Ferncrest Manor Living Center

Inspectors wroteBased on observations, interviews, and record review the facility failed to maintain an effective pest control program.

Inspectors wroteBased on observation and interviews, the facility failed to provide silverware at meal service.

Inspectors wroteBased on interviews and record reviews, the facility failed to maintain a system to accurately reconcile controlled substances for 4 (Medication Cart a, Medication Cart b, Medication Cart c, Medication Cart d) of 4 sampled medication carts reviewed for controlled substance documentation requirements.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to:1. Ensure insulin (a medication that lowers blood glucose) multi-dose flex pens were dated when opened and/or removed from refrigerated storage or discarded as required (Medication Cart a, Medication Cart b, Medication Cart c, Medication Cart d); and,2. Ensure opened, unpackaged, and/or unlabeled medication was not stored inside a medication cart (Medication Cart a). This deficient practice was identified for 4 (Medication Cart a, Medication Cart b, Medication Cart c, Medication Cart d) of 4 sampled medication carts observed for medication storage requirements.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to:1. Ensure staff wore proper Personal Protective Equipment (PPE) while performing care for residents on Enhanced Barrier Precautions (EBP) (Resident #4, Resident #37); and,2. Ensure staff completed hand hygiene and wore proper PPE during the administration of an injection (Resident #131). This deficient practice was identified for 3 (Resident #4, Resident #37, Resident #131) of 6 sampled residents observed for infection control practices.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents' tube feeding pumps were clean and sanitary for 3 (Resident #4, Resident #35, Resident #106) of 33 sampled residents reviewed for environmental concerns during the initial pool observations.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure certified nursing assistants (CNAs) were provided Quality Assurance and Performance Improvement (QAPI) training for 5 (S13CNA, S14CNA, S15CNA, S16CNA, S17CNA) of 5 sampled CNAs reviewed for QAPI training requirements.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide privacy for a resident during incontinence care for 2 (Resident #4, Resident #95) of 2 sampled residents observed during incontinence care.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure fall risk assessments were completed and new individualized fall prevention interventions were implemented to prevent future falls for 3 (Resident #108, Resident #112, Resident #142) of 3 sampled residents investigated for falls.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents who received psychotropic medications were monitored for potential adverse consequences associated with the use of psychotropic medications for 3 (Resident #10, Resident #115, Resident #149) of 5 sampled residents investigated for unnecessary medications.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain a resident's wheelchair in a safe working condition for 1 (Resident #91) of 5 residents reviewed for environment.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure: 1. A resident was positioned as ordered while receiving enteral feedings (a type of liquid nutritional supplement that is typically given through a tube directly inserted into the stomach) (Resident #2); 2. An enteral feeding administration set (tubing used to administer a resident's enteral feeding) for a resident's enteral feeding was changed every 24 hours per the facility policy and physician's order (Resident #2); and, 3. Only qualified staff placed a resident's enteral feeding on hold and/or restarted a resident's enteral feeding (Resident #R4). This deficient practice was identified for 2 (Resident #2, Resident #R4) of 3 (Resident #1, Resident #2, Resident #R4) residents reviewed for enteral feeding maintenance.

Inspectors wroteBased on interview and record reviews, the facility failed to maintain accurate records for 1 (Resident #2) of 3 (Resident #1, Resident #2, Resident #3) sampled residents reviewed for accurate documentation.

Inspectors wroteBased on observation and interview, the facility failed to ensure a resident's privacy during incontinence care for 1 (Resident #R4) of 4 (Resident #1, Resident #2, Resident #3, Resident #R4) residents observed for residents' rights.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure: 1. The facility's dining room was kept in a clean/sanitary manner; and, 2. The facility's hallways were kept in a clean/sanitary manner and in good repair for 3 (Hallway a, Hallway b, Hallway c) of 3 (Hallway a, Hallway b, Hallway c) hallways observed for physical environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure the annual Minimum Data Set (MDS) Assessment was transmitted within the required timeframe after completion for 1 (Resident #69) of 1 (Resident #69) sampled resident reviewed for assessment transmission.

Inspectors wroteBased on interviews and record reviews, the facility failed to maintain a system to accurately reconcile controlled substances for 6 (Medication Cart a, Medication Cart b, Medication Cart c, Medication Cart d, Medication Cart e, Medication Cart f) of 6 (Medication Cart a, Medication Cart b, Medication Cart c, Medication Cart d, Medication Cart e, Medication Cart f) medication carts reviewed for the reconciliation documentation of controlled substances.

Inspectors wroteBased on observation and interview, the facility failed to ensure a nurse secured medications when unatteneded for 1 (Medication Cart b) of 6 (Medication Cart a, Medication Cart b, Medication Cart c, Medication Cart d, Medication Cart e, Medication Cart f) medication carts reviewed for medication storage.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. ensure food stored in the facility's walk in cooler was properly dated and labeled, 2. ensure the dishwasher temperature and sanitizer log was properly maintained.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure the Quality Assurance and Assessment (QAA) committee met at least quarterly; and 2. Ensure the designated Infection Preventionist participated in the quarterly QAA meeting.

Inspectors wroteBased on observations, interviews, and records reviews, the facility failed to: 1. Store clean mop heads in the clean linen area of the facility's laundry room; 2. Store clean linen in a sanitary manner; and, 3. Ensure residents' suction canisters were changed on the scheduled change date for 2 (Resident #62, Resident #82) of 2 (Resident #62, Resident #82) sampled residents reviewed for infection control.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure call lights were within reach for 2 (Resident #24, Resident #101) of 3 (Resident #24, Resident #64, Resident #101) sampled residents investigated for accommodation of needs.

Inspectors wroteBased on interview and record reviews the facility failed to ensure a resident's Minimum Data Set (MDS) assessment reflected the resident's accurate discharge status for 1 (Resident #111 ) of 3 (Resident #109, Resident #110, Resident #111 ) sampled residents investigated for closed records.

Inspectors wroteBased on interviews and record reviews, the facility failed to administer a medication per a physician's orders for 1 (Resident #91) of 5 (Resident #2, Resident #29, Resident #91, Resident #101, Resident #162) residents reviewed for unnecessary medication review.

Inspectors wroteBased on interview and record reviews, the provider failed to ensure a Registered Nurse (RN) worked at least 8 hours for 1 (04/19/2025) of 22 (04/19/2025, 04/20/2025, 04/26/2025, 04/27/2025, 05/03/2025, 05/04/2025, 05/10/2025, 05/11/2025, 05/12/2025, 05/13/2025, 05/14/2025, 05/15/2025, 05/16/2025, 05/17/2025, 05/18/2025, 05/19/2025, 05/20/2025, 05/21/2025, 05/22/2025, 05/23/2025, 05/24/2025, 05/25/2025) days reviewed for staffing requirements.

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility assessment included specific nursing staffing needs for day, night, and weekend shifts.

Inspectors wroteBased on record reviews, interviews, facility document reviews, and facility policy reviews, it was determined that the facility failed to keep a resident free from staff physical and verbal abuse for 1 (Resident #1) of 3 sampled residents reviewed for abuse. This deficient practice resulted in an actual harm on 11/19/2024when Resident #1 was physically abused by S2Maintenance and sustained injuries to his right face and left hand, which resulted in pain.

Inspectors wroteBased on interview and facility document review, it was determined that the facility failed to ensure staff members received behavioral health training for 5 (S2Maintenance, S3Smoking Aide, S4Social Worker, S6Certified Nursing Assistant [CNA], and S7CNA) of 5 personnel records reviewed for required trainings. Findings Included: Review of the Facility's assessment dated [DATE] revealed, in part, the facility had 58 residents with Psychiatric Diagnoses and 14 residents required behavior management. Review of S2Maintenance's personnel record revealed, in part, no documented evidence, and the facility did not present any documented evidence, S2Maintenance received behavioral health training. Review of S3Smoking Aide's personnel record revealed, in part, no documented evidence, and the facility did not present any documented evidence, S3Smoking Aide received behavioral health training. [...]

Inspectors wroteBased on interviews, facility document reviews, and facility policy review, it was determined that the facility failed to ensure an allegation of physical abuse was reported to the Louisiana Department of Health no later than 2 hours after the allegation was made for 1 (Resident #1) of 3 residents investigated for abuse. Findings Included: Review of the facility's policy titled, Reporting, Abuse, Neglect, Misappropriation of Property, last revised on 07/25/2023 revealed, in part, the Director of Nursing, the Assistant Administrator, and/or the Administrator shall immediately notify the designated representatives through the State Incident Management System (SIMS) within 2 hours if an allegation involved physical abuse or resulted in bodily harm or injury. [...]

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure adequate respiratory staff were available to provide respiratory care and services as ordered for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents reviewed for respiratory care.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure Nurse Staffing Agency (NSA) Certified Nursing Assistants (CNAs) were trained on tracheostomy (a surgical opening in the neck to allow air to enter the lungs) and ventilator (a machine that moves air in and out of a person's lungs) safety prior to being assigned to the facility's Technology Dependent Unit (TDU) (unit at the facility that houses the tracheostomy and ventilator residents) for 2 (S6CNA and S7CNA) of 2 (S6CNA and S7CNA) NSA CNAs sampled for tracheostomy and ventilator competency.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure a resident's medication was available for use and administered as ordered for 1 (Resident #6) of 1 (Resident #6) sampled residents reviewed for infection control.

Inspectors wroteBased on record reviews, observations, and interviews, the facility failed to: 1.) Ensure enhanced barrier precautions were implemented for a resident with an indwelling device or wound for 5 (Resident #6, Resident #51, Resident #111, Resident #474 and Resident #475) of 5 (Resident #6, Resident #51, Resident #111, Resident #474 and Resident #475) residents reviewed for enhanced barrier precautions; 2.) Ensure resident care items were identified and contained. 3.) Ensure nursing staff removed their gloves and completed hand hygiene while performing gastrostomy dressing changes for 1 (S10Registered Nurse (RN) of 1 (S10RN) RNs and 1 (S17Licensed Practical Nurse (LPN)) of 1 (S17LPN) LPNs observed for gastrostomy tube dressing changes; [...]

Inspectors wroteBased on record reviews, observations, and interviews, the facility failed to: 1.) Ensure a careplan with measureable interventions was developed for a resident receiving oral antibiotics and wound care for contact dermatitis for 1 (Resident #6) of 4 (Resident #6, Resident #51, Resident #474, and Resident #475) sampled residents reviewed for infection control; 2.) Ensure a careplan with measureable interventions was developed for a resident receiving hospice services for 1 (Resident #474) of 2 (Resident #12 and Resident #474) sampled residents reviewed for hospice services; and, 3.) Ensure a careplan with measureable interventions was developed for a resident with an indwelling urinary catheter for 1 (Resident #474) of 2 (Resident #92 and Resident #474) sampled residents reviewed for urinary catheters.

Inspectors wroteBased on observations and interviews the facility failed to have a resident with clean and trimmed fingernails for 1 (Resident #74) of 2 sampled residents reviewed for activities of daily living care (Resident #50 and Resident #74) in a total sample of 41 residents.

Inspectors wroteBased on record reviews, observations, and interviews, the facility failed to ensure a resident's indwelling urinary catheter (a tube that is passed through the lower abdominal wall directly into the bladder to drain urine) was secure to prevent pulling for 1 (Resident #475) of 4 (Resident #6, Resident #51, Resident #474, and Resident #475) sampled residents reviewed for infection control.

Inspectors wroteBased on record reviews and interviews, the facility failed to: 1. Ensure a residents gastrostomy tube (a tube inserted directly into the abdomen to provide nutrition) site was cleaned as ordered by the physician for 2 (Resident #1 and R5) of 4 (Resident #1, Resident #2, Resident #3, and R5) residents reviewed for gastrostomy site care.

Inspectors wroteBased on record reviews, observations, and interviews, the facility failed to maintain an environment that was free from pests as evidence by: 1. Maggots were identified in a residents gastrostomy tube (a tube that is inserted into a person's stomach to provide nutrition) site; 2. A fly was observed on the gastrostomy tube of 1 (Resident #3) of 2 (Resident #2 and Resident #3) residents observed for gastrostomy tube site care; 3. A fly was observed in the facility's kitchen; 4. Flies were observed in the facility's dining room; and, 5. Flies were observed on a residents bed linens for 1 (R4) of 3 (Resident #2, Resident #3, and R4) resident rooms observed for pests.

Inspectors wroteBased on record reviews and interview, the facility failed to ensure documentation was complete and accurate for residents' activities of daily living (ADLs) and residents' 2 hour rounding for 3 (Resident #1, Resident #2, and Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure direct care staff provided basic life support, including Cardiopulmonary Resuscitation(CPR) per the facility's policy and procedure, to a resident requiring emergency care according to the resident's advance directive and physician's order for 1 (Resident #1) of 5 (Residents #1, #2, #3, #4, and #5) sampled residents. On [DATE], at approximately 11:48 p.m., an Immediate Jeopardy occurred for Resident #1 when the resident, who was a full code, did not receive CPR upon being found pulseless, breathless, and unresponsive. Review of Resident #1's Power of Attorney's (POA) video camera footage of Resident #1's room on [DATE] from 11:48 p.m. through [DATE] at 12:03 a.m. [...]

Inspectors wroteBased on record review and interview, the facility failed to electronically submit payroll information for direct care staffing as required.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure 12 controlled drugs were accurately reconciled for 1 (Medication Cart y) of 2 (Medication Cart x and Medication Cart y,) medication carts observed for controlled drug reconciliation.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the medication error rate was not 5% or greater by having a medication error rate of 14.8%. This deficient practice was identified for 1 [S6Licensed Practical Nurse (LPN)] of 3 nurses (S6LPN, S7LPN, and S8Registered Nurse) who were observed during medication administration.

Inspectors wroteThe facility failed to ensure Respiratory Therapist staff had completed annual respiratory therapy competencies completed for 10 (S9Respiratory Therapist, S10Respiratory Therapist, S11Respiratory Therapist, S12Respiratory Therapist, S13Respiratory Therapist, S14Respiratory Therapist, S15Respiratory Therapist, S16Respiratory Therapist, S17Respiratory Therapist, S18Respiratory Therapist) of 11 (S4Respiratory Therapist, S9Respiratory Therapist, S10Respiratory Therapist, S11Respiratory Therapist, S12Respiratory Therapist, S13Respiratory Therapist, S14Respiratory Therapist, S15Respiratory Therapist, S16Respiratory Therapist, S17Respiratory Therapist, S18Respiratory Therapist) Respiratory Therapist files reviewed.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's representative/power of attorney(POA) was immediately notified of a significant change in his medical condition for 1 (Resident #1) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident remained free from neglect by failing to ensure staff made rounds/checked on a resident every two hours for a resident who was cognitively impaired, had an active tracheostomy status diagnosis, and who was dependent on staff for all activities of daily living. This deficient practice was identified for 1 (Resident #1) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5) sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to report an allegation of neglect timely to the State Survey Agency and Certification Agency as required for 1 (Resident #1) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure tube feedings were administered as ordered for 1 (Resident #3) of 5 (Resident #1, Resident #2, and Resident #3, Resident #4, and Resident #5 ) sampled residents.

Inspectors wroteBased on record review, observation, and interview, the facility failed to: 1) Ensure an order was obtained and/or clarified if a compression device to a resident's legs was to be applied or not with a resident's physician (Resident #3); 2) Ensure nursing staff monitored and/or assessed a resident's compression device (Resident #3); and, 3) Ensure a physician's order for a medication was implemented in a timely manner (Resident #3). This deficient practice was identified for 1 (Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents reviewed for quality of care.

Inspectors wroteBased on record review and interview the facility failed to ensure a resident's physician orders for medication administration was coordinated with a resident's dialysis schedule and the resident's physician (Resident #2). This deficient practice was identified for 1 (Resident #2) of 2 (Resident #2 and Resident #3) sampled residents reviewed for dialysis.

Inspectors wroteBased on record review and interviews, the facility failed to: 1) Ensure a resident received a therapeutic diet as ordered for 1 (Resident #1) of 2 (Resident #1 and Resident #2) sampled residents reviewed for weight loss; 2) Ensure a resident's meal intake was documented for each meal for 2 (Resident #1 and Resident #2) of 2 (Resident #1 and Resident #2) sampled residents reviewed for weight loss; 3) Ensure a resident's dietary recommendation was implemented for 1 (Resident #2) of 2 (Resident #1 and Resident #2) sampled residents reviewed for weight loss; and, 4) Ensure a resident's weight was monitored weekly per physician orders for 1 (Resident #1) of 2 (Resident #1 and Resident #2) sampled residents reviewed for weight loss.