Jefferson Healthcare Center

F-F755.

Review of facility's Quality Assurance (QA) program revealed, in part, a Quality Assurance Performance Improvement (QAPI) plan created on 03/25/2025 which identified a problem with medication cart audit reports. Further review revealed a corrective action plan that included an initial audit would be performed on all medication carts by administrative nurses and weekly audits would be performed to ensure all required nurse signatures were documented. Further review revealed documentation on 04/01/2025, the narcotic book weekly audit was documented as a recurring problem with an intervention to discipline staff for noncompliance.

In an interview on 05/01/2025 at 11:08AM, S2Director of Nursing (DON) confirmed the facility opened the QAPI for medication cart audits which included the narcotic book audits on 03/25/2025. S2DON further confirmed during the current survey, the survey team identified the narcotic reconciliation documentation which was missing nurse signatures and they were inaccurate. S2DON indicated that no disciplinary actions of nursing staff were performed regarding the recurring problems identified in the narcotic book audits. S2DON further indicated continued problems in the above area would indicate the facility's QA/QAPI process had been ineffective and had not been revised.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 27 195272 Department of Health & Human Services Printed: 08/27/2025 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 195272 B. Wing 05/01/2025

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

Jefferson Healthcare Center 2200 Jefferson Hwy Jefferson, LA 70121

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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Level of Harm - Minimal harm or 51373 potential for actual harm Based on interview and record review, the facility failed to ensure the required members of the Quality Residents Affected - Some Assessment and Assurance committee met at least quarterly.

Findings:

Review of the facility's Quality Assurance Policy and Procedure revealed, in part, the facility's Quality Assurance committee would meet at least quarterly to identify issues and develop, implement, and/or oversee implementation of appropriate plans of correction for identified quality deficiencies. Further review revealed the Quality Assurance committee would consist of the Medical Director (MD), the Administrator, the Director of Nursing (DON) and 3 other staff members designated by the facility.

Review of the facility's Quarterly Quality Assurance (QQA) meeting minutes on 07/26/2024 revealed the sign-in sheet documented the staff that participated in the QQA meeting, validated by signatures, included

the DON, the Administrator, Dietary Manager, and MD. Further review revealed no documented evidence, and the facility was unable to present any documented evidence, additional staff were present for the 07/26/2024 QQA meeting

Review of the facility's QQA meeting minutes on 10/30/2024 revealed the sign-in sheet documented the staff that participated in the QQA meeting, validated by signatures, included the included the DON, the Assistant Director of Nursing, 3 Minimum Data Set Nurses, 2 Social Workers, the Dietary Manager, and the Nurse Educator. Further review revealed there was no documented evidence, and the facility was unable to present any documented evidence the MD and the Administrator were present for the 10/30/2024 QQA meeting.

Review of the facility's QQA meeting minutes on 01/30/2025 revealed the sign-in sheet documented the staff that participated in the QA meeting, validated by signatures, included the DON, the Administrator, and the MD. Further review revealed no documented evidence, and the facility was unable to present any documented evidence additional staff were present for the QQA meeting on 01/30/2025.

There was no documented evidence, and the facility was unable to present any documented evidence the facility's Quality Assessment and Assurance committee was composed of all required members on 07/26/2024, 10/30/2024, and 01/30/2025.

In an interview on 05/01/2025 at 11:08AM, S2DON indicated she had no additional documented evidence to present to show the QQA meetings on 07/26/2024, 10/30/2024, and 01/30/2025 had the required members

in attendance.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 27 195272