care planned to meet their needs, identify elopement risk residents, properly care plan for a resident whom had an open EPS case and/or current protective order against family member(s), staff knew the process to notify the proper authorities and when to notify local law enforcement, and staff knew when and what to report to the local law enforcement and state agency.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 25 195389 Department of Health & Human Services Printed: 09/08/2025 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 195389 B. Wing 02/21/2025

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

Heritage Manor of Baton Rouge II 9301 Oxford Place Ave Baton Rouge, LA 70809

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 0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Level of Harm - Minimal harm or potential for actual harm 48333

Residents Affected - Some Based on observations, and interviews the facility failed to ensure a safe, functional, sanitary and comfortable environment. The facility failed to ensure:

1.) Resident air conditioners (AC) were sanitary in Room B and Room E;

2.) Ceiling Tiles were maintained in clean and functional manner on Hall A and Room B;

3.) Floor tiles were maintained in a safe and functional manner in Room C ; and

4.) Bath D was maintained in a sanitary manner for staff and the public.

Findings:

Review of Facility's Policy Titled Resident Environment dated 09/2015 revealed, the following, in part: It is

the policy of this facility to provide a safe, clean, comfortable and homelike environment.

1.)

An observation was conducted on 02/18/2025 at 11:58 a.m. of Room B. The AC unit vent had copious amount of small specks of a black substance throughout the return vent.

An observation was conducted on 02/18/2025 at 12:00 p.m. of Room E which had dry brown and red liquid

on the AC Unit.

2.)

An observation was conducted on 02/18/2025 at 2:00 p.m. of Hall A. There was a ceiling tile at the front of Hall A which had a crack across the entire ceiling tile. Room B had two ceiling tiles above the AC unit which had brown water spots on them.

3.)

An observation was conducted on 02/19/2025 at 1:00 p.m. of Room C. Room C had two chipped floor tiles.

The missing chip in the corner of the floor tiles was approximately 3 to 4 inches wide.

4.)

An observation was conducted on 02/18/2025 at 10:00 a.m. of Bath D. The light fixtures had a copious amount of fluffy gray colored substance, the ceiling vent had copious amounts of fluffy gray colored substance, and the laminate flooring had spaces between each floor tile which were filled with black residue.

The flooring was covered in a sticky residue. A second observation was conducted on 02/19/2025 at 12:00p. m. of Bath D. Bath D remained in the same unsanitary condition as stated above.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 25 195389 Department of Health & Human Services Printed: 09/08/2025 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 195389 B. Wing 02/21/2025

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

Heritage Manor of Baton Rouge II 9301 Oxford Place Ave Baton Rouge, LA 70809

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 0921 An interview was conducted on 02/18/2025 at 12:05 p.m. with Resident #Resident R1. Resident #Resident R1 noted to be short of breath and wheezing. She stated she was concerned the back substance on her AC unit, in Room B, Level of Harm - Minimal harm or could worsen her breathing issues. potential for actual harm

An interview was conducted on 02/19/2025 at 2:08 p.m. with S7MS. S7MS stated he changed ceiling tiles as Residents Affected - Some needed. He reported being aware the ceiling tile down the front of Hall A was cracked and needed to be changed. He confirmed two ceiling tiles in room B above the AC unit needed to be changed from water spots. He confirmed the flooring tiles in Room C were chipped. He stated the tiles were old and he did not have the extra matching tiles to change the chipped tiles.

An interview was conducted on 02/19/2025 at 2:50 p.m. with S6HKS. She confirmed the aforementioned

observations. She reported the AC units should be wiped daily during daily room cleaning. She reported bathrooms should be cleaned at least once daily. After observing Room B she confirmed the copious amounts of black spots on the AC vents should be cleaned. After observation of Room E she confirmed the substance on the AC unit was coffee and juice, and should have been cleaned. After observation of Bath D

she confirmed Bath D was flooded a year ago and the flooring was spaced due to the glue coming up from

the laminate and the flooring needed cleaning. S6HKS confirmed the copious amount of gray fluffy substance on the light fixtures, and ceiling vent should be cleaned. She confirmed Bath D should be cleaned twice daily and had not been.

An interview was conducted on 02/20/2025 at 9:16 a.m. with S1ADM . S1ADM confirmed that the AC units in resident rooms should be maintained clean and sanitary and it was unacceptable to have spilled liquids or black spotted substance on AC units if staff were cleaning them daily. He reported the flooring in Bath D should be fixed. He reported Bath D should be maintained and clean as well. He reported he was unaware of

the flooring being chipped in Room E, and it should be replaced.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 25 195389