Presbyterian Village Of Homer

F 0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Level of Harm - Minimal harm or potential for actual harm 43405

Residents Affected - Few Based on observations and interviews, the facility failed to maintain a safe, clean, comfortable and homelike environment for 2 (#3 and #39) of 2 residents rooms observed. The failed practice was evidenced by 1) Resident #3 and #39's air conditioner vents needed cleaning, and 2) Resident #3's bed control needed cleaning, and 3) Resident #3's room had a bedrail stored under his bed.

Findings:

Resident # 3

Observations on 05/27/2025 at 10:05 a.m. and 05/28/2025 at 12:10 p.m. of Resident #3's room revealed the air conditioner vent was dirty with a buildup of dust, the bed control was noted on the Resident's night stand and was dirty and had a brown sticky substance on it, and a bedrail was noted on the floor under the Resident's bed.

On 05/28/2025 at 3:35 p.m. an observation of Resident #3's room with S2 DON (Director of Nursing) present revealed Resident #3's air conditioner vent had a buildiup of dust, a bedrail was under the Resident's bed, and Resident's bed control was dirty with a brown, sticky substance. S2 DON confirmed that the air conditioner vent and bed control needed to be cleaned and the Resident should not have had a bedrail stored under his bed.

18118

Resident #39

Observations on 05/27/2025 at 9:45 a.m., 05/28/2025 at 10:10 a.m. and at 1:45 p.m. of Resident #39's room revealed the air conditioner unit contained a black substance on the vents and needed to be cleaned.

On 05/28/2025 at 3:45 p.m., an observation of Resident #39's room with S2 DON present revealed Resident #39's air conditioner had a black substance on the vents. S2 DON confirmed the air conditioner vents needed to be cleaned.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 1 of 10 195579 Department of Health & Human Services Printed: 08/26/2025 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 195579 B. Wing 05/29/2025

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

Presbyterian Village of Homer 3700 Hwy. 79 South Homer, LA 71040

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 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40015

Residents Affected - Few Based on record review and interview the facility failed to ensure each resident/RP (Responsible Party) was notified in advance of care planning conferences to enable resident/RP participation for 1 (#27) of 28 sampled residents.

Findings:

Review of facility's undated Care Plan Policy revealed, in part:

Application of Policy .

4. Care plan conferences (meetings) are scheduled for each resident at admission and continuing at least quarterly by the MDS Coordinator. The resident and his/her legal guardian/family member is given at least a seven (7) day notice of invitation to attend and participate in the resident's care planning conferences. The conference may be scheduled at an alternate date and time if more convenient for the resident and/or family member.

5. The MDS Coordinator or designee will invite family members and maintain records of the invitation and whether the resident and/or family member participated in the care plan conference.

6. Participation by the resident and/or family member is not limited to attending the scheduled conference but may be done by conversations in person or by telephone and by sending written letters addressed to the ID (Interdisciplinary) Team. Resident and/or family input can occur at any time.

Review of Resident #27's medical revealed an initial admitted [DATE REDACTED] with diagnoses that included, in part, other seizures, traumatic subarachnoid hemorrhage without loss of consciousness, attention-deficit hyperactivity disorder, anxiety disorder, hypertensive heart disease without heart failure, depression, and non-pressure chronic ulcer of other part of right foot.

Review of MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 4/17/2025 revealed Resident #27 had a BIMS (Brief Interview Mental Status) score of 05, which indicated a severe cognitive impairment.

During an interview on 05/27/2025 at 1:53 p.m. Resident #27's family member reported there had been no care plan meetings.

During an interview on 05/28/2025 at 2:35 p.m. S6 SSD (Social Services Director) reported Resident #27's family/RP was not being notified of upcoming care plan meetings and she did not have care plan meeting announcements for the family/RP as they were not being done.

During an interview on 05/29/2025 at 10:35 a.m. S3 LPN (Licensed Practical Nurse)/MDS Nurse confirmed S6 Social Services was responsible for notify family/RP regard the care plan meeting and would send the care plan meeting invitations to the family/RP.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 10 195579 Department of Health & Human Services Printed: 08/26/2025 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 195579 B. Wing 05/29/2025

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

Presbyterian Village of Homer 3700 Hwy. 79 South Homer, LA 71040

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 #47's care plan dated 05/08/2025 revealed Resident 47's bed was equipped with turning bars for positioning purposes. Interventions included evaluation of the turning bar has been performed per Level of Harm - Minimal harm or policy and procedure; other options have been explored, but family and or Resident have chosen the option potential for actual harm of having the turning bar put in place, and Resident knows how to utilize the turning bar.

Residents Affected - Some Observations on 05/27/25 at 10:00 a.m., and 05/28/2025 at 2:51 p.m. revealed Resident #47 was lying in the bed with bilateral positioning bars in place in the up position on his bed.

Review of Resident #47's record revealed no documentation of a quarterly assessment for bed rails, no assessment for the risk of entrapment prior to installation of bed rails, the consent did not include risk and benefits, no routine inspection of the bed rails, the resident assessment did not contain the components as addressed on the facility's bed rail policy, and there was no documented evidence of the medical need for

the use of bed rails.

On 05/29/2025 at 2:00 p.m. interview with S4 Maintenance Director, S2 DON, S1 Administrator and S3 LPN/MDS confirmed no quarterly assessment for bed rails, no assessment for the risk of entrapment prior to installation of bed rails, the consent did not include risk and benefits, no routine inspection of the bed rails,

the resident assessment did not contain the components as addressed on the facility's bed rail policy, and there was no documented evidence of the medical need for the use of bed rails.

40015

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 10 195579 Department of Health & Human Services Printed: 08/26/2025 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 195579 B. Wing 05/29/2025

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

Presbyterian Village of Homer 3700 Hwy. 79 South Homer, LA 71040

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 0727 Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on

a full time basis. Level of Harm - Minimal harm or potential for actual harm 36664

Residents Affected - Many Based on record reviews and interview, the facility failed to ensure an RN (Registered Nurse) was on duty for 8 consecutive hours per day, 7 days a week, for 4 days within FY (Fiscal Year) Quarter 1 2025 (October 1- December 31).

Findings:

Review of the facility's PBJ (Payroll Based Journal) Staffing Data Report for FY Quarter 1 2025 (October 1- December 31) revealed there were no RN hours for four or more days within the quarter. Further review revealed no RN hours for the dates of 10/27/2024, 11/30/2024, 12/01/2024, and 12/28/2024.

During an interview on 05/28/2025 at 1:00 p.m. S1 Administrator reported he was responsible for completing

the PBJ staffing report. S1 Administrator reviewed the PBJ for FY Quarter 1 2025 (October 1-December 31) and reported during that time period the facility only had one full time RN and 4 part time RNs. S1 Administrator confirmed there was not RN coverage for at least 8 consecutive hours a day for 10/27/2024, 11/30/2024, 12/01/2024, and 12/28/2024 and there should have been.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 10 195579 Department of Health & Human Services Printed: 08/26/2025 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 195579 B. Wing 05/29/2025

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

Presbyterian Village of Homer 3700 Hwy. 79 South Homer, LA 71040

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 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 18118

Residents Affected - Few Based on record review and interview, the facility failed to ensure the physician documented a rationale for denying a gradual dose reduction for 1 (#36) of 5 (#17, #24, #35, #36 and #47) Residents reviewed for unnecessary medications.

Findings:

Review of the medical record revealed Resident #36 was admitted to the facility on [DATE REDACTED]. Resident #36 had diagnoses including restlessness and agitation, pseudobulbar affect, depression, muscle wasting, Alzheimer's disease, dementia, and bipolar disorder.

Review of Resident #36's May 2025 physician orders revealed an order dated 02/26/2025 for Abilify 5 mg (milligrams) every morning and evening.

Review of the consultant Pharmacist report revealed a dose reduction letter dated 03/18/2025 recommended

a gradual dose reduction for Abilify 5 mg bid (two times a day) for Resident #36. Further review of the report revealed the physician chose not to attempt a gradual dose reduction, and failed to give a written clinical rationale.

On 05/28/2025 at 3:50 p.m. interview with S2 DON (Director of Nursing) confirmed the letter from the pharmacist to the physician, requesting a gradual dose reduction, regarding Abilify 5 mg did not have a handwritten rationale for the reason the physician did not want to decrease the medication.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 10 195579 Department of Health & Human Services Printed: 08/26/2025 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 195579 B. Wing 05/29/2025

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

Presbyterian Village of Homer 3700 Hwy. 79 South Homer, LA 71040

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 0908 Keep all essential equipment working safely.

Level of Harm - Minimal harm or 43405 potential for actual harm Based on observation and interview, the facility failed to maintain all mechanical, electrical, and patient care Residents Affected - Few equipment in safe operating condition in the kitchen as evidenced by the deep fryer's internal compartment having a heavy grease buildup.

Findings:

Initial observation of the kitchen on 05/27/2025 at 8:50 a.m. revealed the deep fryer internal compartment had a heavy grease buildup and needed to be cleaned.

On 05/27/2025 at 2:27 p.m. S5 DM (Dietary Manager) confirmed the deep fryer's internal compartment had a grease buildup and needed to be cleaned.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 10 195579