Jefferson Manor Nursing And Re

F-F600

Review of the facility's Abuse/Neglect Prevention Program policy, revised [DATE REDACTED], revealed the following in part: Each resident has the right to be free from mistreatment, neglect, and misappropriation of property.

9. Neglect: failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness.

In the event of any evidence involving neglect, an occurrence will be reported immediately to the Administrator or his or her designee of the facility, who will immediately notify corporate office and the appropriate state officials per state guidelines.

Review of the facility's Mandated Reporting Flowsheet, revised [DATE REDACTED], revealed the following in part: Does

the incident or allegation involve abuse, with or without serious bodily harm, or neglect, exploitation, injury of unknown source or other reportable incident that results in serious bodily harm (an injury involving extreme physical pain, involving substantial risk of death; requiring medical intervention)? If yes, report immediately to

the administrator and to law enforcement as applicable, but not later than 2 hours to the State Survey Agency.

Resident #1

Review of the facility's self-reported incident dated [DATE REDACTED] revealed the following:

Events Entered: [DATE REDACTED] at 9:43 a.m.

Occurred and Discovered: [DATE REDACTED] at 2:45 a.m.

Type of injury: Blank

Incident description: Initial investigation: The fall of Resident #1 was reported to S2ADM at 4:01 a.m.

Developing Issues: While investigating the incident involving the resident, it came to light that a vendor working on the floors may have impeded making rounds every 2 hours.

Review of Resident #1's Nurses' Note dated [DATE REDACTED] revealed the following, in part:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 12 195471 Department of Health & Human Services Printed: 09/04/2025 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 195471 B. Wing 03/10/2025

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

Jefferson Manor Nursing and Rehab Ctr, LLC 9919 Jefferson Hwy. 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 0609 On [DATE REDACTED] at 2:42 a.m.: Upon doing rounds aide walked into room and found resident unresponsive on fall mat. Nurse was immediately called to room upon entering room nurse noticed resident on her fall mat in a Level of Harm - Minimal harm or kneeling position facing the bed. Unable to obtain pulse or blood pressure upon assessment. Initiated CPR potential for actual harm immediately. 911 notified. At 2:53 a.m., Coroner's office notified. Signed by: S5LPN.

Residents Affected - Some Resident #3

Review of Resident #3's Nurses Note dated [DATE REDACTED] revealed the following, in part:

On [DATE REDACTED] at 2:53 a.m.: Upon doing rounds aide found Resident #3 lying down on the floor, nurse was immediately called to the room. Signed by: S5LPN.

Review of the CNA Daily Assignment Sheet from 10:00 p.m. to 6:00 a.m. dated [DATE REDACTED] revealed the following, in part:

S7CNA was assigned to care for the residents residing on Hall A Rooms ,d+[DATE REDACTED]

S8CNA was assigned to care for the residents residing on Hall A Rooms ,d+[DATE REDACTED]

S6CNA was assigned to care for the residents residing on Hall A Rooms ,d+[DATE REDACTED]

On [DATE REDACTED] at 2:04 p.m., a review of the facility's video surveillance footage of Hall A, dated [DATE REDACTED] from 12:00 a.m. until approximately 4:45 a.m., was conducted with S2ADM. Prior to reviewing the footage, S2ADM stated he did not have access to any surveillance footage prior to [DATE REDACTED] at 12:00 a.m. The surveillance footage revealed from 12:00 a.m. to approximately 2:35 a.m., staff neglected to provide any care and services to any resident's residing on Hall A. At 12:35 a.m., a call light was observed to be on in Hall A, which indicated a resident was calling for assistance. S2ADM confirmed the above review of the facility footage revealed no staff rounded on or provided care to any resident on Hall A from 12:00 a.m., on [DATE REDACTED] until approximately 2:37 a.m.

On [DATE REDACTED] at 11:58 a.m., an interview was conducted with S6CNA. She stated she worked the 10:00 p.m. to 6:00 a.m. shift on [DATE REDACTED] and was assigned to provide care for Resident #1 and Resident #3, as well as the residents in Rooms ,d+[DATE REDACTED] on Hall A. She stated on [DATE REDACTED], she was not able to provide care to her assigned residents on Hall A from 10:00 p.m. to 2:30 a.m., due to floor maintenance.

On [DATE REDACTED] at 3:29 p.m., an interview was conducted with S5LPN. S5LPN stated she was assigned to provide care for Resident #1, #3, and all of the residents on Hall A on [DATE REDACTED] and worked the 10:00 p.m. to 6:00 a.m. shift. She stated on the night of [DATE REDACTED] she did not provide care to her assigned residents on Hall

A from 10:00 p.m. until 2:30 a.m. due to floor maintenance.

On [DATE REDACTED] at 10:58 a.m., an interview was conducted with S8CNA. S8CNA stated she worked the 10:00 p. m. to 6:00 a.m., shift on [DATE REDACTED], and was assigned to Rooms ,d+[DATE REDACTED] on Hall A. She stated on [DATE REDACTED],

she did not go to any of the resident's rooms or provide care for the residents on Hall A due to floor maintenance from 10:00 p.m. until 2:30 a.m.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 12 195471 Department of Health & Human Services Printed: 09/04/2025 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 195471 B. Wing 03/10/2025

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

Jefferson Manor Nursing and Rehab Ctr, LLC 9919 Jefferson Hwy. 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 0609 On [DATE REDACTED] at 2:20 p.m., an interview was conducted with S7CNA. She stated she worked the 10:00 p.m. to 6:00 a.m., shift on [DATE REDACTED], and was assigned to Rooms ,d+[DATE REDACTED] on Hall A. She stated she did not perform Level of Harm - Minimal harm or visual checks every two hours or provide care for her assigned residents from 10:00 p.m. until 2:30 a.m. potential for actual harm

On [DATE REDACTED] at 4:36 p.m., an interview was conducted with S2ADM. He stated on [DATE REDACTED] at approximately Residents Affected - Some 4:00 a.m., S5LPN made him aware the floor vendor impeded care by not allowing nursing staff to perform visual checks on residents on Hall A from 10:00 p.m. until approximately 2:30 a.m. He confirmed no residents residing on Hall A received care from 10:00 p.m. through 2:30 a.m. on [DATE REDACTED]. He confirmed any allegations of neglect should be reported to the State Survey Agency within 2 hours. He confirmed he submitted the incident to the State Survey Agency on [DATE REDACTED].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 12 195471 Department of Health & Human Services Printed: 09/04/2025 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 195471 B. Wing 03/10/2025

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

Jefferson Manor Nursing and Rehab Ctr, LLC 9919 Jefferson Hwy. 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 0700 Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed Level of Harm - Minimal harm or consent; and (4) Correctly install and maintain the bed rail. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49343 Residents Affected - Many Based on observations, interviews, and record review the facility failed to ensure residents were assessed for risk of entrapment from bedrails and informed consents were obtained prior to installation of bedrails for 4 (#1, #3, #Resident R1, and #Resident R2) of 4 sampled residents identified for having bedrails in use.

This deficient practice had the potential to affect all 51 residents residing in the facility with bedrails in use.

Findings:

Resident #1

Review of Resident #1's Clinical Record revealed she was readmitted to the facility on [DATE REDACTED] and had diagnoses, which included Foot Drop of Right and Left Foot, Muscle Weakness (generalized), Muscle Wasting and Atrophy, Primary Generalized Osteoarthritis, Abnormal Posture, Cognitive Communication Deficit, and Need of Assistance for Personal Care. Further review revealed Resident #1 expired on [DATE REDACTED].

Review of Resident #1's most recent completed Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE REDACTED], revealed Resident #1 was dependent on staff assistance with bed mobility and transfers.

Review of Resident #1's current Physician Orders revealed the following, in part:

Start date [DATE REDACTED]: Mobility bars x2 to assist with bed mobility and repositioning every shift.

Review of Resident #1's Medication Administration Record (MAR) dated [DATE REDACTED] revealed the following, in part: Start date [DATE REDACTED]: Mobility bars x2 to assist with bed mobility and repositioning every shift.

Review of Resident #1's Clinical Record revealed no documentation of Entrapment Risk Assessments for bedrails.

Review of Resident #1's Clinical Record revealed no documentation of informed consent for bedrails.

An interview was conducted with S5LPN on [DATE REDACTED] at 3:29 p.m. She stated anytime Resident #1 was in bed, her mobility bars were in a raised position.

Resident #3

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 12 195471 Department of Health & Human Services Printed: 09/04/2025 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 195471 B. Wing 03/10/2025

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

Jefferson Manor Nursing and Rehab Ctr, LLC 9919 Jefferson Hwy. 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 0700 Review of Resident #3's Clinical Record revealed she was admitted to the facility on [DATE REDACTED] and had diagnoses, which included Muscle Wasting, Muscle Weakness and Lack of Coordination. Level of Harm - Minimal harm or potential for actual harm Review of Resident #3's quarterly MDS with an ARD of [DATE REDACTED] revealed she had a Brief Interview of Mental Status (BIMS) of 15, which indicated she was cognitively intact. Further review revealed she required partial Residents Affected - Many to substantial/max assist with bed mobility and transfers.

Review of Resident #3's current Physician Orders revealed the following, in part:

Start date [DATE REDACTED]: Mobility bars x2 to assist with bed mobility and repositioning, every shift.

Review of Resident #3's MAR dated [DATE REDACTED] revealed the following, in part:

Start date [DATE REDACTED]: Mobility bars x2 to assist with bed mobility and repositioning, every shift.

Review of Resident #3's Clinical Record revealed no documentation of Entrapment Risk Assessments for bedrails prior to [DATE REDACTED].

Review of Resident #3's Clinical Record revealed no documentation of informed consent for bedrails.

An observation was made and interview was conducted with Resident #3 on [DATE REDACTED] at 3:45p.m. Resident #3's bed had two mobility bars, one on each side of the bed, in an upright position. Resident #3 confirmed

she had not signed a consent for bedrails when the bedrails were implemented, and she used the bedrails for mobility.

Resident #Resident R1

Review of Resident #Resident R1's Clinical Record revealed he was admitted to the facility on [DATE REDACTED] and had diagnoses, which included Muscle Weakness and Acute Paralytic Poliomyelitis.

Review of Resident #Resident R1's quarterly MDS with an ARD of [DATE REDACTED] revealed he had a BIMS of 15, which indicated he was cognitively intact. Further review revealed he required substantial/max assist with bed mobility.

Review of Resident #Resident R1's current Physician Orders revealed the following, in part:

Start date [DATE REDACTED]: Mobility bars x2 to assist with bed mobility and repositioning, every shift.

Review of Resident #Resident R1's MAR dated [DATE REDACTED] revealed the following, in part:

Start date [DATE REDACTED]: Mobility bars x2 to assist with bed mobility and repositioning, every shift.

Review of Resident #Resident R1's Clinical Record revealed no documentation of Entrapment Risk Assessments for bedrails prior to [DATE REDACTED].

Review of Resident #Resident R1's Clinical Record revealed no documentation of informed consent for bedrails.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 12 195471 Department of Health & Human Services Printed: 09/04/2025 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 195471 B. Wing 03/10/2025

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

Jefferson Manor Nursing and Rehab Ctr, LLC 9919 Jefferson Hwy. 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 0700 An observation was made and interview was conducted with Resident #Resident R1 on [DATE REDACTED] at 4:15 p.m. Resident #Resident R1's bed had two mobility bars, one on each side of the bed, in an upright position. Resident #Resident R1 confirmed Level of Harm - Minimal harm or he had not signed a consent for bedrails when the bedrails were implemented, and he used the bedrail for potential for actual harm mobility.

Residents Affected - Many Resident #Resident R2

Review of Resident #Resident R2's Clinical Record revealed she was admitted to the facility on [DATE REDACTED] and had diagnoses, which included Repeated Falls, Other Abnormalities of Gait and Mobility, Muscle Wasting and Atrophy, and Other Lack of Coordination.

Review of Resident #Resident R2's quarterly MDS with an ARD of [DATE REDACTED] revealed she had a BIMS of 14, which indicated she was cognitively intact. Further review revealed she required substantial/max assist with bed mobility.

Review of Resident #Resident R2's current Physician Orders revealed the following, in part:

Start date [DATE REDACTED]: Mobility rails x2 to assist with bed mobility and repositioning, every shift.

Review of Resident #Resident R2's MAR dated [DATE REDACTED] revealed the following, in part:

Start date [DATE REDACTED]: Mobility rails x2 to assist with bed mobility and repositioning, every shift.

Review of Resident #Resident R2's Clinical Record revealed no documentation of Entrapment Risk Assessments for bedrails prior to [DATE REDACTED].

Review of Resident #Resident R2's Clinical Record revealed no documentation of informed consent for bedrails.

An observation was made and interview was conducted with Resident #Resident R2 on [DATE REDACTED] at 3:29 p.m. Resident #Resident R2's bed had two mobility bars, one on each side of the bed, in an upright position. Resident #Resident R2 confirmed

she had not signed a consent for bedrails when the bedrails were implemented, and she used the bedrails for mobility.

An interview was conducted with S9CRN on [DATE REDACTED] at 1:35 p.m. She stated she and another staff member completed entrapment risk assessments. She stated the facility does not obtain consents for bed rails prior to installing them if they are not being used as a restraint. She confirmed they had not obtained informed consents for mobility bars prior to installing them, and no entrapment risk evaluations had been completed prior to [DATE REDACTED].

An interview was conducted with S3DON on [DATE REDACTED] at 3:01 p.m. She stated no staff was assigned to perform entrapment risk assessments or obtain informed consents for residents who had mobility bars ordered. She stated informed consents were not obtained to indicate Resident's #1, #3, #Resident R1, and R#2 had given consent for the mobility bars. She stated entrapment risk assessments were not conducted for residents with mobility bars prior to [DATE REDACTED]. She stated she was unaware consents and entrapment risk assessments should be completed prior to installing mobility bars.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 12 195471