Legacy Nursing And Rehabilitation Of Port Allen

F-F684

Review of the facility's In-service Training Record Documentation revealed, in part, the following:

Names of Person giving the training: S2DON

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 16 195599 Department of Health & Human Services Printed: 09/23/2025 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 195599 B. Wing 06/24/2024

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

Legacy Nursing and Rehabilitation of Port Allen 403 15th Street Port Allen, LA 70767

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 Date of Training: 01/01/2024

Level of Harm - Immediate Purpose of Training: Educating nursing staff on notifying physician/nurse practitioner of incident. jeopardy to resident health or safety Attachment: Documentation and Charting Guidelines

Residents Affected - Few Name of Person giving the training: S3ADON

Date of Training: 04/09/2024

Purpose of Training: Hydration

Attachment: Hydration Policy and Procedure

Review of the facility's undated Documentation and Charting Guidelines Policy revealed, in part, the following:

Purpose:

The purpose of charting and documentation is to provide the following:

A complete account to the resident's care, treatment, response to the care, signs, symptoms, and progress of resident care. Guidance to the physician in prescribing appropriate medication and treatment, assistance

in the development of a plan of care for the resident.

Procedure:

6. Intake and Output:

a. consistent and accurate documentation and measurement of the resident's intake/output.

b. each shift's total intake

c. each shift's total output

d. The 24-hour total intake/output for all shifts.

e. Intake/output documentation shall be recorded when a resident has an IV.

7. IV therapy:

d. 24-hour intake/output record.

Review of the facility's undated Hydration Policy and Procedure revealed, in part, the following:

Purpose:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 16 195599 Department of Health & Human Services Printed: 09/23/2025 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 195599 B. Wing 06/24/2024

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

Legacy Nursing and Rehabilitation of Port Allen 403 15th Street Port Allen, LA 70767

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 To assure that the resident receives sufficient amount of fluid based on individual needs to prevent dehydration. Level of Harm - Immediate jeopardy to resident health or Procedure: safety 3. Intake and Output will be done every shift on residents that have: Residents Affected - Few e. Any other condition that warrant possible dehydration or as ordered by the physician.

Review of Resident #3's medical record revealed Resident #3 was admitted to the facility on [DATE REDACTED] with diagnoses, in part, Unspecified Dementia, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Metabolic Encephalopathy, and Sepsis.

Review of Resident #3's Physician Orders dated May 2024 revealed, in part, the following:

An order dated 05/30/2024 for labs: CBC, CMP, and UA in the morning for diagnosis: Lethargy;

An order dated 05/30/2024 for 500 cc Normal Saline IV one time only for Dehydration for one day;

An order dated 05/31/2024 to send emergency room for evaluation.

Review of Resident #3's Nurse's Note dated 05/30/2024 by S6NP revealed, in part, Staff reports Resident #3 was weak, requiring assistance with feeding, not talking but tracks people and follows command, poor intake yesterday. Give IV bolus 500cc NS today, check CBC, CMP, UA.

Review of Resident #3's Administration Note dated 05/31/2024 at 4:00 a.m. by S4LPN revealed, in part, adult brief dry, In and Out catheter attempted, no urine output, resident weak and fatigue more than normal. Report given to oncoming nurse of resident status.

Review of Resident #3's Nurse's Note dated 05/31/2024 at 7:00 a.m. by S3LPN revealed, in part, Resident #3 was in bed with eyes closed, lethargic, body rigid, extremities twitching, refusing any oral fluids, 0.9% sodium chloride infusing at 20 ml/hr in IV noted to right arm. Night shift reported he had no urine output

during the night shift and was unable to obtain urine when attempted to catheterize him this a.m. S6NP was informed of resident's condition. Received orders to send to hospital.

Review of Resident #3's emergency provider note dated 05/31/2024 revealed, in part, Resident #3's chief complaint was weakness, increased weakness for 2 days. Further review revealed, on 05/28/2024 Resident #3 began to become more weak and less talkative, resident was non-communicative.

Review of Resident #3's history and physical dated 05/31/2024 revealed, in part, Acute Metabolic Encephalopathy-suspect from volume depletion and Acute Cystitis; Hypernatremia- sodium elevated at 148, suspect volume depletion; Acute Cystitis with Hematuria-UA consistent with Acute Cystitis and patient grossly encephalopathic.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 16 195599 Department of Health & Human Services Printed: 09/23/2025 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 195599 B. Wing 06/24/2024

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

Legacy Nursing and Rehabilitation of Port Allen 403 15th Street Port Allen, LA 70767

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 On 06/20/2024 at 9:20 p.m., an interview was conducted with S4LPN. She stated the provider should be notified of any changes in a resident's status. She stated on 05/31/2024 at 4:00 a.m. Resident #3's brief was Level of Harm - Immediate dry, and there was no urine output noted when an In and Out catheter was used to collect the urine jeopardy to resident health or specimen. She stated she didn't notify the NP of no urine output at 4:00 a.m. on 05/31/2024, and should safety have.

Residents Affected - Few On 06/20/2024 at 8:10 a.m., an interview was conducted with S6NP. She stated on 05/30/2024 the nurse notified her Resident #3 was weak and lethargic; she ordered a normal saline bolus via IV with labs to be completed on 05/31/2024 in the morning. She stated she instructed the staff to notify her if there was no improvement or any decline. She stated she expected nursing staff to document and assess a resident's fluid intake and output if she ordered IV fluids for dehydration or if the resident had decreased intake. She stated

she was not notified Resident #3 had no urine output, on 05/31/2024 at 4:00 a.m., when the nurse attempted to collect urine for the urinalysis. She stated she should have been notified of no urine output immediately.

On 06/21/2024 at 11:40 a.m., an interview was conducted with S2DON. She stated intake and output was only tracked if there was an order from the provider. She confirmed the facility's documenting and charting policy indicated to track intake and output for all residents receiving IV therapy. She stated she expected nursing staff to contact the provider for any change in condition. She confirmed she conducted an in-service for nursing staff to notify the physician/nurse practitioner of any resident incidents which included the Documentation and Charting Guidelines Policy on 01/01/2024 and ADON conducted an in-service on the Hydration Policy on 04/09/2024. She stated she was not monitoring compliance of the in-services conducted

on 01/01/2024 and 04/09/2024.

On 06/24/2024 at 10:30 a.m., an interview was conducted with S2DON. She stated Resident #3 should have had accurate intake and output monitoring while receiving IV fluids. She also stated the nurse practitioner should have been notified immediately when Resident #3 had no urine output from the in an out catheter attempt.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 16 195599 Department of Health & Human Services Printed: 09/23/2025 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 195599 B. Wing 06/24/2024

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

Legacy Nursing and Rehabilitation of Port Allen 403 15th Street Port Allen, LA 70767

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 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47500

Residents Affected - Some Based on interviews and record reviews, the facility failed to ensure completed care was documented correctly in resident's records for 3 (#3, #Resident R1, and #Resident R2) of 8 (#1, #2, #3, #Resident R1, #Resident R2, #Resident R3, #Resident R4, and #Resident R5) sampled residents.

Findings:

Resident #3

Review of Resident #3's Medical Record revealed, in part, Resident #3 was admitted to the facility on [DATE REDACTED] with diagnoses which included Unspecified Dementia, Schizophrenia, Benign Prostatic Hyperplasia, Metabolic Encephalopathy, Sepsis, and Acute Embolism and Thrombosis of Left peroneal vein.

Review of Resident #3's MDS with an ARD of 05/07/2024 revealed, in part, Resident #3 was dependent with toileting hygiene.

Review of Resident #3's Late Loss ADL document dated 04/30/2024 through 05/31/2024 revealed, in part, only one shift documented toileting on 04/30/2024, 05/03/2024, 05/04/2024, 05/05/2024, 05/08/2024, 05/11/2024, 05/15/2024, 05/16/2024, 05/17/2024, 05/18/2024, 05/21/2024, 05/23/2024, 05/24/2024, 05/26/2024, 05/27/2024, and 05/29/2024.

Resident #Resident R1

Review of Resident #Resident R1's Medical Record revealed, in part, Resident #Resident R1 was admitted to the facility on [DATE REDACTED] with diagnoses which included Cerebral Infarction, Type 2 Diabetes Mellitus with Diabetic Neuropathy, and Aphasia.

Review of Resident #Resident R1's MDS with an ARD of 04/02/2024 revealed, in part, Resident #Resident R1 was dependent with toileting hygiene.

Review of Resident #Resident R1's Late Loss ADL documentation dated 06/06/2024 through 06/20/2024 revealed, in part, only 1 shift documented toileting on 06/08/2024, 06/11/2024, and 06/17/2024.

Resident #Resident R2

Review of Resident #Resident R2's Medical Record revealed, in part, Resident #Resident R2 was admitted to the facility on [DATE REDACTED] with diagnoses which included Unspecified Psychosis, Schizoaffective disorder, Hyperlipidemia, Major Depressive Disorder, and Dysphagia.

Review of Resident #Resident R2's MDS with an ARD of 05/02/2024 revealed, in part, Resident #Resident R2 required partial/moderate assistance with toileting hygiene.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 16 195599 Department of Health & Human Services Printed: 09/23/2025 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 195599 B. Wing 06/24/2024

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

Legacy Nursing and Rehabilitation of Port Allen 403 15th Street Port Allen, LA 70767

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 0842 Review of Resident #Resident R2's Late Loss ADL Documentation dated 05/01/2024 through 06/16/2024 revealed, in part, one shift documented toileting on 05/06/2024, 05/10/2024, 05/15/2024, 05/20/2024, 05/24/2024, Level of Harm - Minimal harm or 05/25/2024, 05/29/2024, 06/03/2024, 06/07/2024, 06/12/2024, and 06/13/2024. potential for actual harm

On 06/21/2024 at 7:39 p.m., an interview was conducted with S12MDS. She stated the staff was required to Residents Affected - Some document ADLs every shift. She stated the days where toileting was documented once meant the staff did not document on each shift, and the documentation was missing.

On 06/21/2024 at 8:37 p.m., an interview was conducted with S11ADON. She stated CNAs were required to document toileting once a shift and each day included two shifts. S11ADON confirmed the above days were missing documentation.

On 06/21/2024 at 8:40 p.m., an interview was conducted with S2DON. She stated CNAs were required to document toileting on each shift and each day included two shifts. S2DON confirmed there was missing documentation on the toileting documentation for Resident #3, Resident #Resident R1, and Resident #Resident R2.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 16 195599