Southern Hills Healthcare And Rehabilitation

F-F609:

During an interview on 02/04/2025 at 1:00 p.m., S2 DON (Director of Nursing) reported she was unable to find any monitoring of Resident #2.

During an interview on 02/04/2025 at 4:30 p.m., S2 DON reported she had not provided in-service training to all staff on abuse and neglect following the incident with Resident #2 and should have.

During an interview on 02/06/2025 at 10:50 a.m., S1 Administrator acknowledged she was not made aware of the sexual abuse incident of Resident #36 being inappropriately touched by Resident #2, until 02/04/2025. S1 Administrator reported she was out during the incident date and she had not been informed upon return. S1 Administrator acknowledged a report was never submitted to the appropriate state agency or law enforcement and should have been.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 25 195519 Department of Health & Human Services Printed: 09/09/2025 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 195519 B. Wing 02/07/2025

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

Southern Hills Healthcare and Rehabilitation 9105 Baird Road Shreveport, LA 71118

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 02/06/2025 at 11:05 a.m., S2 DON reported she was working on the night of the incident and conducted an abuse in-service on 09/08/2024 with the on-site evening shift and oncoming night Level of Harm - Immediate shift staff but had not in-serviced the day shift or remaining staff members on abuse. S2 DON acknowledged jeopardy to resident health or she was responsible for in-servicing the staff on the abuse/neglect policy including recognizing signs, safety investigations, protection, and reporting procedures and failed to ensure all staff had been in-serviced. S2 DON reported she was responsible for overseeing that interventions were put into place to protect the Residents Affected - Many residents but she had not reviewed the assessments and monitoring findings and should have. S2 DON acknowledged she did not notify the Administrator of the sexual abuse allegations towards Resident #36 or report it to the appropriate state agency or law enforcement and should have.

During an interview on 02/06/2025 at 11:20 a.m., S3 Corporate Nurse reported she was notified of the incident by the DON the following day 09/09/2024. S3 Corporate Nurse reported she should have made sure S1 Administrator was made aware of the sexual abuse incident and she did not. S3 Corporate Nurse acknowledged she was responsible for overseeing the ongoing monitoring put into place and could not confirm the findings or completion of the monitoring.

During an interview on 02/07/2025 at 10:30 a.m., S2 DON acknowledged no interventions had been put into place for the safety of Resident #36 or all other residents related to the sexual abuse incident and should have been.

During an interview on 02/06/2025 at 4:00 p.m., with S1 Administrator and S3 Corporate Nurse, S1Administrator acknowledged she was responsible for providing oversight of the facility's abuse/neglect policy including reporting timeframes and making sure staff was educated on the necessary steps to ensure

the safety and well-being of all residents. S1 Administrator and S3 Corporate Nurse acknowledged the facility failed to properly report the allegation of sexual abuse and appropriately monitor the situation and should have.

The facility implemented an accepted Plan of Removal as confirmed through onsite observations, interviews and record reviews prior to the exit.

The facility's Plan of Removal:

Resident #36 and all other residents has the potential for similar outcome.

On February 5, 2025 the facility began immediate all facility staff in-servicing on how to report allegation of abuse/suspicion of inappropriate sexual conduct and who to report the allegation of abuse/suspicion if noted. Staff will not be allowed to perform their duties until they have been properly trained by the Administrator or properly trained designee. The facility will include in Resident #2's care plan and task behaviors q (every) 2 hours to be monitored by staff. The DON or designee will review behaviors five days a week beginning 02/07/2025 with ongoing monitoring. Resident #2's plan of care has been reviewed/revised with increase supervision. Any resident that exhibits inappropriate sexual behavior will have an individualized Person-Centered Care Plan developed with the appropriate goals to address the protection of those residents deemed incapable of making consent. Beginning February 7, 2025 nursing staff will visually observe Resident #2 every two hours for increase supervision and will be ongoing. Beginning on February 7th Facility Administrator will conduct monthly in-services continuing to educate staff on abuse and reporting requirements.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 25 195519 Department of Health & Human Services Printed: 09/09/2025 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 195519 B. Wing 02/07/2025

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

Southern Hills Healthcare and Rehabilitation 9105 Baird Road Shreveport, LA 71118

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 February 7, 2025 signs will be placed in designated areas as reminder on reporting abuse and signs of abuse. Level of Harm - Immediate jeopardy to resident health or All facility staff will be in-serviced immediately beginning on February 5,2025 on how to report allegation of safety abuse/suspicion of any type of abuse and who to report the allegation/suspicion if noted. Staff will not be allowed to perform their duties until they have been properly trained by the Administrator or properly trained Residents Affected - Many designee. This in servicing began on February 5, 2025 at 4:00 p.m. and ongoing until all staff have been in-serviced.

Any residents that exhibit inappropriate sexual behavior will be monitored by all staff beginning on February 6, 2025. The facility Abuse Coordinator plans to monitor staff competency by direct observation, continued in-servicing, and resident and staff interviews 5 times per week and documenting effects on a facility QA (Quality Assurance) tool. These audits will continue until substantial compliance is achieved and monthly times two months. QA monitoring tools were initiated on February 6, 2025.

The Regional Supervisor conducted an in-service on 02/06/2025 at 5:00 pm with Department Head Staff to include Administrator/Abuse Coordinator, DON on Abuse &Neglect, Elder Justice Act, Review of corporate training video on Abuse and Neglect, State Agency and Law Enforcement. These Department heads will conduct further training of staff during monthly staff meeting. Regional Corporate Supervisors will oversee to ensure compliance.

On February 6, 2025, the facility conducted an Emergency QA with the facility Medical Director's Nurse Practitioner to outline all a fore mentioned protocol. The QA will be ongoing until substantial compliance is achieved. Any residents that exhibit inappropriate sexual behavior will have an individualized/Person Centered Care Plan developed with the appropriate goals to address the protection of those residents deemed in capable of making consent. QAPI (Quality Assurance Performance Improvement) was initiated on February 6, 2025, along with corrective action plan and monitoring tools. QA Committee will review in next Quarterly Meeting.

Date Facility Asserts the Likelihood for Serious Harm to Any Recipient No Longer Exists: 02/07/2025.

44414

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 25 195519 Department of Health & Human Services Printed: 09/09/2025 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 195519 B. Wing 02/07/2025

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

Southern Hills Healthcare and Rehabilitation 9105 Baird Road Shreveport, LA 71118

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 36921 potential for actual harm Based on record review and an interview, the facility failed to ensure the required members were present for Residents Affected - Few quarterly Quality Assessment and Assurance (QAA) meetings reviewed since last annual survey.

Findings:

Review of the facility's Quality Assessment and Assurance Committee Summary sign-in sheet since the last annual survey with S1 Administrator revealed the QAA committee meeting on 10/09/2024 had signatures of

the Administrator, DON (Director of Nursing), Medical Director and a Nurse Practitioner.

During an interview on 2/07/2025 at 5:30 p.m. S1 Administrator confirmed the required members were not present during the QAA committee meeting on 10/09/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 25 195519 Department of Health & Human Services Printed: 09/09/2025 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 195519 B. Wing 02/07/2025

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

Southern Hills Healthcare and Rehabilitation 9105 Baird Road Shreveport, LA 71118

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44414 potential for actual harm Based on record reviews, observation, and interviews, the facility failed to maintain an infection prevention Residents Affected - Some and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. The facility failed to ensure Enhanced Barrier Precautions (EBP) were in place for 1 (#326) of 1 (#326) resident reviewed for antibiotic use.

Findings:

Review of the facility's Enhanced Barrier Precautions policy with a revision date of 03/2024 revealed in part:

Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. EBPs (Enhanced barrier precautions) involve gown and glove use during high-contact resident care activities for residents know to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g. residents with wounds or indwelling medical devices).

EBPs are indicated for residents with any of the following:

Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with

a MDRO.

Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies.

Signs are intended to signal to individuals entering the room the specific actions they should take to protect themselves and the resident. To do this effectively, the sign must contain information about the type of Precautions and the recommended PPE (personnel protection equipment) to be worn when caring for the resident.

Facilities should ensure PPE and alcohol-based hand rub are readily accessible to staff.

Resident #326 was admitted to the facility on [DATE REDACTED] with the following diagnoses not limited to spinal stenosis, fusion of spine, Type 2 Diabetes, and UTI (Urinary tract infection) .

Review of Resident #326's physician orders revealed in part:

01/31/2025 surgical site: posterior middle neck. Clean with wound cleanser and apply island dressing. Monitor for any s/s (signs and symptoms) of infection or increased drainage.

01/31/2025 Ertapenem sodium solution reconstituted 1 gm (gram), use 1 gm intravenously at bedtime for infection related to spinal stenosis, cervical region for 1 day.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 25 195519 Department of Health & Human Services Printed: 09/09/2025 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 195519 B. Wing 02/07/2025

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

Southern Hills Healthcare and Rehabilitation 9105 Baird Road Shreveport, LA 71118

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 Review of Resident #326's medical record revealed a progress note by S17 Nurse Practitioner dated 01/31/2025 which revealed in part: . seen today status post hospitalization for posterior cervical fusion Level of Harm - Minimal harm or decompression . Resident #326 was also found to have UTI and culture grew ESBL (Extended Spectrum potential for actual harm Beta-Lactamase) Klebsiella. Patient was seen in consultation with Infectious Disease and was ordered for Ertapenem 1gm IV (intravenous) every 24 hours for 5 days. Last dose 01/31/2025. Residents Affected - Some

Review of Resident #326's medical record revealed an admit nurse's note by S16 LPN (Licensed Practical Nurse) dated 01/30/2025 at 3:03 p.m. which revealed in part, Resident #326 has a midline in upper left arm and an IV in lower left arm.

Observation on 02/03/2025 at 8:00 a.m. revealed a midline catheter site to left upper arm. Further

observation failed to reveal appropriate signage for EBPs and available PPE supplies for use.

During an interview on 02/03/2025 at 8:00 a.m., Resident #326 reported he had just had neck surgery and IV access was from when he was in the hospital.

During an interview on 02/03/2025 at 1:00 p.m., S2 DON (Director of Nursing) acknowledged Resident #326 had a midline peripheral central catheter in place to left upper arm and a surgical wound to his neck and should have been placed on EBP. S2 DON further acknowledged EBP signage was not in place and PPE was not readily available for staff to use and should be.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 25 195519