The Encore Healthcare and Rehabilitation Center

Inspectors wroteBased on record review and interview, the facility failed to develop a person-centered comprehensive plan of care for 3 (#9, #73, #75) out of a final sample of 37 residents as evidenced by:1. Failing to develop a plan of care for Resident #9's hospice status, and;2. Failing to develop a resident centered comprehensive care plan for Resident #73 and #75. On 07/23/2025, a review of the facility's policy titled, Care Plan Policy and Procedure with a last reviewed date of 02/09/2025 read in part; A comprehensive person-centered care plan will be completed according to the RAI (Resident Assessment Instrument) manual upon admission, significant change, annual and as needed. [...]

Inspectors wroteBased on record review, observation, and interviews, the facility failed to promote resident's dignity during dining by standing over residents while assisting them to eat for 1 (Resident #67) of 37 sampled residents.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure a residents were safe to perform self-administration of medication for 1 (#61) out of 4 residents observed for medication administration.

Inspectors wroteBased on observations, record review and interview, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming for 1 (#25) out of 37 sampled residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide pharmaceutical services, including accurate administration of all drugs and accurately documenting controlled medication reconciliation as evidenced by:1 (#9) of 4 (#9, #36, #41, and #61) residents observed for administration of drugs, the facility failed to ensure Resident #9's Nifedipine was administered per manufacturer's recommendations, andin Med Cart C the facility failed to ensure Resident #79's controlled medication reconciliation was accurately maintained.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the medication error rate was less than 5%. A total of 33 opportunities were observed with 2 medication errors, which resulted in a medication error rate of 6.06%. FindingsA review of the facility's policy titled Medication Administration-General Guidelines which was last reviewed on 02/09/2025, read in part, Policy: Medications are administered as prescribed in accordance with good nursing principles and practices. vi. Tablet Crushing/Capsule Opening: Crushing tablets may require a physician's order. 1. Long-acting or enteric-coated dosage forms should not be crushed; an alternative should be sought. 2. Administration: b. Medications are administered in accordance with written orders of the prescriber. Review of Pfizer Medical.com (Procardia XL Manufacture website), in part: Dosage and Administration. [...]

Inspectors wroteBased on observations and interviews, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles by failing to discard an expired medication in 1 (Med Cart C) of 2 (Med Cart B and Med Cart C) medication carts sampled for medication storage.

Inspectors wroteBased on record review, policy review, and interviews, the facility failed to implement its policy for incident investigation and reporting when staff failed to immediately report alleged staff-to-resident physicall abuse to administrative staff and failed to notify the resident's responsible party (RP) for 1 (#3) out of 7(#1, #2, #3, #R1, #R2, #R3 and #R4) sampled residents.

Inspectors wroteBased on policy review, record review and interviews, the facility failed to ensure reportable incidents of an allegation of staff to resident physical abuse was reported to the State Survey Agency within 2 hours after the allegation was made for 1 (#3) of 7 (#1, #2, #3, #R1, #R2, #R3 and #R4) sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure a Discharge Minimum Data Set (MDS) assessment was completed timely for 1(Resident #38) out of 35 sampled residents investigated.

Inspectors wroteBased on record review and interview, the facility failed to ensure accuracy of the documentation entered into the resident's record for 2 (#35, #71) residents in a final sample of 35 residents evidenced by: 1. inaccurately documenting a presence of a PEG (Percutaneous Endoscopic Gastrostomy) tube for Resident #35; 2. the nurse failing to document the correct reason as to why Resident #71 did not receive a scheduled medication, and another nurse failing to document that Resident #71 received an antibiotic injection immediately after administration per the facility's policy for medication administration.

Inspectors wroteBased on record review and interview, the facility failed to ensure the resident and/or resident's representative (RP) exercised the right to appropriately make informed decisions regarding the right to choose a provider of their preference for hospice services for 1 (#28) of 4 (#5, #7, #28, #42) residents investigated for hospice services in a final sample of 35 residents.

Inspectors wroteBased on record review and interview, the facility failed to accurately code all applicable diagnoses on two consecutive comprehensive MDS (Minimum Data Set) assessments for 1 (#41) of 35 final sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to refer a resident with a newly evident serious mental disorder to the appropriate state designated authority for Level II PASARR (Pre-admission Screening and Resident Review) evaluation and determination for 1 of 1 (#41) residents investigated for PASARR review in a final sample of 35 residents.

Inspectors wroteBased on observations, record review and interview, the facility failed to develop a comprehensive resident centered care plan for 1 (#324) of 35 final sampled residents by failing to develop nursing interventions to address edema to both lower extremities present upon Resident #324's nursing admission assessment.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide necessary care and services that is in accordance with professional standards of practice by failing to ensure oxygen was delivered at the ordered rate for 1 (#42) out of 3 (#12, #42, #71) resident reviewed for respiratory care out of a total sample of 35 residents.

Inspectors wroteBased on observations and interviews, the facility failed to ensure medications were labeled to reflect medication adjustments as the physician ordered for 1 (#55) resident. The deficiency had the potential to affect a census of 69 residents.

Inspectors wroteBased on interview, observations and record review the facility failed to ensure that pharmaceutical services provided to meet the needs of each resident were consistent with state and federal requirements and reflect current standards of practice as evidenced by failing to ensure medication was labeled as per physician orders for 1 (#20) resident. The deficiency had the potential to affect a census of 69 residents.

Inspectors wroteResident #39 Review of the resident electronic record revealed an admit date of 03/08/2022 with diagnoses that included Acute on chronic systolic congestive heart failure, and Unspecified protein calorie malnutrition. Review of Resident #39's physician orders dated 05/2023 read in part Metoprolol Tartrate 50 mg (milligrams) give 1 tab by mouth twice daily. Hold if blood pressure is less than or equal to 100 and or pulse is less than or equal to 60. Review of the Electronic Medication Administration Record (EMAR) dated 05/2023 revealed that on 05/02/2023, 05/07/2023, 05/10/2023, 0512/2023, 05/15/2023, 05/16/2023, and 05/23/2023 Resident #38 was administered Metoprolol Tartrate 50 mg when her pulse was 60. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure its medication rate was not 5 percent or greater as evidenced by a calculated medication error rate of 41.68%.

Inspectors wroteBased on observation, policy review and interview, the facility failed to ensure food products that were stored in compromised cans in the dry storage room were disposed of cans of seasonings were dated after being opened. This deficient practice has the potential to effect the 67 residents that eat meals in the facility.

Inspectors wroteBased on record review and interview, the facility failed to maintain an effective infection control and prevention program as evidenced by: 1. Failing to have an assessment process of the facility's water system in order to implement specific measures to prevent the growth of Legionella and other opportunistic waterborne pathogens in the building's water systems; 2. S15LPN(Licensed Practical Nurse) failing to apply gloves prior to administering Resident's #45 nasal spray and failing to perform appropriate hand hygiene prior to donning gloves during the medication pass, and 3. S13TX (Treatment Nurse) failing to maintain a sterile field, change gloves and sanitize her hands appropriately while performing tracheostomy care on Resident #11. The facility had a census of 68 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's plan of care reflected their advance directives for 2 (#39, #48) residents out of 2 residents investigated for advance directives. Resident #39 Resident #39 was admitted to the facility on [DATE] with diagnoses including Acute on Chronic Heart Failure, Essential Hypertension and Type 2 Diabetes. Review of Resident #39's EHR (Electronic Health Record) revealed the resident was a DNR (Do Not Resuscitate) and to allow natural death if she was unresponsive, pulseless and not breathing. Review of Resident #39's a LaPost (Louisiana Physician Orders for Scope of Treatment) dated [DATE] and advance directive declaration dated [DATE] revealed the resident's code status was DNR. Review of Resident #39's plan of care printed on [DATE] at 1:58 p.m. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to: 1. The nurse failed to notify a resident's physician of change in the resident's physical status when nurse failed to inform the physician of the recurrence of oral lesions; and 2. The CNA (Certified Nurse Assistant) failed to notify the nurse of multiple scratches to the abdomen and arm for 1 (#12) resident out of 45 sampled residents, of a total census of 68 residents.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to follow the plan of care for 1(#48) of 45 sampled residents. The deficient practice was evidenced by the facility failing to place Resident #48's O2 (oxygen) concentrator against the wall and securing the O2 concentrator cord.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that pain management was provided to residents who require such services, for 1 (#12) of 3 (#12, 23, 54) residents investigated for pain, of a total of 45 sampled residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure staff served the therapeutic diet prescribed by the physician for 1 (#28) of 4 (#12, #18, #28, #51) residents sampled for nutrition.

Inspectors wroteBased on observation and interview, the facility failed to protect confidential information for Resident #46 by failing to initiate the computer's privacy screen during a medication pass.