St Jude's Nursing Home

F-F770.

Review of Resident #1's medical records revealed Resident #1's nurse practitioner wrote an order dated 01/29/2025, to obtain a valproic acid level.

There was no documented evidence, and the facility was unable to present any documented evidence Resident #1's laboratory services was carried out as ordered prior to Resident #1's 02/17/2025's hospitalization .

In an interview on 03/11/2025 at 5:02PM, S2DON indicated after the physician or nurse practitioner places

an order for a lab on the lab form, she gives the orders to the floor nurse to enter into the computer. S2DON further indicated once the orders were noted in a resident's record she would file the form, and routine labs were to be drawn on Tuesdays and Thursdays.

In an interview on 03/12/2025 at 2:09PM, S1Chief Operating Officer (COO) indicated she was currently in charge of quality since administration has been out on leave, and identifies problems from grievances, surveys, tracking and trending, and surveys. S1COO indicated she puts Performance Improvement Plans (PIPs) into place after problems are identified.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 9 195517 Department of Health & Human Services Printed: 09/04/2025 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 195517 B. Wing 03/13/2025

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

St Jude's Health & Wellness Center 450a S Claiborne Ave, FL 6 New Orleans, LA 70112

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 In an interview on 03/12/2025 at 2:20PM, S2DON indicated she was responsible for ensuring laboratory orders are carried out. S2DON indicated she could not offer any explanation as to why a valproic acid level Level of Harm - Immediate was not drawn for Resident #1. jeopardy to resident health or safety In an interview on 03/12/2025 at 6:25pm, S6Chief Executive Officer (CEO) indicated he did not feel that the above deficient practice was an Immediate Jeopardy situation and would review the above mentioned Residents Affected - Some findings.

Note: The nursing home is S6CEO did not provide any additional communication or documentation to dispute the above mentioned disputing this citation. findings.

A Plan of Removal was accepted on 03/13/2025 at 4:30PM, which included the following actions to correct

the deficient practice:

The facility planned to improved communication between nursing, pharmacy consult, and medical doctors and put more oversight by leadership of the laboratory process.

A daily audit began starting on March 12th, 2025 and will continue for 1 month. After 30 days, the facility will move to weekly reviews that will happen as part of the high-risk meeting. The audit will include ensuring all lab orders are recorded, drawn timely, and responded to timely.

S6Chief Executive Officer (CEO) or his designee will do a visual check to ensure the audits have occurred.

He will do this once per week for one month.

S6CEO or his designee will attend one high risk meeting a month to verify lab orders are being reviewed.

Education will include the physician and extenders, clinical managers, and facility nurses. A daily review will be completed for a month starting on 3/12/2025 by S2DON or her designee to ensure nothing is missed or not followed up on timely.

S6CEO or his designee will verify education has been completed as stated through a visual review of the sign in sheets once per week for one month.

All staff nurses will be in serviced prior to their next shift on the lab order protocol.

S6CEO/his designee began providing administrative staff with the same education that is being provided to

the nurses on March 13th 2025 around 2PM.

All administrative staff at the facility will be in-serviced by close of business on 3/14/2025.

Starting on 3/12/2025 daily monitoring began of any lab orders, old or new.

Verification that the order has been accurately and successfully been carried out and that the results have been communicated to the medical doctor or nurse practitioner office. These audits are to be done by S2DON or her designee.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 9 195517 Department of Health & Human Services Printed: 09/04/2025 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 195517 B. Wing 03/13/2025

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

St Jude's Health & Wellness Center 450a S Claiborne Ave, FL 6 New Orleans, LA 70112

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 S2DON or her designee will review lab orders in point click care (the facility's charting program), lab results

in lab portal, and review notification to the medical doctor or nurse practitioner. Level of Harm - Immediate jeopardy to resident health or S6CEO or his designee will verify the audits weekly for 4 weeks and will participate in one high risk meeting safety per month to verify compliance.

Residents Affected - Some Starting on 03/12/2025 daily review of labs began and will continue for one month after such time this will be reviewed weekly in the high-risk meeting. Note: The nursing home is disputing this citation. Daily audits will continue with daily frequency until expectations are met. Nurses will be re-educated or counseled when and if there is a deviation from the system.

Lab orders will be added as an agenda item in the daily, weekday, stand-up meeting.

S6CEO or his designee will attend one stand up meeting per week for 60 days to ensure the agenda remains unchanged.

The facility asserted the likelihood for serious harm to any of its residents no longer existed on 03/12/2025 at 8:05PM.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 9 195517 Department of Health & Human Services Printed: 09/04/2025 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 195517 B. Wing 03/13/2025

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

St Jude's Health & Wellness Center 450a S Claiborne Ave, FL 6 New Orleans, LA 70112

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 45877 potential for actual harm Based on observations, interviews, and record reviews, the facility failed to ensure staff utilized the correct Residents Affected - Few personal protective equipment (PPE) when providing care to a resident on enhanced barrier precautions (EBP) for 1 (Resident #10) of 4 (Resident #1, Resident #2, Resident #3, Resident #10) residents observed

during incontinence care.

Findings:

Review of the facility's undated Enhanced Barrier Precautions Policy and Procedure revealed, in part, gowns and gloves should be worn when emptying a urinary catheter.

Observation on 03/10/2025 at 5:18AM revealed an EBP sign on the outside of Resident #10's door.

Observation further revealed S5Certified Nursing Assistant (CNA) entered Resident #10's room without a gown and proceeded to empty Resident #10's urinary catheter into a graduated cylinder.

In an interview on 03/10/2025 at 5:23AM, S5CNA indicated she did not use a gown when emptying urinary catheters and further indicated she did not know that she needed to.

In an interview on 03/10/2025 at 10:25AM, S2Director of Nursing (DON) indicated gowns should be worn when emptying urinary catheters of residents who are on EBP.

In an interview on 03/10/2025 at 10:48AM, S7Infection Preventionist confirmed gowns should be worn when emptying urinary catheters of residents who are on EBP.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 9 195517