Lafon Nursing Facility of the Holy Family

Inspectors wroteBased on interviews and record reviews, the facility failed to maintain the resident's right to confidentiality of their medical records for 80 (Resident #1, Resident #2, Resident #3, Resident #R4, Resident #R5, Resident #R7, Resident #R8, Resident #R9, Resident #R10, Resident #R11, Resident #R12, Resident #R13, Resident #R14, Resident #R15, Resident #R16, Resident #R17, Resident #R18, Resident #R19, Resident #R20, Resident #R21, Resident #R22, Resident #R23, Resident #R24, Resident #R25, Resident #R26, Resident #R27, Resident #R28, Resident #R29, Resident #R30, Resident #R31, Resident #R32, Resident #R33, Resident #R34, Resident #R35, Resident #R36, Resident #R37, Resident #R38, Resident #R39, Resident #R40, Resident #R41, Resident #R42, Resident #R43. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received the correct enteral feeding (liquid nutrition that was administered through a tube directly into the stomach) for 1 (Resident #3) of 1 sampled residents investigated for enteral feedings.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure the medication error rate was not greater than 5 percent by having a medication error rate of 29 percent for 1 (Resident #R4) of 8 sampled residents observed during medication administration.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a resident received medications as ordered by the physician for 1 (Resident #2) of 3 sampled residents records reviewed for pharmaceutical services.

Inspectors wroteBased on observations, interview, and record reviews, the facility failed to ensure nurses documented the administration of enteral feeding (liquid nutrition that was administered through a tube directly into the stomach) for 1 (Resident #3) of 1 sampled residents investigated for enteral feedings.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the S6Treatment Nurse completed appropriate hand hygiene when performing wound care for 1 (Resident #1) of 1 sampled residents observed for infection control practices during wound care.

Inspectors wroteBased on interview and record reviews, the facility failed to ensure the facility's Certified Nursing Assistants (CNAs) received no less than 12 hour of in-services per year for 1 (S12CNA) of 4 sampled CNA's personnel records reviewed for training requirements.

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

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure:1. Enhanced Barrier Precaution (EBP) signage was posted in a conspicuous place to identify a resident on EBP (Resident #3); and,2. Staff wore proper protective equipment (PPE) for EBP during high contact patient care activities (Resident #3). This deficient practice was identified for 1 (Resident #3) of 3 sampled residents reviewed for resident quality of care.

Inspectors wroteBased on observations and interviews, the facility failed to ensure residents in semiprivate rooms had a ceiling suspended curtain around the bed for 2 (Resident #3, Resident #R4) of 4 sampled residents observed for environmental requirements.

Inspectors wroteBased on observation and interviews, the facility failed to ensure staff followed the manufacturer's instructions for the 3 compartment sink to correctly sanitize dishware.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure resident MDS (Minimum Data Set) assessments were completed accurately and reflected the resident's status for 2 (Resident #6, Resident #9) of 19 (Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #9, Resident #11, Resident #12, Resident #13, Resident #20, Resident #24, Resident #28, Resident #52, Resident #67, Resident #71, Resident #81, Resident #83, Resident #84) sampled residents reviewed for MDS accuracy.

Inspectors wroteBased on interviews and record reviews, the facility failed to: 1. Ensure a referral to home health was completed prior to a resident's discharge as ordered (Resident #1); and, 2. Clarify a resident's discharge order to ensure a resident had all the necessary supplies and equipment for Percutaneous Endoscopic Gastrostomy (PEG) tube (a feeding tube inserted directly into the stomach through a small incision in the abdomen) feeding before the resident was discharge home (Resident #1). This deficient practice was identified for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) sampled residents investigated for discharge requirements.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure transfer or discharge reports were completed for 3 (Resident #1, Resident #2, Resident #3) of 3 (Resident #1, Resident #2, Resident #3) sampled residents investigated for transfer and discharge requirements.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a notice of employees' rights against retaliation for reporting crimes against residents was posted in a conspicuous location.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure an allegation of abuse was reported to the State Survey Agency within the required two hours for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) sampled residents investigated for abuse.

Inspectors wroteBased on interviews and record reviews, the facility failed to complete a performance review within 12 months for 1 (S8Certified Nursing Assistant [CNA]) of 5 (S7CNA, S8CNA, S9CNA, S10CNA, S11CNA) personnel records reviewed.

Inspectors wroteBased on interviews and record review, the facility failed to ensure monthly weights were documented for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) sampled residents investigated for nutrition.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a Discharge/Transfer Minimum Data Set (MDS) assessment was completed and transmitted timely for 1 (Resident #66) of 3 (Resident #12, Resident #66, and Resident #80) residents reviewed for resident assessment.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure the accuracy of a Minimum Data Set (MDS) assessment for 1 (Resident #12) of 3 (Resident #12, Resident #66, and Resident #80) sampled residents reviewed.

Inspectors wroteBased on record reviews and interviews, the facility failed to complete performance reviews and provide in-service education based on the outcome of these reviews annually for 2 (S5Certified Nursing Assistant [CNA], S6Receptionist [Rec]) of 3 (S4CNA, S5CNA, S6Rec) ) sampled unlicensed personnel. Findings; Review of S4CNA's personnel record revealed, in part, a hire date of 03/27/2024. Further review of S4CNA's personnel record revealed no documented evidence and the provider did not present any documented evidence of an annual performance evaluation for S4CNA. Review of S5CNA's personnel record revealed, in part, a hire date of 10/03/2022. Further review of S5CNA's personnel record revealed no documented evidence and the provider did not present any documented evidence of an annual performance evaluation for S5CNA. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to keep a resident's environment free of accidents/hazards by failing to ensure the facility's staff used mechanical lift slings that were in good condition for 2 (Resident #3 and Resident #R4) of 4 (Resident #1, Resident #2, Resident #3, Resident #R4) residents investigated for mechanical lift transfers. This deficient practice resulted in an Immediate Jeopardy situation on 04/12/2024 at 4:10 p.m. for Resident #3, when S6Certified Nursing Assistant (CNA) and S10CNA transferred Resident #3 using a mechanical lift, the mechanical lift sling's strap broke, and Resident #3, hit her head when she fell to the floor and had to be sent to the emergency room (ER). [...]

Inspectors wroteBased on record reviews, observations, and interview, the facility failed to ensure staff placed a floor mat on the floor while a resident was in bed per a resident's plan of care as a safety precaution for 1 (Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents.

Inspectors wroteBased on record reviews, observation, and interviews, the facility failed to ensure a physician's order for pain medication was transcribed to the medical record for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) records reviewed.

Inspectors wroteBased on record reviews, observations, and interviews, the facility failed to: 1. Ensure a resident's pressure ulcer (a wound caused by pressure) wound assessments were completed at least weekly for 2 (Resident #48 and Resident #289) of 4 (Resident #3, Resident #17, Resident #48, and Resident #289) sampled residents investigated for pressure ulcers; and, 2. Ensure a resident's pressure ulcer wound care was performed per physician's orders for 1 (Resident #289) of 4 (Resident #3, Resident #17, Resident #48, and Resident #289) sampled residents investigated for pressure ulcers.

Inspectors wroteBased on record review and interview, the facility failed to establish and maintain a method of communication with the contracted dialysis facility for 1 (Resident #67) of 1 (Resident #67) sampled residents reviewed for dialysis services.

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

Inspectors wroteBased on record review, observations, and interviews, the facility failed to: 1. Ensure staff used fresh water and a clean towel when performing incontinence care for 1 (Resident # 3) of the 1 sampled residents observed incontinence care; 2. Ensure staff changed their gloves and performed hand hygiene between wounds, when coming into contact with items in the environment, and between procedures for 4 (Resident #3, Resident #17, Resident #48, and Resident #289) of 4 (Resident #3, Resident #17, Resident #48, and Resident #289) sampled residents observed for wound care; 3. Ensure staff disinfected reusable medical equipment after use for 2 (Resident #1 and Resident #84) of 5 (Resident #1, Resident #84, Resident #48, Resident #8, and Resident #79) residents observed during medication administration.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN), form Centers for Medicare and Medicaid Services (CMS)-10055, was completed prior to the discontinuation of Medicare Part A services (short term skilled nursing care and/or rehabilitation) for 2 (Resident #56 and Resident #25) of 3 (Resident #56, Resident #25, and Resident #189) residents reviewed for termination of Medicare Part A services.

Inspectors wroteBased on observation and record review, the facility failed to ensure water accessible to residents did not exceed 120 degrees Fahrenheit for 2 (Room a and Room b) of 5 (Room a, Room b, Room c, Room d, and Room e) rooms observed for water temperature.

Inspectors wroteBased on record reviews and interview, the facility failed to have documented evidence the Certified Nursing Assistant (CNA) Registry was performed prior to hire for 1 (S10CNA) of 5 (S10CNA, S11CNA, S12CNA, S13CNA, and S14CNA)personnel records reviewed for state registry verification reviews.

Inspectors wroteBased on record review, observation, and interview, the facility failed to: 1) Ensure the surface of the freezer floor was kept clean; 2) Ensure food was not stored on the freezer floor; and, 3) Ensure food available for use was dated, labeled, and not left open to air.

Inspectors wroteBased on record review and interview the facility failed to immediately notify the responsible party of a change in skin condition to Resident's #1's right lower extremity for 1 (Resident#1) of 4 (Resident #1, Resident #2, Resident #3, and Resident #4 ) sampled residents.