F 0644 Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44418

Residents Affected - Few Based on record review and interview, the facility failed to refer a resident with a diagnosed mental disorder to the appropriate state-designated authority for Level II PASARR (Preadmission Screening and Resident Review) evaluation and determination for 1 (#15) of 3 (#15, #32, #49) residents investigated for PASARR in

a final sample of 47 residents.

Findings:

Review of Resident #15's electronic medical record (EMR) revealed she was admitted to the facility on [DATE REDACTED] with diagnoses that included in part, bipolar disorder and major depressive disorder.

Review of Resident #15's Level I PASARR dated 10/07/2022 revealed in part Section III: Mental illness, Question #1 Do you suspect the applicant has, or has the applicant been diagnosed as having a mental illness? Including mental disorders that may lead to chronic disability . schizophrenia, schizoaffective disorder, delusional disorder, other psychotic disorder, bipolar disorder, major depressive disorder .Bipolar disorder was not checked.

Further review of Resident #15's records revealed no evidence that a Level II PASARR had been submitted to the appropriate state-designated authority after Resident #15 had a newly identified mental disorder of bipolar disorder, with an onset date of 10/10/2022.

On 05/20/2025 at 3:10 p.m., an interview and record review was conduct with S5SSD. After review of a psychiatric progress note dated 10/09/2022 for Resident #15, S5SSD confirmed the resident had a qualifying Level II diagnosis of bipolar psychosis. S5SSD confirmed a request for a Level II screening was not submitted for Resident #15. She stated the request for a Level II screening should have been submitted.

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 21 195460 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 195460 B. Wing 05/21/2025

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

Belle Teche Nursing & Rehabilitation Center 1306 W Admiral Doyle Dr New Iberia, LA 70560

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 0656 On 05/20/2025 at 2:26 p.m., a third observation was conducted of Resident #65 in her room. There was a gray drinking cup noted at the bedside with a straw in it. Resident #65 was sitting in her wheelchair and Level of Harm - Minimal harm or contracture to her right wrist was noted. Resident #65 does not have a [NAME] No Spill 360 Grip and Sip cup potential for actual harm at the bedside. An interview was conducted with Resident #65 at this time, and she stated the [NAME] Grip and Sip cup was only given to her during meals and she was told the [NAME] Grip and Sip cup cannot leave Residents Affected - Some the dining room. She stated while she was in her room she had to use the gray drinking cup, and sometimes

it was hard to use.

On 05/21/2025 at 12:26 p.m., a fourth observation was conducted of the resident's room. There was a gray drinking cup noted at the bedside with a straw in it. Resident #65 does not have a [NAME] No Spill 360 Grip and Sip cup at the bedside.

On 05/21/2025 at 12:34 p.m., an interview and observation of Resident #65's room was conducted with S9CN (Certified Nursing Assistant). She stated while the resident was in her room she drank out of the gray drinking cup. She then reviewed a pink sheet above the resident's bed. She stated these listed all of the resident's needs. She stated the pink sheet read the resident is to use [NAME] No Spill 360 Grip and Sip cup at all times while drinking. She confirmed the resident did not have the appropriate drinking cup in her room to drink water out of.

On 05/21/2025 at 12:40 p.m., an interview and observation were conducted with S7LPN (Licensed Practical Nurse). She reviewed Resident #65's physician's orders and confirmed the resident should have a [NAME] No Spill 360 Grip and Sip cup, and she does not. She confirmed the resident only has a gray drinking cup in her room to drink out of.

On 05/21/2025 at 12:42 p.m., an interview and observation were conducted with S4DM (Dietary Manager).

She stated Resident #65 should have a [NAME] No Spill 360 Grip and Sip cup in her room at all times with her to drink out of. She observed her entire room to look for her [NAME] No Spill 360 Grip and Sip cup and stated it was not in the room, and only her gray drinking cup was in her room.

On 05/21/2025 at 12:59 p.m., an interview was conducted with S8OT (Occupational Therapist). She stated that Resident #65 was ordered to have a [NAME] No Spill 360 Grip and Sip cup at all times to drink out of due to the spasticity in the arm from her diagnosis of Cerebral Palsy. She stated the [NAME] No Spill 360 Grip and Sip cup allowed better control of drinking water by controlling the rate of flow and preventing the resident from spilling on herself.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 21 195460 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 195460 B. Wing 05/21/2025

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

Belle Teche Nursing & Rehabilitation Center 1306 W Admiral Doyle Dr New Iberia, LA 70560

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 On 05/22/2025, a review of the facility's policy titled Comprehensive Resident Care Plans with a review date of 01/15/2025, read in part: Purpose: The resident's comprehensive care plan will be developed utilizing the Level of Harm - Minimal harm or results of the comprehensive resident assessment instrument (RAI) plus information gained from resident potential for actual harm and family interviews, care conferencing and health care professional data to determine daily care needs, and to attain, or maintain the resident's highest functional capacity. Residents Affected - Few Resident # 68 was admitted to the facility on [DATE REDACTED] with diagnoses which included, but were not limited to, polymyalgia rheumatica, osteoarthritis, and fibromyalgia, dependent to wheelchair.

A review of Resident #68's quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 05/08/2025 revealed he had a BIMS (Brief Interview for Mental Status) score of 15, suggesting her cognition was intact.

On 05/19/2025 at 11:30 a.m., an interview was conducted with Resident #68. The resident stated she has not been invited to a care plan meeting.

On 05/20/2025 at 1:34 p.m., an interview was conducted with S5SSD (Social Service Director), she confirmed that she was responsible for notifying the RP (Resident Representative) or resident, if they were their own RP, of scheduled care plan meetings. S5SSD stated if the resident was their own RP, then they were given a hand delivered letter inviting them to attend. She confirmed she was unable to provide documentation to confirm that a letter was given to Resident #68 inviting the resident to a care plan meeting.

On 05/20/2025 at 1:55 p.m., an interview was conducted with S6CCC/LPN (Clinical Care Coordinator/Licensed Practical Nurse), she confirmed she was responsible for Resident #68's care plan. S6CCC/LPN confirmed she was unable to provide documentation at this time identifying who attended or the finding of the care plan meeting for Resident #68 that was held on 05/06/2025. She stated there was not a sign-in sheet for staff, residents and RP to sign that they had attended the care plan meeting.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 21 195460 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 195460 B. Wing 05/21/2025

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

Belle Teche Nursing & Rehabilitation Center 1306 W Admiral Doyle Dr New Iberia, LA 70560

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 0677 Review of Resident #86's clinical record revealed she was admitted to the facility on [DATE REDACTED] and had diagnoses with diagnoses that included, but not limited to, of flaccid hemiplegia affecting left non-dominant Level of Harm - Minimal harm or side, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. potential for actual harm

Review of Resident #86's care plan dated 01/17/2024 read in part, resident will receive person centered Residents Affected - Some care; needs assist with hygiene, and grooming.

On 05/19/2025 at 12:11 p.m., an observation of the resident in the dining room revealed her hair was uncombed.

On 05/19/2025 at 2:15 p.m., a follow-up observation of the resident in the dining room revealed her hair remained uncombed.

On 05/20/2025 at 2:39 p.m., an observation of the resident was conducted in her room, which revealed her hair remained uncombed.

On 05/20/2025 at 2:48 p.m., an observation and interview was conducted with S7LPN who was the nurse on

the unit where the resident resided. She confirmed that the staff had not been combing the resident's hair, and they should have.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 21 195460 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 195460 B. Wing 05/21/2025

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

Belle Teche Nursing & Rehabilitation Center 1306 W Admiral Doyle Dr New Iberia, LA 70560

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 0689 On 04/25/2025 at 3:11p.m., the resident had an unwitnessed fall. Action taken was were neuro checks and continue plan of care. Review of Care plan revealed no interventions implemented to address the fall. Level of Harm - Minimal harm or potential for actual harm On 05/07/2025 at 12:45 a.m., the resident had an unwitnessed fall. Review of investigative report revealed

the resident was found sitting on his left side on the floor with his back towards the back door on Hall W and Residents Affected - Some his wheelchair in front of him. Review of Care plan revealed no interventions to address the fall.

On 05/21/2025 at 1:40 p.m., an interview and review of the resident's care plan was conducted with S6CCC/LPN (Clinical Care Coordinator/Licensed practical Nurse) and S19CCC/LPN. S6CCC/LPN was asked about the interventions implemented after the falls. S6CCC/LPN stated that S3ADON (Assistant Director of Nursing) is responsible for conducting the investigations and discussing with the clinical care coordinators through a phone call or morning meeting. S6CCC/LPN and S19CCC/LPN confirmed that for each fall an intervention should have been implemented and was not.

On 05/21/2025 at 3:00 p.m., an interview and review of Resident #56's care plan was conducted with S2DON (Director of Nursing). She presented a handwritten report of interventions implemented after the resident's falls. S2DON explained the following hand written report which included the following, in part:

03/25/2025 - continue plan of care

03/28/2025 - no intervention

04/25/2025 - continue plan of care

05/07/2025 - continue plan of care

S2DON stated CCCs were responsible for updating care plans. S2DON was unable to provide evidence of appropriate interventions placed after the above falls.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 21 195460 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 195460 B. Wing 05/21/2025

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

Belle Teche Nursing & Rehabilitation Center 1306 W Admiral Doyle Dr New Iberia, LA 70560

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 A review of Referral Form for Consultant Dietician for May 2025 revealed that Resident #71's name was not present on the list of residents to be seen by the Dietician. Level of Harm - Minimal harm or potential for actual harm On 05/20/2025 at 2:51 p.m., an interview was conducted with S3ADON and S4DM (Dietary Manager). S4DM and S3ADON confirmed that the last assessment from S16RD for Resident #17 was on 04/08/2025. S4DM Residents Affected - Few stated that she was unsure of why S16RD had not assessed the resident's significant weight loss for May of 2025 because S16RD accesses the significant weight losses herself. S4DM stated that she provided the RD with a Referral Form for Consultant Dietitian, which is composed of names of residents needing to be assessed in addition to those on the weight report for May of 2025. S4DM confirmed that Resident #71's name was not present on this form for May of 2025.

On 05/20/2025 at 4:25 p.m., a phone interview was conducted with S16RD. She confirmed that she last assessed Resident #71's nutritional status on 04/08/2025. S16RD stated that she assesses residents for weight loss based on the report given to her by S4DM. S16RD stated that she does not access a weight report herself. She stated she was not aware of the resident's significant weight loss at her last visit to the facility on [DATE REDACTED], and would have reassessed the resident had she been aware of it.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 21 195460 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 195460 B. Wing 05/21/2025

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

Belle Teche Nursing & Rehabilitation Center 1306 W Admiral Doyle Dr New Iberia, LA 70560

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 0695 a. February 2025: 6th, 7th, 12th, and 20th

Level of Harm - Minimal harm or b. March 2025: 5th, 10th 17th, and 31st potential for actual harm c. May 2025: 2nd Residents Affected - Few 3. Laryngectomy Tube: Change adhesive dressing to laryngectomy tube every day shift every Friday.

Missing signatures:

a. May 2025: 2nd

4. Laryngectomy Tube: Change filter to laryngectomy tube every day shift.

Missing signatures:

a. March 2025: 5th, 10th, and 17th

b. May 2025: 2nd

On 05/21/2025 at 1:25 p.m., a record review and interview was conducted with S2DON (Director of Nursing).

She confirmed that the signatures were missing for Resident #14's laryngectomy care on the MAR for the above stated dates for the months of February 2025, March 2025, and May 2025. She stated that she assumed the care was not completed with the signatures missing for these dates.

On 05/21/2025 at 1:51 p.m., an interview was conducted with Resident #14. She communicated that some days her laryngectomy care is not performed by staff.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 21 195460 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 195460 B. Wing 05/21/2025

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

Belle Teche Nursing & Rehabilitation Center 1306 W Admiral Doyle Dr New Iberia, LA 70560

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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 44269

Residents Affected - Few Based on observations, interviews and policy review, the facility failed to ensure dietary staff prepared, distributed and served food in accordance with professional standards for food service safety as evidenced by 2 dietary assistants (S13DA and S14DA) without a beard restraint.

Findings:

On 05/21/2025 a review of facility's policy titled, Employee Sanitation Practices reviewed on 01/15/2025, revealed in part:

3. Proper Work Attire .b. The food service employee observes the following dress standards: i. Wears a clean hat or other hair restraint. Employees with facial hair wear a beard restraint .

On 05/19/2025 at 8:44 a.m., an initial observation was made of S13DA (Dietary Assistant) assisting with prepping sandwiches with his facial hair not covered.

On 05/19/2025 at 10:35 a.m., a follow up visit in the kitchen was made. S13DA was observed assisting with food preparation for the lunch meal service with his facial hair not covered.

On 05/19/2025 at 10:56 a.m., an observations was made of S14DA assisting with the lunch meal service preparation with his facial hair exposed and not covered.

On 05/19/2025 at 11:30 a.m., an observation was made of S13DA and S14DA assisting with preparing the residents' lunch meal on individual plates. S13DA was observed distributing food from the steam table to each resident's plate and S14DA was observed placing the fixed lunch meal individual plates in an insulated rolling cart to be distributed to residents. S13DA and S14DA failed to cover their beards while preparing and distributing food to residents.

On 05/19/2025 at 12:20 p.m., an interview was conducted with S4DM (Dietary Manager). S4DM stated male staff should have beard coverings over their facial hair when working in the facility's kitchen.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 21 195460 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 195460 B. Wing 05/21/2025

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

Belle Teche Nursing & Rehabilitation Center 1306 W Admiral Doyle Dr New Iberia, LA 70560

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 0849 Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47540

Residents Affected - Few Based on record reviews and interview, the facility failed to obtain the most recent recertification of terminal illness and most recent hospice POC (plan of care) for 1 (#31) out of 1 (#31) resident reviewed for hospice care.

Findings:

A review of the facility's agreement with the Contracted Hospice Agency dated 08/26/2015 read in the part,

the following, Compilation of Records: Nursing facility and hospice shall each prepare and maintain complete and detailed clinical records concerning each Residential Hospice Patient . Each clinical record shall completely, promptly and accurately document all services provided to, and events concerning, each Resident Hospice Patient . Each such record shall be readily accessible and systematically organized to facilitate retrieval by either party.

A review of Resident #31's record revealed he was admitted to the facility on [DATE REDACTED] with diagnoses which included but were not limited to, Encounter for Palliative Care and Parkinson's disease with Dyskinesia.

A review of Resident #31's Quarterly MDS (Minimum Data Set) dated 02/12/2025 revealed Section O: Special Treatments revealed the resident was admitted to hospice care.

A review of Resident #31's physician's orders revealed an order entry with a start date of 04/18/2024 read in part, Admit to Contracted Hospice for dx (diagnosis): Parkinson's disease.

A review of Resident #31's person-centered plan of care, revealed in part, a focus on required hospice services with Contracted Hospice Parkinson's initiated on 04/18/2024.

A review of Resident #31's hospice documents in his contracted hospice binder revealed, in part, that the most recent certification of terminal illness by the Contracted Hospice Agency's physician was signed on 04/16/2024 for the certification period of 04/09/2024 through 07/07/2024.

A review of Resident #31's hospice documents in his contracted hospice binder revealed, in part, that the most recent POC was dated 04/18/2025 for the certification period of 03/05/2025 through 05/03/2025.

On 05/20/2025 at 2:00 p.m. a record review and interview was conducted with S2DON (Director of Nursing). S2DON stated she is responsible for maintaining Resident #31's contracted hospice binder. She stated Resident #31' most recent POC was dated 04/18/2025 for the certification period of 03/05/2025 through 05/03/2025, and his most recent certification was from 04/09/2024 through 0707/2024. She confirmed there was not an updated recertification of terminal illness and POC in Resident #31's contracted hospice binder and should have been.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 21 195460 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 195460 B. Wing 05/21/2025

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

Belle Teche Nursing & Rehabilitation Center 1306 W Admiral Doyle Dr New Iberia, LA 70560

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 0850 Hire a qualified full-time social worker in a facility with more than 120 beds.

Level of Harm - Minimal harm or 44418 potential for actual harm Based on interviews and record reviews, the facility failed to ensure it employed a qualified social worker on Residents Affected - Few a full-time basis. The facility had 150 licensed beds.

Findings:

Record review of S5SSD's resume revealed, in part, education: Bachelors of Science in health Studies (Marketing/Management), Associate of Science and Certificate of General Studies (Health Care Management). S5SSD's resume failed to show a bachelor's degree in social work or a bachelor's degree in a human services field including, but not limited to, sociology, gerontology, special education, rehabilitation counseling, and psychology; and one year of supervised social work experience in a health care setting working directly with individuals.

On 05/20/2025 at 1:30 p.m., an interview was conduct with S5SSD, she confirmed she was serving as the facility social service director, with a BS (Bachelor of Science) degree in business health administration. S5SSD also confirmed she did not have a bachelor degree related to sociology, gerontology, special education, rehabilitation counseling, and psychology.

On 05/21/2025 at 8:46 a.m., an interview was conducted with S1ADM/RN, he confirmed the facility had 150 licensed beds. He stated he was unaware it was the licensed bed number that determined the social service qualifications of the facility. S1ADM/RN confirmed S5SSD had a BS in health science and less than one (1) year of supervised social work experience working directly with residents in a health care setting.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 21 195460 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 195460 B. Wing 05/21/2025

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

Belle Teche Nursing & Rehabilitation Center 1306 W Admiral Doyle Dr New Iberia, LA 70560

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 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 47965 potential for actual harm Based on observation, interview and policy review, the facility failed to maintain an effective infection and Residents Affected - Few control program, by failing to ensure laundry staff wore appropriate personal protective equipment (PPE) while sorting soiled laundry.

Findings:

On 05/21/2025, a review of the facility's policy titled Infection Control, with a last reviewed date of 01/15/2025, indicated, Policy: To establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection .Procedure .14. linens must be handled .to prevent the spread of infection. a. Soiled linens must be handled to contain and minimize aerosolization and exposure to any waste products.

During a tour of the facility's laundry room on 05/21/2025 at 9:00 a.m., S12LS (Laundry Staff) was observed removing laundry from a large yellow barrel and placing the laundry in the washing machine. S12LS was wearing only a pair of gloves during the procedure. She stated the laundry came from resident's rooms and was soiled. S12LS confirmed she should have worn a gown while sorting and loading the soiled laundry in

the washer, but did not.

During an interview with S1ADM/RN (Administrator/Registered Nurse), he stated the facility had an infection preventionist but she was off for the day. S1ADM/RN stated S12LS should have worn a gown to handle the soiled laundry.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 21 195460 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 195460 B. Wing 05/21/2025

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

Belle Teche Nursing & Rehabilitation Center 1306 W Admiral Doyle Dr New Iberia, LA 70560

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 41419 potential for actual harm Based on observations and interviews, the facility failed to maintain electrical patient care equipment in safe Residents Affected - Few operating condition by failing to replace an electrical outlet plate for 1 (Resident #7) out of a finalized sample of 47 residents.

Findings:

On 05/19/2025 at 12:30 p.m., an observation of resident #7's room revealed an electrical outlet near the resident's bed, and within arm's reach of the resident. The outlet did not have a safety plate.

On 05/20/2025 at 9:21 a.m., a second observation of resident #7's room revealed the outlet was still without

a safety plate.

On 05/20/2025 at 3:30 p.m., an observation and interview was conducted with S7LPN (Licensed Practical Nurse) who stated that a work order had been submitted to maintenance to have the plate replaced.

On 05/20/2025 at 3:31 p.m., review of the maintenance log was conducted with S11M (Maintenance), S10CN (Charge Nurse) and S7LPN from present day to 01/2025. The log revealed that a no work order had been submitted for the electrical plate to be replaced. S7LPN and S10CN confirmed that a work order had not been submitted to S11M for replacement of the outlet plate.

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