River Oaks Retirement Manor

F-F700

Review of the facility's policy titled, Administration, with a last revised date of 08/07/2024, read in part: Policy Interpretation and Implementation .1. a. managing the day - to - day functions of the facility .i. ensuring manufacturing recommendations are being followed by staff.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 11 195502 Department of Health & Human Services Printed: 09/13/2025 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 195502 B. Wing 08/08/2024

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

River Oaks Retirement Manor 2500 E. Simcoe Street Lafayette, LA 70501

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 On 08/06/2024 at 2:01 p.m. a joint interview was conducted with S1DON and S2ADM. S1DON stated that

after Resident #1 became entrapped between the boarded bed rail and air mattress, Resident #1's bed was Level of Harm - Immediate replaced with a new bed without boarded bed rails upon his return from the hospital on 07/30/2024. She and jeopardy to resident health or the MDS (Minimum Data Set) nurses assessed the residents who had air mattresses for safety. S1DON also safety stated there was a risk for any resident with bed rails to become entrapped between the bed rails and the mattress. The facility's administration felt the benefits of the boarded bed rails outweighed the risks of having Residents Affected - Some them removed. She stated the facility's administration still felt the boarded bed rails were safe even if a resident was able to roll and become entrapped between the air mattress and boarded rail. She stated that maintenance installed the bed rails and attached the wooden boards to the rails for the residents with air mattresses as ordered. S1DON was asked if the facility utilized the manufacturer's guidelines to ensure the air mattresses were appropriate mattresses for the bed frames and bed rails. She replied that she would have to find those guidelines. S1DON then stated the air mattresses with bed rails with wooden boards attached had been in place when she began working at the facility over one year ago. S2ADM stated the facility was in the process of replacing the older beds in stages, but because of the cost, Residents #Resident R1-#Resident R4 were not given any of the new beds. S1DON confirmed that these 4 residents remained in the old beds with wooden boarded bed rails attached because those residents were just ordered to be on air mattresses within

the last 1 to 2 months. S2ADM stated that there had not been any more orders for new electric beds as of 08/06/2024. S1DON further stated that CNAs (Certified Nursing Assistants) were in-serviced on not moving a resident if they become entrapped in the side rails of the bed after the incident occurred with Resident #1, however there was no specific training on resident entrapment prior to or after Resident #1's accident. S1DON also stated that the CNAs and nurses ensured that the bed rails were in place and residents were safe during their rounds by direct observation. Their charting only required that they document that the bed rails were in place as ordered. Resident #1's plan of care was then reviewed S1DON. She confirmed that the use of bilateral bed rails was an intervention for the resident, but there were no specific interventions or safety interventions for the use or monitoring of the bed rails prior to his accident.

On 08/06/2024 at 3:04 p.m., a joint interview was conducted with S1DON and S3MDSLPN (Minimum Data Set, Licensed Practical Nurse). S3MDSLPN stated that the MDS nurses were responsible for completing the bed rail assessments and creating and updating care plans for all residents who utilized bed rails. Review of

the assessments for Residents #1, #Resident R1-#Resident R4 was reviewed with S3MDSLPN who confirmed the assessment was not completed appropriately to include assessments of the residents' height and weight and bed dimensions. She confirmed the assessment failed to include other interventions that had been attempted prior to the use of the bed rails. Residents #1, #Resident R1-#Resident R4's care plans failed to reveal any interventions for the safe use of bilateral bed rails with a wooden board attachment including increased monitoring or safety interventions to prevent entrapment. It was confirmed there was evidence of ongoing monitoring for safe use of the boarded side rails for these residents after Resident #1's accident. S3MDSLPN stated had worked at

the facility for several years and the process of using the air mattress and wooden boarded bed rails had always been in place. S1DON asserted that there was no issue with use of the mattresses and boarded bed rails at this time. S1DON was asked again to provide the manufacturer's guidelines for the beds and mattresses, but she could not provide them.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 11 195502 Department of Health & Human Services Printed: 09/13/2025 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 195502 B. Wing 08/08/2024

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

River Oaks Retirement Manor 2500 E. Simcoe Street Lafayette, LA 70501

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 On 08/07/2024 at 8:57 a.m., an interview was conducted with S5MAINTSUP (Maintenance Supervisor). He stated that he had been in maintenance for two years at the facility, and they have always used the boarded Level of Harm - Immediate bed rails for beds with air mattresses. He stated that due to the height of the mattress, the boarded side rails jeopardy to resident health or were needed as a fail-safe, to keep residents from falling out of bed. He stated maintenance attached the safety boards to the bed rails of the beds. He did not refer to any manufacturer's guidelines or recommendations for

the mattresses or beds to ensure they were compatible, safe, and approved by the manufacturer. He stated Residents Affected - Some he simply did what the facility had always done which was attach wooden boards to the outside of the side rails for those residents who required air mattresses. He received the orders for the air mattresses from the administrative nurses, and placed the mattresses on the beds and was not sure if they had referred to any manufacturer instructions. S5MAINTSUP further stated that maintenance routinely inspected the side rails to ensure they were functioning properly, but he did not have any documented evidence of the inspection.

On 08/07/2024 at 7:00 p.m., an interview was conducted with administrative staff. S1DON, S2ADM, S3MDSLPN, S7ADON (Assistant Director of Nursing), S8SSD (Social Services Director), S9CNASUP (Certified Nursing Assistant Supervisor), S10MR (Medical Records), and S11IP (Infection Preventionist) were all present for the interview. S1DON stated MDS nurses were responsible for creating and updating resident care plans. S3MDSLPN denied there was anything in care plan that addressed monitoring the residents with boarded bed rails more frequently, nor any specific safety interventions related to the boarded rails in Residents #Resident R1- #Resident R4's care plan. S2ADM stated that the intervention to attach the wooden boards to

the side rails of the beds for residents who required air mattresses was already in place when he became the administrator. He was not aware of the manufacturer's guidelines for the air mattress, the bed frame, or the manufacturer's safety recommendations for entrapment prevention when side rails were in use. He also stated that did question the wooden boards when he became administrator, but just went with it because there were no resident complaints or issues. He never checked the manufacturer's guidelines to ensure that

the wooden boards were an appropriate attachment for the side rails. S2ADM confirmed the wooden boards were not an appropriate intervention to apply to the side rails. S2ADM confirmed S6REP (Medline Representative) reported that mattress stabilizers were on the corners of Resident #Resident R1-#Resident R4's bed that prevented the air mattress from lying flush on the bed frame causing the mattress to be unstable. S2DM confirmed these stabilizers were removed on 08/07/2024. It was unknown if Resident #1's bed had these stabilizers attached at the time of the accident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 11 195502