Inspection Reports for
Hessmer Nursing and Rehabilitation Center
3707 HWY 114, HESSMER, LA, 71341
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Inspection Report — Feb 5, 2025
Complaint Investigation CMS
Date: Feb 5, 2025
Visit Reason
The inspection was conducted to investigate complaints of resident-to-resident abuse and to assess compliance with regulations regarding abuse prevention, accurate resident assessments, care planning, psychotropic medication use, dietary services, and food safety.
Complaint Details
The complaint investigation substantiated resident-to-resident physical abuse of Resident #72 by Resident #35 on 07/19/2024. The facility confirmed the abuse and took actions including moving Resident #35 to a secured unit and transferring him to a behavioral hospital. The investigation was incomplete as other residents were not monitored for safety.
Findings
The facility substantiated an incident of resident-to-resident physical abuse involving Resident #35 hitting Resident #72 with a cane. The investigation was incomplete as other residents were not monitored. Additional deficiencies included inaccurate coding and care planning for hearing aids, failure to provide clinical rationale for psychotropic medication use, improper portion control and food service practices, inadequate dietary staff training, and unsafe food storage and labeling practices.
Deficiencies (8)
F 0600: The facility failed to protect Resident #72 from physical abuse by Resident #35, who hit Resident #72 with a cane causing minimal harm.
F 0610: The facility failed to thoroughly investigate resident-to-resident abuse allegations, as monitoring and interviewing of other residents was not completed.
F 0641: The facility failed to accurately code Resident #48's Minimum Data Set assessment for hearing aid use.
F 0656: The facility failed to implement a care plan for Resident #48's hearing aid needs.
F 0758: The facility failed to provide clinical rationale for continuing psychotropic medications for Resident #26 as required.
F 0800: The facility failed to provide residents with correct portion sizes and nourishing diets as per the approved menu.
F 0802: The facility failed to ensure dietary staff were competent and properly trained to safely and effectively carry out food and nutrition service functions.
F 0812: The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, including improper labeling, storage, and refrigeration of food items.
Report Facts
Residents reviewed for abuse: 3
Residents sampled for psychotropic medication review: 5
Residents sampled for hearing aid assessment: 42
Residents affected by food service deficiencies: 75
Date of abuse incident: Jul 19, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2 DON | Director of Nursing | Confirmed substantiation of resident abuse and incomplete investigation |
| S4 LPN | Licensed Practical Nurse | Documented abuse incident involving Resident #35 and Resident #72 |
| S8 DM | Dietary Manager | Confirmed dietary deficiencies including improper portion control, sanitization, and food storage |
| S9 DS | Dietary Staff | Observed serving incorrect portion sizes and improper sanitization monitoring |
| S15 MDS | MDS Coordinator | Confirmed inaccurate MDS coding for Resident #48's hearing aid |
| S16 MDS | MDS Coordinator | Confirmed inaccurate MDS coding for Resident #48's hearing aid |
| S3 Social Services Director | Social Services Director | Confirmed Resident #48 had hearing aids since 08/03/2023 |
Inspection Report — Jan 30, 2024
Routine CMS
Date: Jan 30, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with regulatory standards related to maintaining a safe, clean, and homelike environment, as well as food service safety.
Findings
The facility failed to maintain residents' rooms and assistive devices in good condition, with multiple broken over-bed tables and damaged wheelchairs observed. Additionally, the kitchen and food service areas were found to be unsanitary with improper storage and lack of documented temperature checks.
Deficiencies (4)
F 0584: The facility failed to maintain residents' rooms and assistive devices in good condition, including cracked floor tiles in Room A and damaged wheelchairs for four residents.
F 0584: Broken over-bed tables with exposed particle board were found in multiple residents' rooms, with 17 tables removed for repair or replacement.
F 0812: The facility failed to store dishes and utensils under sanitary conditions, maintain clean food preparation equipment, and ensure the kitchen was sanitary.
F 0812: Food, dishwasher, and three-compartment sink temperatures were not performed or recorded on 01/26/2024 and 01/27/2024.
Report Facts
Residents sampled for environment: 29
Residents affected by food service deficiency: 77
Broken over-bed tables removed: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S1 Administrator | Confirmed floor and wheelchair conditions needing repair. | |
| S2 DON | Confirmed removal of 17 broken over-bed tables needing repair or replacement. | |
| S4 LPN | Confirmed broken over-bed tables and removal for maintenance. | |
| S5 Maintenance | Confirmed removal of broken over-bed tables. | |
| S6 CNA | Confirmed broken over-bed tables and condition of residents' assistive devices. | |
| S7 CNA | Verified residents' use of broken over-bed tables. | |
| S8 Dietary Manager | Confirmed unsanitary kitchen conditions and lack of temperature documentation. |
Inspection Report — Jun 7, 2023
Complaint Investigation CMS
Date: Jun 7, 2023
Visit Reason
The investigation was conducted due to a complaint regarding inadequate supervision of a high-risk resident leading to elopement and unsafe smoking practices at the facility.
Complaint Details
The complaint investigation was substantiated. Resident #1, identified as high risk for elopement and an unsafe smoker, eloped from the secured unit through an unlocked gate while left unsupervised outside smoking. The resident was found uninjured approximately a quarter mile away. Staff involved received counseling and formal write-ups.
Findings
The facility failed to provide adequate supervision to prevent elopement and failed to supervise an unsafe smoker, resulting in a resident eloping through an unlocked gate. Corrective actions were implemented prior to the State Agency's investigation, and the issue was determined to be past noncompliance.
Deficiencies (1)
F 0689: The facility failed to ensure residents received adequate supervision to prevent elopement and failed to supervise an unsafe smoker, resulting in a resident eloping through an unlocked courtyard gate unnoticed by staff.
Report Facts
Residents reviewed for elopement: 5
Residents affected: 1
Risk assessments updated: 12
Residents at risk on secure unit: 8
Residents at risk in general population: 4
Date of elopement incident: Mar 13, 2023
Date of corrective action completion: Mar 17, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S1 ADM | Administrator | Notified of resident elopement, gave key fob to carpenters, located resident after elopement, involved in corrective actions |
| S2 DON | Director of Nursing | Notified of resident elopement, assessed resident after return, counseled staff involved |
| S4 LPN | Licensed Practical Nurse | Nurse on duty during elopement, involved in supervision and reporting |
| S5 CNA | Certified Nursing Assistant | Escorted resident outside to smoke unsupervised, notified staff when resident was missing, received formal write-up |
| S11 Corporate ADM | Corporate Administrator | Conducted root cause analysis and walkthrough after elopement, implemented vendor key fob policy changes |
Inspection Report — Feb 15, 2023
Complaint Investigation CMS
Date: Feb 15, 2023
Visit Reason
The inspection was conducted based on complaints regarding failure to implement a person-centered care plan for a resident and failure to maintain an infection prevention and control program to prevent COVID-19 transmission.
Complaint Details
The investigation was complaint-driven, focusing on allegations that the facility failed to provide appropriate oxygen therapy to Resident #11 and failed to maintain COVID-19 infection control protocols for Residents #31, #71, and #81. The complaints were substantiated with findings of incorrect oxygen administration and lapses in COVID-19 isolation and testing procedures.
Findings
The facility failed to administer oxygen therapy as ordered for one resident and failed to maintain proper COVID-19 infection control practices for three residents, including improper isolation and testing procedures.
Deficiencies (2)
F 0656: The facility failed to implement a person-centered care plan and administer oxygen therapy as ordered for Resident #11, who was receiving oxygen at 5 liters per nasal cannula instead of the ordered 3 liters.
F 0880: The facility failed to maintain an infection prevention and control program to properly prevent COVID-19 transmission for Residents #31, #71, and #81, including improper isolation and inadequate documentation of testing.
Report Facts
Residents affected: 1
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S1 DON | Director of Nursing | Confirmed oxygen order and infection control deficiencies during interviews |
| S3 LPN | Licensed Practical Nurse | Observed administering oxygen and interviewed regarding oxygen therapy |
| S5 Treatment Nurse | Treatment Nurse | Performed COVID-19 testing and confirmed testing procedures |
| S6 LPN | Licensed Practical Nurse | Performed rapid COVID-19 test and reported results |
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