Trinity Neurologic Rehabilitation Center

F-F600

Review of the facility policy titled Abuse, with a revision date of 05/15/2023, revealed the following, in part:

Definitions:

Sexual Abuse: Non-consensual sexual contact of any type with a resident.

Responsibilities of Facilities and Covered Individuals

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 20 195177 Department of Health & Human Services Printed: 09/11/2025 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 195177 B. Wing 01/12/2025

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

Lakeshore Manor Nursing & Rehab 1400 Lindberg Drive Slidell, LA 70458

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 0609 2. Reporting responsibilities for reasonable suspicion of a crime in accordance with State law:

Level of Harm - Immediate e. Sexual abuse jeopardy to resident health or safety Response to Allegations and Suspicions

Residents Affected - Few 1. Allegations may be verbal or in writing and will be reported to the administrator of the facility and other officials as required.

Review of Resident #33's Clinical Record revealed the resident was admitted to the facility on [DATE REDACTED] with diagnoses which included Hemiplegia and Hemiparesis following cerebral infarction affecting the left non-dominant side, Unspecified Dementia, Difficulty in Walking, Cognitive Communication Deficit and Legal Blindness.

Review of Resident #33's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/01/2024 revealed Resident #33 had a Brief Interview for Mental Status (BIMS) of 08, which indicated the resident had moderate cognitive impairment.

On 01/06/2025 review of the facility's self-reported incident dated 01/05/2025 at 09:59 p.m. revealed:

Resident Victim: Resident #33

Accused: S5MAIN

Accused Allegations: Sexual Abuse

Protective Actions: Suspended Pending Outcome

Incident Description: #Resident R1 told S6CNA that she saw S5MAIN kissing her roommate (Resident #33) on the forehead and the cheek. She says that she overheard S5MAIN tell Resident #33 he could see her cat when

she was walking naked in the hallway.

An interview was conducted on 01/08/2025 at 1:13 p.m. with Resident #33's sister. She stated Resident #33 had dementia and was not cognitively intact. She stated she was notified of an incident involving Resident #33 and a worker at the facility on 01/05/2025. She stated an employee of the facility told her a male worker kissed Resident #33 on her jaw and inappropriately touched/stroked her back and arm with his hands. She stated Resident #33 would not want an unknown male kissing and touching her. She stated, if Resident #33 had all her cognitive abilities, the resident would have suffered serious psychosocial harm from the male staff kissing and touching her while in her bed. She stated Resident #33 wouldn't want that person near her and would have been fearful.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 20 195177 Department of Health & Human Services Printed: 09/11/2025 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 195177 B. Wing 01/12/2025

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

Lakeshore Manor Nursing & Rehab 1400 Lindberg Drive Slidell, LA 70458

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 0609 An interview was conducted on 01/07/2024 at 10:20 a.m. with #Resident R1. #Resident R1 stated approximately a week ago,

she was in her room in bed when S5MAIN came into the room, walked over to Resident #33's bed, tried to Level of Harm - Immediate wake her up by whispering to her and rubbing her back and arm. #Resident R1 stated S5MAIN kissed Resident #33's jeopardy to resident health or left cheek, sat down next to Resident #33 on her bed, began to rub Resident #33's back and arm, and again safety kissed her on the cheek and the neck. #Resident R1 stated other staff members witnessed S5MAIN sitting on Resident #33's bed. #Resident R1 stated she heard S5MAIN tell Resident #33 he wanted to see her beautiful cat Residents Affected - Few again, and that he had seen her beautiful cat while she was naked in the hall. #Resident R1 said she reported the incident to S6CNA a few days after she witnessed it. She stated when she reported it to S6CNA on 01/05/2025 another staff member was present on 01/05/2025.

Review of #Resident R1's MDS with an ARD of 12/26/2024 revealed the resident was admitted to the facility on [DATE REDACTED] and had a BIMS of 15, which indicated the resident was cognitively intact.

An interview was conducted on 01/08/2025 at 2:40 p.m. with S8CNA. She stated at some time between Christmas and New Year's Day, she was checking on the residents shortly after she reported for her shift

after 3:00 p.m. and saw S5MAIN in Resident #33's room. She stated S5MAIN sat on Resident #33's bed, talked to her, rubbed the resident's shoulder with his hand, and then kissed her on the cheek. She stated the

observation made her feel uncomfortable and she thought it was inappropriate. She stated she did not report

the incident to administration and stated she would have if it happened again. She stated she did communicate what she saw with S6CNA and S7CNA. She confirmed she should have reported what she saw because it was sexual abuse.

An interview was conducted on 01/07/2025 at 3:56 p.m. with S7CNA. S7CNA stated S8CNA recently told him she saw S5MAIN sitting on Resident #33's bed, talking to her and making inappropriate sexual statements. S7CNA stated on 01/05/2025, #Resident R1 told him she had witnessed S5MAIN sitting on Resident #33's bed, talking to her and making inappropriate sexual statements. S7CNA said he never reported this to his supervisor or the administrator.

An interview was conducted on 01/07/2025 at 12:01 p.m. with S6CNA. She stated on 01/05/2025, #Resident R1 reported to her that approximately a week ago, S5MAIN came into the room, walked over to Resident #33's bed, leaned over Resident #33, rubbed her arm and back, kissed her, and asked her if she wanted coffee. S6CNA stated #Resident R1 reported she heard S5MAIN tell Resident #33 he had seen her cat meaning vagina. S6CNA stated she reported #Resident R1's allegations to S4LPN and S3RN.

An interview was conducted on 01/10/2025 at 1:36 p.m. with S2DON. S2DON said Resident #33 had a BIMS of 8 and had cognitive impairment. S2DON stated on 01/05/2025, around 6:00 p.m., S3RN reported #Resident R1 had witnessed S5MAIN in her room with Resident #33. #Resident R1 reported S5MAIN kissed Resident #33's forehead and cheek, rubbed Resident #33's arm and back, and made sexually inappropriate comments to Resident #33. S2DON stated she immediately contacted S1ADMIN and the Regional Director of Clinical. S2DON stated she was not aware a staff member had witnessed the incident and confirmed the staff that witnessed

it should have immediately reported it so Resident #33 could have been protected.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 20 195177 Department of Health & Human Services Printed: 09/11/2025 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 195177 B. Wing 01/12/2025

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

Lakeshore Manor Nursing & Rehab 1400 Lindberg Drive Slidell, LA 70458

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 0609 An interview was conducted on 01/10/2025 at 2:30 p.m. with S1ADMIN. S1ADMIN said Resident #33 had dementia. S1ADMIN stated on 01/05/2025, around 7:00 p.m., S2DON told him #Resident R1 reported she witnessed Level of Harm - Immediate S5MAIN kiss Resident #33 on the forehead and heard S5MAIN make an inappropriate comment to Resident jeopardy to resident health or #33 about her cat. S1ADMIN stated S5MAIN told him a few weeks ago after he spoke to the residents he left safety the room and kissed Resident #33 on her forehead while leaving. S1ADMIN stated he was not aware an employee had witnessed the incident between S5MAIN and Resident #33 and had not reported it. S1ADMIN Residents Affected - Few stated he had not reported the incident to police.

Plan of Removal

The surveyor confirmed the following had been initiated and/or implemented prior to exit:

Corrective Action:

1. The accused has not worked in the building since 01/02/2025 and is currently on indefinite suspension pending further review.

2. Resident #33 was evaluated by the Nurse Practitioner on 01/08/2025.

3. DON/Designee has in-serviced all employees and agency staff prior to the beginning of their shift on abuse, noting sexual and verbal, and the proper reporting procedure and how to identify abuse and signs of abuse. Employees gave verbal returned demonstrations of types of abuse, signs and proper reporting procedures.

4. Social Services/Designee performed a psychosocial evaluation on Resident #33 on 01/10/2025.

5. DON/Designee has consulted with outside psych services 01/11/2025 to evaluate Resident #33 for psychosocial harm and is scheduled 01/13/2025.

6. From these evaluations, if any concerns are identified, the facility will develop a plan of care to address any concerns, trauma, etc. that might be identified.

7. DON/Designee has put daily monitors in place on 01/10/2025 for each shift for Resident #33 that staff will ask resident does she feel safe in the facility with no psycho-social harm exhibited.

8. The administrator/Designee has reported the alleged violation of abuse to the police on 01/10/2025.

Identification of others at risk:

1. DON/Designee has interviewed interviewable residents on 01/10/2025 to determine if they have experienced sexual/verbal abuse, and if they feel safe in the facility with no findings.

2. DON/Designee has observed non interviewable residents on 01/11/2025 for non-verbal psycho-social signs of sexual/verbal abuse with no findings.

Systemic Changes:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 20 195177 Department of Health & Human Services Printed: 09/11/2025 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 195177 B. Wing 01/12/2025

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

Lakeshore Manor Nursing & Rehab 1400 Lindberg Drive Slidell, LA 70458

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 0609 1. DON/Designee has in-serviced all employees and agency personnel starting on 01/10/2025 and will educate all employees and agency staff prior to the beginning of their shift on abuse, noting sexual and Level of Harm - Immediate verbal, and the proper reporting procedure and how to identify abuse and signs of abuse. Employees gave jeopardy to resident health or verbal returned demonstration of types of abuse, signs and proper reporting procedures. safety Monitoring: Residents Affected - Few 1. Audits have been conducted and are ongoing by DON or designee on 10 residents questioning if they have experienced sexual/verbal abuse, and if they feel safe in the facility weekly x's 4 weeks, then monthly x's 2 months.

2. Audits have been conducted and are ongoing by DON or designee on 10 non interviewable residents to observe for any non-verbal signs of physical/sexual/verbal weekly x's 4 weeks, then monthly x's 2 months.

3. DON/Designee has conducted and is ongoing interview audits of 5 staff members from various shifts and departments to ensure that there has not been observations of inappropriate behavior between staff members and residents in the past 30 days with cognitively intact or cognitively impaired residents.

4. Audit trends will be reported to facility QAPI for review and further recommendations.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 20 195177 Department of Health & Human Services Printed: 09/11/2025 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 195177 B. Wing 01/12/2025

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

Lakeshore Manor Nursing & Rehab 1400 Lindberg Drive Slidell, LA 70458

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 0641 Ensure each resident receives an accurate assessment.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47173 potential for actual harm Based on interviews and record review, the facility failed to ensure resident assessments accurately reflected Residents Affected - Few the resident's status for 1(#52) of 23 residents reviewed for MDS.

Findings:

Review of the clinical record revealed Resident #52 was admitted to the facility on [DATE REDACTED] with diagnoses, which included Dementia, Difficulty Walking, Dysarthria following Cerebrovascular Accident, Other lack of Coordination, Depression and Failure to Thrive.

Review of Resident #52's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/24/2024 revealed in part, the following:

Section P: Restraints: Chair prevents rising -used less than daily.

On 01/09/2025 at 2:50 p.m., an interview was conducted with S17PTA. She stated she was familiar with Resident #52. She stated he had become weaker and could not sit up independently in a wheelchair for a period of time. She stated he lacked trunk control and a Geri chair would be used for safety and support.

On 01/09/2025 at 1:45 p.m., an interview was conducted with S8MDS. She stated Resident #52 used a Geri chair when out of bed for support and safety due to lack of trunk control. S8MDS reviewed Resident #52's Quarterly MDS with an ARD of 10/24/2024 and stated the MDS was coded for, Chair prevents rising- used less than daily. S8MDS confirmed Resident #52's Geri chair was not used as a restraint and the MDS was coded in error.

On 01/09/2025 at 1:55 p.m., an interview was conducted with S2DON. She stated Resident #52 used a Geri chair for support and safety due to poor trunk control and not a restraint. She confirmed the MDS should not have been coded as a restraint.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 20 195177 Department of Health & Human Services Printed: 09/11/2025 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 195177 B. Wing 01/12/2025

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

Lakeshore Manor Nursing & Rehab 1400 Lindberg Drive Slidell, LA 70458

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 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47173

Residents Affected - Few Based on record review and interviews the facility failed to ensure resident's plan of care was revised for the use of a geri chair for 1 (#52) of 23 sampled residents reviewed for care plans.

Findings:

Review of the clinical record revealed Resident #52 was admitted to the facility on [DATE REDACTED] with diagnoses, which included Dementia, Difficulty Walking, Dysarthria following CVA, Other lack of Coordination, Depression and Failure to Thrive.

Review of Resident #52's most recent Care Plan revealed no documentation related to resident using a geri chair.

On 01/07/2024 at 10:10 a.m., an interview was conducted with S10CNA. She stated Resident #52 used a geri chair.

On 01/09/2025 at 10:35 a.m., an interview was conducted with S11CNA. She stated Resident #52 used a geri chair.

On 01/09/2025 at 4:00 p.m., an interview was conducted with S9CNA. He stated he started working at the facility in August 2024. He stated Resident #52 had always used a geri chair when he got out of bed. He stated he had never seen Resident #53 use a regular wheelchair.

On 01/09/2025 at 1:45 p.m., an interview was conducted with S8MDS. She stated she was responsible for MDS assessments and Care Plans. She stated Resident #52 used a geri chair when he got out of bed for support and safety due to lack of trunk control. She reviewed the current care plan and confirmed Resident #52 was not care planned for using a geri chair.

On 01/09/2025 at 1:55 p.m., an interview was conducted with S2DON. She stated Resident #52 used a geri chair for support/safety due to poor trunk control. She stated she was not aware a resident needed to be care planned for a geri chair but she would update the care plan now.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 20 195177 Department of Health & Human Services Printed: 09/11/2025 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 195177 B. Wing 01/12/2025

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

Lakeshore Manor Nursing & Rehab 1400 Lindberg Drive Slidell, LA 70458

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50093

Residents Affected - Some Based on record review, observations, and interviews, the facility failed to store food in accordance with professional standards for food service safety.

The facility failed to ensure:

1. Staff properly sealed, labeled, and dated food after opening; and

2. Staff removed expired items available for consumption.

Findings:

Review of the facility's policy titled Refrigerated Storage dated ,d+[DATE REDACTED], revealed the following, in part:

Intent:

To provide guidance related to safe storage of refrigerated foods.

Guidelines:

10. Refrigerated foods should be properly covered, labeled, and dated.

11. Leftover food or unused portions of packaged foods should be covered, labeled, and dated.

15. Items leftover from tray line, such as poured milk or juice, will be labeled, and dated and used for the next meal. Such items will be discarded at the end of the day.

On [DATE REDACTED] at 8:52 a.m., an observation of Refrigerator A made with S16DM revealed the following:

1. ,d+[DATE REDACTED] full, gallon of 2% reduced fat milk with an expiration date of [DATE REDACTED];

2. Two gallons of 2% reduced fat milk with an expiration date of [DATE REDACTED];

3. Five small containers of fruit, unlabeled and undated; and

4. ,d+[DATE REDACTED] full, large container of jelly, unlabeled and undated.

On [DATE REDACTED] at 9:11 a.m., an observation of Refrigerator B made with S17DM revealed the following:

1. One loaf of bread, unlabeled and undated;

2. ,d+[DATE REDACTED] used loaf of bread, unlabeled and undated;

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 20 195177 Department of Health & Human Services Printed: 09/11/2025 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 195177 B. Wing 01/12/2025

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

Lakeshore Manor Nursing & Rehab 1400 Lindberg Drive Slidell, LA 70458

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 3. ,d+[DATE REDACTED] used loaf of bread, unlabeled and undated;

Level of Harm - Minimal harm or 4. ,d+[DATE REDACTED] used, ,d+[DATE REDACTED] pound of grated parmesan cheese, unsealed, open to air; potential for actual harm 5. Five pound bag of feta cheese, unsealed, open to air; and Residents Affected - Some 6. ,d+[DATE REDACTED] used, 16 ounce block of margarine, unsealed, open to air, and undated.

On [DATE REDACTED] at 9:17 a.m., an interview was conducted with S17DM. She confirmed the above mentioned findings. S17DM confirmed stored foods should be properly labeled, dated, and sealed once opened. S17DM confirmed expired items should have been removed and not be available for consumption.

On [DATE REDACTED] at 2:32 p.m., an interview was conducted with S1ADMIN. He stated all stored food should be labeled, dated, and sealed, once opened. S1ADMIN confirmed food with an expired dated should be removed and not be available for consumption.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 20 195177 Department of Health & Human Services Printed: 09/11/2025 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 195177 B. Wing 01/12/2025

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

Lakeshore Manor Nursing & Rehab 1400 Lindberg Drive Slidell, LA 70458

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48872 potential for actual harm Based on observations, interviews, and record review, the facility failed to implement and maintain an Residents Affected - Few infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to ensure:

1. Staff properly utilized Enhanced Barrier Precaution (EBP) Personal Protective Equipment (PPE) during care for 2 of 2 (#53 and #57) residents observed for EBP;

2. The facility's infection control and prevention policy was reviewed annually. This had the potential to effect all 92 residents in the facility.

Findings:

1.

Review of the facility's policy revised 03/26/2024, titled Infection Prevention and Control Transmission-Based Precautions Enhanced Barrier Precautions revealed the following, in part:

Policy:

Enhanced barrier precautions are an infection control intervention used to reduce transmission of Central Disease Center (CDC) targeted multidrug-resistant organisms that employs targeted gown and glove use

during high-contact resident care activities.

Gown and gloves are worn by personnel during high-contact care activities for residents with chronic wounds or indwelling medical devices.

Resident #53

Review of Resident #53's Clinical Record revealed she was admitted to the facility on [DATE REDACTED].

Review of Resident #53's current Physician Orders revealed the following, in part:

Start date- 06/19/2024. Percutaneous Endoscopic Gastrostomy (PEG) site care every day.

Start date- 04/22/2024. Place on enhanced barrier precautions.

Resident #57

Review of Resident #57's Clinical Record revealed she was admitted to the facility on [DATE REDACTED] with diagnoses which included Left Leg Wound.

Review of Resident #57's current Physician Orders revealed the following, in part:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 20 195177 Department of Health & Human Services Printed: 09/11/2025 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 195177 B. Wing 01/12/2025

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

Lakeshore Manor Nursing & Rehab 1400 Lindberg Drive Slidell, LA 70458

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 Start date- 04/22/2024. Place resident on enhanced barrier precautions related to left leg wound.

Level of Harm - Minimal harm or An observation was made on 01/07/2025 at 2:15 p.m. of Resident #53 and Resident #57's door to their potential for actual harm shared room. A sign was noted on the door that read EBP which included instructions to wear gown and gloves during high contact activity. Residents Affected - Few

A simultaneous observation was made on 01/07/2025 at 2:15 p.m. of S14LPN providing assistance to both Resident #53 and #57 in their shared room. S14LPN applied a clean gown and gloves and entered the residents' room. Resident #57 requested S14LPN's assistance to be repositioned. S14LPN's gown came in contact with Resident #57 and Resident #57's linen which S14LPN used to reposition her upright in the geriatric chair. Between assisting Resident #57 and #53, S14LPN did not change her gown. With the dirty gown, S14LPN administered Resident #53's medications through the PEG Tube. After S14LPN completed medication administration for Resident #53, she removed the soiled gown and gloves. Without donning clean PPE, S14LPN repositioned Resident #57 in her geriatric chair as mentioned above.

An interview was conducted on 01/07/2025 at 2:18 p.m. with S14LPN. S14LPN stated Resident #53 was on EBP because of the PEG tube. She stated Resident #57 had an open wound, but was not on EBP and did not require gown and glove use with care. S14LPN confirmed the above observations of her providing care to Resident #53 and Resident #57. S14LPN stated she should have changed her gown after she repositioned Resident #57 and before administering medication to Resident #53.

An interview was conducted on 01/08/2025 at 8:35 a.m. with S2DON. S2DON confirmed Resident #53 had a PEG tube and was on EBP. S2DON confirmed Resident #57 had a wound and was on EBP. S2DON confirmed a gown and gloves should be worn when a resident on EBP was repositioned. S2DON stated she expected the nurse to change her gown after Resident #57 was repositioned and before Resident #53 was administered medication by PEG tube. She stated she expected the nurse to apply a gown and glove before repositioning Resident #57.

2.

Review of the facility's policy titled Infection Prevention and Control Program had a published date of 11/2017 and a revision date of 06/08/2022.

Review of the facility's documentation for annual review of the above policy revealed no evidence of annual review.

An interview was conducted on 01/08/2025 at 4:50 p.m. with S1ADMIN. S1ADMIN stated he did not know

the last time the facility's Infection Prevention and Control policy was reviewed and could not provide documentation of an annual review having been conducted.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 20 195177