Terrebonne General Med Ctr SNF

Based on observations, interviews, and record reviews the facility failed to ensure percutaneous endoscopic gastrostomy tube flushes before and after medication administration for 1 (Resident #11) of 1 sampled resident with a percutaneous endoscopic gastrostomy tube (a feeding tube inserted through the abdomen into the stomach, commonly used for long-term nutrition, fluids, and medication delivery).Findings:Review of Resident #11's physician's orders dated 02/08/2026 revealed, in part, flush the feeding tube with the lowest volume necessary to clear the tube before and after administration unless a specific volume is ordered.Review of Elsevier Performance Manager Training for Medication Administration via Feeding Tubes revealed, in part, flush the feeding tube with a minimum of 15 milliliters of purified water before and after the administration of medications. Observation on 02/09/2026 at 12:02PM revealed S4Registered Nurse did not flush Resident #11's percutaneous endoscopic gastrostomy tube before and after medication administration. Observation on 02/09/2026 at 4:54PM revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record reviews, the facility failed to implement Enhanced Barrier Precautions (EBP) for 2 (Resident #5, Resident #11) of 2 sampled residents observed for infection control practices. Findings:Review of the Centers for Disease Control's 04/02/2024 article Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 04/02/2024, revealed, in part, personal protective equipment, which included the use of gowns and gloves, should be used during high-contact resident care activities that provided opportunities for the transfer of methicillin drug resistant organisms (bacteria or other germs that developed resistance to multiple antibiotics) to staff's hands and clothing. Further review revealed examples of high-contact resident care activities included device care, which included care of feeding tubes, and wound care. Review of the facility's Infection Control policy and procedure revealed, in part, the policy did not include a developed policy for the implementation of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure a Notice of Medicare Non-Coverage (NOMNC) Form (CMS-10123) was given to all Medicare beneficiaries who were discharged home with benefit days remaining, at least two days before the end of a Medicare covered Part A stay, for 3 (Resident #201, Resident #202, Resident #203) of 3 (Resident #201, Resident #202, Resident #203) sampled residents reviewed for beneficiary notification. Findings: Resident #201 Review of Resident #201's medical record revealed, in part, Resident #201 was admitted for Medicare Part A services on 09/03/2024, and was discharged home on [DATE]. Review of Resident #201's Notice of Medicare Non-coverage (NOMNC) form revealed, in part, Resident #201's last covered day of Medicare Part A services was on 09/20/2024. Further review revealed there was no notification date documented on the NOMNC form. Resident #202 Review of Resident #202's medical record revealed, in part, Resident #202 was admitted for Medicare Part A services…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure Certified Nursing Assistant (CNA) registry verification was completed prior to hire for 1 (S6Nursing Assistant [NA]) of 5 (S3CNA, S4CNA, S5NA, S6CNA, S7CNA) personnel records reviewed for registry verification. Findings: Review of S6NA's personnel record revealed a hire date of 05/20/2024. Further review revealed no documented evidence, and the facility did not present any documented evidence, a CNA registry check was obtained prior to hire for S6NA. In an interview on 02/05/2025 at 12:10PM S1Director indicated a CNA registry check was not obtained prior to hire for S6NA, as required.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record reviews, the facility failed to ensure a staff member received dementia trainings for 1 (S3Certified Nursing Assistant [CNA]) of 5 (S3CNA, S4CNA, S5Nursing Assistant [NA], S6CNA, S7CNA) personnel records reviewed for required trainings. Findings: Review of the facility's Skilled Nursing Facility assessment dated [DATE] revealed, in part, the facility had 31 residents with behavioral health needs, and serviced a population that was typically over [AGE] years old. Further review revealed CNAs were to receive trainings on Bathing and Dementia Care and Communicating with Residents with Dementia during orientation and/or annual competencies. Review of S3CNA's personnel record revealed, in part, no documented evidence, and the facility did not present any documented evidence, S3CNA received trainings on Bathing and Dementia Care and Communicating with Residents with Dementia during orientation and/or annual competencies. In an interview on 02/04/2025 at 4:25PM, S1Director indicated S3CNA…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record reviews, and interviews the facility failed to: 1. Ensure the registered nurse (RN) performed hand hygiene and applied gloves after contact with equipment and prior to touching and administering medication for 4 (Resident #56, Resident #57, Resident #58, and Resident #59) of 4 (Resident #56, Resident #57, Resident #58, and Resident #59) sampled residents observed during medication administration; 2. Ensure the RN and certified nursing assistant (CNA) performed hand hygiene and changed gloves appropriately as required during wound care for 1 (Resident #58) of 1 (Resident #58) sampled residents observed during wound care; and, 3.Ensure the licensed practical nurse (LPN) performed hand hygiene and applied gloves after contact with her uniform and equipment prior to performing blood glucose monitoring for 1 (Resident #56) of 1 (Resident #56) sampled residents observed during blood glucose monitoring. Findings: Review of the facility's Hand Hygiene policy and procedure revealed, in part: -wash hands with soap and water when hands are visibly dirty or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record reviews and interviews, the facility: 1. Failed to ensure staff were provided abuse and neglect training (S8Agency Registered Nurse (RN), S9Agency RN, and S10Agency RN); and 2. Failed to ensure staff were provided dementia management training (S6Certfied Nursing Assistant (CNA) and S11CNA). This deficient practice was identified for 5 (S6CNA, S8Agency RN, S9Agency RN, S10Agency RN, and S11CNA) of 8 (S6CNA, S8Agency RN, S9Agency RN, and S10Agency RN, S11CNA, S12Licensed Practical Nurse (LPN), S13CNA, and S14CNA) personnel records reviewed. Findings: 1. Review of the facility's Skilled Nursing Facility (SNF) schedule from 10/29/2023 through 12/09/2023 revealed, in part, S8Agency RN, S9Agency RN, and S10Agency RN worked at the facility as a Registered Nurse. Review of S8Agency RN's personnel file revealed no documented evidence and the provider did not present any documented evidence abuse and neglect training was completed since date of hire of 10/18/2023. Review of S9Agency RN's personnel file revealed no documented evidence and the provider did not present any…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interviews, the facility failed to ensure their policy and procedure included: 1. A process of screening employees to prevent abuse, neglect, and exploitation of residents; and, 2. A process for training employees on abuse, neglect, and exploitation of residents. Findings: Review of the facility's Identifying and Reporting Allegations of Abuse/Neglect policy dated 08/28/2023 revealed no documented evidence and the facility did not present any documented evidence the policy included how the facility would perform screening of employees to prevent abuse, neglect, and exploitation of residents and how employees would be trained on abuse, neglect, and exploitation of residents. In an interview on 02/15/2024 at 3:00 p.m., S1Assistant [NAME] President of Nursing Services acknowledged the facility's policies did not identify how the facility would perform screening of employees to prevent abuse, neglect, and exploitation of residents and how employees would be trained on abuse, neglect, and exploitation of residents and it should have.

Based on record reviews, observations, and interviews, the facility failed to ensure medications were locked and not available for use at a resident's bedside for 1 (Resident #56) of 4 (Resident #56, Resident #57, Resident #58, and Resident #59) sampled residents observed for medications left at the bedside. Findings: Review of the facility's Storage of Medications after Dispensing to Provider policy revealed, in part, medications should be stored in a safe and secure manner, and storage locations should provide a locking mechanism for safety and security of medications. Further review revealed all locking mechanisms should be utilized to assure medications were secure at all times, and medications should not be left unattended or at a patient's bedside. Review of Resident #56's January and February 2024 physician's orders revealed, in part, no documented evidence of an order for Resident #56 to have medications available for self-administration at the bedside. Review of Resident #56's record revealed no documented evidence and the facility did not present any documented evidence…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.