Southern Oaks Nursing & Rehabilitation Center

F-F607

During a phone interview on 03/12/2025 at 4:45 p.m. S4 CNA reported on 03/01/2025 around 5:50 a.m. she observed S3 CNA having intercourse with Resident #1. S4 CNA further reported she immediately left out of Resident #1's room to report what she saw to the nurse, while S3 CNA and Resident #1 continued to have intercourse.

Review of Abuse/Neglect Prevention Program (Revised on 09/08/2021) failed to include immediate response by staff to protect an alleged victim of physical and psychosocial harm during and after the investigation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 17 195558 Department of Health & Human Services Printed: 09/04/2025 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 195558 B. Wing 03/17/2025

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

Southern Oaks Nursing & Rehabilitation Center 1524 Glen Oaks Place Shreveport, LA 71103

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 03/13/2025 at 8:10 a.m. S1 Administrator reported the facility did not report the incident between Resident #1 and S3 CNA because he did not recognize it was abuse because it was Level of Harm - Immediate consensual. jeopardy to resident health or safety During an interview on 03/13/2025 at 12:49 p.m. S5 Corporate Nurse reported S4 CNA had done the appropriate thing in immediately notifying a nurse after witnessing the 03/01/2025 incident between S3 CNA Residents Affected - Few and Resident #1. S5 Corporate Nurse further reported CNAs were trained according to facility policy that if a CNA witnesses abuse, they are to report the abuse immediately to the nurse and the nurse would be the one to intervene.

During an interview on 03/13/2025 at 1:16 p.m. S2 DON confirmed CNAs had been taught according to facility policy to immediately get a nurse when an abuse incident was observed and the nurse would then intervene.

During an interview on 03/17/2025 at 2:15 p.m. S1 Administrator and S5 Corporate Nurse reported S1 Administrator was the designated oversight person when deficient practice occurs and was responsible for ensuring deficient practice did not occur. S1 Administrator and S5 Corporate Nurse also reported the Administrator, as the designated oversight person, was responsible for ensuring staff have been educated on

the correct policy and procedure. S1 Administrator and S5 Corporate Nurse further confirmed, after their

review of regulations, S4 CNA should have stayed with Resident #1 and attempted to intervene while calling for help. S1 Administrator and S5 Corporate Nurse further reported an administrative breakdown had occurred when staff had not been trained to call for help immediately and to stay with residents in an abuse situation to intervene and protect the resident.

During an interview on 03/17/2025 at 2:20 p.m. S5 Corporate Nurse reported training oversight for the administrator and the administrative staff was the responsibility of the NHA (Nursing Home Administrator) Supervisor and the Chief Operating Officer.

During an interview on 03/17/2025 at 2:35 p.m. S2 DON reported S4 CNA, who witnessed the 03/01/2025 incident between Resident #1 and S3 CNA, left the room while the sexual act was still in progress, and did not respond immediately to intervene and protect Resident #1.

The facility's Plan of Removal:

Resident # 1 was the resident identified as the recipient involved in the noncompliance.

All residents have the potential to be affected by this noncompliance.

No other residents at the facility were noted to have been affected by this noncompliance.

On the evening of 03-14-2025, an inservice to the Administrator by NHA (Nursing Home Administrator) Supervisor, was completed. This inservice contained the following content:

Nursing facility staff are entrusted with the responsibility to protect and care for the residents of the facility. Nursing facility staff are expected to recognize that engaging in a sexual relationship with a resident, even a willingly engaged and consensual relationship, is not consistent with the staff member's role as a caregiver and will be considered an abuse of power.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 17 195558 Department of Health & Human Services Printed: 09/04/2025 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 195558 B. Wing 03/17/2025

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

Southern Oaks Nursing & Rehabilitation Center 1524 Glen Oaks Place Shreveport, LA 71103

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 And:

Level of Harm - Immediate All staff are to respond immediately to protect the alleged victim physically and psychologically during and jeopardy to resident health or after the investigation and to protect the integrity of the investigation. safety

The victim of the abuse is to be examined for injuries both physical and psychological, and medically treated Residents Affected - Few as indicated.

Increased supervision of the alleged victim and residents may be necessary, depending on the circumstances.

Room and/or staffing changes may be necessary to protect the resident from the alleged perpetrator.

Staff must protect the victim from retaliation and provide emotional support and counseling to the resident

during and after the investigation, as needed.

On 03-15-25, following the Administrator's inservice, a baseline competency interview was completed. He was interviewed by the facility DON. The specifics asked in this baseline competency interview are as follows to ensure information was learned and retained from the inservice:

1. Employee Inappropriate Sexual Encounters

a. As an employee of this facility, can you have any type of sexual activity or relationship including sexual intercourse with a resident, even if it is consensual with the resident?

Yes No (answer should be No)

b. Sexual activity includes the following: sexual intercourse, anal intercourse, oral sex and any of other type of sexual engagement. True False (answer should be true)

c. As an employee of this facility, if you witness any type of sexual activity including sexual intercourse by a staff member, are you to respond immediately to protect the alleged victim physically and psychologically

during and after the investigation and to protect the integrity of the investigation?

Yes No (answer should be Yes)

d. As an employee of this facility, if you witness any type of sexual activity, you must attempt to intervene by keeping the resident in direct line of sight and attempt to notify other staff members. State several ways you can do this

(examples -- yell for the person to stop, yell in an attempt to get others to help, pull the call cord out of the wall for the ER light, yell from the person's doorway down the hall, etc)

e. If any of the above questions are answered incorrectly, immediately stop and reinservice the employee. Explain your corrective action below.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 17 195558 Department of Health & Human Services Printed: 09/04/2025 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 195558 B. Wing 03/17/2025

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

Southern Oaks Nursing & Rehabilitation Center 1524 Glen Oaks Place Shreveport, LA 71103

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 2. Do you have any other concerns about sexual encounters at the facility that you would like to talk with administration about? Yes or No Level of Harm - Immediate jeopardy to resident health or Completion dates of the educational inservice and baseline competency completion for S1 Administrator: safety 03-14-2025 and 03-15-2025 respectively.

Residents Affected - Few A QAPI (Quality Assurance and Performance Improvement) monitor to assure sustained compliance of the facility staff will be implemented and will be completed the Administrator, DON, ADON (Assistant Director of Nursing), LPN (Licensed Practical Nurse) Charge Nurse, or Weekend RN (Registered Nurse) Supervisor, by interviewing random staff members. Questions from the Post Event Sustained Monitoring Interview related to Sexual Abuse definitions and Immediate Protection of the Resident Physically and Psychologically During and After the Investigation plan of this facility will be reviewed. This will occur 3 times a week for the next 6 weeks, and then monthly thereafter until compliance is maintained to be assured that the facility staff are aware of what immediate protection of the resident during and after an abuse investigation is, and how to respond to provide this protection and appropriated interventions.

Effectiveness of the corrective actions will be discussed weekly for 6 weeks at the Quality Assurance and Performance Improvement Meeting with findings added to the QAPI minutes. Additional inservices and/or corrective actions will be implemented as needed.

Date of Compliance: 03-17-2025

Date Facility Asserts the Likelihood for Serious Harm to Any Recipient No Longer Exists: 03/17/2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 17 195558