Calcasieu Community Care Center

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure the resident's Minimum Data Set (MDS) assessments were accurately coded to reflect the resident's status for 2 (#26, #88) out of 37 sampled residents.

Inspectors wroteNumber of residents sampled: 29 house d, 30 house c Number of residents cited: Failure to store distribute and serve food in accordance with professional standards for food service safety .steam table temps, cleanliness of bowls, improper wearing hair nets, temps not taken prior serving.

Inspectors wroteBased on record review and interview, the facility failed to maintain an effective antibiotic stewardship program to monitor antibiotic use by failing to develop an antibiotic stewardship program with effective surveillance and tracking and trending of antibiotic use. This deficient practice had the potential to effect a census of 115.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the individual designated as the Infection Preventionist, completed specialized training in infection prevention and control. This had the potential to affect a census of 115residents.

Inspectors wroteBased on observations, interview and record review, the facility failed to prepare mechanically altered therapeutic diets to meet the nutritional requirements for 4 (#52, #88, #93 and #106) residents out of 8 (#28, #37, #52, #68, #88, #93, #96 and #106) residents reviewed for weight and nutrition. The facility did not use the recommended liquid additive consistently when preparing pureed foods as defined by the recipe, and not serve residents' meals according to planned nutritional menus as recommended by the registered dietitian for residents #52, #88, #93, and #106 who received puree diets and found to have weight loss. 1) Resident #52 had a weight loss of 9.17% in 3 months and a 17.86% in less than 6 months. 2) Resident #88 had a weight loss of 12.13% in one month and 22.76% in 6 months. 3) Resident #93 had a weight loss of 7.63% in three months. [...]

Inspectors wroteBased on observation, and interviews, the facility failed to ensure recipes for pureed foods and menus were followed for residents who recieved puree diets. This deficient practice affected 8 (#28, #37, #52, #68, #88, #93, #96 and #106) of 8 residents that received a pureed diet.

Inspectors wroteBased on review of the Quality Assurance and Performance Improvement (QAPI) Program and interview, the facility failed to take actions aimed at performance improvement and after implementing those actions, measure its success and track performance. This was evidenced by lack of evidence of: 1. Measuring or tracking success of actions implemented; 2. collection and analysis of data; and, 3. in-services conducted with staff. This deficient practice had the potential to affect a census of 115 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to assess if the practice to self-administer medication was clinically appropriate for 1 (#110) resident investigated to self-administer medication out of a finalized sample of 40 residents. The deficient practice had to potential to affect 115 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure the assessment accurately reflected the resident's status by failing to accurately code the Minimum Data Set (MDS) for 1(#52) of 40 sampled residents, as evidenced by Resident #52 not being coded for weight gain and hospice care. The deficient practice had the potential to effect a total census of 115 residents.

Inspectors wroteBased on record review and interview, the facility failed to refer residents with a newly diagnosed mental disorder to the appropriate state-designated authority for Level II PASARR (Preadmission Screening and Resident Review) evaluation and determination for 1 (#73) out of 3(#11, #49, #73) sampled residents investigated for PASARR, in a final sample of 40 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents identified with Mental Disorder and/or Intellectual Disability had an accurately completed PASARR (Pre-admission Screening and Resident Review ) Level I and/or Level II for 2 (#11, #49) of 3 (#11, #49, #73) residents reviewed for PASAAR screening out of a final sample of 40 residents.

Inspectors wroteBased on observation, interview and policy review, the facility failed to ensure that a resident's enteral feeding was properly labeled for 1 (#106) resident out of 1 (#106) sampled residents reviewed for tube feeding. The deficient practice had the potential to affect a total of 4 residents receiving enteral feedings.

Inspectors wroteBased on record review, observation, and interview, the facility failed to properly store respiratory equipment for 2 (#10, #96) out of 2 (#10, #96) residents investigated for respiratory care in a final sample of 40 residents.

Inspectors wroteBased on observation and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety by failing to ensure refrigerated food items that were opened were labeled with the date they were opened before storing. This deficient practice had the potential to affect the 115 residents who consumed food prepared in the kitchen.

Inspectors wroteBased on observation, policy review, and interviews, the facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented for 1 (#19) of 8 (#19, #41, #52, #555, #73,# 93, #103, and #106) residents reviewed that required EBP.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that 3 (#1, #2 #5) out of 5 (#1-#5) sampled residents participated in care planning meetings. This was evidenced by failure to provide evidence that family representatives were invited to a care planning meetings and residents stating they had never participated in a care planning meeting. The deficient practice had the potential to affect a total census of 95.

Inspectors wroteBased on record reviews and interview, the facility failed to notify the State Long Term Care Ombudsman of facility-initiated transfers for 2 (#1, #4) out of 5 (#1, #2, #3, #4, #5) residents investigated for hospitalizations. This deficient practice has the potential to affect a census of 95 residents.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure resident rights by failing to initiate resident grievances received during monthly resident council meetings and failing to demonstrate the facility's resolution for such grievances. This deficient practice had the potential to effect a census of 85.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that their grievance policy and procedure was followed. The facility failed to ensure the residents were aware of the procedure for filing a grievances. The deficient practice had the potential to effect a census of 85.

Inspectors wroteBased on record review and interview, the facility failed to maintain a complete medical record on each resident for 1 (Resident #63) out of a sample of 37 residents. This was evidenced by failing to ensure I&O's (Intake and Output) were documented daily, every shift. This deficient practice had the potential to affect a census of 85 residents.

Inspectors wroteBased on observations, records reviews and interviews the provider failed to ensure that a resident's assessment accurately reflected the resident's status for 2 (Resident #63 and Resident #45) residents investigated out of a finalized sample of 37 residents as evidenced by: 1. Failing to ensure Resident #63's MDS assessment accurately identified dialysis status, antipsychotic and antianxiety use; and, 2. Failing to ensure that Resident #45's MDS (Minimum Data Set) accurately identified his Level II PASARR (Preadmission Screening and Resident Review) status.

Inspectors wroteBased on record review and interview, the facility failed to develop/implement a comprehensive centered care plan for 2 (Resident #45 and Resident #67) out of 37 sampled residents. This deficient practice had the potential to affect a census of 85. 1. Failing to develop a comprehensive centered care plan for Resident #45 for PASRR (Preadmission Screening and Resident Review); and 2. Failing to follow care plan for restorative program for Resident #67.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that 1 (#49) out of 37 sampled residents participated in care planning meetings. This was evidenced when the resident stated she had never participated in a care planning meeting. The deficient practice had the potential to affect a total census of 85.

Inspectors wroteBased on observations, record review and interviews the provider failed to ensure staff provided active and passive range of motion for 1 (#67) of 3 (#11, #52, #67) residents investigated for rehab and restorative care. The deficient practice had the potential to effect the 8 residents receiving restorative care.

Inspectors wroteBased on record review and interview, the facility failed to maintain acceptable parameters of nutritional status, by failing to ensure the RD (Registered Dietitian) conducted nutritional assessments for 1 (Resident #63) out of 4 (Resident #20, Resident #45, Resident #47, Resident #63) residents investigated for nutrition out of a total sample of 37 residents.

Inspectors wroteBased on record reviews, observation, and interview, the facility failed to provide necessary care and services in accordance with the professional standards of practice and the resident's plan of care for 1 (#13) of 37 sampled residents reviewed.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that residents who required dialysis received such services consistent with professional standards of practice for 1 (Resident #63) out 1 (Resident #63) residents sampled for dialysis services as evidenced by: 1. Failing to monitor and assess a dialysis fistula before, and upon return from outpatient hemodialysis, and; 2. Failing to ensure ongoing communication and collaboration with the dialysis facility through dialysis communication forms.

Inspectors wroteBased on record review and interview, the facility failed to have documented evidence the Certified Nursing Assistant (CNA) Registry was verified for 3 (S15CNA, S16CNA, and S17CNA) of 3 (S15CNA, S16CNA, and S17CNA) CNA personnel records reviewed. This deficient practice had the potential to affect a total census of 85.