F-F689
All facility policies related to scald prevention were requested of S1 Administrator on 04/30/2025 at 4:55 p.m. None were provided.
Review of the facility's Incident Investigation and Reporting Policy (provided to surveyor 05/22/2025) with latest revision date of 05/2024 revealed in part:
to provide guidance to the facility for investigation and reporting incidents of abuse, neglect and/or other reportable incidents .
5. Additional incidents that must have a thorough investigation and may require reporting, as determined by
the NF .Burns
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 32 195532 Department of Health & Human Services Printed: 08/26/2025 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 195532 B. Wing 05/22/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Town & Country Health & Rehab 614 Weston Street Minden, LA 71055
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 6. The facility will thoroughly investigate all alleged violations under the direct supervision of the Administrator. The facility will take all necessary steps to prevent occurrence while the investigation is in Level of Harm - Immediate progress. Consider emergency QA meeting and processes as needed. jeopardy to resident health or safety 7. During and after the investigation, the residents will be protected from harm through frequent supervision by staff. Residents Affected - Many 8 .The investigation will include the following:
a. Written report from the person reporting the incident
b. Name, phone number, address of the person reporting the incident
c. Name, phone number, address of all witnesses.
d. Signed statements from all witnesses including the accused if applicable, stating time and date. Detailed account of incident using incident witness statement section of incident report
e. Resident's statement regarding the incident, if appropriate
f. If only oral information can be obtained for a statement there must be at least two persons present to receive information.
g. The reporter must have the statement read back to him/her. Reporter must sign. Recorder and witness must also sign.
i. Necessary corrective/preventative action
Review of facility inservice training from 05/04/2024 to 04/30/2025 revealed no staff training related to hot liquids and the prevention of resident burns.
During an interview on 04/30/2025 at 10:58 a.m., S2 DON (Director of Nursing) and S7 Corporate Nurse, all investigation and corrective actions for the 2nd degree burn that occurred on 01/15/2025 were requested.
During an interview on 04/30/2025 at 2:38 p.m., S2 DON reported she could not find any investigation of how Resident #72's burn occurred, including the temperature of hot liquids served to residents. S2 DON further reported she could not locate any corrective actions that had been implemented to prevent resident burns from hot liquids.
During an interview on 04/30/2025 at 3:03 p.m., S8 DM (Dietary Manager) reported temperature checks were not done before putting brewed coffee into the pump dispensers for service to the residents. S8 DM reported today was the first time she had heard anything about a concern regarding the temperature of the coffee because Resident #72 was burned with coffee back in January.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 32 195532 Department of Health & Human Services Printed: 08/26/2025 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 195532 B. Wing 05/22/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Town & Country Health & Rehab 614 Weston Street Minden, LA 71055
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 During an interview on 04/30/2025 at 4:55 p.m., S1 Administrator confirmed no corrective actions were implemented to prevent burn injuries prior to today because today was the first I've heard about it. S1 Level of Harm - Immediate Administrator reported he did not do the investigation, and did not interview S6 CNA (Certified Nursing jeopardy to resident health or Assistant) to see how she fixed the coffee for Resident #72 when serving it from the cart. safety
The facility implemented the following actions to correct the deficient practice beginning on 04/30/2025: Residents Affected - Many 1. S1 Administrator and S2 DON (Director of Nursing) were in-serviced by the Regional Supervisor on 4/30/2025 at 4:00 p.m. on the facility policy on Incident Investigation and Reporting - to include taking action to protect and prevent future occurrences. The Dietary Staff was in-serviced on tempering coffee prior to service. CNAs were in-serviced on not rewarming coffee in the microwave, fill cup only 1/2 full, assisting those residents that require assistance and offering coffee cup lids to residents that consume coffee. In-service was done by ADON (Assistant Director of Nursing) on 4/30/2025 at 1:15pm.
2. How other residents with the potential to be affected by the same deficient practice will be identified and what will be done for them: 95 residents and new admissions have the ability to have this alleged situation affect them. The Dietary staff was in-serviced on tempering coffee prior to service. CNAs were in-serviced on not rewarming coffee in the microwave, fill cup only 1/2 full and offering to place lids on cups of residents that drink coffee. Inservice was done on 4/30/2025 at 1:15 p.m.
3. What measures will be put into place or what systematic changes will be made to ensure that the deficient practice does not recur: Staff were in-serviced on tempering coffee as follows: once the coffee is brewed, the Dietary staff will add a scoop of ice to temper the coffee to 130-135 degrees F (Fahrenheit) to prevent serving excessively hot coffee. The facility also implemented inservice training to nursing staff in reference to not rewarming coffee, only filling cup 1/2 capacity and offering lids to cups to residents that drink coffee.
4. NFA (Nursing Facility Administrator) and DON were in-serviced on Incident Investigation and Reporting on 4/30/2025 at 4:00 p.m.
The S1 Administrator and S2 DON had an in-service completed via in person lecture by the Regional Supervisor on 4/30/2025 at 4:00 p.m. on the facility policy on Incident Investigation and Reporting to include taking action on adverse events to protect and prevent future recurrences.
Inservice training to nursing staff in reference to not rewarming coffee, only filling coffee cups to half capacity, and serving coffee with lids to those residents at high risk for spills was completed by the ADON on 4/30/25 at 1:15 p.m. via in person lecture.
Education with Nursing staff, dietary staff, was completed on 4/30/2025 at 1:15 p.m. Education involved the process listed and actions the facility will take. The education was verbal from NFA with dietary staff and verbal from ADON to nursing staff.
Policies have been reviewed with no revisions at this time.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 32 195532 Department of Health & Human Services Printed: 08/26/2025 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 195532 B. Wing 05/22/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Town & Country Health & Rehab 614 Weston Street Minden, LA 71055
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 Date Facility Asserts the Likelihood for Serious Harm to Any Recipient No Longer Exists: 04/30/2025.
Level of Harm - Immediate Validation of Plan of Removal: jeopardy to resident health or safety Review of incident logs from 05/01/2025 to 05/22/2025 revealed no incidents related to burns.
Residents Affected - Many Review of grievance logs from 05/01/2025 to 05/22/2025 revealed no grievances related to the temperature of coffee or other liquids served to residents.
Review of inservice training records from 05/01/2025 to 05/22/2025 revealed in part:
-04/30/2025 to kitchen staff 04/30/2025 at 1:00 p.m.-Temper coffee immediately after brewing so it is palatable but safe temp level for the residents' consumption
-04/30/2025 to LPNs, therapy and restorative staff by S3ADON-When giving coffee to residents do not rewarm in microwave, fill cup 1/2 full, cups with lids for residents at high risk for spills, assist those residents that require assistance. Method of deliver=verbal; response=receptive.
-04/30/2025 to nursing staff and CNAs by S3ADON-When giving coffee to residents-don't rewarm in microwave, fill cup 1/2 full, cups with lids for residents at high risk for spills, assist those residents that require assistance. Method of delivery=verbal; response=receptive
-04/30/2025-inservice given to S1Administrator and S2DON by S22Regional Supervisor on Incident investigation and reporting.
-05/19/2025 to Nursing Staff-Tips to Achieve Past Noncompliance if an Adverse Event Occurs.
Review of facility QA meeting notes revealed an emergency QA meeting was held on 04/30/2025 regarding Resident #72's burn from hot coffee.
Review of Coffee Temperature Logs maintained in the kitchen from 04/30/2025 to 05/22/2025 revealed daily temperature checks of coffee prior to service to residents with none greater than 135 degrees F.
Review of Resident Council meeting minutes from meeting held 05/01/2025 revealed in part no complaints about the temperature of coffee or other hot liquids.
Review of facility monitoring for burn/scald incidents revealed weekly monitoring of all incident reports by the facility administrator.
Review of facility monitoring of coffee temperatures revealed twice weekly monitoring (on Mondays and Thursdays) of coffee temperatures prior to being made available for service to residents.
Review of Resident #72's progress notes from 05/01/2025 to 05/22/2025 revealed no further burns or incidents with coffee or other hot liquids.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 32 195532 Department of Health & Human Services Printed: 08/26/2025 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 195532 B. Wing 05/22/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Town & Country Health & Rehab 614 Weston Street Minden, LA 71055
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 During an interview on 05/22/2025 at 8:45 a.m., S25CNA said she has had a lot of inservices about the temperature of hot liquids, make sure it's not too hot, don't overfill the cup so it doesn't splash over sides, put Level of Harm - Immediate a sip-through lid on the cups, don't reheat. Said snack/hydration cart comes out at 10:00 a.m., 2:00 p.m. and jeopardy to resident health or 6:00 p.m.-does not have a microwave on the cart. If resident complains coffee is not hot, don't reheat it and safety get them a fresh cup. If had spill where resident was burned, she would notify the nurse.
Residents Affected - Many During an interview on 05/22/2025 at 8:48 a.m., S17CNA Supervisor confirmed inservice training had been done for the CNAs, nurses, and therapy about serving hot liquids-fill cup 1/2 full, offer a lid, never re-heat coffee or other hot liquids in the microwave, get a fresh cup of coffee. If what is in the carafe is not hot enough, have the kitchen make a fresh batch. If soup, don't re-heat, get a fresh bowl or have the kitchen re-heat what is on the steam table.
During an interview on 05/22/2025 at 8:55 a.m., S23CNA reported had an inservice about hot liquids-don't re-warm in the microwave-if residents complain it is not hot, get them a fresh cup, same with soup, don't fill
the cup or bowl all the way up. Said some residents have been complaining the coffee is not hot enough, get them a fresh cup or have the kitchen brew a fresh carafe-never re-heat in the microwave. Said she was not aware of any other residents being burned/scalded by hot liquids.
During an interview on 05/22/2025 at 9:20 a.m., S12CNA said they had been inserviced on hot beverages-get a whole new carafe if coffee is not hot enough-never reheat in the microwave, don't fill all the way to the top, put a lid on they can sip through especially if they are weak, have tremors, etc. Snack/hydration cart comes out at 10:00 a.m., 2:00 p.m. , and 6:00 p.m.
During an interview on 05/22/2025 at 9:06 a.m., S14LPN reported nursing staff had inservice on hot beverages-don't overfill-set beverage on over-bed table-supervise residents who need assistance, lids with sip spout for residents who are weak or have tremors (i.e. Parkinson's). Reported no further burn/scald injury incidents.
During an interview on 05/22/2025 at 9:12 a.m., S8DM reported the kitchen staff now checks the temperature of coffee before it is placed in the carafes to serve to residents. Reported coffee required 196 degree F water to brew, so ice was added after brewing to bring temp to a safe level of not more than 135 degrees F prior to being made available for service to residents. S8DM reported the supply vendor for dietary and the facility's corporate nurse both advised 135 degree F was the max safe temperature for hot liquids. S8DM Confirmed S1Administrator had conducted inservice training to kitchen staff on checking the temperature of the coffee and measures to bring it to a safe temperature for service to residents.
Observation and interview on 05/22/2025 at 10:20 a.m. in the dining room-Resident #44 was drinking coffee from an open plastic mug with a handle. Resident #44 reported the coffee was good, was hot enough and not too hot-never been burned by the coffee. Review of Resident #44's record revealed an MDS dated [DATE REDACTED] with a BIMS score of 3.
Observation and interview on 05/22/2025 at 10:21 a.m. Resident #62 was drinking coffee from an open plastic mug with a handle. Resident #62 reported the coffee was good, was hot enough and not too hot-never been burned by the coffee. Review of Resident #62'srecord revealed an MDS dated [DATE REDACTED] with a BIMS score of 14.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 32 195532 Department of Health & Human Services Printed: 08/26/2025 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 195532 B. Wing 05/22/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Town & Country Health & Rehab 614 Weston Street Minden, LA 71055
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 Observation and interview on 05/22/2025 at 10:22 a.m. Resident #74 was drinking coffee from an open plastic mug with a handle. Resident #74 reported the coffee was good, was hot enough and not too Level of Harm - Immediate hot-never been burned by the coffee. Review of Resident #74's record revealed an MDS dated [DATE REDACTED] with jeopardy to resident health or a BIMS score of 4. safety
During an interview on 05/22/2025 at 10:25 a.m. Resident #72 said she had not had any further burns from Residents Affected - Many coffee or other hot liquids, said they now put her coffee in a disposable cup with a lid that she can drink through and pass it to her.
During an interview on 05/22/2025 at 10:28 a.m. Resident #15 in her room-reported she was a coffee drinker, said she had never been burned by the coffee or other hot liquids, the coffee was hot enough, not too hot. Review of Resident #15 's record revealed an MDS dated [DATE REDACTED] with a BIMS score of 10.
Observation on 05/22/2025 from 10:40 a.m. to 11:00 a.m.: S23CNA and S24CNA were passing snacks and beverages to residents in their rooms from the snack/hydration cart. The cart-top had recessed spaces for holding pitchers of cold liquids (tea, kool-aid, water) and a space for holding a metal push-pump coffee dispenser. 12 ounce disposable insulated to go cups with non-slip grip with snap-on leak resistant lids with a sip-through opening. S23CNA served surveyor a cup (asked to serve just like she would a resident) in 12 oz. insulated to go cup 1/2 full, with a lid that had a sip-through opening, temperature palatable and not scalding. Did not do formal temp check. Temp monitoring from kitchen was 125 degrees F. S23CNA and S24CNA served Resident #64 a cup of coffee in his room, cup 1/2 full with lid. Review of Resident #64's MDS dated [DATE REDACTED] revealed a BIMS score of 14.
During a telephone interview on 05/22/2025 at 3:43 p.m. S22Regional Supervisor reported he has been having a weekly telephone meetings with S1Administrator to review all of the corrective measures and monitoring. S22Regional Supervisor reported he had been doing verbal monitoring, but with this incident he had a monitoring tool sheet for the weekly meeting. S22Regional Supervisor reported he was working with a manufacturer that brews coffee at 125 degrees F and was considering ordering one to try it out. S22Regional Supervisor for right now they are doing an ice dump to get the temperature down to 130-135 degrees F.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 32 195532 Department of Health & Human Services Printed: 08/26/2025 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 195532 B. Wing 05/22/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Town & Country Health & Rehab 614 Weston Street Minden, LA 71055
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 0908 Keep all essential equipment working safely.
Level of Harm - Minimal harm or 37867 potential for actual harm Based on observations and interviews, the facility failed to maintain all mechanical equipment in safe Residents Affected - Few operating condition by having a thick, heavy buildup of lint on the lint filters and floor of two of two large, industrial gas dryers in the laundry facility.
Findings:
Review of the facility's Maintenance Procedures policy (latest revision date 08/2013) revealed in part: The following is a list of minimum requirements for scheduling of cleaning and maintenance: daily-clean lint from dryer filters.
Review of the facility's Laundry Safety policy (latest revision date 08/2013) revealed in part: Clean lint screen
on dryer at the end of every shift.
An observation of the laundry area beginning on 04/30/2025 at 2:09 p.m. with S11 Housekeeping/Laundry revealed the lint filters for the two large industrial gas dryers had a heavy buildup of lint on the filters that was pulling away from the filters. The large dryer on the left also had a 3-4 inch deep pile of lint built up on the back right corner of the lint filter floor.
During an interview on 04/30/2025 at 2:20 p.m., S11 Laundry/Housekeeping reported the lint filters were supposed to be changed at least after every third load. S11 Laundry/Housekeeping confirmed the lint buildup was more than three loads worth and needed to be cleaned.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 32 195532