Pilgrim Manor Skilled Nursing And Rehabilitation

F-F726

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 11 195594 Department of Health & Human Services Printed: 09/17/2025 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 195594 B. Wing 08/01/2024

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

Pilgrim Manor Skilled Nursing and Rehabilitation 1524 Doctors Drive Bossier City, LA 71111

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 Review of facility's surveillance video footage of the front entrance area on 07/30/2024 at 8:50 a.m. with S1Administrator and S3Corporate Nurse revealed in part, the following sequence of events on 07/23/2024: Level of Harm - Immediate jeopardy to resident health or 6:59:40 p.m. S5Evening Receptionist left the front desk to assist a wheelchair bound resident towards the safety back of the facility.

Residents Affected - Many 6:59:50 A visitor was observed entering the facility through the sliding doors, which opened upon approach to the entrance; front desk was observed to be unattended.

7:03:15 p.m. S5Evening Receptionist, returned to front desk, having left the front desk unattended for approximately 3 to 4 minutes.

During an interview on 07/29/2024 at 2:40 p.m., S9Day Receptionist reported the front door was unlocked

during the day for anyone to enter the facility and the sliding glass door automatically opened when a person approaches the front entrance.

During an interview on 07/30/2024 at 9:00 a.m., S1Administrator, reported the S5Evening Receptionist not knowing Resident #1 was a resident and was at risk for elopement contributed to the safety process failure. S1Administrator acknowledged the front door was left unattended upon review of 07/23/2024's surveillance video and confirmed a resident could elope when someone enters the unlocked front door. S1Administrator acknowledged the front door entrance was not secure and there were times the desk may not be manned. S1Administrator further acknowledged the facility did not have a lock down unit or wander guard system in place to aide in measures to prevent elopement.

During an interview on 07/30/2024 at 9:10 a.m., S3Corporate Nurse, reported she reviewed Resident #1's initial elopement assessment the night Resident #1eloped and confirmed Resident #1 had been evaluated as not at risk for elopement by S4ADON. S3Corporate Nurse further acknowledged the 07/23/2024 elopement evaluation failed to include the family in the elopement assessment process, and S4ADON should have, to capture a history of elopement from the home.

Review of S4ADON's personnel record failed to reveal nursing assessment competencies were completed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 11 195594