Savoy Care Center

F-F610.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 33 195619 Department of Health & Human Services Printed: 08/31/2025 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 195619 B. Wing 03/28/2025

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

Savoy Care Center 906 Cherry Street Mamou, LA 70554

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 a facility policy on 03/26/2025 at 12:39 p.m., titled Abuse Prevention, with revision date of 03/21/2012, read in part . Each resident shall remain free from harm. Level of Harm - Immediate jeopardy to resident health or Abuse - the ill treatment or disregard of an individual, whether purposeful, or due to carelessness, safety inattentiveness or omission of the perpetrator

Residents Affected - Some Emotional Abuse - any threatening behavior or statement directed to a person including, but not limited to ridicule, gestures that subject the person to humiliation or degradation, threatening motions or noises Note: The nursing home is intended to startle or frighten the person. disputing this citation. Physical Injury - an act that physically hurts or damages an individual's body where damage is inflicted by external force.

Neglect - failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. An intentional act of omission by an employee which denies the standard of care and treatment due to an individual as required by law, rules, regulations, policies, procedures, guidelines or care plans.

Physical Abuse - any physical motion of action, e.g. hitting, spitting, slapping, punching, kicking, pinching, directed toward the individual .

Threat- any condition or situation that could cause or result in severe, temporary or permanent injury or harm to the mental or physical condition of individuals or their death.

Verbal Abuse - use of oral, written, or gestured language by which abuse occurs. Includes: Name calling, swearing., taunting, and using derogatory terms to describe persons with disabilities.

Psychological Abuse - includes: humiliation, harassment, threats of punishment or deprivation, sexual coercion, and intimidation.

If alleged abuse occurs staff will: Take immediate action to protect the individual(s) involved including removal of the alleged abuser. Ensure that any health or psychological needs of the resident are provided for. Notify the DON immediately.

Review of a facility policy on 03/25/2025 at 4:16 p.m., titled Abuse and Neglect-Clinical Protocol, with revision date of 01/01/2025, read in part . Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, neglect, misappropriation of property or financial abuse, involuntary seclusion, and mental abuse including abuse facilitated or enabled through the use of technology. Neglect, means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 33 195619 Department of Health & Human Services Printed: 08/31/2025 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 195619 B. Wing 03/28/2025

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

Savoy Care Center 906 Cherry Street Mamou, LA 70554

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 a facility policy on 03/26/2025 at 1:30 p.m. titled Resident Rights with revision date of 12/2021, read in part . Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws Level of Harm - Immediate guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a jeopardy to resident health or dignified existence; be treated with respect, kindness, and dignity; and to be free from abuse and neglect. safety

Interview on 03/24/2025 at 1:04 p.m. with S1 Administrator confirmed the facility had no reportable incidents, Residents Affected - Some and no submission to the State Agency since last survey on 06/12/2024.

Note: The nursing home is Interview on 03/25/2025 at 2:36 p.m. with S1 Administrator and S2 DON confirmed the facility had not disputing this citation. investigated staff to resident verbal and emotional abuse that occurred for Resident #15 by S4 CNA on 02/16/2025, because they did not consider the incident as an abuse allegation, and so they did not investigate it as such. S2 DON confirmed the facility had not performed monitoring of S4 CNA, and had not interviewed any other resident following Resident #15's allegations of verbal abuse by S4 CNA.

Interview on 03/25/2025 at 2:36 p.m. with S1 Administrator and S2 DON, confirmed last month (02/2025), Resident #25 pulled Resident #6's hair. S2 DON stated she did not see this incident as resident to resident abuse, and confirmed the facility had not reported the resident to resident abuse to the State Agency.

Interview on 03/25/2025 at 2:57 p.m. with S3 ADON, revealed Resident #68's transfer status is 2-person lift according to his care plan. S3 ADON revealed that all staff should access a resident's transfer status prior to transfer by looking at the residents' POC in the kiosk on the hall. S3 ADON confirmed mechanical lift was documented in Resident #68's POC for transfer status.

Interview on 03/26/2025 at 5:10 p.m. with S2 DON, revealed that when a resident's POC was entered into

the electronic system, it then fired to the kiosk located on the halls for the CNAs to view. S2 DON stated that staff were to look at the kiosk prior to caring for residents to determine their transfer status. S2 DON confirmed that Resident #68 was care planned as a 2-person lift, and should not have been transferred without another staff member present and without the use of a lift.

Interview on 03/27/2025 at 11:00 a.m. with S2 DON revealed she was aware of an incident between Resident #25 and Resident #51 that occurred sometime last month. S2 DON stated she was told by staff that Resident #25 and Resident #51 was arguing over a cookie, but was not informed of Resident #25 hitting Resident #51. S2 DON confirmed she did not further investigate the documented resident to resident abuse

on 02/21/2025 when Resident #25 hit Resident #51 in the face with a box of cookies, but should have. S2 DON revealed the incident was not reported to the State Agency because she was not aware of the resident to resident altercation between Resident #25 and Resident #51 on 02/21/2025.

The Immediate Jeopardy was removed on 03/28/2025 at 6:04 p.m. after it was verified through observation,

interview and record review that the facility submitted and implemented a Plan of Removal that included the following:

The facility identified 4 instances of abuse/neglect in the facility:

1. Staff to Resident verbal and emotional abuse on 02/16/2025, when S4 CNA verbally and emotionally abused Resident #15;

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 33 195619 Department of Health & Human Services Printed: 08/31/2025 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 195619 B. Wing 03/28/2025

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

Savoy Care Center 906 Cherry Street Mamou, LA 70554

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 2. Resident to Resident abuse on 02/21/2025, when Resident #25 physically abused Resident #51;

Level of Harm - Immediate 3. Resident to Resident abuse on 03/08/2025, when Resident #25 physically abused Resident #6; and jeopardy to resident health or safety 4. Neglect, when S6 CNA neglected Resident #68.

Residents Affected - Some These instances have the ability to affect all residents that reside in the facility.

Note: The nursing home is The facility implemented the following actions to remove the immediacy: disputing this citation.

On 03/27/2025 in-service was completed with all current staff on shift for abuse and neglect policy and procedure, lifting protocol, and what constitutes abuse and neglect.

On 03/27/2025 S4 CNA was placed on administrative leave pending thorough investigation.

On 03/27/2025 S6 CNA was in services on proper lifting techniques with proper return demonstration completed.

On 03/27/2025 S2 DON completed a monitoring tool to ensure all allegations for abuse and neglect were properly and thoroughly investigated. The daily monitoring tool was to include any allegation of abuse and neglect was reported to S2 DON and S1 Administrator, and SIMS reporting was completed. Monitoring to be completed daily for 30days, then 3 times weekly for 2 weeks to ensure compliance is sustained.

On 03/27/2025 Administrative oversight was provided to S1 Administrator and S2 DON by the regional administrator. The regional administrator shall thoroughly investigate all allegations of abuse and neglect to prevent the likelihood of further incidents of abuse. Regional administrator will monitor S1 Administrator weekly by direct observation and onsite oversight weekly for 30 days.

On 03/28/2025 at 2:00 p.m. there was a mandatory all staff meeting to discuss Abuse and Neglect Policy and procedure, reportable incidents, lifting protocols, and use of lifters. In-service also included monitoring for and reporting resident to resident abuse, staff to resident abuse, and neglect. The facility shall thoroughly investigate any and all allegations of abuse and neglect to prevent the likelihood of further incidents of abuse. Any staff member not in serviced will be in serviced prior to the beginning of their shift.

On 03/28/2025 a monitoring tool was initiated for nurse's notes to be reviewed daily for any alleged cases of abuse and neglect to be investigated as necessary. All alleged cases will be brought to S2 DON and S1 Administrator's attention and investigation and reporting are to be done immediately.

On 03/28/2025 the above allegations and monitoring was added to the facility's QAPI, and shall be discussed monthly for the next 3 months.

Facility completion date 03/28/2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 33 195619