Lacombe Nursing Centre

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents' call lights were within reach for 2 (#8 and #76) of 2 residents reviewed for accommodation of needs.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide maintenance services necessary to maintain a sanitary, orderly, and comfortable interior by failing to ensure:Halls A, B, and C ceiling tiles were maintained in good repair; andRoom BB was maintained safely, sanitarily, and in good repair.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents or resident representatives understood the arbitration agreement signed on admission for 3 (#11, #15, and #17) of 3 residents reviewed for arbitration.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure a resident fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding by failing to ensure enteral water flushes were administered per Physician's Orders for 1 (#49) of 1 resident reviewed for enteral feedings.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that drugs were stored and labeled properly in accordance with current accepted professional principles. The facility failed to ensure insulin pens containing multiple doses of insulin were clearly labeled with a puncture date for 1 (#67) of 2 residents observed during insulin administration.

Inspectors wroteBased on observation and interviews, the facility failed to ensure garbage and waste were properly contained in the outdoor trash dumpster. This deficient practice had the potential to affect the 73 residents currently residing in the facility.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections by failing to ensure:1. Nursing staff sanitized insulin pen rubber seal prior to extracting insulin for 2 (#30 and #67) of 2 residents observed for insulin administration.2. Nursing staff disinfected the glucometer between resident use for 1 (#67) of 2 residents observed during blood glucose monitoring.

Inspectors wroteBased on observations and interviews, the facility failed to store and prepare food under sanitary conditions by failing to ensure the food was properly stored and labeled in the facility's kitchen. This deficient practice had the potential to affect all of the 69 facility residents who were served from the facility's kitchen. Review of facility's undated policy titled, How to Store Under Sanitary Conditions revealed in part:1. For dry storage-All items must be in a container with a lid or in a labeled zip lock bag. All items must be labeled with what it is, the date it was opened and the initial of the person who placed it in there. On 07/28/2025 at 8:27 a.m., an observation was made of the kitchen food preparation area with S5CK. The observation revealed and S5CK confirmed the following items were found to be open and undated.1 - 20 ounce package of whole wheat sliced bread; [...]

Inspectors wroteBased on record review and interviews, the facility failed to maintain complete and accurate records in accordance with accepted professional standards and practices for 4 (#3, #6, #19, and #32) of 19 sampled residents reviewed for accurate documentation. The facility failed to ensure the following: 1. Resident #3's medication administration and wound care treatment administration were accurately documented; 2. Resident #6's Percutaneous Endoscopic Gastrostomy (PEG) site care was accurately documented; 3. Resident #19's medication administration and wound care treatment administration was accurately documented; and4. Resident #32's suprapubic catheter care was accurately documented. 1. [...]

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure all medical records regarding the resident's code status consistently reflected the resident's wishes for 2 (#4 and #66) of 25 residents reviewed in the initial screening for advanced directives. Review of the facility’s undated policy titled, “LaPOST”, revealed the following, in part:Procedure6. Place the original LaPOST form in a prominent and appropriate place in the medical record. Do not document code status in the electronic record. Resident #4Review of Resident #4’s clinical record revealed he was admitted to the facility on [DATE]. Review of Resident #4's current Physician Orders revealed the following, in part:Order date: [DATE]-Full Code Status. Review of Resident #4's hard, physical chart revealed a Louisiana Physician Orders for Scope of Treatment (LaPOST) dated [DATE]. [...]

Inspectors wroteBased on interviews, video observation, and record review, the facility failed to protect the resident's right to be free from physical abuse for 1 (#4) of 24 sampled residents reviewed for abuse. The facility failed to ensure Resident #4 was free from physical abuse by Resident #50. Review of the facility's policy dated 2025 and titled, Policy for Prohibition of Abuse revealed in part, the following:Each resident has the right to be free from abuse. Resident #4Review of Resident #4's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Parkinson's Disease, Depression, and Mild Intellectual Disabilities. Review of Resident #4's Quarterly MDS with an ARD of 06/05/2025 revealed a BIMS of 11, which indicated he was moderately cognitively impaired. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure allegations of physical abuse were reported to the State Agency in the required timeframe for 1 (#4) of 24 sampled residents reviewed for abuse. Review of the facility's policy dated 02/2025 and titled, Policy for Prohibition of Abuse revealed in part, the following:Reporting:1. Report incidents to the state agency as required. Internal Reporting Timelines:Abuse: Immediately. Resident #4Review of Resident #4's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Parkinson's Disease, Depression, and Mild Intellectual Disabilities. Review of Resident #4's Quarterly MDS with an ARD of 06/05/2025 revealed a BIMS of 11, which indicated he was moderately cognitively impaired. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a resident with an identified mental health diagnosis was referred for a Preadmission Screening and Resident Review (PASRR) Level II evaluation as required for 1 (#2) of 3 (#2, #9, and #47) residents reviewed for PASRR.Review of Resident #2's clinical record revealed he was admitted to the facility on [DATE] with diagnoses which included Major Depressive Disorder. Further review revealed he was diagnosed with Adjustment Disorder on 10/26/2019 and Schizophrenia on 12/23/2019. Review of Resident #2's Level 1 PASRR dated 09/24/2019 revealed Section III: Mental Illness, did not have Adjustment Disorder or Schizophrenia selected as a diagnosis. On 07/30/2025 at 9:30 a.m., an interview was conducted with S7SSD. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide necessary care and services for the provision of respiratory care in accordance with professional standards of practice. The facility failed to ensure a resident's oxygen was administered at the physician ordered rate for 1 of 1 (#10) residents reviewed for respiratory care. Review of Resident #10's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included Senile Degeneration of the Brain. Review of Resident #10's current Physician Orders revealed the following, in part:Start date 05/12/2025 - Oxygen at 3L per nasal cannula continuous every shift. An observation was made on 07/28/2025 at 12:02 p.m. of Resident #10 in her room wearing oxygen per nasal cannula at 2.5L.An observation was made on 07/29/2025 at 9:00 a.m. [...]

Inspectors wroteBased on observations and interview, the facility failed to post the name, address, and telephone numbers of the Office of the State Long-Term Care Ombudsman program, in a form and manner accessible and understandable to residents and resident representatives. This deficient practice had the potential to affect any of the 71 residents residing in the facility. On 07/28/2025 at 9:45 a.m., an observation of the facility revealed no posting/signage of the required Office of the State Long-Term Care Ombudsman Program names, addresses, and telephone numbers. On 07/28/2025 at 9:50 a.m. an observation was made throughout the facility with S3ADON. S3ADON confirmed there was no information regarding the Office of the State Long-Term Care Ombudsman Program posted in the facility.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 1 (#3) of 3 (#1, #2, and #3) sampled residents. The facility failed to ensure Resident #3 was coded correctly for falls.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident's plan of care was revised by failing to update fall interventions after each fall for 1 (#3) of 3 (#1, #2, and #3) residents reviewed for falls.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to provide necessary care and services for the provision of respiratory care in accordance with professional standards. The facility failed to ensure oxygen tubing and humidifier bottle were properly labeled for 4 (#11, #43, #62, and #64) of 4 (#11, #43, #62, and #64) residents reviewed for oxygen therapy.

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to store, prepare, and distribute foods under sanitary conditions. The facility failed to ensure food and dietary supplements used for resident consumption was not expired. There were 35 facility residents who were provided dietary supplements from the facility's kitchen and nursing stations.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice by failing to ensure device site care orders were obtained for 1 (#56) of 3 (#25, #39, and #56) residents reviewed for indwelling devices.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure a resident's code status matched and was maintained throughout the clinical record for 1 (Resident #63) of 25 residents reviewed for code status in the initial screening.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection for 1 (#25) of 3 (#25, #56, and #270) resident's reviewed for infection control. The facility failed to ensure staff wore proper Personal Protective Equipment (PPE) while providing care to a resident who was on Enhanced Barrier Precautions (EBP).

Inspectors wroteBased on observation and interviews, the facility failed to ensure nurse staffing data requirements were documented on daily postings. This deficient practice had the potential to affect any of the 71 residents residing in the facility.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a Discharge/Transfer MDS assessment was completed and transmitted timely for 1 (#65) of 1 (#65) resident reviewed for Resident Assessment.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents with hand contractures had an appropriate call light to notify staff for assistance for 1 (#2) of 2 (#2 and R2) residents reviewed with contractures.

Inspectors wroteBased on interviews and record review, the facility failed to ensure resident assessments accurately reflected the resident's status for 1 (#1) of 3 (#1, #2, and #3) residents reviewed for Resident Assessment.

Inspectors wroteF689 Based on observations, interviews and record review, the facility failed to implement appropriate interventions, to monitor effectiveness of interventions, and to modify interventions following a fall for 1 (#2) of 3 (#1, #2, and #3) residents reviewed for falls. The facility failed to: 1. Ensure the bed remained in the low position for Resident #2; and 2. Implement new or appropriate safety interventions after each fall for Resident #2.

Inspectors wroteBased on interviews and record review, the facility failed to ensure a resident's physician/ physician's representative and responsible party were notified after a resident fall for 1 (#3) of 3 (#1, #2, and #3) residents reviewed for falls.