Inspection Reports for
Chateau Terrebonne Health Care Center
1386 WEST TUNNEL BLVD., HOUMA, LA, 70360
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Inspection Report — May 20, 2025
Annual Inspection CMS
Date: May 20, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident care, medication administration, bed-hold policies, care planning, and smoking assessments.
Findings
The facility was found deficient in several areas including failure to assess and authorize a resident for self-administration of medications, failure to provide written notice of bed-hold policies to residents upon hospital transfer, failure to complete a care plan conference within 7 days of assessment for a resident, and failure to complete quarterly safe smoking assessments for a resident.
Deficiencies (4)
F 0554: The facility failed to assess and authorize Resident #143 for self-administration of medications, with unauthorized medications found at the bedside.
F 0628: The facility failed to provide written notice of the bed-hold policy to Resident #16 and Resident #86 or their responsible parties upon hospital transfer.
F 0657: The facility failed to complete a care plan conference within 7 days of the comprehensive assessment for Resident #119.
F 0684: The facility failed to complete quarterly safe smoking assessments for Resident #11 as required.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Indicated medications should not have been at Resident #143's bedside | |
| Assistant Administrator | Confirmed residents were not provided Notice of Hospital Transfer/Therapeutic Leave policy | |
| Minimum Data Set Nurse (MDS Nurse) | Confirmed Resident #119 should have had a care plan conference | |
| Quality Improvement (QI) Nurse | Confirmed Resident #119 did not have a scheduled care plan conference in April 2025 | |
| MDS Coordinator | Confirmed Resident #11 lacked quarterly Safe Smoking Assessments for December 2024 and March 2025 | |
| Director of Nursing (DON) | Confirmed Resident #11 should have had quarterly Safe Smoking Assessments completed |
Inspection Report — May 9, 2024
Annual Inspection CMS
Date: May 9, 2024
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements related to medication self-administration and respiratory care.
Findings
The facility failed to assess two residents for self-administration of medications and improperly left medications at the bedside. Additionally, the facility failed to ensure sanitary tracheostomy care for one resident, as a contaminated inner cannula was inserted.
Deficiencies (2)
F 0554: The facility failed to assess residents for self-administration of drugs for 2 of 29 sampled residents. Medications were left at the bedside contrary to policy.
F 0695: The facility failed to ensure a resident's tracheostomy care was completed in a sanitary manner. The inner cannula fell onto bed linen and was then inserted without replacement.
Report Facts
Residents sampled: 29
Residents affected: 2
Medication doses: 4
Medication doses left for self-administration: 2
Tracheostomy care frequency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S6 Licensed Practical Nurse | Licensed Practical Nurse | Confirmed medications should not be left at bedside and administered partial doses to Resident #61 |
| S1 Director of Nursing | Director of Nursing | Stated medications should not be left at bedside for Residents #9 and #61 |
| S3 Respiratory Therapist | Respiratory Therapist | Performed tracheostomy care and inserted contaminated inner cannula |
| S4 Respiratory Director | Respiratory Director | Confirmed improper insertion of contaminated inner cannula by S3 Respiratory Therapist |
Inspection Report — Jul 26, 2023
Complaint Investigation CMS
Date: Jul 26, 2023
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to ensure the menu prescribed by the registered dietician was followed for one resident.
Complaint Details
The complaint was substantiated based on observations, record review, and interviews confirming the facility did not follow the prescribed menu for Resident #2 and failed to offer appropriate alternatives when food items were unavailable.
Findings
The facility failed to provide the prescribed menu items to Resident #2 on multiple occasions, including not providing a hot ham and cheese sandwich and omitting zucchini from a meal without offering an appropriate alternative. Interviews with staff and the resident confirmed these issues and lack of proper communication regarding food shortages.
Deficiencies (1)
F 0803: The facility failed to ensure the menu prescribed by the registered dietician was followed for Resident #2. Resident #2 did not receive the hot ham and cheese sandwich or zucchini as prescribed, and no documented reason or alternative was provided.
Report Facts
Residents sampled for dietary services: 5
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Asked Resident #2 what was wrong and provided a peanut butter and jelly sandwich. | |
| Certified Nursing Assistant (CNA) | Acknowledged the kitchen ran out of zucchini and failed to offer an alternative to Resident #2. | |
| Dietary Manager | Stated the kitchen should not run out of food and dietary workers should have called for more zucchini. | |
| Dietary Worker | Stated the facility rarely runs out of food and explained the substitution of salads for zucchini. |
Inspection Report — Jun 13, 2023
Complaint Investigation CMS
Date: Jun 13, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to report an incident of neglect resulting in elopement of Resident #96 and failure to provide adequate supervision to prevent elopement for residents identified at risk.
Complaint Details
The complaint investigation focused on the failure to report an elopement incident involving Resident #96 and inadequate supervision to prevent elopement. The Immediate Jeopardy was removed after the facility implemented a plan including increased supervision, staff in-service, door code changes, and monitoring protocols. The investigation also included a failure to maintain communication with the dialysis center for Resident #65.
Findings
The facility failed to report an elopement incident involving Resident #96 and failed to provide adequate supervision to prevent elopement, resulting in an Immediate Jeopardy situation. The facility also failed to maintain ongoing communication with a dialysis center and act on dietician recommendations for Resident #65. A plan of removal was implemented and the Immediate Jeopardy was removed on the day of the survey.
Deficiencies (4)
F0609: The facility failed to timely report suspected abuse, neglect, or theft and report investigation results to proper authorities for Resident #96 who eloped from the facility.
F0689: The facility failed to provide adequate supervision to prevent elopement for Resident #96, resulting in an Immediate Jeopardy situation.
F0698: The facility failed to maintain ongoing communication with the dialysis center and act on Registered Dietician's recommendations for Resident #65.
F0835: The facility failed to administer resources effectively by not providing adequate supervision to prevent elopement for Resident #96, resulting in an Immediate Jeopardy situation.
Report Facts
Residents at risk for elopement: 10
Dates missing Nursing Facility/Dialysis Communication Sheets: 15
BIMS score: 3
Date of elopement incident: Feb 9, 2023
Date of survey completion: Jun 13, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S1 Administrator | Administrator | Present during elopement incident; did not report incident as required. |
| S13 QI Nurse | Quality Improvement Nurse | In-serviced Administrator and staff on elopement reporting and prevention; oversaw plan of removal. |
| S18 LPN | Licensed Practical Nurse | Notified staff of Resident #96 outside the facility during elopement incident. |
| S2 DON | Director of Nursing | Responsible for elopement risk assessments and supervision policies. |
| S6 ADON | Assistant Director of Nursing | Responsible for contacting physician regarding dietician recommendations but failed to follow up. |
| S3 Dietary Manager | Dietary Manager | Reported dietician recommendations to nursing leadership. |
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