Every finding on record at Northwest Louisiana Veterans Home

Based on record review, observations, and interview, the facility failed to ensure correct use and maintenance of bed rails by ensuring residents were assessed for the risk of entrapment from bed rails, and failing to obtain an informed consent from resident or resident representative prior to installation for 1 (#60) out of 1 (#60) resident reviewed for accidents. Findings: Review of the facility's Restraint Policy with a revision date of 06/2024 revealed the following: 3. Residents must be assessed for use of appropriate restraint/safety device to meet their particular needs. An assessment of the use of bed rails may also be needed if half, three-quarter, or full bedrails are being used. Enablers such as rails may be used for aiding in turning and repositioning, assisting with transfers and providing a feeling of comfort and security for the resident. The side rails should not limit the resident's movement in and out of bed. Review of Resident #60's medical record revealed an admit date of 06/07/2025 with diagnoses of but not limited to generalized anxiety disorder, muscle weakness, repeated falls, essential hypertension, gastric reflux disease, dementia, dysphagia, anemia, age-related physical debility, and history of fracture of right femur. Observation on 06/16/2025 at 8:30 a.m. revealed Resident #60 in bed with side rails raised at head of bed. Observation on 06/17/2025 at 1:00 p.m. revealed Resident #60 in bed with side rails up at the head of bed. Review of Resident #60's MDS (minimum data set) dated 06/06/2025 revealed Resident #60 had a BIMS (brief interview mental status) score of 5 indicating severely impaired cognition. Review of Resident #60's medical record failed to reveal an assessment for risk of entrapment from bed rails and a signed consent for bed rails prior to installation had been done. During an interview on 06/18/2025 at 10:00 a.m. S5 Skilled Unit Manager confirmed Resident #60 had side rails in use and did not have an assessment for risk of entrapment and a signed consent for side rail use prior to bed installation.

Based on record review and interviews, the facility failed to ensure a resident with an order for psychotropic medication as needed (PRN) was not subjected to chemical restraints for 1 (#4) of 5 (#3, #4, #5, #7 and #160) residents reviewed for unnecessary medications. The facility failed to ensure Resident #4's PRN order for psychotropic medication was limited to 14 days. Findings: Review of Resident #4's medical record revealed an admission date of 03/28/2025 with diagnoses which included metabolic encephalopathy and anxiety disorder. Review of Resident #4's physician orders revealed an order dated 03/31/2025 for Vistaril (a medication used to treat the symptoms of anxiety) 25 mg (milligram) po (by mouth) q (every) 6 hours prn for anxiety without a stop date. Review of Resident #4's June 2025 MAR (Medication Administration Record) revealed in part, Resident #4 received Vistaril on 06/01/2025 at 7:57 a.m., 06/05/2025 at 7:51 a.m., 06/06/2025 at 3:50 p.m., 06/10/2025 at 5:57 p.m. and 06/14/2025 at 5:43 p.m. During an interview on 06/18/2025 at 9:00 a.m., S5Skilled Unit Manager acknowledged Resident #4 had an order in place for prn Vistaril which did not have a stop date. During an interview on 06/18/2025 at 9:30 a.m., S2DON (Director of Nursing) acknowledged Resident #4 had an order for prn Vistaril for anxiety greater than 14 days and did not have a stop date.

Based on record reviews and interview the facility failed to ensure residents were provided information regarding formulation of an Advance Directive upon their admission for 5 (#3, #4, #5, #7 and #60) of 6 initial pool residents. Findings: Resident #3 Review of Resident #3's medical record revealed an admission date of 03/27/2025. Review of Resident #3's medical record failed to reveal documentation that Resident #3 and/or Resident #3's representative received information regarding advance directives. Resident #4 Review of Resident #4's medical record revealed an admission date of 03/28/2025. Review of Resident #4's medical record failed to reveal documentation that Resident #4 and/or Resident #4's representative received information regarding advance directives. Resident #5 Review of Resident #5's medical record revealed an admission date of 06/23/2025. Review of Resident #5's medical record failed to reveal documentation that Resident #5 and/or Resident #5's representative received information regarding advance directives. Resident #7 Review of Resident #7's medical record revealed an admission date of 04/02/2025. Review of Resident #7's medical record failed to reveal documentation that Resident #7 and/or Resident #7's representative received information regarding advance directives. Resident #60 Review of Resident 60's medical record revealed an admission date of 06/07/2025. Review of Resident #60's medical record failed to reveal documentation that Resident #60 and/or Resident #60's representative received information regarding advance directives. During an interview on 06/17/2025 at 3:00 p.m., S4Assistant Administrator acknowledged Residents #3, #4, #5, #7 and #60 were not provided written information regarding the formulation of an Advance Directive and should have been.

Based on record reviews and interviews the facility failed to ensure residents and/or residents' RP (Responsible Party) were informed of the risks, benefits and side effects of psychotropic/antipsychotic medications for 3 (#4, #5 and #7) of 5 (#3, #4, #5, #7 and #160) residents reviewed for unnecessary medications. Findings: Resident #4 Review of Resident #4's medical record revealed an admission date of 03/28/2025 with diagnoses which included metabolic encephalopathy and anxiety disorder. Review of Resident #4's physician orders revealed Resident #4 received the psychotropic medication Vistaril 25 mg (milligram) po (by mouth) q (every) 6 hours prn (as needed) for anxiety. Further review of Resident #4's medical record failed to reveal documentation of a consent for the use of psychotropic medication. During an interview on 06/18/2025 at10:40 a.m., S5Skilled Unit Manager acknowledged Resident #4 did not have a consent in place for the use of Vistaril and should have. Resident #5 Review of Resident 5's medical record revealed an admission date of 06/03/2025 with diagnoses which included unspecified dementia, major depressive disorder and anxiety disorder. Review of Resident #5's physician orders revealed Resident #5 received the antipsychotic medication Zyprexa 5 mg po q hs (hour of sleep). Further review of Resident #5's medical record failed to reveal documentation of a consent for the use of antipsychotic medication. During an interview on 06/17/2025 at 2:10 p.m., S2DON (Director of Nursing) acknowledged Resident #5 did not have a consent in place for the use of Zyprexa and should have. During an interview on 06/18/2025 at 8:43 a.m., S2DON confirmed Resident #5 and/or RP had not been provided education in advance on the risks and benefits of taking Zyprexa. Resident #7 Review of Resident 7's medical record revealed an admission date of 04/02/2025 with diagnoses which included type 2 diabetes and anxiety disorder. Review of Resident #7's physician orders revealed Resident #7 received the psychotropic medication Lexapro 10 mg po q day for anxiety disorder. Further review of Resident #7's medical record failed to reveal documentation of a consent for the use of psychotropic medication. During an interview on 06/18/2025 at 8:43 a.m., S2DON confirmed Resident #7 and/or RP had not been provided education in advance on the risks and benefits of taking Lexapro. S2DON further confirmed a consent had not been obtained upon admission to the skilled unit and should have been.

Based on record review and interview the facility failed to ensure a Physician/Nurse Practitioner (NP) or Resident Representative was notified after a resident had an in-house code and was transferred to the emergency room (ER) for 1 (Resident #1) of 3 (Resident #1, #2, and #3) sampled residents. Findings: Review of the facility's LDVA (Louisiana Department of Veteran Affairs) Veteran and Resident Manual dated 10/07/2022 revealed in part: I. Notification of changes: i. facility management must immediately inform the veteran's/resident's legal representative or an interested family member when there is: b. a significant change in the veteran's/resident's physical, mental, or psychosocial status (e.g. (for example), a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications); d. a decision to transfer or discharge the veteran/resident from the facility. Review of Resident #1's Medical Record revealed an admitted [DATE] with the following diagnoses, in part: acute respiratory failure with hypoxia, type 2 diabetes, major depressive disorder, anxiety disorder, pancreatic mass, and other pulmonary embolism. Review of Resident #1's Medical Record failed to reveal a Physician/NP or Resident Representative had been notified of Resident #1's in-house code and transfer toER on [DATE]. During a telephone interview on 04/09/2024 at 2:00 p.m., Resident #1's Representative reported family was not notified Resident #1 coded and was sent toER on [DATE]. During an interview on 04/09/2024 at 4:45 p.m., S3ADON (Assistant Director of Nursing), acknowledged the facility had not notified Resident #1's Representative of the code and transfer to ER and should have. During an interview on 04/11/2024 at 8:00 a.m., S2DON (Director of Nursing) verified documentation of notification of change could not be located in Resident #1's Medical Record. S2DON acknowledged Resident #1's Representative and Physician/NP should have been notified. During an interview on 04/11/2024 at 9:00 a.m., S1Administrator acknowledged Resident #1's Representative or Physician had not been notified of the change in condition and should have been notified. During an interview on 04/11/2024 at 2:15 p.m., S5NP could not confirm she had been notified of Resident #1 having been transferred to theER on [DATE].

Based on record reviews and interviews, the facility failed to ensure services provided by the facility met professional standards of quality. The facility failed to ensure Nursing staff accurately documented glucose checks for 1 (Resident #1) of 3 (Resident #1, #2, and #3) sampled residents. Findings: Review of the facility's Blood Glucose Monitoring policy with a revision date of 05/11/2023 revealed in part: I. Purpose: to provide a policy for accurate and timely monitoring of blood glucose levels. F. Blood Sugar Testing: Document results on the Medication Administration Record (MAR) . Review of Resident #1's Medical Record revealed an admitted [DATE] with the following diagnoses, in part: acute respiratory failure with hypoxia, type 2 diabetes, major depressive disorder, anxiety disorder, pancreatic mass, and other pulmonary embolism. Review of Resident #1's Physician orders revealed an order dated 01/23/2024, which read in part: Humulin R to house sliding scale bid (two times a day) - blood glucose finger stick: 200 - 250 = 2 units; 251 - 300 = 4 units; 301- 350 = 6 units; 351- 400 = 9 units . Review of Resident #1's MAR failed to reveal documentation of Resident #1's blood glucose levels ordered for 01/24/2024 at 4:00 p.m. and 01/25/2024 at 6:00 a.m. Review of Resident #1's Medical Record revealed a nurse's note by S3ADON (Assistant Director of Nursing) dated 01/25/2024 at 4:36 p.m., which read in part: S3ADON called to room for unresponsive resident (Resident #1). Respirations very shallow with agonal breathing and pulse very weak . Blood Sugar 404 . During an interview on 04/11/2024 at 2:15 p.m., S5NP (Nurse Practitioner) reported blood glucose levels should be documented on the resident's MAR each time the glucose is checked in order to track and trend a resident's blood sugar. During an interview on 04/11/2024 at 2:30 p.m., S2DON (Director of Nursing) confirmed she could not locate documentation of Resident #1's blood glucose levels ordered for 01/24/2024 at 4:00 p.m. and 01/25/2024 at 6:00 a.m. S2DON acknowledged blood sugar levels should be documented on the resident's MAR. S2DON confirmed if the blood sugar levels were not documented on the MAR there would be no way for the NP to evaluate Resident #1's blood sugars.

Based on record reviews, observations, and interviews the facility failed to provide respiratory care consistent with professional standards for 3 (#1, #3, #5) of 3 (#1, #3, #5) residents reviewed for respiratory care. The facility failed to ensure respiratory equipment was properly stored while not in use. Findings: Review of the Facility's Nebulizer Use policy revealed in part: III. Procedure B. After each use the nurse will: 3. Store nebulizer mask and tubing in plastic bag when not in use. Resident #1 An observation on 10/11/2022 at 8:35 a.m. revealed Resident #1's nebulizer mask lying on the bedside table and not stored in a plastic bag. During an interview on 10/11/2022 at 8:45 a.m. S4 RN (Registered Nurse) confirmed Resident #1's nebulizer mask was not stored properly in a plastic bag while not in use and should have been. Resident #3 An observation on 10/11/2022 at 8:30 a.m. revealed Resident #3's nebulizer mask lying in the bedside table drawer and O2 (oxygen) nasal cannula lying in Resident #3's wheelchair. Further observation revealed nebulizer mask and O2 nasal cannula were not stored in plastic bags. During an interview on 10/11/2022 at 8:45 a.m. S4 RN confirmed Resident #3's nebulizer mask and O2 nasal cannula were not stored properly in plastic bags while not in use and should have been. Resident #5 An observation on 10/11/2022 at 8:40 a.m. revealed Resident #5's O2 nasal cannula lying on the floor and not stored in a plastic bag. During an interview on 10/11/2022 at 8:45 a.m. S4 RN confirmed Resident #5's O2 nasal cannula was not stored properly in a plastic bag while not in use and should have been.

Based on record reviews and interviews, the facility failed to ensure a medical record reflected the resident's advance directive choices for 1 (#108) of 7 (#1, #2, #3, #5, #6, #107, #108) residents reviewed for advance directives. The facility failed to ensure Resident #108 had a signed physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: Review of the facility's Consent for Cardiopulmonary Resuscitation (CPR) policy revealed in part: IV. Procedure A. Upon admission to the facility, the resident will complete the Resident Consent for Cardiopulmonary Resuscitation At that time, the facility will determine the resident's code status; Full Code or No Code/DNR. C. If the resident has indicated No Code/DNR status, CPR will not be performed on the resident in the event of cardiopulmonary arrest and should not be done in the case of extreme emergency. A Do Not Resuscitate will be initiated by the resident's physician. F. For legal reasons, a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] on the bottom of the Consent for Cardiopulmonary Resuscitation . A verbal or telephone order is not acceptable . Review of Resident #108's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #108's medical record revealed a document titled Resident Consent for Cardiopulmonary Resuscitation, with DNR status chosen and signed by Resident #108's RP (Responsible Party) on [DATE]. Further review of Resident #108's Resident Consent for Cardiopulmonary Resuscitation failed to reveal a physician's signature. Review of Resident #108's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on [DATE] at 12:00 p.m. S2 LPN (Licensed Practical Nurse) acknowledged Resident #108 did not have a signed physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on [DATE] at 12:00 p.m. S3 Clerk reported Resident #108's Resident Consent for Cardiopulmonary Resuscitation was in a notebook awaiting physician's signature. During an interview on [DATE] at 12:15 p.m. S1 ADON (Assistant Director of Nursing) acknowledged Resident #108's DNR order had not been signed by a physician and was not valid. S1 ADON reported Resident #108's code status would be a full code until signed by a physician.

Based on observation, record reviews, and interview the facility failed to ensure vision assessments were correct for 1 (6) of 3 (6,11,31) residents reviewed for lack of correction for visual probems out of a stage 2 sample of 12 residents. Findings: Observation on 6/4/12 at 11:00 a.m. resident 6 was in his room in a wheelchair with eyeglasses in place. Review of the MDS (Minimum Data Set), reference date of 5/14/12, revealed resident 6 had impaired vision with no corrective lenses. During an interview on 6/6/12 at 2:20 p.m. S1 RN reviewed the MDS and stated resident 6 does wear glasses and the assessment was incorrect. Review of the care plan for resident 6 revealed a plan of care for impaired vision related to [MEDICATION NAME] Degeneration. One of the approaches were to ensure that glasses are clean, free from scratches and in good repair.

Based on observation and interview the facility failed to ensure residents' emergency call lights were functioning properly for 4 (#36, #20, #23, #28) of 16 (#1, #8, #26, #6, #37,#36, #20, #23, #28, #39, #13, #19, #40, #22, #9, #14) residents observed during Stage I out of a total of 16 residents who resided on the Medicare Hall. The facility failed to ensure the emergency bathroom call light cords were not wrapped around the grab bar rendering the call system non-functional (#36, #20, #23, #28). Findings: 1. Observation on 7/5/11 at 10:35 a.m. revealed the emergency call light cord in resident #36's bathroom was wrapped around the grab bar and did not activate the emergency bathroom call light when the cord was pulled. Further observation revealed the emergency call light had to be pushed down manually on the wall to activate it. Observation on 7/7/11 at 2:25 p.m. revealed the emergency call light cord in resident #36's bathroom was wrapped around the grab bar and did not activate the emergency bathroom call light when the cord was pulled. Further observation revealed the emergency call light had to be pushed down manually on the wall to activate it. During an interview on 7/7/11 at 2:25 p.m., CNA #S3 agreed the emergency call light cord was wrapped around the grab bar and she could not activate the emergency bathroom call light when she pulled the cord. She stated the cord should not have been wrapped around the grab bar. 2. Observation on 7/5/11 at 10:25 a.m. revealed the emergency call light cord in resident #23's bathroom was wrapped around the grab bar and did not activate the emergency bathroom call light when the cord was pulled. Further observation revealed the emergency call light had to be pushed down manually on the wall to activate it. Observation on 7/5/11 at 10:25 a.m. revealed the emergency call light cord in resident #20's bathroom was wrapped around the grab bar and did not activate the emergency bathroom call light when the cord was pulled. Further observation revealed the emergency call light had to be pushed down manually on the wall to activate it. Observations on 7/7/11 at 2:30 p.m. revealed the emergency call light cord in resident #20's and #23's bathroom was wrapped around the grab bar and did not activate the emergency bathroom call light when the cord was pulled. Further observation revealed the emergency call light had to be pushed down manually on the wall to activate it. 3. Observation during the environmental tour on 7/7/11 at 2:30 p.m. with the Maintenance Supervisor #S4 revealed the emergency bathroom call light cord in resident #28's bathroom was wrapped around the grab bar and #S4 agreed the emergency bathroom call light could not be activated with it wrapped around the grab bar.

Based on record review and interviews the facility failed to ensure residents were given notice prior to a roommate change for 2 of 2 (#36, 19) residents reviewed for exercise of rights related to notification prior to a roommate change out of a total of 3 resident that triggered for exercise of rights under Admission, Transfer, and Discharge Review. Findings: During an interview on [DATE] at 1:40 p.m. resident #19 stated he has had 2 or 3 different roommates in the last 9 months. Resident #19 stated he was not given notice of the roommate changes; "they just move them in and move them out." During an interview on [DATE] at 1:55 p.m., resident #36 stated his former roommate passed away a few weeks ago and he got a new roommate. Resident #36 stated no one told him he was getting a new roommate, but it was obvious when the staff started moving clothes into the room. Review of resident #19's record failed to reveal documentation regarding notification of roommate changes. Review of resident #36's record failed to reveal documentation that he was getting a new roommate. Review of the record for resident #39 (resident #36's roommate) revealed documentation that resident #39 was moved into resident #36's room on [DATE]. Review of the facility's policy for Transfer within Facility revealed a resident may be transferred to another unit or room when warranted by an improvement or deterioration in the resident's functional status and when ordered by the physician, if indicated. Review of the Transfer within Facility policy revealed the following procedures: A) Prior to any room change, except in emergency or delayed medical moves, the Staffing Team must send an e-mail or written memo/three part to the Administrator with copies to the DON, Medical Director, Assistant Administrator, and the Social Worker recommending the move. B) The Admissions Committee members will then discuss the move(s) at the next Admissions Committee Meeting and approve or disapprove the move(s). C) A physician's orders [REDACTED]. The unit nurse will notify the receiving unit nurse of the transfer. The unit nurse will document the move on the 24 Hour Unit Report form and on the Daily Unit Census Report. D) During normal working hours, the unit nurse will inform Social Services of the transfer. Social Services will notify the resident and /or his/her authorized representative of a change in room or roommate assignment. During an interview on [DATE] at 11:05 a.m. LPN #S6 stated there has to be a reason for the resident to be moved to a different room, then they talk with the resident or the family member and notify them of the room change. LPN #S6 stated they also have to notify Administration, Social Services, the Assistant Administrator and the final determination comes from the DON or ADON as to who moves. During an interview on [DATE] at 11:15 a.m. RN #S5 stated resident #19 did have roommate changes and that his last three roommates went to the hospital and expired at the hospital. RN #S6 stated documentation should be on the chart when a resident has a new roommate or a roommate changes rooms. RN #S6 stated the Social Worker #S7 was responsible for the non-skilled residents on the 300 hall. During an interview on [DATE] at 11:35 a.m. Social Services Director (SSD) #S8 stated she spoke with #S7 and he was unable to recall speaking with resident #19 about the changes in roommates. SSD #S8 further stated #S7 remembered speaking with resident #36's daughter, but did not notify resident #36 of the roommate change. SSD #S8 stated the resident should be informed anytime there is a change in room or a roommate change and the responsible party should also be notified. SSD #S8 reviewed the records for resident #19 and resident #36 and stated there was no documentation in either record of a roommate change or the resident being notified and there should have been.

Based on observation, record review and an interview the facility failed to create an accurate assessment of a resident 's dental needs for 1of 2 residents reviewed for dental services out of a total of 2 residents identified on the QCLI report for dental services. (#13) Findings: An observation on 7/5/11 at 3:30 p.m. revealed resident #13 had no teeth. Review of the admission MDS dated [DATE] section L, Oral/Dental status was documented at Z = x that indicated None of the above were present (A. broken or loosely fitting full or partial denture, B. no natural teeth or tooth fragments, C. abnormal mouth tissue, D. obvious or likely cavity or broken natural teeth, E. inflamed or bleeding gums or loose natural teeth, F. mouth or facial pain, discomfort or difficulty with chewing, G. unable to examine). During an interview on 7/07/11 at 2:31 p.m. #S5 RN agreed the MDS was coded incorrectly for dental status.