Resthaven Nursing & Rehab Center, Llc

F-F812

On 08/19/24 3:36 p.m., an interview was conducted with S22RD (Registered Dietician). S22RD stated that

she performed a walkthrough of the entire kitchen quarterly with the last walkthrough conducted on 06/19/2024. Reviewed S22RD's quarterly report dated 6/19/2024 that stated no cleanliness issues noted with S22RD. S22RD reported that she observed the kitchen randomly when she visited the facility but it was not a full detailed inspection. S22RD stated she had not done a walkthrough of the entire kitchen since 06/19/2024 and has had no reports of any cleanliness issues nor has she observed any since then. She stated that she had been aware of the ongoing presence of gnats in the kitchen for a few months. She further stated that administration was aware of the presence of gnats in the kitchen.

Review of the facility's State of Louisiana Department of Health, Office of Public Health, Retail Food Notice of Violations dated 06/11/2024 at 9:30 a.m. read in part: Non-Critical Items: Code Reference: Non-food contact surfaces are not cleaned at a frequency necessary to preclude accumulation of soil residues.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 24 195414 Department of Health & Human Services Printed: 09/12/2025 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 195414 B. Wing 08/20/2024

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

Resthaven Nursing & Rehab Center, LLC 1103 W McNeese Lake Charles, LA 70605

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 08/19/2024 at 3:50 p.m., an interview and review of the Food Notice of Violations referenced above was conducted with S1ADM. S1ADM stated that the State Sanitarian reported to her the results of his inspection Level of Harm - Immediate before he left the faciity on the day of inspection. She stated that no intervention was needed after the jeopardy to resident health or inspection because the Sanitarian had informed her that all deficiencies had already been corrected. S1ADM safety stated S16DM (Dietary Manager) was responsible for the cleanliness of the kitchen. S1ADM stated that S16DM had not reported any issues with cleanliness in the kitchen. S1ADM stated that S22RD (Registered Residents Affected - Many Dietician) came three times a month. If S22RD identified any issues in the kitchen, she would have notified S1ADM, but she had not. She stated that S3RA (Regional Administrator) was at the facility twice a week and conducted full facility rounds, but he had not reported any kitchen concerns. S1ADM stated she was aware of issues with gnats in the kitchen that was reported to her on 08/09/2024. S1ADM stated she observed gnats in the kitchen on 08/09/2024 and called pest control. She reported that pest control came on 08/12/2024 for the gnat problem and that this was the last date she recalled being in the kitchen.

On 08/20/2024 at 8:50 a.m., an interview was conducted with S3RA (Regional Administrator). He stated that

he was not aware of the cleanliness issue in the kitchen. He stated that he conducted rounds in the facility and observed the kitchen on 08/12/2024. He stated there were no pest or cleanliness issues in the kitchen

on 08/12/2024 that he observed. S3RA stated he may have documentation of these rounds of which was requested.

On 08/20/2024 at 10:17 a.m., an interview and email review was conducted with S1ADM. The email dated 06/5/2024 at 1:37 p.m. was from S1ADM to S16DM. The email read: I realized I skipped over dietary. Staff are not wearing beard covers. Ice build-up on the floor of the fridge. Garlic bread without date. Food items in bag on floor under the shelf. S1ADM stated that she sent this email to S16DM after a third party consultant mock survey had been conducted. She stated she had forgotten to address these issues in a meeting, and sent the email to notify S16DM of the findings.

On 08/20/2024 at 1:51 p.m., an interview was conducted with S3RA, S1ADM, and S16DM. Both S3RA and S1ADM stated they were unaware of the cleanliness issues in the kitchen and were attempting to manage

the pest issues. S1ADM stated that she was last near the kitchen on 08/12/2024 when the pest control was present, but was in the hallway behind the kitchen and did not enter the kitchen. S1ADM stated she did not remember entering the kitchen after this date. S3RA stated there were no cleanliness issues that he observed on 08/12/2024. S16DM stated that she was responsible for doing visual checks to ensure daily, weekly, and monthly cleaning/sanitation tasks were completed by kitchen staff and that she was responsible for ensuring they did so effectively. S16DM stated she was last present in the kitchen on 08/16/2024, just prior to survey entrance (08/18/2024). S1ADM stated she was ultimately responsible for the kitchen as she was S16DM's direct supervisor.

No documentation of S3RA or S1ADM kitchen rounds were provided before exit.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 24 195414 Department of Health & Human Services Printed: 09/12/2025 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 195414 B. Wing 08/20/2024

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

Resthaven Nursing & Rehab Center, LLC 1103 W McNeese Lake Charles, LA 70605

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 0850 Hire a qualified full-time social worker in a facility with more than 120 beds.

Level of Harm - Minimal harm or 47123 potential for actual harm Based on interviews and record reviews, the facility failed to ensure it employed a qualified social worker on Residents Affected - Few a full-time basis. The facility had 160 licensed beds with a census of 111 residents.

Findings:

Review of the facility's license revealed they had a total number of 160 licensed beds.

On 08/19/2024 at 10:20 a.m., an interview was conducted with S2DON (Director of Nursing). S2DON was asked who the current social worker was for the facility. She replied that S1ADM (Administrator) had been

the facility's acting social worker for over a month now. They were currently advertising to hire a social worker but have not had any luck finding someone that met the requirements.

Record review of S1ADM resume revealed, in part, education: Masters in Health Administration, Bachelors in Nutritional Sciences and Minor in Biological Sciences. S1ADM's resument failed to show a bachelor's degree

in social work or a bachelor's degree in a human services field including, but not limited to, sociology, gerontology, special education, rehabilitation counseling, and psychology; and one year of supervised social work experience in a health care setting working directly with individuals.

On 08/19/2024 at 5:06 p.m., a joint interview was conducted with S1ADM and S3RA (Regional Administrator). S1ADM confirmed that her resume was accurate. She stated she did not have a year of social work experience. S1ADM confirmed she assumed the role of the facility's social worker in July of 2024. S3RA (Regional Administrator) stated that S4HR (Human Resources) also assisted the administrator as a social worker and she had her bachelor's degree.

Record review of S4HR resume revealed, in part, education: Bachelor of Science in mass communication with concentration in journalism. Failed to show a bachelor's degree in social work or a bachelor's degree in

a human services field including, but not limited to, sociology, gerontology, special education, rehabilitation counseling, and psychology; and one year of supervised social work experience in a health care setting working directly with individuals.

On 8/20/2024 at 9:04 a.m., an interview was conducted with S4HR. She stated the administrator was currently the facility's social worker. S4HR stated she assisted S1ADM with scheduling appointments for dental, podiatry, care conferences, and other paperwork aspects of the job. S4HR stated she had a Bachelors in Mass Communication with a Concentration in Journalism. She had been employed with the facility for three years now, and had never worked with the geriatric population.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 24 195414 Department of Health & Human Services Printed: 09/12/2025 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 195414 B. Wing 08/20/2024

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

Resthaven Nursing & Rehab Center, LLC 1103 W McNeese Lake Charles, LA 70605

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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 49784 potential for actual harm Based on observation, interview and record review, the facility failed to maintain an effective infection control Residents Affected - Few and prevention program and implement accepted infection control practices to help prevent and control the spread of an infectious communicable disease, COVID-19 by failing to post proper signage outside the resident's entrance room clearly identifying the type of transmission based precautions and appropriate PPE (Personal Protective Equipment) be used for 1 (#110) of 3 (#27, #82, #110) residents investigated for transmission based precautions (TBP).

This deficient practice had the ability to affect 6 residents in the facility that were on transmission based precautions.

Findings:

A review of the facility's policy, COVID-19 SURVEILLANCE PLAN- Guidelines to Prevent/Control/Treat the Coronavirus (COVID-19), last reviewed on 2/14/2024, revealed, the following in part: Implementing Proper Infection Control Guidelines: Isolation rooms must be identified with proper signage outside the entrance of

the room indicating the type of isolation (contact and droplet).

Review of Resident #110's physician's order dated 8/15/2024 read: Contact/droplet isolation: positive Covid-19 every shift.

On 8/18/2024 at 10:40 a.m., Resident #110's room door was observed without any signage posted on the door indicating the type of transmission based precaution the resident was on nor of the PPE required to enter the room.

On 8/18/2024 at 10:41 a.m., an observation of Resident #110's room entrance was conducted with S24RN (Registered Nurse) who confirmed Resident #110 was COVID-19 positive and on isolation TBP. She confirmed no signage was posted on or around Resident #110's door indicating the type of transmission based precaution the resident was on nor of the PPE required to enter the room. S24RN acknowledged that there should be a TBP sign posted on the resident's door.

On 8/20/2024 at 12:20 p.m., and interview was conducted with S20IP (Infection Preventionist) and S25IP. S20IP confirmed that Resident #110 should have had a sign placed on his room door per the facility's policy.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 24 195414 Department of Health & Human Services Printed: 09/12/2025 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 195414 B. Wing 08/20/2024

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

Resthaven Nursing & Rehab Center, LLC 1103 W McNeese Lake Charles, LA 70605

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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Level of Harm - Minimal harm or 49784 potential for actual harm Based on observations, record review and interviews, the facility failed to maintain an effective pest control Residents Affected - Many program by failing to ensure the facility's kitchen was free from insects. The deficient practice had the potential to affect 110 residents who ate meals from the kitchen. 111 residents resided in the facility.

Findings:

On 8/18/2024 at 4:05 p.m., an interview and observation of the dishwashing room was conducted with S16DM (Dietary Manager), S1ADM (Administrator), and S19MA (Maintenance Assistant). A large swarm of gnats were observed flying around the dishwashing room. S16DM stated that a bug light was out of order in

the kitchen.

On 8/18/2024 at 4:45 p.m. a tour of the kitchen by the survey team was conducted with S15PM (Production Manager) and S16DM during which the following was observed:

1. One live cockroach crawling behind the stove;

2. One live cockroach crawling in the dry food storage room; and

3. Three dead roaches in a small red bucket stored under the food prep counter.

On 8/19/2024 at 3:36 p.m., an interview with S22RD (Registered Dietician) was conducted. S22RD stated that she performs a walkthrough of the entire kitchen quarterly, last being on 6/19/2024. She stated that she was aware of the ongoing gnat problem in the kitchen for a few months and that administration was aware of this.

On 8/19/2024 at 3:50 p.m., an interview was conducted with S1ADM who stated she was made aware there were gnats in the kitchen on 8/09/2024. She observed gnats flying in the kitchen on this date and called pest control. She reported that pest control came on the 8/12/2024 for the gnat problem. She confirmed gnats remained in the kitchen and that the pest treatment was not effective.

On 8/20/2024 at 1:51 p.m., an interview was conducted with S3RA (Regional Administrator), S1ADM, and S16DM. Both S3RA and S1ADM stated they were of the pest control issues persisted and previous pest treatments were not effective.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 24 195414