Inspection Reports for
Lakeview Manor Nursing and Rehabilitation Center
400 HOSPITAL ROAD, NEW ROADS, LA, 70760
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Inspection Report — Mar 12, 2025
Routine CMS
Date: Mar 12, 2025
Visit Reason
Routine state inspection of Lakeview Manor Nursing and Rehabilitation Center to assess compliance with healthcare regulations including resident care, safety, and infection control.
Findings
The facility had multiple deficiencies including failure to timely report verbal abuse allegations, incomplete and inaccurate resident assessments, failure to implement care plans especially for enteral feeding and fall prevention, medication storage issues, and inadequate infection control practices.
Deficiencies (13)
F 0609: Facility failed to timely report allegations of verbal abuse to the State Survey Agency within 2 hours for 1 resident.
F 0636: Facility failed to complete comprehensive Minimum Data Set (MDS) admission assessments within the required 14-day timeframe for 1 resident.
F 0641: Facility failed to ensure accurate resident assessments by miscoding discharge status and ostomy status for 2 residents.
F 0656: Facility failed to implement a resident's comprehensive care plan by not administering enteral feeding as ordered for 1 resident.
F 0657: Facility failed to review and revise a resident's care plan to reflect new aggressive behaviors for 1 resident.
F 0658: Facility failed to ensure nursing staff verified and accurately documented enteral feeding orders for 1 resident.
F 0677: Facility failed to provide scheduled bed baths for 1 resident dependent on staff for activities of daily living.
F 0689: Facility failed to implement effective fall interventions for 1 resident with a history of falls, including unsafe bed positioning.
F 0692: Facility failed to ensure a resident received enteral feedings as ordered, contributing to significant weight loss for 1 resident.
F 0726: Facility failed to ensure nursing staff competency in verifying and administering enteral feedings and in using appropriate PPE for Enhanced Barrier Precautions.
F 0761: Facility failed to ensure medication rooms and carts were free of expired supplements, loose pills, and unlabeled insulin pens.
F 0812: Facility failed to ensure food was properly dated, sealed, stored, and staff with facial hair wore beard restraints in the kitchen.
F 0880: Facility failed to ensure staff utilized appropriate PPE including gowns when providing care to residents on Enhanced Barrier Precautions for indwelling devices.
Report Facts
Residents reviewed for comprehensive assessments: 5
Residents reviewed for discharge: 2
Residents reviewed for appliances: 2
Residents reviewed with enteral feeding: 2
Residents reviewed for accidents: 4
Residents reviewed for ADLs: 3
Residents reviewed for accident hazards: 4
Residents reviewed for nutrition and/or enteral feeding: 4
Residents reviewed on Enhanced Barrier Precautions: 5
Residents residing in facility: 97
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S6RN | Registered Nurse | Named in findings related to enteral feeding administration errors and PPE noncompliance |
| S2DON | Director of Nursing | Named in findings related to staff competency and infection control oversight |
| S8LPN | Licensed Practical Nurse | Named in medication storage observations |
| S17CK | Cook | Named in food storage and safety observations |
| S4DM | Dietary Manager | Named in food storage and safety observations |
| S1ADM | Administrator | Named in interviews regarding fall prevention and food safety |
| S13NP | Nurse Practitioner | Named in interviews regarding enteral feeding orders and resident weight management |
Inspection Report — Sep 25, 2024
Complaint Investigation CMS
Date: Sep 25, 2024
Visit Reason
The inspection was conducted based on complaints regarding failure to notify resident representatives of significant changes in condition, incomplete and inaccurate medical record documentation, and failure to maintain an infection prevention and control program.
Complaint Details
The complaint investigation found substantiated failures related to notification of resident representative, documentation of resident condition and medication administration, and infection control practices.
Findings
The facility failed to notify a resident's representative of a significant change in condition, failed to document the resident's change in condition, provider notification, and medication administration, and failed to ensure staff wore proper PPE for a resident on Enhanced Barrier Precautions.
Deficiencies (3)
F 0580: The facility failed to ensure nursing staff notified the resident's representative of a significant change in condition for Resident #1 on 08/27/2024.
F 0842: The facility failed to maintain complete and accurate medical records for Resident #1, including documentation of change in condition, provider notification, and administration of Zofran on 08/27/2024.
F 0880: The facility failed to maintain an infection prevention and control program by not ensuring staff wore proper PPE for Resident #2 on Enhanced Barrier Precautions during urinary catheter care.
Report Facts
Residents Affected: 1
Residents Affected: 1
BIMS Score: 4
BIMS Score: 3
Inspection Report — Apr 25, 2024
Annual Inspection CMS
Date: Apr 25, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident assessments, PASRR screening, fall prevention, infection control, and overall resident safety.
Findings
The facility failed to ensure accurate resident assessments, maintain PASRR Level 1 pre-admission screening documentation, provide adequate supervision to prevent falls, and maintain proper infection prevention and control practices including PPE use.
Deficiencies (4)
F0641: The facility failed to ensure Resident #28's Minimum Data Set yearly assessment was accurately coded for PASRR Level II and Resident #15's MDS assessments did not reflect the use of a bed alarm despite its use.
F0645: The facility failed to maintain a record of the Level 1 PASRR pre-admission screening form for Resident #6, which is required to ensure accurate screening prior to admission.
F0689: The facility failed to ensure adequate supervision and staff rounding every 2 hours to prevent falls for Resident #15, who had multiple documented falls and was not rounded on during critical times.
F0880: The facility failed to maintain an infection prevention and control program by not ensuring S5CNA wore proper PPE, specifically a gown, while providing incontinent care to Resident #42 on Enhanced Barrier Precautions.
Report Facts
Falls documented: 11
Residents reviewed for PASRR: 4
Residents reviewed for falls: 3
Residents on Enhanced Barrier Precautions: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S3MDS | Confirmed Resident #28 and #15 MDS coding issues. | |
| S4MDS | Confirmed Resident #28 MDS coding issues. | |
| S2DON | Director of Nursing | Confirmed MDS coding issues, PASRR screening responsibility, fall risk supervision expectations, and PPE requirements. |
| S6CNA | Certified Nursing Assistant | Assigned to Resident #15; admitted failure to round every 2 hours. |
| S7LPN | Licensed Practical Nurse | Assigned to Resident #15; confirmed fall risk and need for 2-hour rounding. |
| S8CNA | Certified Nursing Assistant | Assigned to Resident #15 on 04/22/2024; failed to round every 2 hours. |
| S10SW | Social Worker; confirmed missing PASRR Level 1 form for Resident #6. | |
| S5CNA | Certified Nursing Assistant | Failed to wear gown during incontinent care for Resident #42 on Enhanced Barrier Precautions. |
| S1ADM | Administrator | Reviewed video footage confirming failure to round on Resident #15. |
| S9CNAS | Certified Nursing Assistant Supervisor | Verified failure to round on Resident #15 by S8CNA. |
Inspection Report — May 17, 2023
Complaint Investigation CMS
Date: May 17, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to ensure accurate documentation of residents' code status and sanitary food storage practices.
Complaint Details
The investigation was complaint-driven, focusing on inaccurate documentation of Resident #149's code status and unsanitary food storage conditions. Resident #149's wishes were substantiated as Full Code, contradicting facility records indicating DNR.
Findings
The facility failed to ensure Resident #149's code status was accurately documented, showing conflicting orders and chart labels. Additionally, the facility failed to store and label food properly in the kitchen, risking food safety for residents.
Deficiencies (2)
F 0578: The facility failed to ensure Resident #149's medical records consistently reflected her code status wishes, with documentation showing DNR orders despite her stated preference for Full Code.
F 0812: The facility failed to store and label food properly in the walk-in freezer, refrigerator, and dry storage room, including unlabeled opened food and expired items.
Report Facts
Residents reviewed for Advanced Directives: 32
Residents affected by food storage deficiency: 96
Expired chocolate milk cartons: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S3LPN | Interviewed regarding code status sticker on Resident #149's chart | |
| S2DON | Interviewed confirming Resident #149's code status wishes and documentation errors | |
| S1ADM | Interviewed confirming expectations for accurate code status documentation | |
| S4DM | Interviewed and responsible for ensuring staff compliance with food storage policy |
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