Survey Report for 191560

DEPARTMENT OF HEALTH AND HUMAN SERVICES		FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES		OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION	(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER	(X2) MULTIPLE CONSTRUCTION	(X3) DATE SURVEY COMPLETED
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION	191560	A. BUILDING __________ B. WING ______________	02/12/2021
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
NOLA SJH II, LLC	507 UPSTREAM STREET, RIVER RIDGE, LA, 70123
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE		TITLE	(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID PREFIX TAG	SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY SHOULD BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)
L0543
L0543	33625 Based on record review and interviews the agency failed to ensure medications were provided as ordered per the physician per the plan of care for 1(#1) of 5 (#1-#5) sample patient records who received in-patient hospice services. Findings: Review of Patient #1's Record revealed Patient #1 was admitted to the agency on 3/25/2020 with diagnoses, in part: Left Ventricular Failure, Chronic Atrial Fibrillation, Cardiomyopathy, Malignant Neoplasm of Prostate and Secondary Malignant Neoplasm. Review of Patient #1's Hospice Certification and Plan of Care for Certification Period of 03/25/2022 to 06/22/2020 revealed Patient #1 was to receive the following medications per his plan of care, in part: Levothyroxine (a thyroid medication) oral 25 micrograms oral (mcg) one tablet daily Metoprolol Tartrate (blood pressure medication) oral 50 milligrams (mg) every 12 hours Myretriq (medication to treat an overactive bladder) 25mg 1 tablet daily Prednisolone (steroid medication) oral 5mg daily Zytiga (a medication used with steroid medication to treat prostate cancer) oral 500 mg 2 tablets daily Review of Patient #1's March 2020 Medication Administration Record revealed, in part: no documented evidence of any staff having initialed as administering Levothyroxine oral, Metoprolol Tartrate oral, Myrbetriq oral, Prednisolone, and Zytiga oral on 03/28/2020 at 9:00am. In an interview on 02/10/2021 at 10:20am, S1Executive Director confirmed Patient #1's Plan of Care was not followed for his medications. S1Executive Director stated she had not additional documentation of Patient #1 having received his medications as ordered per his plan of care for Patient #1 on 03/28/2020.