Colonial Nursing Home

F 0609 Interview on 05/29/2025 1:25 p.m. with S1 Administrator revealed she was responsible for SIMS reporting for

the facility. S1 Administrator revealed the alleged staff to resident physical abuse occurred on 03/21/2025 at Level of Harm - Minimal harm or approximately 5:50 a.m., and she was made aware of the allegation on 03/21/2025 at 8:30 a.m. S1 potential for actual harm Administrator revealed she entered the incident into SIMS on 03/21/2025 at 1:29 p.m. S1 Administrator confirmed that the incident of alleged staff to resident abuse was not entered into the SIMS within the Residents Affected - Few required timeframe, but should have been.

51082

Resident #156

Review of Resident #156's medical record revealed an admitted [DATE REDACTED], with diagnoses that included, in part .Cerebral Infarction due to Thrombosis of Right Posterior Cerebral Artery, Cocaine Abuse with Cocaine-Induced Mood Disorder/Sleep Disorder, and Anxiety Disorder.

Review of Resident #156's Admission MDS with an ARD of 05/02/2025, revealed a BIMS score of 04, which indicated severe cognitive impairment. The MDS revealed Resident #156 was independent for transfers and used a walker for mobility.

Review of Resident #156's Care plan with a target completion date of 08/11/2025, read in part .Elopement risk related to reported history of Altered Mental Status, Cocaine use with wandering attempts to leave hospital noted. 05/15/2025-Elopement attempt noted: willfully attempted to leave facility without notifying staff, wanted to be discharged back home. Interventions included in part; Elopement precautions: Census checks every 1 hour, each shift related to history of Delirium and wandering (initiated on 05/02/2025). Supervision increased to 1:1 for safety. Vistaril injection IM (intramuscular)1 time as ordered per S14 NP for anxiety. (initiated on 05/15/2025).

Review of Resident #156's facility progress notes dated 05/16/2025 at 1:00 p.m., written by S2 DON read in part: Resident #156 left facility (exited X-hall bathroom window) after eating breakfast this morning. He was located & transported back to the facility in stable condition. Upon questioning, resident was noted alert & oriented x 4 with appropriate verbal responses. Resident #156 stated that he left facility to try to find a ride back to his home in New [NAME].

Review of a SIMS report completed by the facility revealed on 05/16/2025 at approximately 8:15 a.m. Resident #156 eloped from the facility. The facility was made aware of the elopement on 05/16/2025 at 8:30 a.m. The facility entered the allegation into SIMS reporting system on 05/16/2025 at 6:18 p.m.

Interview with S1 Administrator on 05/29/2025 at 8:56 a.m., revealed on 05/16/2025 at approximately 8:15 a. m. Resident #156 eloped from the facility. S1 Administrator revealed she was made aware of the elopement

on 05/16/2025 at approximately 8:30 a.m. S1 Administrator confirmed she did not report Resident #156's elopement out of the facility within the 2 hour required timeframe, but should have.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 14 195445 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 195445 B. Wing 05/29/2025

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

Colonial Nursing and Rehabilitation Center 426 North Washington Street Marksville, LA 71351

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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47004 potential for actual harm Based on observation, interview, and record review, the facility failed to provide the necessary care and Residents Affected - Few services to provide a necessary communication aid for 1 (#35) of 1 Resident reviewed for communication.

The total sample size was 30. Findings:

Review of Resident #35's Electronic Health Record revealed the Resident was admitted to the facility on [DATE REDACTED] with diagnoses that included in part . Type 2 Diabetes Mellitus, Major Depressive Disorder, Unspecified Dementia, and Generalized Anxiety Disorder.

Review of Resident #35's Quarterly MDS with an ARD date of 05/21/2025 revealed Resident #35 had BIMS of 8 (Moderate Cognitive Impairment). Resident #35's ability to understand others was documented as- sometimes.

Review of Resident #35's Comprehensive Person Centered Care Plan revealed resident had difficulty communicating related to language barrier. Interventions included: Provide a communication board.

Interview and observation on 05/27/2025 at 12:14 p.m. with Resident #35 revealed he had difficulty understanding English, and did not speak English. Resident #35 shook his head no, when asked if he could understand English. Observation of Resident #35's room at that time revealed there was no communication aid/board to assist in communication with resident.

Interview on 05/28/2025 at 8:40 a.m. with S7 CNA revealed she was assigned care of Resident #35. S7 CNA stated Resident #35 did not speak English and understood very little English. S7 CNA stated she determined Resident #35's needs by pointing and guessing at things until resident would shake his head yes or no. S7 CNA stated she never used a communication aid or picture board with Resident #35 because he did not have one.

Observation on 05/28/2025 at 8:50 a.m. of Resident #35's room revealed there was no communication aid to assist in communication with resident.

Interview on 05/28/2025 at 8:54 a.m. with S4 LPN revealed Resident #35 had difficulty with communication as he could not speak English. S4 LPN stated she communicated with Resident #35 by using gestures. S4 LPN confirmed Resident #35 did not have a communication board, or any type of communication aid in his room to assist with communication. S4 LPN revealed Resident #35 would benefit from a communication board to assist in communication.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 14 195445 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 195445 B. Wing 05/29/2025

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

Colonial Nursing and Rehabilitation Center 426 North Washington Street Marksville, LA 71351

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 0692 Review of Resident #8's Dietary Admission Assessments revealed in part .

Level of Harm - Minimal harm or 04/21/2025-weight in pounds: 181, current diet: Diabetisource 1.50 at 50 cc/hr (mils per hour). Risk for potential for actual harm malnutrition due to need for feeding tube, Recommended continue with same plan of care. Electronically signed by S8 Dietary Manager. Residents Affected - Some 04/30/2025-weight in pounds: 175, current diet: Diabetisource 1.50 at 50 cc/hr (mils per hour). Risk for malnutrition due to need for feeding tube, Recommended continue with same plan of care. Electronically signed by S8 Dietary Manager.

05/19/2025-weight in pounds: 162, current diet: Diabetisource 1.50 at 50 cc/hr (mils per hour). Risk for malnutrition due to need for feeding tube, Recommended continue with same plan of care. Electronically signed by S8 Dietary Manager.

Review of Resident #8's weight change evaluation form completed by S2 DON revealed in part .Resident #8 had a weight loss of 19 pounds in 1 month. Notes: total 19 pound weight loss in past month noted on return from hospital on 04/30/2025 status post recent history of aspiration pneumonia with NPO status and new peg tube placement noted. Plan: continue tube feeding, refer to RD for evaluation. Other: referral to RD for review, care plan updated.

On 05/29/2025 after further review of Resident #8's medical record there was no evidence of documentation of the RD's evaluation or referral sent for Resident #8's significant weight loss.

Telephone interview on 05/29/2025 at 12:46 p.m., with S10 Registered Dietician (RD) revealed she came to

the facility on ce or twice a month to assess residents. S10 RD revealed that the facility would email her names of residents needing to be seen by her during her visit. S10 RD stated she reviewed residents' weights on a monthly basis. S10 RD stated Resident #8's significant weight loss was due to his multiple hospitalization s. S10 RD confirmed that she did not receive any evaluation request or referrals regarding Resident #8's significant weight loss from the facility upon his return from the hospital.

Interview on 05/29/2025 at 2:03 p.m. with S2 DON revealed she was responsible for notifying S2 RD of changes in resident's weights via a referral or request for an evaluation. S2 DON stated she sent out a referral and requested an evaluation from S10 RD concerning Resident #8's significant weight loss. S2 DON could not provide documentation of an evaluation or referral sent to S10 RD concerning Resident #8's significant weight loss.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 14 195445 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 195445 B. Wing 05/29/2025

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

Colonial Nursing and Rehabilitation Center 426 North Washington Street Marksville, LA 71351

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 0812 (1) bag of liquid eggs located in cooler #1 was not labeled with an open date or stored in a sealed container and should have been. Level of Harm - Minimal harm or potential for actual harm 3. Interview with S8 Dietary Manager on 05/29/2025 at 09:07 a.m. revealed the facility did not have separate snack refrigerators. S8 Dietary Manager revealed snacks are stored and served from hydration carts at Residents Affected - Some 09:30 a.m., 02:30 p.m., and 07:00 p.m. daily.

S8 Dietary Manager revealed the hydration cart prepared at 07:00 p.m. daily included all snacks that were readily available to the residents till 5:00 a.m. the next day. S8 Dietary Manager revealed content of the 07:00 p.m. hydration cart consisted of juice, water, graham crackers, peanut butter crackers, and premade sandwiches that were stored in an ice cooler. S8 Dietary Manager revealed types of sandwiches stored in ice cooler on 07:00 p.m. hydration cart included peanut butter and jelly, turkey, bologna, and pimento cheese sandwiches. S8 Dietary Manager stated (2) two gallon zip lock bags were filled with ice and placed in ice cooler to keep sandwiches cool until sandwiches were discarded at 05:00 a.m. the next day.

On 05/29/2025 at 09:18 a.m. observation of snack ice cooler revealed a 25 quart portable ice cooler that was not temperature regulated.

On 05/29/2025 at 10:52 a.m. interview with S8 Dietary Manager revealed temperatures were not being monitored for ice cooler that stored sandwiches between 07:00 p.m. and 5:00 a.m. daily. S8 Dietary Manager confirmed turkey and pimiento cheese sandwiches were considered potentially hazardous food and should be stored in a monitored temperature regulated refrigerator and they were not.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 14 195445 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 195445 B. Wing 05/29/2025

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

Colonial Nursing and Rehabilitation Center 426 North Washington Street Marksville, LA 71351

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 0880 On 05/28/2025 at 09:55 a.m. observation of Resident #11's wound care performed by S9 Treatment Nurse revealed Resident #11's left great toe wound was cleansed with the contaminated 4x4 normal saline soaked Level of Harm - Minimal harm or gauze. potential for actual harm

On 05/28/2025 at 10:07 a.m. interview with S9 Treatment Nurse confirmed she contaminated Resident #11's Residents Affected - Some 4x4 gauze during wound care preparation when she placed it directly on the computer keyboard. S9 Treatment Nurse confirmed she then used the contaminated wound care supplies to complete Resident #11's wound care to his left great toe. S9 Treatment Nurse confirmed she should have placed the 4x4 gauze

on a clean barrier during wound care preparation to prevent contamination, but did not. S9 Treatment Nurse confirmed she should have discarded the contaminated 4x4 gauze before providing wound care to Resident #11, but did not.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 14 195445 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 195445 B. Wing 05/29/2025

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

Colonial Nursing and Rehabilitation Center 426 North Washington Street Marksville, LA 71351

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 0925 On 05/29/2025 at 09:08 a.m. observation of the facility kitchen revealed one live fly flying throughout the kitchen area. Level of Harm - Minimal harm or potential for actual harm On 05/29/2025 at 10:52 a.m. interview with S8 Dietary Manager revealed the facility recently began having issues with live flies. S8 Dietary Manager confirmed she has observed live flies in kitchen area and the Residents Affected - Some kitchen should always be free of flies or any other insects/pest, but was not.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 14 195445