Nottingham Regional Rehab Center

F-F684

On 06/04/2024 at 12:30 p.m., an interview was conducted with S2DON. She stated she was unaware who was responsible for PEG and nephrostomy dressing changes or where it was charted.

On 06/05/2024 at 11:00 a.m., an interview was conducted with S16UM. She stated for residents who had PEG tubes and nephrostomy tubes, there would be an order which read, Monitor site q shift. She stated nurses should monitor those sites for redness, swelling, tenderness, and drainage. She stated floor nurses were responsible for changing dressings to PEG tube and nephrostomy tube sites. She stated all residents who had PEG tubes had a split gauze dressing to the site. She stated nurses should change PEG tube dressings daily and as needed. She stated orders for nephrostomy dressing changes would come from the doctor. She stated it was the floor nurses responsibility to change the nephrostomy dressing as ordered. She stated every morning herself, S14WC, S15ADON and S2DON met together for a morning meeting and discussed all newly admitted residents and reviewed their orders to ensure they were appropriate.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 30 195488 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 195488 B. Wing 06/10/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

White Oak Post Acute Care 2828 Westfork Baton Rouge, LA 70816

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 On 06/05/2024 at 11:22 a.m., an interview was conducted with S15ADON. She stated she was responsible for putting the admission orders in for Resident #1 and ensuring they were correct. She stated she did not Level of Harm - Immediate receive orders to change the dressing for Resident #1's nephrostomy tube upon admission. She confirmed jeopardy to resident health or she should have called the doctor to obtain orders for the nephrostomy tube dressing changes and did not. safety She stated she did not enter orders to monitor the sites for Resident #1's PEG tube and nephrostomy tube and should have. Residents Affected - Few

On 06/05/2024 at 2:38 p.m., an interview was conducted with S2DON. She stated S15ADON or S16UM were responsible for putting in orders for newly admitted residents. She stated any resident who had an indwelling device, such as a PEG tube or nephrostomy tube needed to have orders to monitor the site and orders for dressing changes. She reviewed Resident #1's physician orders and confirmed the resident did not have orders to monitor the sites or change the dressings for the PEG tube and nephrostomy tube sites.

She confirmed when an order was not obtained or entered into the residents electronic medical record, it did not populate in the MAR or TAR for the nurses to complete. She confirmed there was no documentation Resident #1's PEG site and nephrostomy site had been monitored and dressing changes performed. She stated Resident #1's nephrostomy site and PEG site should have been monitored and any concerns reported to the Nurse Practitioner. She confirmed Resident #1 should have had dressing changes completed to the PEG and nephrostomy tube sites.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 30 195488 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 195488 B. Wing 06/10/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

White Oak Post Acute Care 2828 Westfork Baton Rouge, LA 70816

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0837 Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing Level of Harm - Minimal harm or the facility. potential for actual harm 44590 Residents Affected - Many Based on interviews and record review, the facility failed to ensure the administrator reported to and was accountable to the governing body. S1ADM failed to ensure the facility's QAPI program was maintained.

This deficient practice had the potential to affect a census of 87 residents.

Findings:

A review of the facility's undated policy, Quality Assurance and Performance Improvement (QAPI), as of 06/10/2024, revealed, in part, the following:

11. Governance and leadership:

a. The governing body and/or executive leadership is responsible and accountable for the QAPI program.

b. Governing oversight responsibilities include, but are not limited to the following:

ii. Ensuring the program is ongoing, defined, implemented, maintained, and addresses identified priorities.

iii. Ensuring the program is sustained during transitions in leadership and staffing.

c. The QA Committee shall communicate its activities and the progress of its subcommittee PIPs to the governing body at least quarterly.

A review of the facility's QAPI Committee Members revealed, in part, the following:

Medical Director;

Administrator;

Director of Nursing;

Assistant Director of Nursing;

MDS Nurse(s)

Dietary Manager;

Maintenance Manager;

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 30 195488 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 195488 B. Wing 06/10/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

White Oak Post Acute Care 2828 Westfork Baton Rouge, LA 70816

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0837 Housekeeping Manager; and

Level of Harm - Minimal harm or Human Resources Manager. potential for actual harm

An interview was conducted on 06/10/2024 at 3:05 p.m. with S1ADM. He confirmed S2DON was responsible Residents Affected - Many for the facility's QAPI Program. He confirmed he did not have anything to do with the QAPI Program since he began this position.

A review of the facility's QAPI Program was attempted on 06/10/2024 with no documentation provided for review.

An interview was conducted on 06/10/2024 at 3:10 p.m. with S2DON. She confirmed she was responsible for

the facility's QAPI Program. She confirmed the facility had not held their quarterly QAPI Committee Meetings with the Medical Director since the previous administrator left in February 2024.

An interview was conducted on 06/10/2024 at 3:45 p.m. with S10RCN. She confirmed S2DON was expected to report to her. She confirmed quarterly QAPI Committee Meetings with the facility's Medical Director in attendance should have been conducted per company policy. She confirmed corporate was not made aware

the facility had not been conducting meetings per company policy.

An interview was conducted on 06/10/2024 at 4:45 p.m. with S21RD. She stated the facility's governing body contracted the management company she worked for to manage and run the facility's day to day operations.

She stated the management company, on behalf of the governing body, expected S1ADM to report to her.

She confirmed S1ADM had not made her aware the facility was not conducting QAPI Meetings per company policy and should have.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 30 195488 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 195488 B. Wing 06/10/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

White Oak Post Acute Care 2828 Westfork Baton Rouge, LA 70816

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0838 Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Level of Harm - Minimal harm or potential for actual harm 44590

Residents Affected - Many Based on record review and interview, the facility failed to complete a facility-wide assessment to determine what resources were necessary to care for the residents competently during both day-to-day operations and emergencies.

This deficient practice had the potential to affect a census of 87 residents.

Findings:

Review of the facility's CMS 672, dated 06/10/2024, revealed, in part, the following:

Total Residents (F78): 87

A. Bladder Status

Indwelling or external catheter: 10

Occasionally or frequently incontinent of bladder: 45

Occasionally or frequently incontinent of bowel: 39

B. Mobility

Ambulation with assistance or assistive device: 4

C. Mental Status

Documented signs and symptoms of depression: 6

Documented psychiatric diagnosis: 26

Dementia or Alzheimer's disease: 5

Behavioral healthcare needs: 15

D. Skin Integrity

Pressure ulcers: 14

Receiving preventative skin care: 83

E. Special Care

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 30 195488 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 195488 B. Wing 06/10/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

White Oak Post Acute Care 2828 Westfork Baton Rouge, LA 70816

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0838 Hospice Care: 4

Level of Harm - Minimal harm or Chemotherapy: 1 potential for actual harm Dialysis: 7 Residents Affected - Many IV therapy: 5

Respiratory treatment: 4

Ostomy care: 7

Injections: 21

Tube feedings: 3

Mechanically altered diets: 17

Rehabilitative services: 62

Assistive devices while eating: 6

F. Medications

Any psychoactive medication: 39

Antipsychotic medications: 21

Antianxiety medications: 7

Antidepressant medications: 30

Antibiotics: 5

Pain management program: 22

G. Other

Who do not communicate in the dominant language of the facility: 1

Review of the facility's Facility Assessment Tool, as of 06/06/2024, revealed, in part, the following:

Date of Assessment or Update: 05/14/2024

1.3 Diseases, Conditions, Physical and Cognitive Disabilities:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 30 195488 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 195488 B. Wing 06/10/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

White Oak Post Acute Care 2828 Westfork Baton Rouge, LA 70816

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0838 Indicate if you accept residents or if current residents have or may develop, the following common conditions that require complex medical care and management. Additional common diagnoses may be added in blank Level of Harm - Minimal harm or spaces provided. potential for actual harm Psychiatric/Mood Disorders - Blank; Residents Affected - Many Heart/Circulatory System - Blank;

Neurological System - Blank;

Vision - Blank;

Musculoskeletal System - Blank.

Neoplasm - Blank;

Metabolic Disorders - Blank;

Respiratory System - Blank;

Genitourinary system - Blank;

Diseases of Blood - Blank;

Digestive System - Blank;

Integumentary System - Blank; and

Infectious Diseases - Blank.

2.1 Resident Support/Care Needs:

List the types of care that your resident population requires and that you provide for your resident population. List by general categories, adding specifics as needed. The intent is to identify and reflect on resources needed to provide these types of care.

General Care: Highlight and check all that apply.

Activities of Daily Living - Blank;

Mobility and Fall/Fall with Injury Prevention - Blank;

Bowel/Bladder - Blank;

Skin Integrity - Blank;

Mental Health and Behavior - Blank;

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 30 195488 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 195488 B. Wing 06/10/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

White Oak Post Acute Care 2828 Westfork Baton Rouge, LA 70816

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0838 Medications - Blank;

Level of Harm - Minimal harm or Pain Management - Blank; potential for actual harm Infection Prevention and Control - Blank; Residents Affected - Many Management of Medical Conditions - Blank;

Therapy - Blank;

Other Special Care Needs - Blank;

Nutrition - Blank; and

Provide Person-Centered/Directed Care: Psycho/Social/Spiritual Support - Blank.

3.1 Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies:

Administration - Blank; Nursing Services - Blank;

Food and Nutrition Services - Blank;

Therapy Services - Blank;

Medical/Physician Services - Blank;

Pharmacist - Blank;

Behavioral and Mental Health Providers - Blank;

Support Staff - Blank;

Chaplain/Religious Services - Blank;

Volunteers/Students - Blank; and

Other - Blank.

3.8 Physical Environment and Building/Plant Needs:

List physical resources for the following categories. Describe your processes to ensure adequate supplies and to ensure equipment is maintained to protect and promote the health and safety of residents.

Services (Waste management, hazardous waste management, telephone, HVAC, dental, barber/beauty, pharmacy, laboratory, radiology, occupational, physical, respiratory and speech therapy, gift shop, religious, exercise, recreational music, art therapy, cafe'/snack bar/bistro.) - Blank;

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 30 195488 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 195488 B. Wing 06/10/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

White Oak Post Acute Care 2828 Westfork Baton Rouge, LA 70816

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0838 Other Physical Plant Needs (Sliding doors, ADA compliant entry/exit ways, nourishment accessibility, nurse call system, emergency power) - Blank; Level of Harm - Minimal harm or potential for actual harm Medical Supplies (Blood pressure monitors, compression garments, gloves, gowns, hand sanitizer, gait belts, infection control products, heel and elbow suspension products, suction equipment, thermometers, urinary Residents Affected - Many catheter supplies, oxygen, oxygen saturation machine, Bi-PAP, bladder scanner) - Blank; and

Non-medical Supplies (Soaps, body cleansing products, incontinence supplies, waste baskets, bed and bath linens, individual communication devices and computers) - Blank.

An interview was conducted on 06/06/2024 at 6:45 p.m. with S1ADM. He confirmed he was responsible for ensuring the facility assessment was completed and reviewed annually. He confirmed the areas documented above were left blank which did not accurately reflect the facility's current population and/or their needs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 30 195488 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 195488 B. Wing 06/10/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

White Oak Post Acute Care 2828 Westfork Baton Rouge, LA 70816

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0865 Have a plan that describes the process for conducting QAPI and QAA activities.

Level of Harm - Minimal harm or 44590 potential for actual harm Based on record review and interview, the facility failed to develop, implement and maintain an effective, Residents Affected - Many comprehensive, data-driven QAPI (Quality Assurance and Performance Improvement) program focused on indicators of the outcomes of care and quality of life.

This deficient practice had the potential to affect a census of 84 residents.

Findings:

A review of the facility's undated policy, Quality Assurance and Performance Improvement (QAPI), as of 06/10/2024, revealed, in part, the following:

Policy: It is the policy of this facility to develop, implement and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life.

Policy Explanation and Compliance Guidelines:

2. The QA Committee shall be interdisciplinary and shall:

b. Meet at least quarterly and as needed .

4. The facility will maintain documentation and demonstrate evidence of its ongoing QAPI program.

5. The plan and supporting documentation will be presented to the State Survey Agency . upon request.

A review of the facility's QAPI Committee Members revealed, in part, the following:

Medical Director;

Administrator;

Director of Nursing;

Assistant Director of Nursing;

MDS Nurse #1;

MDS Nurse #2;

Dietary Manager ;

Maintenance Manger;

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 30 195488 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 195488 B. Wing 06/10/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

White Oak Post Acute Care 2828 Westfork Baton Rouge, LA 70816

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0865 Housekeeping Manager; and

Level of Harm - Minimal harm or Human Resources Manager. potential for actual harm

A review of the facility's QAPI Plan and Supporting Documentation was attempted on 06/10/2024 with no Residents Affected - Many documentation produced for review.

An interview was conducted on 06/10/2024 at 3:05 p.m. with S1ADM. He confirmed S2DON was responsible for the facility's QAPI Program. He stated he did not have anything to do with the QAPI Program since he began this position, and confirmed he did not have any QAPI documentation.

An interview was conducted on 06/10/2024 at 3:10 p.m. with S2DON. She confirmed she was responsible for

the facility's QAPI Program. She confirmed she was unable to provide any of the facility's QAPI Meeting Minutes. She confirmed the facility had not held their quarterly QAPI Committee Meetings with the Medical Director since the previous administrator left in February 2024 and was not sure when the most recent meeting would have been held or what was discussed because she could not locate any documentation. She confirmed the facility should be able to produce this documentation and was not able to. She confirmed the facility should have been holding quarterly QAPI Committee Meetings with their Medical Director and they were not. She confirmed the facility's monthly internal QAPI meetings with department heads had not occurred either and should have.

An interview was conducted on 06/10/2024 at 3:45 p.m. with S10RCN. She confirmed quarterly QAPI Committee Meetings with the facility's Medical Director in attendance should have been conducted per company policy. She confirmed corporate was not aware the facility had not been conducting meetings per company policy. She confirmed if the facility was not following policy for the meetings, corporate should have been made aware.

An interview was conducted on 06/10/2024 with 4:45 p.m. with S21RD. She stated the facility's Governing Body was the Owner/CEO and the CFO. She stated the facility's Governing Body contracted the management company she worked for to manage and run the facility day to day. She stated the management company expected S1ADM to report to her and she had not been aware the facility was not conducting QAPI Meetings per company policy.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 30 195488 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 195488 B. Wing 06/10/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

White Oak Post Acute Care 2828 Westfork Baton Rouge, LA 70816

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0941 Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. Level of Harm - Minimal harm or potential for actual harm 44590

Residents Affected - Some Based on record review and interviews, the facility failed to ensure effective communication was performed as mandatory training for all direct care staff for 3 (S7CNA, S8CNA, S9CNA) of 5 (S5LPN, S6LPN, S7CNA, S8CNA, S9CNA) personnel files reviewed.

Findings:

Review of the facility's Facility Assessment Tool, as of 06/06/2024, revealed, in part, the following:

Date of Assessment or Update: 05/14/2024

3.4 Staff Training, Education and Competencies: Describe the staff training/education and competencies that are necessary to provide the level and types of support and care needed for your resident population.

Communication - All staff members are expected to be effective at communicating with each other, with residents, with family members and with other visitors to the facility.

Review of the facility's policy titled In-service Training, undated, revealed, in part, the following:

Policy Interpretation and Implementation:

1. All personnel will receive ongoing education as required by federal and state laws.

6. The director of nursing will maintain a planned annual schedule of in-services to be provided .

8. It is the responsibility of the director of nursing, or designee, to ensure that in-services and training provided by the facility are adequate to meet current standards of healthcare delivery and meet or exceed state and federal requirements.

Review of the facility's In-service titled Staff Meeting held 04/17/2024, revealed, in part, the following:

Summary of Contents: Customer Service.

No documented evidence S7CNA, S8CNA or S9CNA were present for the training on 04/17/2024.

Review of S7CNA's personnel file revealed a hire date of 12/16/2020. Further review of S7CNA's personnel file revealed no documented evidence S7CNA attended the mandatory training offered by the facility regarding effective communication.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 30 195488 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 195488 B. Wing 06/10/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

White Oak Post Acute Care 2828 Westfork Baton Rouge, LA 70816

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0941 Review of S8CNA's personnel file revealed a hire date of 03/06/2024. Further review of S8CNA's personnel file revealed no documented evidence S8CNA attended the mandatory training offered by the facility Level of Harm - Minimal harm or regarding effective communication. potential for actual harm

Review of S9CNA's personnel file revealed a hire date of 01/10/2024. Further review of S9CNA's personnel Residents Affected - Some file revealed no documented evidence S9CNA attended the mandatory training offered by the facility regarding effective communication.

An interview was conducted on 06/06/2024 at 6:35 p.m. with S2DON. She stated she held a staff meeting on 04/17/2024, at which time she provided education regarding effective communication. She confirmed this was the only time she had provided education for direct care staff regarding effective communication. She confirmed all direct care staff were not in attendance and had not received a make-up training; including S7CNA, S8CNA, and S9CNA. She confirmed she did not have any additional trainings scheduled to address effective communication.

An interview was conducted on 06/06/2024 at 6:45 p.m. with S1ADM. He confirmed S2DON was responsible for providing all trainings to direct care staff. He confirmed he would expect the facility to provide all trainings as required by state and federal regulations.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 30 195488