Below average — CMS composite of the measures below.
A standard survey is most likely before 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 Natchitoches Community Care Center during CMS and state inspections, most recent first.
A resident with multiple medical conditions, including diabetes and a foot ulcer, had an abrasion on the right rear thigh that required wound care. Although a nurse practitioner gave a verbal order for specific wound care, the order was not transcribed into the physician's orders, and the care was not formally implemented as required by facility policy. Nursing staff confirmed the omission, resulting in wound care being provided without the necessary physician order.
A resident with multiple health conditions, including a foot ulcer and fungal skin infection, received wound care from an LPN who did not remove personal items or sanitize the work area before treatment and failed to perform hand hygiene between glove changes, contrary to facility policy. Both the LPN and DON confirmed these infection control lapses during interviews.
A resident did not receive mail in a timely manner, with some pieces being over five months old, due to a lack of clear procedures for mail handling at the facility. The resident's mail included important documents such as bills and retirement check notifications.
A resident with moderate cognitive impairment was served a salad with ham, contrary to their religious dietary preference for no pork. Despite facility policy requiring dietary preferences to be assessed and communicated, staff confirmed the resident was inappropriately served and the same salad was returned after removing the ham. The Dietary Manager acknowledged the error, confirming a new salad should have been provided.
A resident with moderate cognitive impairment and religious dietary restrictions was served a salad containing ham, which was against her beliefs. Despite her request for a turkey salad, staff removed the ham and returned the same salad, which she refused. The incident was reported but not formally recorded as a grievance until weeks later, after the resident's discharge. Staff interviews confirmed the grievance process was not followed timely.
A facility failed to document a clinical rationale for denying a dosage reduction of Trazodone for a resident with Major Depressive Disorder. The resident, who was cognitively intact, was receiving the medication as part of their treatment plan. Despite a request for a Gradual Dose Reduction, the NP did not provide the required documentation, which was confirmed during an interview with the DON.
A facility failed to ensure the accuracy of an MDS assessment for a resident, omitting critical information about her skin conditions and nutritional status. The resident, with multiple health issues including diabetes and vascular disease, had documented sores and treatment orders for wounds, which were not reflected in the MDS. The MDS nurse incorrectly assumed the wounds had resolved, leading to an inaccurate assessment.
A facility failed to promptly notify the RD of a tube feeding change for a resident with cerebral infarction and gastrostomy status. The resident's Peptamen 1.5 was substituted with Pivot 1.5 due to stock issues, but the RD was informed two days later, highlighting a communication lapse and lack of policy.
A resident with moderately impaired cognition reported not receiving her medication and confronted an LPN at the nurses' station. The LPN slammed the door in the resident's face, leading to a physical altercation where the resident was pushed and fell, injuring herself. Staff interviews and video footage confirmed the incident, highlighting a failure to treat the resident with respect and dignity.
A resident receiving PEG tube feedings in a facility experienced significant weight loss due to an incorrect feeding rate being administered. The RN Clinical Coordinator misread the RD's recommendation, resulting in the resident receiving 25 ml/hr instead of the recommended 45 ml/hr. Despite the resident's complaints of hunger and nausea, the facility failed to notify the physician or adjust the feeding rate, highlighting a lack of standardized processes for dietary recommendations.
A resident receiving PEG tube feeding experienced significant weight loss and hunger due to incorrect transcription of RD recommendations, while another resident developed a stage 2 pressure ulcer due to delayed skin assessment. The facility lacked standardized processes for implementing dietary recommendations and failed to adhere to policies for medication orders and skin assessments.
A resident with a PEG tube experienced significant weight loss due to an incorrect feeding rate entered by a clinical coordinator, who misread the dietician's recommendation. Despite the resident's communication of hunger and weight loss, the error persisted until surveyor intervention. Interviews revealed a lack of standardized processes for implementing dietary recommendations, contributing to the deficiency.
The facility failed to maintain the dignity and privacy of two residents. One resident was exposed during wound care due to open window blinds, while another was assisted with meals by an LPN standing over their bed, contrary to facility policy. The incidents highlight lapses in adhering to dignity and privacy standards.
Two residents in a facility did not receive necessary ADL support and incontinence care. One resident with severe cognitive impairment was not assisted with oral hygiene or nail care, while another resident, dependent on staff for incontinence care, was left in wet briefs for extended periods. Staff interviews confirmed these lapses, highlighting deficiencies in adhering to care plans.
A facility failed to complete necessary Dialysis Communication Forms for a resident with chronic kidney disease before sending them to a dialysis facility. Despite the resident having an intact cognition and receiving dialysis three times a week, the forms were not completed on multiple occasions, missing vital information such as problems since the last visit, diet, fluid restrictions, and vital signs. Interviews with facility staff confirmed the oversight, and a contracted dialysis facility RN noted the frequent lack of completed forms.
A facility failed to monitor a resident's medication regimen, specifically for edema while on Furosemide and for side effects and effectiveness of Lexapro. The resident, with severe cognitive impairment and multiple diagnoses, required careful monitoring as per their care plan. However, the July 2024 MAR showed no documentation of such monitoring, which was confirmed by the Clinical Coordinator, leading to a deficiency in care.
The facility failed to maintain proper infection control practices during meal service and wound care. A CNA did not perform hand hygiene between assisting two residents during meal service. Additionally, a Treatment Nurse exited a resident's room without doffing gown and gloves after performing wound care, breaching Enhanced Barrier Precautions.
Failure to Transcribe and Implement Verbal Wound Care Order
Penalty
Summary
The facility failed to provide care and services that met professional standards of quality by not ensuring that a nurse practitioner's verbal wound care order was transcribed and implemented for a resident. The facility's policy requires that each wound site have a separate wound care order specifying the wound location, cleaning method, primary dressing, and frequency of dressing change. For a resident admitted with multiple diagnoses including Type 2 Diabetes Mellitus with a foot ulcer and muscle weakness, the care plan documented an actual impairment to skin integrity on the right rear thigh due to an abrasion. However, review of the physician's orders showed no wound care order for the abrasion, despite documentation in the skin and wound evaluation that described the wound and the treatment being provided. Observations confirmed that wound care was being performed on the abrasion, but the specific orders for cleaning, applying Nystatin powder and collagen, and covering with a dry dressing were not present in the physician's orders. Interviews with nursing staff and the wound care nurse practitioner confirmed that a verbal order for wound care had been given but was not transcribed into the resident's physician orders and therefore not formally implemented. This lapse resulted in the resident's wound care being conducted without the required physician order, contrary to facility policy and professional standards.
Failure to Follow Infection Control Practices During Wound Care
Penalty
Summary
The facility failed to adhere to established infection control practices during wound care for a resident with multiple medical conditions, including Type 2 Diabetes Mellitus with a foot ulcer, cerebral infarction, muscle wasting, and a fungal skin infection. During an observed wound care procedure, the LPN responsible did not remove the resident's personal items or sanitize the side table before placing a barrier pad and beginning treatment. This action was not in accordance with the facility's wound care policy, which requires preparation of a clean, dry work area at the bedside. Additionally, the LPN did not perform hand hygiene between glove changes throughout the wound care process, despite the resident's care plan specifically noting the risk for multi-drug resistant organism (MDRO) infections and the need for proper hand hygiene. Both the LPN and the Director of Nursing confirmed during interviews that these infection control steps were omitted, acknowledging that the required procedures were not followed during the resident's wound care treatment.
Failure to Deliver Resident Mail Timely
Penalty
Summary
The facility failed to ensure timely delivery of mail to a resident, violating the resident's right to receive mail promptly. The facility's policy mandates that mail and packages be delivered to residents within 24 hours of arrival at the facility. However, a resident reported receiving a stack of mail in January 2025, which included 12 or 13 pieces of mail, some of which were date-stamped as received by the facility several months prior. This mail included important documents such as bills and letters regarding uncashed retirement checks. Interviews with facility staff revealed that the Accounts Manager, who had been working at the facility for about five months, found a large pile of undelivered mail in the office upon starting her role. She was not informed of the procedure for handling the mail and had to seek guidance from multiple staff members. The Accounts Manager confirmed that some of the resident's mail was over five months old. The facility administrator acknowledged the delay in mail delivery and recognized that the resident should receive all mail addressed to them, even if it pertains to bills or insurance information.
Failure to Honor Religious Dietary Preferences
Penalty
Summary
The facility failed to respect and honor a resident's religious dietary preferences, which is a violation of the resident's rights to dignity and self-determination. The resident, who had moderate cognitive impairment and required assistance with eating, was served a salad with ham despite having a documented preference and physician order for no pork due to religious beliefs. This incident occurred despite the facility's policy that requires dietary preferences to be assessed and communicated to the interdisciplinary team upon admission. Interviews with facility staff, including the Dietary Manager, Assistant Director of Nursing, and a Certified Nursing Assistant, confirmed that the resident was served a salad with ham and that the ham was removed and the same salad was returned to the resident, which was inappropriate given the resident's religious dietary restrictions. The Dietary Manager acknowledged that the homemaker was responsible for ensuring that food served to residents adhered to their dietary preferences and orders, and confirmed that a new salad without ham should have been provided to the resident.
Failure to Timely Record Grievance Regarding Dietary Preferences
Penalty
Summary
The facility failed to adhere to its grievance policy by not recording a grievance within the appropriate timeframe for a resident who had dietary preferences due to religious beliefs. The resident, who had moderate cognitive impairment, was served a chef salad containing ham, which was against her religious dietary restrictions. Despite the resident's request for a salad with turkey, the staff removed the ham from the original salad and served it back to her, which she refused. The incident was reported to a dietary aide and a nurse, but the grievance was not formally recorded until several weeks later, after the resident had been discharged. Interviews with facility staff confirmed the incident and acknowledged that the resident should have been served a new salad without ham. The Dietary Manager was aware of the incident on the day it occurred but did not file a grievance until prompted by the State Ombudsman weeks later. The Assistant Director of Nursing also confirmed the resident's dietary preferences were not respected, and the grievance process was not followed as per the facility's policy, leading to a delay in addressing the resident's concerns.
Failure to Document Clinical Rationale for Medication Dosage Decision
Penalty
Summary
The facility failed to ensure that a clinical rationale was documented for the denial of a psychoactive medication dosage reduction for one of the sampled residents. The facility's policy requires that when a Gradual Dose Reduction (GDR) is contraindicated, the prescribing clinician must document a clinical rationale. However, in the case of a resident with diagnoses including Parkinson's Disease, Major Depressive Disorder, Type 2 Diabetes Mellitus, and Hypertension, the necessary documentation was not provided. The resident, who was cognitively intact with a BIMS score of 15, was receiving Trazodone for Major Depressive Disorder. The Pharmaceutical Consultant Report indicated that a GDR was requested for the resident's Trazodone dosage, but the Nurse Practitioner (NP) did not document a valid clinical rationale for denying the dosage reduction. During an interview, the Director of Nursing (DON) acknowledged the lack of documentation and confirmed with the NP that the clinical rationale should have been documented. This oversight indicates a failure to adhere to the facility's policy on documenting clinical rationales for medication management decisions.
Inaccurate MDS Assessment for Resident's Skin Conditions
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for a resident, specifically regarding her skin conditions and nutritional status at the time of the Assessment Reference Date (ARD). The resident, who was admitted from a skilled nursing facility, had multiple diagnoses including congestive heart failure, Alzheimer's disease, vascular dementia, diabetes mellitus with diabetic neuropathy, and peripheral vascular disease. The Quarterly MDS did not accurately reflect the resident's skin conditions, as it omitted information about existing ulcers, wounds, and skin problems. The MDS nurse, responsible for completing the assessment, incorrectly assumed that the resident's wound had resolved before the ARD. Further investigation revealed that the resident had sores on her pinky toes, as documented by an LPN in the Nurse's Notes, and had ongoing treatment orders for a laceration on the right lateral foot and a diabetic ulcer on the right medial calf. The resident's medical history, including type 2 diabetes and a previous toe amputation, placed her at high risk for foot complications. Despite this, the MDS did not reflect these conditions, leading to an inaccurate assessment of the resident's health status.
Failure to Notify RD of Tube Feeding Change
Penalty
Summary
The facility failed to ensure timely communication with the Registered Dietician (RD) regarding a change in tube feeding orders for a resident. The resident, who was cognitively intact and had medical diagnoses including cerebral infarction and gastrostomy status, was initially receiving Peptamen 1.5 as an enteral feed. On a specific date, the facility ran out of Peptamen 1.5, and a Nurse Practitioner (NP) authorized the use of Pivot 1.5 as an equivalent substitute. However, the nurse who received this order did not inform the RD as instructed, leading to a delay in the RD being notified about the change in the resident's nutritional plan. The Director of Nursing (DON) later acknowledged that there was no existing policy for notifying the RD about changes in tube feeding orders. The RD was eventually informed two days later, both by phone and email, about the substitution of Pivot 1.5 for Peptamen 1.5. This delay in communication was attributed to the Clinical Coordinator not informing the RD upon returning to work. The lack of a formal policy and the failure of staff to communicate promptly with the RD resulted in a deficiency in maintaining the resident's nutritional care plan.
Resident's Dignity Compromised in Medication Dispute
Penalty
Summary
The facility failed to ensure a resident was treated with respect and dignity, as evidenced by an incident involving a resident with moderately impaired cognition. The resident, who had a history of cerebral infarction, gout, hypertension, and major depressive disorder, reported not receiving her thyroid medication and approached the nurses' station to address the issue. The resident claimed that a nurse, identified as S3 LPN/ADON, slammed the door in her face, leading to a confrontation where the resident was pushed and subsequently fell, injuring her hip and hand. Interviews with staff members corroborated the resident's account of the incident. S5 LPN, who was present during the altercation, confirmed that the resident accused S3 LPN/ADON of lying about administering the medication, which escalated into a physical altercation. S6 CNA and S9 CNA also witnessed the incident, noting that the nurse slammed the door in the resident's face and later engaged in a physical struggle with the resident, resulting in the resident's fall. Video surveillance footage reviewed by the facility's administration confirmed the sequence of events, showing the resident approaching the nurses' station, the door being slammed, and the subsequent physical interaction between the resident and the nurse. The footage supported the accounts provided by the staff and the resident, highlighting the inappropriate handling of the situation by S3 LPN/ADON, which compromised the resident's dignity and safety.
Deficiency in Nutritional Management for Resident with PEG Tube Feeding
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, resulting in a deficiency related to the nutritional management of a resident receiving PEG tube feedings. The administration did not ensure that the Registered Dietician's (RD) recommendations for PEG tube feedings were accurately transcribed into the medical record. This led to a situation where a resident, who was cognitively intact and able to communicate, received an incorrect feeding rate of 25 ml/hr instead of the recommended 45 ml/hr. This error persisted from July 5, 2024, to July 15, 2024, resulting in significant weight loss for the resident. The resident expressed feelings of hunger, nausea, and concern about weight loss, which were communicated to the nursing staff. Despite these complaints, the facility failed to notify the physician or adjust the feeding rate accordingly. The RN Clinical Coordinator admitted to misreading the RD's recommendation and entering the incorrect feeding rate into the system. The resident experienced a weight loss of 9.6 pounds, which was 7.79% of her body weight, during this period. Interviews with facility staff revealed a lack of a standardized process for obtaining, communicating, and implementing dietary recommendations. The Director of Nursing (DON) and Quality Improvement (QI) Nurse acknowledged the absence of a system to ensure accurate communication and entry of RD recommendations. The Assistant Director of Nursing (ADON) also failed to verify the accuracy of the feeding rate against the RD's recommendations, contributing to the resident's inadequate nutritional intake.
Deficiencies in Nutritional and Skin Care Management
Penalty
Summary
The facility failed to ensure services met professional standards of quality by not accurately transcribing and implementing recommendations from the Registered Dietician (RD) for a resident receiving nutrition via PEG tube feeding. The RD recommended a feeding rate of 45 ml/hr, but the RN Clinical Coordinator incorrectly entered the order as 25 ml/hr. This error led to the resident experiencing significant weight loss, hunger, and nausea over a period of several days. Despite the resident's complaints and a request to increase the feeding rate, the physician was not notified in a timely manner, and the feeding rate remained incorrect for an extended period. Additionally, the facility did not perform and document a comprehensive skin assessment for another resident who was readmitted after hospitalization. The resident developed a stage 2 pressure ulcer, which was not assessed or treated until several days after their return to the facility. The facility's policy required a comprehensive skin assessment within 24 hours of readmission, but this was not completed until four days later, delaying necessary wound care. Interviews with staff revealed a lack of a standardized process for obtaining, communicating, and implementing dietary recommendations, contributing to the errors in the resident's care. The facility's failure to adhere to its policies and procedures for medication orders and skin assessments resulted in immediate jeopardy for the resident receiving PEG tube feeding and potential harm for other residents receiving similar care.
Incorrect PEG Tube Feeding Rate Leads to Resident's Weight Loss
Penalty
Summary
The facility failed to ensure that a resident with a PEG tube maintained acceptable nutritional and hydration status, consistent with the resident's comprehensive assessment. This deficiency was identified when a clinical coordinator incorrectly entered a physician's order for a nutritional feeding rate at 25 ml/hr instead of the recommended 45 ml/hr. The resident, who was cognitively intact and able to communicate via typing, expressed feelings of hunger, nausea, and significant weight loss over a period of time due to the incorrect feeding rate. The resident's medical record revealed a significant weight loss of 9.6 pounds, or 7.79% of body weight, between the dates of the incorrect feeding rate. Despite the resident's communication of hunger and weight loss to the nursing staff, the feeding rate was not corrected until after the surveyor's intervention. The clinical coordinator admitted to misreading the dietician's recommendation, which led to the incorrect order being placed and maintained for several days. Interviews with facility staff revealed a lack of a standardized process for obtaining, communicating, and implementing dietary recommendations. The Director of Nursing and Quality Improvement Nurse acknowledged the absence of a system to ensure accurate communication and entry of dietician recommendations. The Assistant Director of Nursing, who was responsible for supervising the clinical coordinator, also failed to verify the accuracy of the feeding rate against the dietician's recommendations, contributing to the resident's inadequate nutritional intake.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure the privacy and dignity of two residents during care activities. For one resident, the treatment nurses did not close the window blinds while providing wound care, leaving the resident exposed to a person outside cutting the lawn. The resident, who had a BIMS score indicating intact cognition, was unaware of the exposure during the procedure but expressed concern about being seen undressed. This incident occurred despite the facility's policy emphasizing the importance of maintaining residents' dignity and privacy. In another instance, an LPN assisted a resident with meal service while standing over the resident's bed, despite the presence of chairs in the room. The facility's policy on meal assistance clearly states that residents should be fed with attention to dignity, which includes not standing over them. The LPN admitted to not knowing that standing while assisting residents with meals was against policy, indicating a lack of awareness or training regarding the facility's standards for maintaining resident dignity during meal times.
Deficiencies in ADL Support and Incontinence Care
Penalty
Summary
The facility failed to provide necessary services for residents who were unable to perform Activities of Daily Living (ADLs) independently, specifically in maintaining good grooming and personal hygiene. Resident #33, who had severe cognitive impairment and required substantial assistance for personal hygiene, was observed with poor oral hygiene and long, dirty fingernails. Despite being scheduled for regular personal and oral care, staff did not assist Resident #33 with brushing her teeth or trimming her nails, as confirmed by both the resident and the LPN. Resident #77, who was dependent on staff for incontinence care due to muscle weakness and impaired cognition, did not receive timely incontinent care. The resident reported not being changed while in her wheelchair and expressed discomfort in asking for assistance, as staff were aware of the need for regular changes. Observations confirmed that Resident #77 was left in wet briefs for extended periods, and staff interviews revealed a lack of adherence to the facility's policy of providing care every two hours. Interviews with staff, including the CNA and RN Clinical Coordinator, confirmed the lapses in care for Resident #77, acknowledging that the resident should have been changed more frequently. The facility's failure to provide adequate care for these residents highlights deficiencies in adhering to care plans and ensuring the well-being of residents who are unable to perform ADLs independently.
Failure to Complete Dialysis Communication Forms
Penalty
Summary
The facility failed to provide appropriate dialysis care and services for a resident who required such services. Specifically, the facility did not complete the necessary Dialysis Communication Forms for a resident with chronic kidney disease, among other diagnoses, before sending them to the dialysis facility. The resident, who had an intact cognition as per their BIMS score, was observed to have a catheter site on the right chest wall and received dialysis services three times a week. Despite the resident being sent to dialysis with a communication binder, the forms within the binder were not completed on multiple occasions, failing to include vital information such as problems or concerns since the last visit, current diet, fluid restrictions, and vital signs. Interviews with facility staff, including an LPN and the Director of Nursing (DON), confirmed that it was the nursing staff's responsibility to complete these forms with pertinent information before the resident's dialysis sessions. The DON acknowledged that the forms were not completed on several specified dates, which was a requirement. Additionally, a telephone interview with an RN at the contracted dialysis facility revealed that the facility frequently did not complete the dialysis communication forms, which were essential for reviewing the resident's vitals and other necessary information upon their arrival for dialysis treatment.
Failure to Monitor Resident's Medication Regimen
Penalty
Summary
The facility failed to adequately monitor a resident's drug regimen, leading to a deficiency in care. Specifically, the facility did not monitor a resident for edema while they were on a diuretic medication, Furosemide, and also failed to monitor for side effects and effectiveness of an antidepressant, Lexapro. The resident, who had severe cognitive impairment with a BIMS score of 4, was admitted with diagnoses including Alzheimer's Disease, Heart Failure, Hypertension, and Other Depressive Disorders. The resident required varying levels of assistance with daily activities, indicating a need for careful monitoring of their medication regimen. The resident's care plan included interventions for depression and hypertension, which required monitoring for side effects and effectiveness of medications, as well as monitoring for edema. However, a review of the July 2024 Medication Administration Record (MAR) revealed no documentation of such monitoring. This lack of documentation was confirmed by the Clinical Coordinator during an interview, indicating a failure to adhere to the care plan and physician's orders, thus resulting in a deficiency in the resident's care.
Infection Control Lapses During Meal Service and Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two specific incidents. During a meal service, a CNA assisted two residents without performing hand hygiene between assisting each resident. This was confirmed through observation and interview, where the CNA acknowledged the lapse in hand hygiene, and an LPN confirmed that hand hygiene should have been performed between assisting residents. In a separate incident, a Treatment Nurse and an assisting Treatment Nurse were observed performing wound care on a resident requiring Enhanced Barrier Precautions. The assisting Treatment Nurse exited the resident's room to retrieve supplies without removing the gown and gloves used during the procedure, which was confirmed through an interview. This failure to follow proper infection control practices during wound care was noted as a deficiency in the facility's infection prevention and control program.
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 31 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) |
|---|---|---|---|---|
| Courtyard Of Natchitoches | 1.8 mi | ★★★★★ | 14 | 0 |
| Natchitoches Nursing And Rehabilitation Center, Ll | 1.8 mi | ★★★★★ | 17 | 0 |
| Autumn Leaves Nursing & Rehab Center, Llc | 25.4 mi | ★★★★★ | 7 | 0 |
| Colfax Nursing And Rehab, Llc | 26 mi | ★★★★★ | 13 | 0 |
| Green Meadow Haven | 26.3 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Natchitoches Community Care Center.
100% money-back within 48 hours.
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.