F0800

E

Failure to Provide Ordered Meals, Supplements, and Feeding Assistance to Dependent Residents

Natchitoches, Louisiana Survey Completed on 02-24-2026

Penalty

No penalty information released

Summary

The facility failed to provide nourishing, palatable, well-balanced diets and supplements as ordered and to ensure necessary feeding assistance for three dependent residents. Facility policy stated that clients are to be served their diets as ordered, and care plans and MDS assessments documented that these residents were cognitively intact but dependent on staff for all activities of daily living, including feeding. For one resident with quadriplegia, chronic kidney disease, neuromuscular dysfunction, pressure ulcers, anorexia, malnutrition, and an inability to feed himself, the care plan directed staff to feed all meals and give supplements as prescribed. This resident reported usually only getting to eat one meal a day, that staff sometimes did not come to feed him, and that if he was asleep staff would not wake him to feed him. He also stated he did not receive his ordered supplements very often or every day and denied refusing them.

Another resident with quadriplegia, severe protein-calorie malnutrition (on hospice), low BMI, depression, and a stage 4 sacral pressure ulcer was also documented as cognitively intact and dependent on staff for all ADLs. His care plan included providing and serving diet as ordered. He reported that he sleeps a lot and that staff did not always wake him to feed him if he was asleep. He further stated that two of six meals over a weekend were missed because he was sleeping and no one returned to feed him, and that when he was fed he felt rushed, which caused him to feel full too quickly.

A third resident with type 2 diabetes mellitus, quadriplegia, hypertension, major depressive disorder, cognitive communication deficit, and osteoporosis, also cognitively intact and fully dependent on staff, reported relying on staff for feeding and usually being fed only after all trays were passed on the hall. She stated there were two occasions in recent weeks when she did not receive her meal tray because it remained on the cart and was returned to the kitchen. On one of those occasions, after she asked a CNA and an agency nurse to retrieve the tray, they told her the kitchen was already shut down and being cleaned, so she did not receive anything to eat. Staff interviews corroborated systemic issues: a CNA reported problems with residents being fed at dinner due to meal carts arriving during shift change, an LPN reported residents (including the first two residents) complaining they had not been fed or had not eaten, and the dietary manager described communication failures about residents leaving and returning to the facility, resulting in meal tickets not being printed and residents not receiving trays, without these issues being reported to the Administrator.