Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Courtyard Of Natchitoches during CMS and state inspections, most recent first.
A resident with dementia and other diagnoses developed a new unstageable sacral pressure ulcer, and hospice and facility nursing staff documented wound care orders including Dakin’s gauze, Vashe cleansing, and q2h side-to-side turning. The resident’s care plan remained unchanged and did not reflect the actual pressure ulcer or the updated repositioning intervention, and the RN/MDS acknowledged the care plan should have been revised but was not.
Failure to provide timely pressure ulcer care and turning documentation. A resident with dementia and other medical conditions developed a new sacral PU that was identified by hospice, with orders for Dakin's gauze and later for side-to-side repositioning every 2 hours. The wound care was not documented until several days later, and the MAR/TAR did not reflect the turning order; hospice also found the resident lying on her back despite the order.
A resident with severe cognitive impairment, multiple chronic conditions, and a care plan noting vaccine refusal due to allergies received a high-dose influenza vaccine without documented prior education or signed consent from the resident or health care proxy, as required by facility policy. An LPN administered the vaccine based on a list of residents reported to have consented, without verifying consent in the record, and the only documented refusal form from the responsible party was signed several days after the vaccine had already been given.
Improper Storage of Refrigerated Food Items: Surveyors observed multiple refrigerated food items in the kitchen that were unsealed or unpackaged, unlabeled, or missing open/discard dates, including smoked ham lunch meat, lettuce, and cheese. Dietary staff confirmed that food in the cooler should have been sealed, labeled, and dated, and that the expired cheese should have been discarded.
A resident with intact cognition and multiple chronic conditions was assessed and care planned to self-administer only eye drops, with no orders permitting bedside storage of other medications. However, surveyors observed Diclofenac arthritis cream, Nystatin cream, and Hydrocortisone cream left unattended in the resident’s room and bathroom, and the resident reported self-administering these creams after receiving them from a nurse. The ADON confirmed that the resident was authorized only for self-administration of eye drops and that the topical creams should not have been left in the room, demonstrating the facility’s failure to follow its own self-administration assessment and policy.
A resident with quadriplegia, central cord syndrome, edema, and intact cognition, who relied on a wheelchair for mobility and required extensive assistance with ADLs, repeatedly reported that her wheelchair was too small and causing hip discomfort. CNAs confirmed the complaints and notified the administrator, and staff observed that the resident had gained weight and sometimes had edema. Surveyors observed the resident seated with her hips tightly pressed against the wheelchair sides and later noted redness and indentations on both hips after transfer, which an LPN confirmed were from the wheelchair. Therapy staff reported they had not been informed by nursing that the wheelchair was too small, and despite awareness of the issue, no effective action was taken to provide an appropriately sized wheelchair.
A resident with severe cognitive impairment received Seroquel without a documented supporting diagnosis in the chart, and the MDS noted antipsychotic use with no indication. The care plan called for psychotropic medication monitoring every shift, but the facility did not monitor for side effects or behaviors, and internal medication review documents flagged the lack of a supporting diagnosis for the Seroquel order.
The facility failed to refer a resident for an updated Level II PASARR review after new psychiatric diagnoses were identified. The resident had prior anxiety and depression, was sent out for psych eval after a change in mental status, then returned with new dx of Delusional Disorder and Schizoaffective Disorder; the SSD confirmed no new referral was sent to the state authority.
A resident with swallowing problems and physician orders for no straws, bread, or rice was repeatedly served bread during meals. Staff confirmed the resident’s meal ticket did not reflect the current diet order, and the resident stated she was always given bread even though she could not eat it.
A resident with intact cognition and no order for bedside medication storage had Diclofenac Arthritis Cream observed on the bedside table, and later Diclofenac Arthritis Cream, Nystatin Cream, and Hydrocortisone Cream were found unattended on a table in the bathroom. The resident said the creams came from the nurse, and the ADON confirmed they should not have been left unattended.
Failure to Honor Resident Food Preferences: Two residents with intact cognition were served meals that did not match documented dislikes. One resident with DM, anxiety, and HTN was served chicken pasta with meat despite a stated dislike of meat in pasta, and another resident with MM and CKD was served broccoli despite a documented dislike and no alternate vegetable. An LPN and the Administrator confirmed the meals did not honor resident preferences.
A resident's protected health information (PHI) was left visible on an unattended EMR cart, as observed by surveyors. An LPN admitted to leaving the cart unattended without securing the computer screen, and the DON confirmed that staff are required to lock screens when not present. This incident violated the facility's HIPAA privacy policy.
Surveyors found a medication cart left unattended and unlocked in a hallway, with several drawers open and medications accessible. An LPN confirmed the cart should have been locked and secured when not in use, in accordance with facility policy. The DON also stated that medication carts are required to be locked when unattended.
Staff failed to accurately document the administration of medications and completion of ordered care tasks on the MAR for two residents with complex medical needs. Despite performing the required tasks, LPNs did not consistently record times and initials as required by facility policy, resulting in incomplete and inaccurate medical records.
A resident with intact cognition and significant medical needs entrusted a staff member with a large sum of settlement money for safekeeping and distribution to family. The staff member failed to safeguard the funds, claiming they were stolen from her home, did not report the theft, and did not return the money. Facility investigation confirmed the misappropriation of the resident's property by the staff member.
A resident with intact cognition and complex medical needs reported that a staff member misappropriated a significant sum of money. Although the staff member admitted to the misappropriation, the facility did not conduct a thorough investigation, failed to interview all relevant residents, and did not provide comprehensive in-service education to all staff. Additionally, the resident was not consistently monitored for safety or emotional well-being during the investigation, and several staff members lacked awareness of misappropriation as a form of abuse.
Two residents were placed in physical restraints, including a Geri-chair and a pommel cushion, without required physician orders, consents, or risk assessments. Staff interviews confirmed that the facility lacked both the necessary documentation and a policy for restraints or bed rails.
The facility did not obtain physician's orders, informed consent, or conduct risk assessments before installing bed rails for three residents with significant medical and cognitive impairments. Staff confirmed the absence of required documentation and policies related to bed rail use.
A resident with pressure ulcers did not receive the required weekly skin assessments and wound measurements, as confirmed by interviews with the Wound Care Nurse and RN Charge. This failure to document care is contrary to the facility's policies, which mandate weekly documentation to manage pressure ulcers effectively.
A facility failed to ensure consistent documentation of a resident's code status. Despite having a physician's order and signed consent for DNR status, the resident's care plan incorrectly indicated Full code status. Staff were aware of the DNR status through the resident's dashboard and hard chart, but the care plan was not updated accordingly, leading to a discrepancy.
A resident with severe cognitive impairment and osteoporosis experienced a leg injury during repositioning by two CNAs, who failed to report an audible pop immediately. The resident later complained of leg pain, prompting a nurse to investigate and send the resident for an x-ray, which revealed a spiral fracture. The facility's administrator confirmed the CNAs should have reported the incident immediately.
A facility failed to use a mechanical lift for transferring a non-weight bearing resident, as required by the care plan. Two CNAs used a lift pad instead, citing issues with finding a functional lift. The resident, with severe cognitive impairment and osteoporosis, was transferred without the necessary equipment, contrary to facility policy.
The facility failed to maintain wheelchairs in good repair, affecting five residents. Observations showed peeling and cracked armrest cushions, with one resident's family member noting the issue had persisted for months. The DON confirmed the need for replacement during environmental rounds.
The facility failed to meet residents' nutritional needs by not adhering to prescribed portion sizes for pureed meals. Kitchen staff used a 4oz scoop that was not filled to capacity, resulting in residents receiving less than the required portions. This affected multiple residents, including those needing double portions, and was confirmed by staff observations and interviews.
The facility did not provide a Notice of Medicare Non-Coverage (NOMNC) to three residents before discontinuing their Medicare Part A services, despite having benefit days remaining. The social worker acknowledged not issuing the required notice and was unaware of the necessity to do so.
A facility failed to develop a comprehensive Hospice Care Plan for a resident admitted to hospice care, despite the resident's serious health conditions and a physician's order. Interviews confirmed the resident was receiving hospice services, but the care plan did not reflect this, indicating a lapse in care planning.
A resident with a history of dizziness and balance issues fell while trying to get into bed without assistance. The facility failed to update the care plan with new fall prevention strategies after the incident. The MDS coordinator was unaware of the fall due to a lack of communication, resulting in the care plan not being revised.
A resident with a history of osteoporosis and pain did not receive the prescribed Duloxetine dosage due to a failure in entering a physician's order. The resident was supposed to receive 60 mg daily, but the order was not processed, and the resident missed the medication from 09/16/2024 to 09/24/2024. The ADON confirmed the oversight during an interview.
The facility failed to implement a dietitian's recommendations for two residents, leading to deficiencies in maintaining their nutritional status. One resident experienced significant weight loss without receiving recommended dietary supplements, while another resident with mild malnutrition did not receive suggested nutritional supplements or vitamins for wound healing. The ADON confirmed that necessary orders were not entered.
A resident with a history of falls and multiple diagnoses, including dementia and incontinence, experienced a significant delay in receiving assistance after using the call light. Despite being informed that help would arrive soon, the resident waited approximately 35 minutes for assistance to use the restroom. The facility's policy requires call light responses within 15 minutes, but this was not adhered to, indicating a deficiency in staff competency and response time.
A resident with a milk allergy and lactose intolerance was given Ensure, a supplement containing milk protein, three times daily due to weight loss. Despite the care plan requiring nondairy alternatives, staff confirmed the administration of Ensure. The RD admitted to the oversight, assuming the resident only had lactose intolerance.
The facility did not follow professional standards for food service safety by failing to cover, label, and date refrigerated food items after opening. An open block of cheese and a cup of oranges were found uncovered and undated in the refrigerator, confirmed by the kitchen lead. This oversight could impact the 92 residents receiving meals from the kitchen.
Care Plan Not Revised for New Sacral Pressure Ulcer
Penalty
Summary
The facility failed to ensure that a resident’s comprehensive person-centered care plan was reviewed and revised after a new unstageable pressure ulcer of the sacral region was identified. The resident was admitted with diagnoses including pulmonary embolus, anorexia, hypertension, urinary tract infection, and unspecified dementia, and a pressure ulcer risk care plan had been initiated earlier for mild risk for pressure ulcer/pressure injury. On 03/17/2026, a new diagnosis of pressure ulcer of the sacral region, unstageable, was added to the resident’s record after hospice staff found a new wound to the sacrum during a visit, with the facility nurse present and informed of a new wound order for Dakin’s gauze to the wound bed. Review of the resident’s handwritten physician’s telephone orders showed wound care orders entered on 03/14/2026, 03/16/2026, and 03/17/2026, including Dakin’s gauze to the sacral wound bed, turning and repositioning side to side only every 2 hours per posted turn schedule, and cleansing the unstageable sacral pressure ulcer with Vashe, applying Dakin’s Solution moistened gauze, and covering with a dry dressing daily and as needed. The resident’s care plan did not include revisions for the actual pressure ulcer and did not include the intervention for turning and repositioning side to side only every 2 hours per the posted turn schedule. During interview, the RN/MDS stated the care plan should have been revised to include the unstageable sacral pressure ulcer and the change in turning and repositioning intervention, but it was not.
Failure to Provide Timely Pressure Ulcer Care and Turning Documentation
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not ensured for a resident admitted with diagnoses including pulmonary embolus, anorexia, hypertension, UTI, and unspecified dementia. Hospice identified a new sacral wound on 03/14/2026, and a telephone order was given for Dakin's gauze to the wound bed. The facility later documented the wound as an unstageable sacral pressure ulcer with slough, serosanguinous drainage, and erythema to the peri-wound area, with measurements recorded on 03/18/2026. The resident's March 2026 TAR did not show the wound care order until 03/18/2026, and there was no documentation of turning and repositioning side to side every 2 hours as ordered. The record and interviews showed the hospice nurse informed the facility nurse of the new wound and wound care order when the ulcer was discovered, and the facility nurse confirmed she was present when the wound was assessed. A later order directed the resident to be turned and repositioned side to side only every 2 hours, but hospice records dated 03/23/2026 and 03/24/2026 showed the resident lying on her back. The hospice nurse confirmed the resident should not have been lying on her back because of the sacral pressure ulcer and the turning order, and the treatment nurse confirmed wound care documentation did not begin until 03/18/2026 even though it should have started when the wound was found.
Failure to Obtain and Document Consent and Education Prior to Influenza Vaccination
Penalty
Summary
The facility failed to follow its policy requiring education and signed consent prior to administering influenza and pneumonia vaccinations. The written policy titled “Pneumonia/Influenza Vaccinations” directed staff to contact the resident and family to explain the importance of vaccinations and to obtain signed consent from the resident and/or family. For one resident, admitted with chronic kidney disease stage 5, end stage renal disease, pneumonia, schizophrenia, and bipolar disorder, the record identified a health care proxy as the responsible party and a care plan focus of refusing vaccines due to allergy to some components, with an intervention to assess for consent or refusal upon admission and periodically with the resident and responsible party. The resident’s MDS showed a BIMS score of 3, indicating severely impaired cognition. Despite these requirements and the resident’s cognitive status and care plan, the physician’s order for a high-dose influenza vaccine was implemented and the vaccine was administered on a documented date and time without any documented evidence of prior education, consent, or refusal from the resident or health care proxy. The eMAR confirmed the vaccine was given, while the medical record lacked a signed consent form or documentation of education about risks and benefits before administration. A subsequent influenza vaccination request and consent form, signed by the responsible party several days after the vaccine was given, documented a refusal of the influenza vaccine on an ongoing basis. Staff interviews confirmed that an LPN administered the vaccine based on a list of residents purported to have consented, without personally verifying a signed consent, and the infection control nurse and ADON acknowledged that consent/refusal and education should have been obtained and documented before the vaccine was administered, but this did not occur for this resident.
Improper Storage of Refrigerated Food Items
Penalty
Summary
The facility failed to store refrigerated food items in accordance with professional food service standards by leaving food uncovered or unsealed, unlabeled, and without open or discard dates. During a kitchen observation with Dietary staff, surveyors found an unsealed, unlabeled package of smoked ham lunch meat, an unsealed bag of lettuce with brown discoloration and an illegible label due to moisture, unpackaged and undated loose cheese slices, and an unpackaged block of cheese labeled with a discard date of 01/04/2026. Dietary staff confirmed that food stored in the cooler should have been sealed, labeled, and dated, and confirmed that the expired cheese should have been discarded but was not.
Failure to Follow Self-Administration Assessment Limits for Topical Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure the interdisciplinary team assessed and determined clinical appropriateness for self-administration of medications in accordance with its policy for one resident. The facility’s policy required that if a resident desired to self-administer medications, the interdisciplinary team would assess the resident’s cognitive, physical, and visual abilities and document the results on a Self-Administration Assessment form in the medical record. The resident in question had diagnoses including COPD, primary insomnia, depression, and nicotine dependence, and a BIMS score of 15 indicating intact cognition. The resident’s care plan documented a physician’s order for unsupervised self-administration of carboxymethylcellulose eye drops only, and the Self-Administration of Medication assessment form indicated the resident was fully capable to self-administer eye drops, but topical medications (including patches) were not selected as medications the resident was capable of self-administering. There were no physician’s orders allowing the resident to store medications at the bedside. Despite this, surveyor observations and interviews showed that multiple topical medications were present and left unattended in the resident’s room and bathroom, and the resident reported self-administering them. Diclofenac arthritis cream was observed on the bedside table, and later Diclofenac arthritis cream, Nystatin cream, and Hydrocortisone cream were observed on a table next to the resident’s toilet. The resident stated she administered the creams herself and that a nurse had given her the cream in a medicine cup, although she could not recall which nurse. The ADON confirmed during the survey that these topical medications should not have been left unattended in the resident’s bathroom and that, per the self-administration assessment, the resident was only allowed to self-administer eye drops and not topical creams. This discrepancy between the documented assessment/physician orders and the actual practice of allowing the resident to self-administer and keep topical medications in the room led to the cited deficiency.
Failure to Provide Appropriately Sized Wheelchair for Resident
Penalty
Summary
The facility failed to reasonably accommodate a resident’s needs and preferences by not providing a wheelchair appropriate for her size. The resident, admitted with diagnoses including edema, unspecified quadriplegia, acute pain, muscle spasm, central cord syndrome of the cervical spinal cord, and seizures, had intact cognition with a BIMS score of 15 and used a wheelchair for mobility. Her MDS and care plan documented limited physical mobility, bilateral upper and lower extremity impairments, and dependence on staff for transfers, toileting, and personal hygiene, as well as risk for pressure ulcers and the need to avoid striking extremities on hard surfaces. During observation, the resident was seen sitting in a wheelchair with no space between her hips and the sides of the chair, and she reported that the wheelchair was too small, rubbed against her hips, and that she had previously informed the administrator of this issue over a month earlier after gaining weight. Multiple CNAs confirmed that the resident had complained that her wheelchair was too small and was hurting her hips, and that they had notified the administrator and shown her that the wheelchair did not fit properly. Another staff member reported noticing that the resident’s wheelchair was too small and that the resident had edema at times and had gained weight. On a subsequent observation, three CNAs were seen transferring the resident from the wheelchair to bed via Hoyer lift, and redness and indentations were observed on both hips where they had been pressed against the sides of the wheelchair; an LPN confirmed these findings. Therapy staff stated that residents are screened every three months and as needed, but nursing had not notified therapy that this resident’s wheelchair was too small. The administrator acknowledged that a requisition for a larger wheelchair had been cancelled and confirmed that no other measures had been implemented to obtain an appropriately sized wheelchair for the resident.
Unnecessary Psychotropic Medication Use and Lack of Monitoring
Penalty
Summary
The facility failed to ensure a resident's drug regimen was free from unnecessary medications by not having a documented medical condition supporting the use of Seroquel and by not monitoring for side effects and behaviors related to psychotropic medication use. Resident #8 was admitted with diagnoses including Other Unspecified Anxiety Disorder, Insomnia, and blindness of both eyes, and the quarterly MDS showed a BIMS score of 6 indicating severe cognitive impairment. The MDS also indicated the resident had received an antipsychotic with no indication noted. The resident's care plan identified use of psychotropic medications, including Seroquel, with interventions to administer the medication as ordered and monitor for side effects and effectiveness every shift. Physician orders showed Seroquel 25 mg at bedtime related to insomnia, and facility medication review documentation noted there was no supporting diagnosis for the current Seroquel order. A doctor report later identified that the resident was on Seroquel therapy and requested an acceptable diagnosis, and the DON confirmed the resident's chart was not updated to reflect bipolar disorder and that the facility was not monitoring the resident for side effects or behaviors of psychotropic medications.
Failure to Refer Resident for Updated PASARR Level II Review After New Psychiatric Diagnoses
Penalty
Summary
The facility failed to refer a resident with newly diagnosed mental disorders to the appropriate state-designated authority for a Level II PASARR evaluation and determination. The resident had an initial admission diagnosis that included a personal history of mental and behavioral disorders, anxiety disorder, and major depressive disorder, and the record also showed a prior OBH PASRR Level II Evaluation Summary & Determination Notice stating that a Level II was not required because the individual did not have a serious mental illness and had no intensive behavioral health treatment reported. The resident was sent out of the facility for psychiatric evaluation due to a change in mental status and then had an inpatient psychiatric admission. After that hospitalization, the record showed new diagnoses of Delusional Disorder and Schizoaffective Disorder, Depressive type. Review of the record found no evidence that a new review or Level II PASARR had been submitted after those diagnoses were added. In interview, the Social Services Director confirmed responsibility for sending PASARR referrals and acknowledged that the facility did not send a new referral after the new diagnoses were identified.
Diet Orders Not Followed for Resident With Swallowing Restrictions
Penalty
Summary
The nursing facility failed to follow a physician’s diet orders for a resident with swallowing problems. The resident had diagnoses including COPD, primary insomnia, depression, and nicotine dependence, and had a BIMS score of 15 indicating intact cognition. Her physician orders and care plan specified a regular diet with regular texture and thin liquids, but with single cup sips only, no straws, and no dry or particulate foods such as bread and rice because of aspiration concerns identified after an MBS that showed some aspiration of liquids improved by avoiding straws and dry foods. Despite these orders, the resident was observed being served and eating bread on multiple occasions, including a BLT sandwich at lunch and later a tray with mashed potatoes, bread, and baked turkey. The resident stated she was always served bread during meal service and did not know why she kept receiving it since she could not eat it. Staff interviews confirmed that the physician orders prohibited bread, rice, and straws, and acknowledged that the resident was served bread during meals and that her meal ticket did not reflect the current diet order.
Medications Left Unattended at Resident Bedside and in Bathroom
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored in a secure manner by leaving medications at the bedside for one resident without a physician order allowing bedside storage. Resident #48 was admitted on 05/12/2025 with diagnoses including Chronic Obstructive Pulmonary Disease, Primary Insomnia, Depression, and Nicotine Dependence. The resident’s quarterly MDS dated 11/19/2025 showed a BIMS score of 15, indicating intact cognition, and the resident was independent with bed mobility, transfers, eating, and toileting. The medical record contained no physician’s orders permitting the resident to keep medications in the room at the bedside. During observation and interview on 01/05/2026, Diclofenac Arthritis Cream was seen on the resident’s bedside table. The resident stated she was running low on the cream and needed more. During a later observation and interview, Diclofenac Arthritis Cream, Nystatin Cream, and Hydrocortisone Cream were observed on a table next to the resident’s toilet in the bathroom. The resident stated she had received the creams from the nurse and that one nurse would give her some cream in a medicine cup. S2 ADON later accompanied the surveyor to the room and confirmed that the Diclofenac Arthritis Cream, Nystatin Cream, and Hydrocortisone Cream should not have been left unattended in the resident’s bathroom.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor and accommodate resident food preferences for 2 of 7 residents reviewed for dining. The report states that the facility policy on Promoting/Maintaining Resident Self-Determination required resident choice and accommodation of preferences to the extent possible. The deficiency was identified during observation, interview, and record review, and the report states the practice had the potential to affect 87 residents who consumed meals from the kitchen. Resident #5 had an admission date of 06/09/2016 and diagnoses including Type 2 Diabetes Mellitus without complications, Anxiety Disorder, and Essential Primary Hypertension. Her Annual MDS showed a BIMS score of 15, indicating intact cognition. During lunch observation, she was served chicken pasta with white cream sauce, broccoli, and garlic breadstick, and the chicken pasta was untouched. She stated she did not like meat in her pasta and would not eat the meal. Her meal ticket listed dislikes of beef and meat in pasta, and an LPN confirmed she was served food that did not honor her preferences. Resident #29 had an admission date of 09/04/2024 and diagnoses including Multiple Myeloma and Chronic Kidney Disease, with a BIMS score of 15. During lunch observation, he was eating in the dining area but did not eat the broccoli on his tray, stating he did not like broccoli. His meal ticket listed broccoli as a dislike, and no alternate vegetable was served. An LPN and the Administrator confirmed he was served food that did not honor his preferences.
Failure to Protect Resident PHI Due to Unattended EMR Cart
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of medical records for one resident. During an observation on Hall B, an unattended medical cart was found with the electronic medical record (EMR) screen left open, displaying a resident's protected health information (PHI). The cart remained unattended until a staff member, identified as an LPN, returned. Upon interview, the LPN acknowledged leaving the cart unattended with the resident's PHI visible and admitted not ensuring the privacy and confidentiality of the information. The Director of Nursing confirmed that staff are expected to lock computer screens when leaving them unattended to protect resident PHI. This deficiency was identified through observation, interview, and record review, and was found to be in violation of the facility's policy requiring all workforce members to adhere to HIPAA Privacy Standards and prevent unauthorized disclosure of PHI.
Unattended and Unlocked Medication Cart Found During Survey
Penalty
Summary
Surveyors observed that Cart X, containing medications, was left unattended and unlocked in Hall B, with three of its eight drawers open. This occurred during a medication pass and was witnessed at 8:55 a.m. The cart remained unsecured until a staff member, identified as an LPN, returned. Upon interview, the LPN confirmed that the cart was supposed to be locked and all drawers closed when not attended, acknowledging that the medications were not stored in a safe and secure manner. The facility's policy requires all medications to be stored in locked compartments and for medication carts to be locked when unattended, which was not followed in this instance. The Director of Nursing also confirmed that medication carts are to be locked when unattended to ensure security.
Failure to Accurately Document Medication Administration and Care Tasks
Penalty
Summary
The facility failed to maintain accurate and complete medical records in accordance with accepted professional standards and its own policies. Specifically, staff did not consistently document the administration of medications and completion of ordered care tasks on the Medication Administration Record (MAR) for two residents. The facility's policies require that all medications administered be recorded with time and staff initials on the MAR, and that the electronic MAR (E-MAR) serves as a permanent, legal document within the electronic health record. For one resident with multiple diagnoses including severe cognitive impairment, repeated falls, malnutrition, and dementia, there were multiple instances where staff failed to record the administration of medications such as Levothyroxine, Donepezil, Atorvastatin, Latanoprost, Memantine, and topical creams, as well as the completion of care tasks like applying an overlay on the mattress and ensuring the use of pillow heel boots. These omissions occurred across several dates and shifts, with missing documentation for both day and night shifts. Another resident, with diagnoses including diabetes and hypothyroidism and intact cognition, also had missing documentation for medication administration (Levothyroxine, Novolin R), blood glucose monitoring, and other ordered care tasks over several days. Interviews with administrative and nursing staff confirmed that while medications and care tasks were performed as ordered, the required documentation was not completed on the MARs for the affected residents. Staff acknowledged that the records were not accurate and should have been properly documented according to facility policy.
Staff Misappropriation of Resident Funds
Penalty
Summary
A deficiency occurred when a staff member, S7 Rehab Tech, misappropriated a resident's funds by agreeing to hold a large sum of money for the resident and subsequently failing to safeguard or return the funds. The resident, who had intact cognition as indicated by a BIMS score of 15 and diagnoses including cervical spine fusion, seizures, quadriplegia, and depression, received a settlement check and entrusted S7 Rehab Tech with approximately $12,000 in cash. The staff member was supposed to distribute portions of the money to the resident's family and hold the remainder for the resident, as per the resident's instructions. After the money was given to S7 Rehab Tech, the staff member reported to the resident that the funds were stolen from her home during a break-in. S7 Rehab Tech did not file a police report regarding the alleged theft and did not return the funds to the resident. The staff member admitted to holding the money and acknowledged that she should not have agreed to the arrangement. The resident attempted to recover the funds and communicate with S7 Rehab Tech, but the staff member avoided contact and blocked the resident's phone number. The facility's investigation, prompted by a rumor and subsequent interviews, confirmed that the staff member had misappropriated the resident's funds. The staff member admitted to the actions during interviews with facility administration and the rehab director. The incident was substantiated as misappropriation of property/funds, as the staff member wrongfully used the resident's money without proper consent or protection, in violation of facility policy and resident rights.
Failure to Thoroughly Investigate Misappropriation of Resident Property
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of misappropriation of resident property involving a resident with intact cognition and significant medical conditions, including quadriplegia and depression. The resident reported that a staff member was asked to hold a large sum of money, which was later reported stolen from the staff member's home. The staff member admitted to taking the money, and the incident was substantiated by the facility. Despite the admission, the investigation was not comprehensive. Not all cognitively intact residents were interviewed regarding similar issues, and not all facility and therapy staff received in-service education on misappropriation of resident property or funds. Several staff members, including CNAs and therapy staff, demonstrated a lack of understanding about misappropriation and its classification as a form of resident abuse. Some staff members were unaware of the incident or had not received any related training or education following the event. Additionally, the resident who reported the incident did not receive consistent monitoring or safety checks during the investigation process. The facility's own policy required timely and thorough investigations and monitoring of the resident's emotional well-being during such incidents, but these steps were not fully implemented. The administrator acknowledged that the investigation was limited due to the staff member's admission and confirmed that key investigative and monitoring actions were not completed.
Failure to Obtain Orders, Consents, and Assessments for Physical Restraints
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints imposed for discipline or convenience, as evidenced by the lack of required physician orders, consents, and risk assessments for two residents. One resident, admitted with multiple diagnoses including chronic kidney disease and impaired cognition, was observed using a Geri-chair for mobility without documentation of a physician's order, signed consent, or completed risk assessment. The resident's care plan indicated the use of the Geri-chair, but the necessary regulatory steps were not followed. Another resident, with a history of dementia, falls, and severely impaired cognition, was observed using a pommel cushion in a wheelchair. The medical record did not contain a physician's order, consent, or risk assessment for this device, despite its use being documented in the care plan. Interviews with facility staff, including the DON and Administrator, confirmed that the facility had not obtained the required documentation for these restraints and did not have a policy in place for restraints or bed rails.
Failure to Obtain Orders, Consent, and Assessments for Bed Rail Use
Penalty
Summary
The facility failed to ensure proper procedures were followed regarding the use of bed rails for three residents. Specifically, there was no evidence of physician's orders, informed consent from the residents or their representatives, risk assessments for entrapment, or care plan documentation related to the use of assist rails. Observations confirmed that all three residents were using bed rails, and staff interviews acknowledged that required assessments, consents, and orders had not been obtained. Additionally, the facility did not have a policy in place for the use of bed rails. The residents involved had significant medical histories, including chronic conditions such as chronic kidney disease, heart failure, dementia, and a history of falls. Cognitive assessments indicated that at least two of the residents had moderate to severe cognitive impairment. Despite these factors, the facility did not document any individualized assessment or planning for the use of bed rails, nor did it obtain the necessary authorizations or consents prior to their installation and use.
Failure to Document Weekly Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with pressure ulcers, as required by professional standards of practice. The resident, who was admitted with multiple diagnoses including stage 3 pressure ulcer of the right hip and stage 2 pressure ulcer of the sacral region, did not receive the mandated weekly skin assessments and wound measurements on specified dates. The facility's wound care documentation policy requires weekly documentation of all existing and new wounds, including detailed assessments of the wound's status and condition. Interviews with the Wound Care Nurse and the Registered Nurse Charge confirmed the absence of documentation for the required weekly skin evaluations and measurements for the resident on the specified dates. This lack of documentation indicates a failure to adhere to the facility's policies and procedures for managing pressure ulcers, which are crucial for promoting healing and preventing further complications.
Inconsistent Documentation of Resident's Code Status
Penalty
Summary
The facility failed to ensure that all medical records regarding a resident's code status consistently reflected the resident's current wishes. The resident, who had multiple diagnoses including cerebral infarction and type II diabetes mellitus, had a physician's order for Do Not Resuscitate (DNR) status created and confirmed on 11/11/2024. The resident had also signed a consent form for DNR status on 10/22/2024, which was confirmed by the physician. However, the resident's care plan, which should have been updated to reflect the DNR status, incorrectly indicated a Full code status as of 10/23/2024. During interviews and record reviews, it was revealed that the facility's staff, including an LPN and the MDS Coordinator, were aware of the DNR status as indicated in the resident's dashboard on Point Click Care (PCC) and the hard chart. Despite this, the care plan was not updated to reflect the DNR status, leading to a discrepancy between the resident's documented wishes and the care plan. The MDS Coordinator confirmed that the care plan should have been updated when the new DNR order was received, but it was not, resulting in the deficiency.
Failure to Report Change in Condition Immediately
Penalty
Summary
The facility failed to ensure immediate reporting of a change in condition for a resident, which is a deficiency in their care protocol. The incident involved a resident with severe cognitive impairment and multiple diagnoses, including a displaced spiral fracture of the left femur, atrial fibrillation, unspecified dementia, and osteoporosis. The resident required substantial assistance with daily activities and was care planned for osteoporosis, with specific interventions for safety and transfer assistance. On the morning of the incident, two CNAs were repositioning the resident when they heard an audible popping sound from the resident's leg. Despite hearing the pop, the CNAs did not report the incident to the nurse immediately, as the resident did not show any immediate signs of pain or distress. The resident was then placed in a wheelchair and taken to the dining room. It was only after the resident complained of leg pain while sitting at the dining table that the CNAs informed the nurse about the earlier popping sound. The nurse, upon being informed, examined the resident and, after consulting with the charge nurse and the resident's doctor, decided to send the resident to the emergency room for further evaluation. An x-ray confirmed a spiral fracture in the resident's left femur. The delay in reporting the initial incident by the CNAs was acknowledged by the facility's administrator as a failure to adhere to the facility's policy on reporting accidents and incidents immediately, regardless of the perceived severity.
Failure to Use Mechanical Lift for Resident Transfer
Penalty
Summary
The facility failed to adhere to its policy for transferring non-weight bearing residents, resulting in a deficiency. The policy requires the use of a mechanical lift with two-person assistance for transferring residents who are non-weight bearing. However, on 11/19/2024, two CNAs transferred a resident from bed to wheelchair using a lift pad instead of the mechanical lift, as outlined in the resident's care plan. The CNAs reported that they opted for the lift pad because it was quicker and mechanical lifts were often unavailable due to being hidden or having dead batteries. The resident involved had a history of severe cognitive impairment, osteoporosis, and other medical conditions, necessitating careful handling during transfers. The resident's care plan specifically required the use of a Hoyer lift with two-person assistance for all transfers to ensure safety. Despite this, the CNAs proceeded with the transfer using the lift pad, which was confirmed by the facility's administrator through interviews and camera footage review. This action was contrary to the care plan and facility policy, leading to the deficiency finding.
Wheelchair Armrest Cushions in Disrepair
Penalty
Summary
The facility failed to maintain residents' wheelchairs in good repair, compromising the residents' right to a safe and comfortable environment. Observations revealed that the armrest cushions of wheelchairs for five residents were peeling and in disrepair. Specifically, Resident #19 was observed sitting in a wheelchair with both arm cushions in disrepair. Resident #40's wheelchair arm cushions were also in disrepair, with the resident's son noting that the condition had persisted for 6-8 months. Similar conditions were observed for Residents #47, #49, and #67, with cracked and non-intact surfaces on their wheelchair arm cushions. During environmental rounds with the Director of Nursing (DON), these deficiencies were confirmed, indicating a need for replacement of the damaged equipment.
Failure to Adhere to Prescribed Portion Sizes for Pureed Meals
Penalty
Summary
The facility failed to meet the nutritional needs of residents by not adhering to the prescribed portion sizes for pureed meals, as observed during a survey. The lunch menu for residents on pureed diets specified serving sizes of 3/4 cup for pureed chicken spaghetti and 1/2 cup for pureed green beans. However, the kitchen staff used a 4oz scoop for all food items, which was not filled to capacity, resulting in residents receiving less than the required portion sizes. This discrepancy was confirmed through observations and interviews with kitchen staff, including the Kitchen Lead and Kitchen Assistant Manager, who acknowledged the failure to serve the correct portion sizes. The deficiency affected multiple residents, including those who required double portions as per their meal cards. Observations revealed that residents often received inadequate amounts of food, as confirmed by CNAs assisting them during meals. The Dietary Manager also confirmed that the staff should have followed the serving sizes indicated on the approved menus. The lack of a menu with serving sizes posted in the kitchen contributed to the staff's inability to serve the correct portions, leading to the nutritional inadequacy of meals provided to residents.
Failure to Issue Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) to three residents or their responsible parties before discontinuing Medicare Part A services. This deficiency was identified during a review of the Skilled Nursing Facility (SNF) Beneficiary Review forms for the residents. It was found that the NOMNC, Form CMS-10123, was not provided to the residents prior to their discharge from Medicare Part A services, despite having benefit days remaining. In an interview, the social worker (S4 SW) admitted to not issuing the NOMNC to the residents and was unaware of the requirement to do so.
Failure to Develop Hospice Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive Hospice Care Plan for a resident who was admitted to hospice care. The resident, who had multiple serious health conditions including malignant neoplasm, end-stage renal disease, and heart disease, was admitted to hospice on July 22, 2024. Despite the resident's significant health needs and the physician's order to admit the resident to hospice care, the care plan did not include hospice care, which is a critical component of the resident's treatment and support. Interviews with facility staff, including an LPN and MDS coordinators, confirmed that the resident was receiving hospice services, with a hospice nurse visiting weekly and aides visiting twice a week. However, the MDS coordinators acknowledged that the resident's care plan should have included hospice care but did not. This oversight indicates a lapse in ensuring that the resident's care plan was comprehensive and reflective of their current health care needs, as required by regulatory standards.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to revise the care plan for a resident after a fall incident, which is a deficiency in care planning. The resident, who had a history of dizziness, chronic obstructive pulmonary disease, chronic kidney disease, and anemia, was at moderate risk for falls due to gait and balance problems. Despite these risks, the care plan was not updated with new interventions after the resident fell while attempting to get into bed without assistance. The fall occurred on September 16, 2024, and was documented in the progress notes, but the care plan remained unchanged. The MDS coordinator responsible for the resident's care plan was unaware of the fall incident, as it was not reported in the morning meeting following the event. This lack of communication resulted in the care plan not being revised to include new fall prevention strategies. The resident acknowledged the fall during an interview, stating that he attempted to get into bed without help, believing he could manage on his own. The oversight in updating the care plan highlights a failure in the facility's process for addressing and preventing falls among residents.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to ensure that physician's orders for a resident were followed, leading to a deficiency in meeting professional standards of practice. The resident, who was cognitively intact with a BIMS score of 15, had a medical history that included osteoporosis, an unspecified fracture of the right wrist and hand, anemia, and pain. On 09/20/2024, a physician's order was made to change the resident's Duloxetine dosage to 60 mg daily to help manage back pain and osteoarthritis. However, the order was not entered into the system, and the resident did not receive the prescribed medication. Further review of the resident's Medication Administration Record (MAR) for September 2024 revealed that the resident had not been receiving the previously prescribed 30 mg of Duloxetine daily from 09/16/2024 through 09/24/2024. The resident's care plan included the use of antidepressant medication for pain management, with interventions to ensure the resident was free from discomfort or adverse reactions related to the therapy. During an interview on 09/24/2024, the Assistant Director of Nursing (ADON) confirmed that the order was not entered, and the resident did not receive the medication as prescribed.
Failure to Implement Dietitian's Recommendations for Nutritional Support
Penalty
Summary
The facility failed to ensure that two residents maintained acceptable nutritional status by not implementing the registered dietitian's recommendations. Resident #11, who had severe cognitive impairment and required assistance with eating, experienced significant weight loss over a six-week period. Despite the dietitian's recommendation to encourage supplements for improved nutrition, there were no physician's orders for dietary supplements, and the Medication Administration Records (MARs) showed no documentation of supplements being provided. The Assistant Director of Nursing (ADON) confirmed that an order for supplements was not entered, which should have been done. Similarly, Resident #195, who had a history of metabolic encephalopathy, vitamin deficiency, and other conditions, was identified as having mild malnutrition with a BMI less than 22. The dietitian recommended supplements between meals and specific vitamins for wound healing. However, there were no physician's orders for these supplements or vitamins, and the MARs did not document their provision. The resident confirmed not receiving any supplements, and the ADON acknowledged that the necessary orders were not entered, which should have been carried out by the floor nurse.
Delayed Call Light Response for Resident with High Fall Risk
Penalty
Summary
The facility failed to ensure that nurse aides demonstrated competency in responding to residents' needs, as evidenced by a delayed call light response for a resident. The resident, who had a history of falls and was at high risk due to confusion and gait/balance problems, required prompt assistance. Despite using the call light to request help to use the restroom, the resident waited approximately 35 minutes before receiving assistance. This delay occurred even after an LPN informed the resident that help would arrive soon and notified another staff member of the resident's need. The resident's clinical record indicated multiple diagnoses, including dementia and frequent urinary and bowel incontinence, necessitating timely assistance. The care plan emphasized the importance of anticipating and meeting the resident's needs promptly, with specific instructions for call light accessibility and response. However, the staff failed to adhere to the facility's policy of responding to call lights within 15 minutes, as confirmed by the Director of Nursing. This incident highlights a deficiency in the facility's ability to provide timely care, potentially compromising the resident's well-being.
Failure to Accommodate Resident's Milk Allergy
Penalty
Summary
The facility failed to honor and accommodate a resident's food allergies and intolerances, specifically by providing a supplement containing milk protein to a resident with a documented milk allergy and lactose intolerance. The resident, who had diagnoses including cerebral palsy and severely impaired cognitive skills, was dependent on staff for all activities of daily living. Despite the resident's care plan indicating a need for nondairy alternatives, the resident was given Ensure, a supplement containing milk protein, three times daily due to weight loss. Interviews with facility staff, including a CNA, LPN, and the Assistant Director of Nursing (ADON), confirmed the administration of Ensure to the resident. The Registered Dietitian (RD) responsible for the resident's dietary plan admitted to recommending Ensure, mistakenly assuming the resident only had lactose intolerance and not a milk allergy. This oversight led to the administration of a product containing milk protein, contrary to the resident's documented allergies and care plan requirements.
Failure to Properly Store and Label Refrigerated Food Items
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by not ensuring that refrigerated food items were properly covered, labeled, and dated after opening. During an observation of the kitchen, an open block of cheese and a cup of oranges were found on the refrigerator shelf, both uncovered, exposed to air, and undated. This observation was confirmed by the S7 Kitchen Lead, who acknowledged that all opened food items should be covered and dated, but this protocol was not followed. This deficiency had the potential to affect the 92 residents who received meals served from the kitchen.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 23 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Natchitoches
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Natchitoches Nursing And Rehabilitation Center, Ll | 0 mi | ★★★★★ | 17 | 0 |
| Natchitoches Community Care Center | 1.8 mi | ★★★★★ | 0 | 0 |
| Green Meadow Haven | 24.6 mi | ★★★★★ | 6 | 0 |
| Autumn Leaves Nursing & Rehab Center, Llc | 26.5 mi | ★★★★★ | 7 | 0 |
| Sabine Retirement And Rehab Center | 26.8 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.