Broadway Nursing And Rehabilitation Ctr (the)

F-F839

Review of the facility's undated Professional Licensure Verification Policy revealed, in part, all employees with a professional license would be verified upon hire and as required through the appropriate licensure board.

Review of the facility's undated Administrator Job's Description revealed, in part, the Administrator reported to the Regional Director and was responsible for adopting and enforcing rules and for the healthcare and safety of patients and others.

Review of the facility's undated Director of Nursing's Job Description revealed, in part, the DON reported to

the Administrator. Further review revealed the DON's responsibility was to assist with interviewing, evaluating and selecting new personnel.

Review of the facility's undated Human Resources/Payroll Manager Job Description revealed, in part, the Human Resources/Payroll Manager reported to the Administrator and was responsible for maintenance of all personnel files in compliance with local and federal laws.

Review of S5Unlicensed Personnel's Employee Status Change signed by S7Team Member Specialist (TMS)

on 11/20/2024 revealed, in part, S5UnlicensedPersonnel had a title change from Certified Nurse Aide (CNA) to LPN.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 21 195583 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 195583 B. Wing 02/17/2025

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

The Broadway Nursing and Rehabilitation Ctr 7534 Highway 1 Lockport, LA 70374

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 S5Unlicensed Personnel's personnel file revealed, in part, S5Unlicensed Personnel signed the Licensed Staff (Registered Nurse/Licensed Practical Nurse) Job Description on 11/22/2024. Level of Harm - Immediate jeopardy to resident health or Review of an email communication received by S7TMS dated 01/29/2025 at 12:15PM from the Louisiana safety State Board of Practical Nurse Examiners revealed, in part, S5Unlicensed Personnel did not have an active Practical Nurse License in the state of Louisiana. Residents Affected - Many

In an interview on 02/10/2025 at 12:30PM, S7TMS indicated she was responsible for verifying licensure for newly hired staff at the time of hire, and when there was a position change. S7Team Member Specialist/Human Resources further indicated on 11/20/2024 she officially changed S5Unlicensed Personnel's status from a CNA to a LPN. S7TMS further indicated on 01/24/2025 she emailed the Louisiana State Board of Practical Nurse Examiners inquiring about S5Unlicensed Personnel's LPN status and received an answer that S5Unlicensed Personnel did not pass the National Council Licensure Examination for Practical Nurses (NCLEX-PN) with the Louisiana State Board of Practical Nurse Examiners.

In an interview on 02/10/2025 at 2:41PM, S2DON indicated S5Unlicensed Personnel started training as a LPN on 11/20/2024. S2DON further indicated a nurse in training would observe and provide nursing care under supervision of another licensed nurse. S2DON further indicated she should have called the Louisiana State Board of Practical Nurse Examiners to verify S5Unlicensed Personnel had a Louisiana nursing license

before allowing S5Unlicensed Personnel to provide care and services to residents in the capacity of a LPN.

In an interview on 02/12/2025 at 3:15PM S1Administrator indicated he directed S7TMS to change S5Unlicensed Personnel's status from CNA to LPN. S1Administrator further indicated he directed S2DON to allow S5Unlicensed Personnel to perform duties as a LPN. S1Administrator further indicated he should have verified S5Unlicensed Personnel had a valid Louisiana Practical Nurse license before allowing her to perform care and services as a Louisiana Practical Nurse.

In an interview on 02/17/2025 at 10:15AM S1Administrator indicated there was a likelihood of serious injury, serious harm, serious impairment or death due to having unlicensed personnel providing nursing services.

In an interview on 02/17/2025 at 11:15AM S6Chief Operations Officer (COO) indicated there was a likelihood of serious injury, serious harm, serious impairment or death due to having unlicensed personnel providing nursing services. He further indicated he would be providing administrative on site supervision and remote oversite for 3 months as part of the correction plan.

The facility implemented the following actions to correct the deficient practice beginning on 01/24/2025 with a completion date of 01/31/2025:

1. S5Unlicensed Personnel was suspended on 01/24/2025, and terminated on 01/29/2025.

2. All 87 residents identified on the electronic medical record system audit trail report had the potential to be affected by the deficient practice.

3. To ensure the deficient practice would not reoccur the following measures had been implemented.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 21 195583 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 195583 B. Wing 02/17/2025

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

The Broadway Nursing and Rehabilitation Ctr 7534 Highway 1 Lockport, LA 70374

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 a. S1Administrator, S2DON, and S7TMS were in-serviced on licensure verification and reporting wrong doing. S1Administrator was in-serviced on 01/24/2025, S2DON was in-serviced on 01/29/2025 and S7TMS Level of Harm - Immediate was in-serviced on 01/30/2025. jeopardy to resident health or safety b. Cognitive resident interviews were completed by S51Regional RN regarding any medication administration concerns or other nursing concerns on 01/30/2025. Residents Affected - Many c. Full facility wide audit started on 01/24/2025 on all nurses to ensure active license in place.

d. In-service on reporting wrongdoing was completed by S1Administrator, S2DON, S7TMS, and staff by 01/31/2025.

e. Audits were completed on 01/31/2025 of resident's electronic medical records documentation who received care from S5Unlicensed Personnel while S5Unlicensed Personnel worked in the capacity as a LPN to ensure no harm occurred.

4. The facility would monitor its performance to ensure solutions were sustained by completing the following:

a. S7TMS to verify licensure prior to nurse hired or role change if currently working. S2DON would be provided with a copy for double verification at the facility level.

b. S4Corporate Compliance Officer to audit weekly for compliance for three months and

annually.

5. Plan of Correction to be completed by 01/31/2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 21 195583 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 195583 B. Wing 02/17/2025

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

The Broadway Nursing and Rehabilitation Ctr 7534 Highway 1 Lockport, LA 70374

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 0839 Employ staff that are licensed, certified, or registered in accordance with state laws.

Level of Harm - Immediate 41461 jeopardy to resident health or safety Based on interviews, and record reviews the facility failed to ensure personnel had the appropriate state licensure to provide care and services to residents. This deficient practice was identified for 1 (S5Unlicensed Residents Affected - Many Personnel) of 50 (S1Administrator, S2Director of Nursing [DON], S3Assistant Director of Nursing [ADON], S5Unlicensed Personnel, S14Agency Licensed Practical Nurse [LPN], S16LPN, S17LPN, S18Registered Nurse [RN], S19LPN, S20RN, S21Physician, S22Physician, S23Podiatrist, S24RN, S25RN, S26RN, S27RN, S28Treatment RN, S29LPN, S30LPN, S31LPN, S32LPN, S33LPN, S34LPN, S35LPN, S36Minimum Data Set [MDS]Coordinator/LPN, S37LPN, S38LPN, S39LPN, S40LPN, S41LPN, S42LPN, S43LPN, S44LPN, S45LPN, S46LPN, S47LPN, S48LPN, S49LPN, S50LPN, S51LPN, S52Quality Assurance [QA] LPN, S53Physician Assistant, S55Agency LPN, S56Agency LPN, S57LPN, S58LPN, S59LPN, S60Agency LPN, S61Agency LPN) personnel files reviewed for active and current licensure.

The deficient practice resulted in an immediate jeopardy situation on 11/20/2024 when S5Unlicensed Personnel worked in the capacity of a LPN and performed nursing tasks without a Louisiana nursing license.

This deficient practice affected 87 residents who were identified by the facility as having received care and services from S5Unlicensed Personnel until S5Unlicensed Personnel was suspended on 01/24/2025 and terminated on 01/29/2025.

The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a past noncompliance citation.

Findings:

Review of the facility's undated Professional Licensure Verification Policy revealed, in part, all employees with a professional license would be verified upon hire and as required through the appropriate licensure board.

Review of the facility's undated Administrator Job's Description revealed, in part, the Administrator reported to the Regional Director and was responsible for adopting and enforcing rules and for the healthcare and safety of patients and others.

Review of the facility's undated Director of Nursing's Job Description revealed, in part, the DON reported to

the Administrator. Further review revealed the DON's responsibility was to assist with interviewing, evaluating and selecting new personnel.

Review of the facility's undated Human Resources/Payroll Manager Job Description revealed, in part, the Human Resources/Payroll Manager reported to the Administrator and was responsible for maintenance of all personnel files in compliance with local and federal laws.

Review of S5Unlicensed Personnel's Employee Status Change signed by S7Team Member Specialist (TMS)

on 11/20/2024 revealed, in part, S5UnlicensedPersonnel had a title change from Certified Nurse Aide (CNA) to LPN.

Review of S5Unlicensed Personnel's personnel file revealed, in part, S5Unlicensed Personnel signed the Licensed Staff (Registered Nurse/Licensed Practical Nurse) Job Description on 11/22/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 21 195583 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 195583 B. Wing 02/17/2025

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

The Broadway Nursing and Rehabilitation Ctr 7534 Highway 1 Lockport, LA 70374

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 0839 Review of facility documentation revealed, in part, the facility identified 87 residents had received care and services from S5Unliensed Personnel working in the capacity of an LPN from 11/20/2024 until 01/24/2025. Level of Harm - Immediate jeopardy to resident health or Review of an email communication received by S7TMS dated 01/29/2025 at 12:15PM from the Louisiana safety State Board of Practical Nurse Examiners revealed, in part, S5Unlicensed Personnel did not have an active Practical Nurse License in the state of Louisiana. Residents Affected - Many

In an interview on 02/10/2025 at 12:30PM, S7TMS indicated she was responsible for verifying licensure for newly hired staff at the time of hire, and when there was a position change. S7Team Member Specialist/Human Resources further indicated on 11/20/2024 she officially changed S5Unlicensed Personnel's status from a CNA to a LPN. S7TMS further indicated on 01/24/2025 she emailed the Louisiana State Board of Practical Nurse Examiners inquiring about S5Unlicensed Personnel's LPN status and received an answer that S5Unlicensed Personnel did not pass the National Council Licensure Examination for Practical Nurses (NCLEX-PN) with the Louisiana State Board of Practical Nurse Examiners.

In an interview on 02/10/2025 at 2:41PM, S2DON indicated S5Unlicensed Personnel started training as a LPN on 11/20/2024. S2DON further indicated a nurse in training would observe and provide nursing care under supervision of another licensed nurse. S2DON further indicated she should have called the Louisiana State Board of Practical Nurse Examiners to verify S5Unlicensed Personnel had a Louisiana nursing license

before allowing S5Unlicensed Personnel to provide care and services to residents in the capacity of a LPN.

In an interview on 02/12/2025 at 3:15PM S1Administrator indicated he directed S7TMS to change S5Unlicensed Personnel's status from CNA to LPN. S1Administrator further indicated he directed S2DON to allow S5Unlicensed Personnel to perform duties as a LPN. S1Administrator further indicated he should have verified S5Unlicensed Personnel had a valid Louisiana Practical Nurse license before allowing her to perform care and services as a Louisiana Practical Nurse.

In an interview on 02/17/2025 at 10:15AM S1Administrator indicated there was a likelihood of serious injury, serious harm, serious impairment or death due to having unlicensed personnel providing nursing services.

The facility implemented the following actions to correct the deficient practice beginning on 01/24/2025 with a completion date of 01/31/2025:

1. S5Unlicensed Personnel was suspended on 01/24/2025, and terminated on 01/29/2025.

2. All 87 residents identified on the electronic medical record system audit trail report had the potential to be affected by the deficient practice.

3. To ensure the deficient practice would not reoccur the following measures had been implemented.

a. S1Administrator, S2DON, and S7TMS were in-serviced on licensure verification and reporting wrong doing. S1Administrator was in-serviced on 01/24/2025, S2DON was in-serviced on 01/29/2025 and S7TMS was in-serviced on 01/30/2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 21 195583 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 195583 B. Wing 02/17/2025

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

The Broadway Nursing and Rehabilitation Ctr 7534 Highway 1 Lockport, LA 70374

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 0839 b. Cognitive resident interviews were completed by S51Regional RN regarding any medication administration concerns or other nursing concerns on 01/30/2025. Level of Harm - Immediate jeopardy to resident health or c. Full facility wide audit started on 01/24/2025 on all nurses to ensure active license in place. safety d. In-service on reporting wrongdoing was completed by S1Administrator, S2DON, S7TMS, and staff by Residents Affected - Many 01/31/2025.

e. Audits were completed on 01/31/2025 of resident's electronic medical records documentation who received care from S5Unlicensed Personnel while S5Unlicensed Personnel worked in the capacity as a LPN to ensure no harm occurred.

4. The facility would monitor its performance to ensure solutions were sustained by completing the following:

a. S7TMS to verify licensure prior to nurse hired or role change if currently working. S2DON would be provided with a copy for double verification at the facility level.

b. S4Corporate Compliance Officer to audit weekly for compliance for three months and

annually.

5. Plan of Correction to be completed by 01/31/2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 21 195583