Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Nursing And Rehabilitation Center, Ll during CMS and state inspections, most recent first.
A resident council grievance about agency nurses giving meds late was raised repeatedly in council meetings, including concerns about night shift and weekend medication timing. The Admin confirmed she reviewed and signed the minutes, was aware of the complaints, had no documentation showing the concern was addressed, and acknowledged there was no effective resolution.
A resident with multiple chronic conditions, including DM and quadriplegia, received several scheduled bedtime meds hours late, outside the facility’s required 1-hour window, and the resident reported repeated delays without refusing meds. In a separate case, staff failed to follow a physician’s Novolog sliding-scale order for a resident with DM, CKD, and PVD by not notifying the NP when blood glucose readings were greater than 400, despite documented values above that threshold.
Pharmacy Consultant Reports were not consistently reviewed or addressed for narcotic reconciliation and MAR documentation. A pharmacist audit found only 60% of narcotic doses were documented in the MAR, and interviews showed leadership turnover, missed communication between the former DON and Admin, and continued emailing of reports to the former DON after she resigned, leaving the 01/2026 report unaddressed.
Missing eMAR/eTAR Documentation for Medications and Monitoring: Multiple residents had absent charting for scheduled meds, treatments, and required assessments in the eMAR/eTAR, including pain scales, BP/pulse checks, skin and dialysis monitoring, smoking checks, and other ordered observations. The QI nurse stated nurses are expected to chart in real time, and the Regional VP confirmed the missing documentation and noted that refusals should have been documented when applicable.
Controlled medication handling was inaccurate for one resident and improper wasting procedures were used for two residents. An LPN and the off-going nurse missed a missing tablet during the narcotic count, leaving the count off by one, and two other residents’ popped controlled meds were taped back into blister packs instead of being wasted with a second nurse present, as expected by the DON.
Expired treatment supplies were found in Cart C during an observation with an LPN. Fourteen individually wrapped reinforced gelling fiber rope dressings were past expiration and remained available for use, and the LPN confirmed she had used the expired supplies to treat a resident's wounds that day. The facility policy required expired medication and supplies to be removed from active supply and destroyed, but the items were still in the cart.
The facility failed to notify the Ombudsman in writing of an unplanned discharge for a resident with acute respiratory failure with hypoxia, ESRD, DM2, and COPD. The QI Nurse stated only hospitalizations were reported, and the SSD confirmed she was only aware of reporting hospitalizations and did not report the resident’s discharge to the Louisiana Ombudsman Program.
Missing Annual Performance Reviews for Two CNAs: The facility failed to complete annual performance reviews for two CNAs whose personnel records showed no evidence of a review within the past 12 months. HR confirmed both CNAs did not have completed annual reviews, and the Admin confirmed they should have had them.
An LPN used a blood pressure cuff between multiple residents during med pass without sanitizing or disinfecting it between uses. The DON later confirmed the cuff was not cleaned between residents, despite the facility’s Standard Precautions policy requiring infection control measures to prevent HAI transmission.
The facility failed to provide ordered meals, supplements, and adequate feeding assistance to several cognitively intact but fully dependent residents. One resident with quadriplegia, malnutrition, and pressure ulcers reported often receiving only one meal per day, not being awakened or assisted for meals, and not consistently receiving prescribed supplements. Another resident with quadriplegia and severe protein-calorie malnutrition stated that staff did not always wake him for meals, that multiple meals were missed when he was sleeping, and that he felt rushed when being fed. A third resident with quadriplegia and diabetes reported relying on staff for feeding, sometimes not receiving her meal tray because it was left on the cart and returned to the kitchen, and on one occasion being told the kitchen was closed so she received nothing to eat. Staff interviews described problems with feeding during shift change, residents reporting missed meals, and communication failures that led to meal tickets not being printed for residents who had returned from the hospital.
A resident with quadriplegia, intact cognition, depression, low BMI, and a stage 4 sacral pressure ulcer required assistance with all ADLs but repeatedly did not have an accessible call light. Surveyors observed the call bell placed between the bed and side rail and later on a dresser, both out of the resident’s reach. The resident reported being unable to use the call system and sometimes relying on a roommate to call for help, and stated they would not have been able to summon assistance over a weekend if needed. A hospice RN noted that although the call bell was placed within reach during her visit, she did not believe the resident could effectively use it, and the administrator later confirmed the call bell was not within reach.
A resident with quadriplegia, intact cognition, and multiple comorbidities, fully dependent on staff for ADLs, reported repeated delays in receiving incontinent care despite a care plan requiring prompt call light response and q2h peri care. The resident stated that requests for assistance beginning in the early morning hours were not addressed for several hours and that staff sometimes turned off the call light without providing care. The resident filed multiple grievances about call bell response times, and an SSD, an LPN, a CNA, and the ombudsman all confirmed that the resident had complained of not being bathed and changed in a timely manner, demonstrating a failure to provide necessary ADL services and timely incontinent care.
Surveyors found that the facility failed to meet professional standards by not completing ordered monthly suprapubic catheter changes for a resident, and by not entering or following wound clinic orders for a Stage 3 gluteal pressure ulcer, resulting in the wound being observed open without a dressing. In addition, another resident with diabetic and chronic foot ulcers had physician wound care orders that were not followed, demonstrating multiple lapses in adherence to ordered catheter and wound treatments by nursing staff, including an LPN and the treatment RN.
Staff failed to maintain resident dignity during meals when several CNAs stood while feeding total-care residents who required full assistance with eating. One resident with quadriplegia and chronic pain, another with quadriplegia, multiple contractures, chronic pain, and visual impairment, and a third with dementia, generalized weakness, dysphagia, and coordination deficits were all observed being fed by standing CNAs. In interviews, the CNAs confirmed these residents were total care and dependent for meals, and the DON acknowledged that staff had been instructed not to stand while feeding residents.
A cognitively intact resident was unable to access money from a personal trust fund despite repeatedly requesting it from the Administrative Assistant/Office Manager. The resident sought reimbursement for wheelchair parts and other purchases made by family, and submitted receipts, which were forwarded to a regional financial consultant for approval. The Administrative Assistant/Office Manager acknowledged that reimbursement checks were not issued within the required 3-day timeframe after receipt submission, resulting in a delay in the resident’s access to his own funds.
A resident with intact cognition and multiple conditions, including neuromuscular bladder dysfunction and a suprapubic catheter, did not have the catheter addressed in the comprehensive person-centered care plan, despite physician orders for catheter placement, routine care each shift, and scheduled changes. The facility's policy required care plans to identify resident problems and needs and to be reviewed at least quarterly, yet the care plan contained no documentation related to the suprapubic catheter. The resident was observed in a wheelchair with the suprapubic catheter hanging from the wheelchair arm, and the care plan coordinator confirmed that the catheter had not been included in the care plan as required.
A resident with diabetes, cellulitis, venous insufficiency, and multiple lower extremity ulcers had physician orders and a care plan for daily wound care and monitoring of infected wounds. Surveyors observed an RN performing wound care with a clean field prepared, but using soiled gloves to handle scissors from the clean field, failing to perform hand hygiene between glove changes, and using the same pair of gloves to cleanse and dress three separate purulent wounds while repeatedly accessing clean supplies. The resident was also observed with a soiled dressing with yellow drainage on one leg and exposed wounds with copious slough on the other leg and foot. The RN later acknowledged not following hand hygiene and glove-change practices, and the DON confirmed these findings.
A resident with a history of dementia and hip issues experienced a fall and was in significant pain, prompting a STAT x-ray order. Although the x-ray revealed a nondisplaced intertrochanteric fracture and results were available the same evening, nursing staff did not follow up or review the results until the next morning, resulting in a delay in care. Both LPNs involved acknowledged the lapse in timely follow-up, and the DON confirmed that standard protocol was not followed.
The facility failed to monitor and address the nutritional needs of two residents, leading to significant deficiencies. One resident experienced severe weight loss due to inadequate meal intake documentation and lack of assistance, while another was not provided a meal tray during lunchtime. Staff interviews revealed lapses in communication and adherence to care protocols, contributing to these deficiencies.
The facility failed to include the Infection Preventionist (IP) in its Quality Assessment and Assurance (QAA) committee meetings, as required by policy. Despite having various staff members present, the IP's absence was confirmed by the Administrator, highlighting a significant oversight in infection control and prevention efforts for the facility's 58 residents.
A facility failed to notify a physician about a resident's 3+ edema, as required by physician orders. Despite multiple instances of 3+ edema documented over several months, the physician was not informed. An LPN confirmed the oversight, and the DON acknowledged the failure to meet professional standards of care.
A resident with cognitive intactness and multiple health conditions required assistance with ADLs, including nail care. Despite a care plan intervention to trim nails, observations revealed long, dirty nails, and the resident expressed a desire for them to be cut. The DON confirmed the need for nail trimming, indicating a lapse in care.
A facility failed to develop a comprehensive person-centered care plan for a resident with schizophrenia, diabetes mellitus, and chronic pain syndrome, who was involved in active discharge planning. Despite the resident's expressed desire to move to another facility, the care plan lacked discharge planning. Interviews confirmed the oversight, with the MDS coordinator attributing it to the care plan being completed before her employment, and the Administrator acknowledging the deficiency.
The facility failed to provide an ongoing activities program that supports residents' choices, particularly on weekends. Three residents reported a lack of organized activities, with one resident noting that bingo was the only activity offered during the week. Staff interviews confirmed the absence of weekend activities, and the Activity Director's time card showed no logged hours on the days in question. This deficiency affected the residents' ability to engage in meaningful activities as outlined in their care plans.
A hospice resident with Alzheimer's and other conditions experienced an accident resulting in injury and unrelieved pain. Despite the facility's policy requiring notification of the physician for abnormal pain, the Medical Director was not informed. The resident was found on the floor with a potential injury, but the facility delayed sending her to the ER, waiting for hospice assessment. Pain relief was ineffective, and the resident remained in severe pain until she was eventually sent to the ER the next day.
A resident with Alzheimer's and under hospice care experienced a fall and reported pain. Despite orders for Hydromorphone and Lorazepam every four hours, the resident did not receive these medications as prescribed, resulting in a nearly 12-hour gap in pain management. The resident was eventually sent to the ER for further evaluation and pain control.
The facility failed to maintain resident privacy during showering by leaving the shower room door open, contrary to policy. This affected two residents, one of whom expressed a preference for the door to be closed. Staff confirmed the door should have been closed, highlighting a breach of residents' rights to privacy and dignity.
A resident with severe cognitive impairment and a urinary tract infection did not receive the prescribed antibiotic, Augmentin, as ordered by the physician. The medication was not administered over several days, and there were no documented refusals. This failure was confirmed by the DON and a Corporate RN, highlighting a lapse in following the facility's medication administration policy.
The facility failed to properly dispose of garbage and refuse, as a dumpster outside the kitchen was found with its sliding door open, allowing a cat to jump out. Trash was on the ground, and a torn mattress and two walkers were outside the dumpster area. Despite signage to keep the door closed, it remained open. The Housekeeping Supervisor confirmed the area should be clean and the door closed, which was not adhered to.
The facility failed to ensure a safe and comfortable environment by not repairing a toilet base in a resident's room and a shower room door on X Hall. A resident reported the toilet had been in disrepair since moving in last year, and maintenance confirmed the issues. Observations revealed broken material under the toilet and a hole in the shower door.
A facility failed to ensure residents received care according to professional standards and care plans, affecting six residents. Critical lab results were not communicated to physicians, and ordered lab tests were not obtained. One resident with a history of Coumadin toxicity was hospitalized due to continued administration of Coumadin despite critical lab results. Other residents experienced missed medication doses and incomplete lab monitoring, highlighting deficiencies in adherence to physician orders and monitoring protocols.
The facility failed to effectively manage lab monitoring and communication, impacting several residents. A resident with a history of Coumadin toxicity was not properly monitored, leading to an Immediate Jeopardy situation. Other residents experienced missed lab draws and medication administration errors, highlighting systemic issues in the facility's resource management.
The facility failed to provide a private space for Resident Council Meetings, holding them in an open area near the entrance and nurses' station, compromising privacy. Additionally, the facility did not promptly address ongoing grievances from residents about staff not rounding, call lights not being answered, beds not being made, and loud CNAs at night. These issues persisted over several months, with the facility's response limited to monthly staff in-service training.
A resident with diabetes was not provided with an artificial sugar sweetener, Sweet'n Low, as part of their dietary needs. The resident reported not having access to the sweetener for several days, affecting their meal consumption. The deficiency was due to the dietary management's oversight in ordering and maintaining an adequate supply of artificial sweeteners, and the administrator acknowledged the failure to ensure availability for residents on diabetic precaution diets.
A resident with moderate cognitive impairment and a history of wandering eloped from a facility due to inadequate supervision. The resident asked an agency nurse to unlock the front door, expressing a desire to see his wife, and left unnoticed. The nurse, unaware of the resident's elopement risk, did not notify other staff or increase supervision. The resident was later found 0.4 miles away by staff from his Intensive Outpatient Program.
A resident at risk for elopement exited the facility unattended after an agency nurse unlocked the front door without notifying other staff. The resident, who was moderately cognitively impaired, was found 0.4 miles away on a busy roadway. The facility lacked effective supervision and communication systems, and there was no policy to train all staff on managing elopement risks.
Resident Council Medication Timing Complaints Not Resolved
Penalty
Summary
The facility failed to act promptly on grievances raised by residents during monthly Resident Council meetings regarding agency nurses not giving medications timely. Resident Council minutes from 01/19/2026 documented a new business concern that an agency nurse was not giving meds timely. Minutes from 02/26/2026 showed the old business item was not resolved to the residents’ satisfaction and again noted agency nurses not giving meds timely on the night shift. Minutes from 03/11/2026 again reflected that the issue was not resolved and that agency nurses were not giving meds timely at night. During the Resident Council meeting on 03/23/2026, residents stated that an agency nurse continued to give medications late on weekends and/or at night and that the issue had been discussed at multiple meetings without being resolved. On 03/24/2026, the Administrator confirmed she had signed the meeting minutes to verify review of them, was aware of the complaints, had no documentation showing the concern had been addressed, and confirmed there had not been an effective resolution.
Late Medication Administration and Failure to Follow Insulin Notification Orders
Penalty
Summary
The facility failed to ensure scheduled medications were administered within the required time window for one resident. The resident had diagnoses including Type 2 diabetes mellitus with diabetic neuropathy, quadriplegia, and major depressive disorder, and her quarterly MDS indicated intact cognition. Her physician orders included bedtime medications such as trazodone, baclofen, Protonix, sucralfate, and rosuvastatin, with scheduled administration times of 8:00 p.m. or 9:00 p.m. The facility policy stated scheduled medications were to be given within one hour before and one hour after the scheduled time. The resident’s medication administration audit showed multiple doses of these medications were given several hours late, including administrations after 11:00 p.m., after midnight, and once at 3:26 a.m. The resident stated she had complained to staff about receiving bedtime medications late and reported that one night she did not receive them until after 12:30 a.m.; she also stated she did not refuse any medications. The QI Nurse reviewed the audit and acknowledged the medications were not administered within the required timeframe, and the Regional VP and DON both confirmed the resident was not receiving scheduled medications timely. The facility also failed to follow physician orders for another resident with Type II diabetes mellitus due to underlying condition with diabetic neuropathy, peripheral vascular disease, and chronic kidney disease stage 3. The resident had an order for Novolog sliding scale insulin that required the NP to be notified if blood glucose was greater than 400. Review of the March eMAR showed blood sugars of 457, 441, and 451 on three separate days, and nurses’ notes for those dates contained no documentation that the NP was notified. The DON stated the nursing staff did not notify the NP for the blood sugars greater than 400, but should have.
Pharmacy Consultant Reports Not Reviewed or Addressed for Narcotic Documentation
Penalty
Summary
The facility failed to administer its resources efficiently and effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident because monthly Pharmacy Consultant Reports were not consistently utilized, reviewed, or addressed for narcotic medication reconciliation and documentation. A facility policy on controlled substances stated that the director or designee investigates discrepancies, documents irreconcilable discrepancies, and notifies the administrator and consultant pharmacist when major discrepancies or patterns occur. A pharmacist audit titled PRN Documentation Audit- 12/2025 reviewed 160 narcotic order administrations and found only 96 were documented in the medical record, with only 60% of doses correctly documented. During interviews, the Regional VP stated there had been significant leadership turnover since 01/2026, including multiple DONs, unit managers, and treatment nurses, and attributed poor nursing documentation, including narcotic documentation, to that turnover. The pharmacist stated he rounds monthly, reconciles narcotics randomly, emailed his reports to the Administrator and DON, and had alerted the DON to the low documentation rate, which he described as alarming. The former DON stated she was informed of the poor narcotic documentation and discrepancies, began an in-service, and asked the Unit Manager to audit medication carts randomly, but she did not communicate the 12/2025 findings or monitoring to the Administrator. The Administrator stated she was unaware of the 12/2025 findings, that reports continued to be emailed to the former DON after she resigned, and that neither she nor other staff received or addressed the 01/2026 pharmacist report.
Missing eMAR/eTAR Documentation for Medications and Monitoring
Penalty
Summary
The facility failed to ensure that residents’ electronic medication administration records (eMARs) and electronic treatment administration records (eTARs) were accurately documented for four residents. The deficiency was identified through interview and record review and involved missing documentation for medications, treatments, and monitoring tasks that were ordered for multiple days. The facility policy titled Medication Administration stated that medications are to be documented as each medication is prepared on the MAR. For one resident with diagnoses including peripheral vascular disease and depression, the 02/2026 eMAR showed no documentation on multiple dates for several scheduled medications and treatments, including Benadryl Allergy, Lexapro, amoxicillin-pot clavulanate, Coreg, Eliquis, Procardia XL, Pro-Stat, smoking checks, pain scale documentation, enhanced barrier precautions, abdominal binder use, and monitoring for tardive dyskinesia, target behaviors, and active bleeding/bruising related to anticoagulant therapy. The record review also found no progress note documentation or evidence of refusals for those missed entries. For another resident with diagnoses including type 2 diabetes mellitus with diabetic neuropathy, the 03/2026 eMAR/eTAR lacked documentation for numerous medications and monitoring orders, including atorvastatin, B12 folate, duloxetine, ferrous sulfate, melatonin, metoprolol, nifedipine ER, renal vitamin, trazodone, vitamin C, Vraylar, Zyrtec, clonazepam, famotidine, gabapentin, midodrine, amino acids, calcium acetate, tizanidine, dialysis thrill and bruit checks, blood pressure and pulse monitoring, pain scale documentation, weekly skin assessment, and multiple other ordered observations such as edema, odor, urine color, opioid overdose monitoring, psychotropic side effects, and substance abuse impairment checks. The resident’s progress notes also did not show refusals or other documentation for the missing entries. For the remaining two residents, record review showed repeated missing eMAR documentation for scheduled medications and treatments across March 2026. One resident with chronic atrial fibrillation, paranoid schizophrenia, dementia, depression, and hypertension had missing documentation for multiple medications including amiodarone, atorvastatin, cholecalciferol, donepezil, ferrous sulfate, fish oil, Lasix, metoprolol, quetiapine, trazodone, Xarelto, methadone, Colace, divalproex, famotidine, memantine, and several monitoring and care tasks such as pain scale checks, smoking checks, hourly elopement-risk monitoring, bleeding/bruising monitoring, edema checks, tardive dyskinesia monitoring, and observation for psychotropic side effects. Another resident with diabetes, depression, anxiety, COPD, and venous insufficiency had missing documentation for medications and treatments including duloxetine, Flomax, folic acid, Linzess, methadone, MiraLax, potassium chloride, pravastatin, ascorbic acid, ferrous sulfate, fluticasone, furosemide, insulin aspart, metformin, desmopressin, cyproheptadine, Robaxin, and multiple ordered monitoring and care tasks such as pain scale documentation, enhanced barrier precautions, edema checks, suprapubic catheter care, head-of-bed elevation, pressure-reducing cushion use, and observation for opioid overdose and psychotropic side effects. In interview, the QI nurse stated nurses are expected to chart in real time and acknowledged that if it was not charted in the eMAR/eTAR, it did not happen. The Regional VP stated the nurses should always chart in real time or document refusals and confirmed the missing documentation during record review.
Controlled Medication Count and Wasting Errors
Penalty
Summary
Pharmaceutical services failed to ensure accurate disposition and administration of controlled medications for multiple residents. During review of Cart A, Resident #62’s blister pack for diphenoxylate/atropine 2.5 mg/0.025 mcg showed tablet #10 was popped open and unaccounted for, and the controlled drug record listed 25 tablets when only 24 were actually present. The LPN stated she and the off-going nurse counted the tablets at the start of the shift but both overlooked the missing tablet and did not document the discrepancy. The facility also failed to follow proper wasting procedures for controlled substances for Resident #46 and Resident #64. Resident #46’s lorazepam 0.5 mg blister pack showed tablet #58 was popped and placed back into the packaging with the back of the card taped. Resident #64’s butalbital/acetaminophen/caffeine 50 mg/325 mg/40 mg blister pack showed tablets #2 and #14 were popped and placed back into the packaging with the back of the card taped. The DON stated nurses were expected to destroy controlled substances appropriately with a second nurse present and not tape tablets back into the blister packaging, and confirmed the taped medications should have been destroyed appropriately but were not.
Expired Treatment Supplies Found in Medication/Treatment Cart
Penalty
Summary
Drugs and biologicals were not stored in accordance with accepted professional principles when expired treatment supplies were found available for resident use in Cart C. During observation of the cart with an LPN, 14 individually wrapped reinforced gelling fiber rope dressings measuring .75 inches by 18 inches were found with an expiration date of 08/12/2025. The facility policy stated that all expired medication and supplies are to be removed from active supply and destroyed, but the expired dressings remained in the cart. The LPN confirmed the expired supplies were present in the cart and stated she had used the expired treatment supplies to treat a resident's wounds that day during treatments, but should not have. The LPN also confirmed the expired rope dressings should have been disposed of properly and were not.
Failure to Notify Ombudsman of Unplanned Discharge
Penalty
Summary
The facility failed to notify the Ombudsman in writing of a resident transfer/discharge for Resident #71. Resident #71 was admitted on 02/09/2026 and discharged on 02/18/2026, with diagnoses including acute respiratory failure with hypoxia, end stage renal disease, type 2 diabetes mellitus with unspecified complications, and chronic obstructive pulmonary disease. Review of the Discharge-Return Not Anticipated MDS showed the discharge was unplanned. During interviews, the Emergency Transfer Log was requested, and the QI Nurse stated the facility only reported hospitalizations to the Louisiana Ombudsman Program. The SSD stated she was responsible for notifying the Louisiana Ombudsman Program of resident transfers, but she was only aware to report hospitalizations and had not reported any unplanned or planned discharges from the facility. The SSD confirmed she did not report Resident #71’s unplanned discharge to the Louisiana Ombudsman Program.
Missing Annual Performance Reviews for Two CNAs
Penalty
Summary
The facility failed to complete annual performance reviews at least once every 12 months for 2 of 5 CNA personnel records reviewed. Review of S12 CNA's personnel record showed a hire date of 07/30/2024, and there was no evidence of an annual performance review completed in the past 12 months. Review of S13 CNA's personnel record showed a hire date of 10/17/2024, and there was no evidence of an annual performance review completed in the past 12 months. During interviews, S14 HR confirmed that S13 CNA did not have a completed annual performance review and that S12 CNA did not have a completed annual performance review. S1 Admin also confirmed that both CNAs should have had an annual completed performance review but did not.
Failure to Clean Blood Pressure Cuff Between Resident Uses
Penalty
Summary
The facility failed to ensure infection control measures were practiced to provide a safe, sanitary environment and prevent the development and transmission of communicable diseases and infections by not ensuring medical equipment was cleaned between uses with multiple residents during medication administration. Review of the facility policy titled Standard Precautions stated that standard precautions would be used as a primary strategy for preventing healthcare-associated infections among patients and healthcare personnel. During observation of medication administration, an LPN used a blood pressure cuff between multiple residents without sanitizing or disinfecting it between resident uses. In interview, the DON confirmed the LPN did not clean the blood pressure cuff between uses with multiple residents but should have.
Failure to Provide Ordered Meals, Supplements, and Feeding Assistance to Dependent Residents
Penalty
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.
Failure to Ensure Accessible Call Light for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate a resident’s needs and preferences by not ensuring an appropriate and accessible call light system. The resident was admitted with major depressive disorder, quadriplegia, low BMI, depression, and a stage 4 sacral pressure ulcer, and had a BIMS score of 13 indicating intact cognition. The resident had impairments on both sides and required assistance with all ADLs. During an observation, the resident was seen lying in bed with the call bell positioned between the bed and side rail, out of reach. The resident reported being unable to use the call bell system and stated that at times he had to ask his roommate to call for help. Further observations showed that on another day the resident was again lying in bed with the call bell placed on a two-drawer dresser, out of reach. The resident stated that he would not have been able to call for help over the weekend if needed. The hospice RN reported that during her visit the call bell had been within reach but she did not think the resident could use it. In a subsequent interview, the administrator confirmed that the call bell was not within reach and the resident reported difficulty using the current call bell system due to mobility issues when it was not appropriately placed at all times.
Failure to Provide Timely Incontinent and ADL Care
Penalty
Summary
The facility failed to provide timely assistance with activities of daily living, specifically incontinent care, to a resident who was fully dependent on staff. The resident had multiple diagnoses including Type 2 Diabetes Mellitus, quadriplegia, essential hypertension, major depressive disorder, cognitive communication deficit, and osteoporosis, and had an admission MDS BIMS score of 15 indicating intact cognition. Her care plan, reviewed on 03/04/2026, identified an ADL self-care performance deficit related to impaired mobility and included interventions such as responding to call lights promptly and providing perineal care every two hours and as needed. Despite these documented interventions, the resident reported that staff did not respond to her call bell in a timely manner for incontinent care. The resident stated that she began requesting incontinent care assistance at 2:30 a.m. and was not changed until between 7:00 a.m. and 7:30 a.m., and that staff sometimes entered her room, turned off the call light, and left without providing care. She reported using an Alexa device to track the time and stated she had notified several staff members, including the administrator, about these delays. The Social Services Director confirmed that the resident had filed three grievances in the last three months, two of which involved call bell response times related to incontinent care. An LPN and a CNA both reported that the resident had informed them she was not being cared for in a timely manner, and the ombudsman also reported that the resident had complained of not being bathed and changed in a timely manner. These observations and interviews demonstrated that the facility did not follow its own policy and care plan interventions to ensure timely ADL and incontinent care for this resident.
Failure to Follow Physician Orders for Catheter and Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure services met professional standards of quality for residents with suprapubic catheter and wound care needs. One resident with multiple diagnoses including Type 2 diabetes, UTIs, cellulitis of both lower limbs, venous insufficiency, neuromuscular bladder dysfunction, and bowel and bladder incontinence had a physician order dated 09/15/2025 for a suprapubic catheter change every month and PRN for leakage/occlusion, with the GU bag to be changed on the 15th of each month. Review of the November and December Treatment Administration Records (TARs) showed that the scheduled suprapubic catheter changes on 11/15/2025 and 12/15/2025 were not documented as completed, and there was no documentation or progress note explaining why the catheter was not changed. The LPN responsible for treatments and the Unit Manager both confirmed, after reviewing the TARs, that the catheter had not been changed in those months despite the standing order and the facility expectation that missed treatments be documented with a reason. The same resident was also followed by an external wound care clinic for a left posterior gluteal pressure ulcer. A wound care clinic physician note dated 01/02/2026 documented an open Stage 3 pressure ulcer on the left posterior gluteus, with orders to cleanse with normal saline once daily, apply a topical antibiotic compound once daily when available, and cover with a 6x6 border gauze dressing once daily. Review of the resident’s January 2026 physician orders and TAR revealed no orders entered for treatment of this left posterior gluteal pressure ulcer and no documentation that the ordered wound care was performed. During interview, the treatment RN stated that she receives and inputs wound care clinic orders into the computer and adds them to the facility’s orders and TAR, and that the resident never refuses wound care. However, observation on 01/14/2026 showed the resident had an open wound on the left posterior gluteus with no dressing or bandage in place, and the treatment RN confirmed there were no other treatment orders for this wound beyond application of Calazinc cream to the buttocks and groin. Another resident with diagnoses including Type 2 diabetes with skin ulcer, non-pressure chronic ulcer of the right heel and midfoot, CKD stage 3A, Charcot joint of the left ankle and foot, depression, and an unspecified open wound of the left foot had physician orders for wound care that included cleansing with normal saline, applying ointment to the wound bed, covering with sterile gauze, and wrapping with Kerlix secured with tape. The report identifies this as an additional instance where physician wound care orders were not followed, contributing to the overall finding that the facility failed to provide care and services in accordance with professional standards of quality for wound and catheter management for sampled residents.
Staff Standing While Feeding Total-Care Residents During Meals
Penalty
Summary
Staff failed to honor residents' rights to a dignified existence and self-determination during meal service by standing while feeding multiple dependent residents. Resident #8, admitted on 10/12/2022 with diagnoses including other muscle spasm, complete C5-C7 quadriplegia, and other chronic pain, was observed on 01/12/2026 at 12:39 p.m. being fed by S7 CNA, who was standing during the meal. In a subsequent interview, S7 CNA stated that Resident #8 was total care and required assistance with meals. Resident #9, admitted on 11/19/2025 with multiple contractures, quadriplegia, other muscle spasm, chronic pain syndrome, age-related nuclear cataract, myopia, and primary generalized osteoarthritis, was observed on 01/12/2026 at 12:44 p.m. being fed by S8 CNA, who was standing, and again on 01/13/2026 at 12:26 p.m. being fed by S10 CNA, who was also standing. Both CNAs reported that this resident was total care and required assistance with meals. Resident #10, admitted on 12/26/2025 with unspecified dementia, generalized muscle weakness, lack of coordination, other symbolic dysfunctions, dysphagia, and idiopathic normal pressure hydrocephalus, was observed on 01/13/2026 at 12:25 p.m. being fed by S9 CNA, who was standing. S9 CNA stated that this resident was total care and required meal assistance. The DON (S2) confirmed that all staff were aware they were not to stand while feeding residents and that these CNAs should not have been standing to feed residents.
Failure to Provide Timely Access to Resident Trust Fund Reimbursement
Penalty
Summary
The deficiency involves the facility’s failure to honor a cognitively intact resident’s right to manage his own financial affairs by not providing timely access to his personal funds. A quarterly MDS with an ARD of 11/24/2025 documented that Resident #4 had a BIMS score of 15, indicating he was cognitively intact. During an interview on 01/13/2026 at 9:25 a.m., the resident reported he had been unable to obtain money from his trust fund despite requesting it from the Administrative Assistant/Office Manager since 10/28/2025 and being repeatedly told he would receive it “tomorrow.” The Administrative Assistant/Office Manager stated the resident wanted money from his trust fund to reimburse his family for wheelchair parts and other purchases made in October 2025, and that he submitted receipts for these items on 12/02/2025, which she then emailed to the regional financial consultant for approval. In a subsequent interview, she confirmed she did not provide the reimbursement checks to the resident within 3 days after he submitted his receipts, and acknowledged that she should have done so. This sequence of events shows that despite the resident’s intact cognition and repeated requests, the facility did not ensure timely disbursement of the resident’s trust fund money following submission of receipts, resulting in a delay in his access to his own funds.
Failure to Develop Care Plan for Resident with Suprapubic Catheter
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan addressing a resident's suprapubic indwelling catheter. The facility's policy required each resident to have a person-centered care plan identifying problems, needs, strengths, preferences, goals, and how the interdisciplinary team would provide care, with review and revision at least quarterly and with MDS assessments. Resident #7 was admitted with multiple diagnoses including Type 2 diabetes mellitus with diabetic mononeuropathy, UTI, anxiety, cellulitis of both lower limbs, edema, venous insufficiency, and neuromuscular dysfunction of the bladder. The resident had intact cognition, as evidenced by a BIMS score of 14 on the quarterly MDS. Physician orders included a urology consult for suprapubic catheter placement, suprapubic catheter care with soap and water every shift, and monthly suprapubic catheter changes with PRN changes for leakage or occlusion. Despite these orders and the presence of the suprapubic catheter, review of the resident's care plan showed no documentation or evidence that the catheter was addressed in the care plan. During observation, the resident was seen sitting in a wheelchair in the hallway with the suprapubic indwelling catheter hanging on the right wheelchair arm with a privacy cover. In an interview, the care plan coordinator, who was responsible for developing and updating all resident care plans and stated she reviewed and revised care plans quarterly and with changes in condition, confirmed that the care plan for this resident did not address the suprapubic catheter but acknowledged that it should have been included.
Failure to Follow Standard Precautions During Multi-Site Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff followed its infection prevention and control program and standard precautions during wound care for a resident with multiple lower extremity wounds. The facility’s policy on Standard Precautions required hand hygiene and appropriate use of personal protective equipment (PPE), including gloves and gowns, as the primary strategy to prevent healthcare-associated infections. The resident’s medical record showed multiple diagnoses including Type 2 diabetes with diabetic mononeuropathy, cellulitis of both lower limbs, edema, chronic venous insufficiency, and neuromuscular bladder dysfunction. The resident’s MDS indicated intact cognition, partial/moderate assistance with hygiene, and an infection of the foot with purulent drainage. The care plan documented actual skin integrity impairment with arterial and venous ulcers and directed staff to treat ulcers as indicated, keep skin clean and dry, and monitor and document wound status and signs of infection. Prior to the observed wound care, the resident was seen sitting in a wheelchair in the hallway with a suprapubic indwelling catheter bag hanging on the wheelchair arm and covered for privacy. A soiled dressing with yellow drainage was observed on the right leg, and the left lower leg and left foot had no dressings in place, leaving wounds exposed with copious slough in the wound bed. Physician orders for the resident included daily and PRN wound care to multiple sites on both lower extremities and toes, specifying cleansing with normal saline, application of an antibiotic compound, and coverage with ABD pads and Kerlix wraps secured with tape. During the observed wound care, the treatment RN prepared a clean field on the bedside table with normal saline, ABD pads, gauze, scissors, and a bottle of antibiotic compound, and donned a gown and clean gloves. She removed the old dressing from the right lower anterior leg wound and then removed dressings from the left lower leg and left foot, using the same soiled gloves to pick up scissors from the clean field to cut remaining bandages and then placing the scissors on the resident’s bed. After exposing wounds with copious yellow purulent drainage, she removed her gloves and donned a new pair without performing hand hygiene. She cleansed and dressed the right anterior wound, then, without changing gloves, handled clean supplies on the bedside table and cleansed and treated three separate wounds on the left lower leg and left toe, using the same gloves throughout. The RN did not change soiled gloves between wounds and continued to reach into the clean supply area. After completing wound care, she removed her gown and gloves and walked away to discard supplies. In interviews, the treatment RN acknowledged she failed to sanitize or wash her hands between glove changes and that she used the same soiled gloves to clean three separate wounds without changing them, and the DON confirmed these findings.
Failure to Timely Follow Up on STAT X-ray Results
Penalty
Summary
The facility failed to provide care and services that met professional standards of quality by not ensuring timely follow-up on STAT x-ray results for a resident with a history of Alzheimer's Disease, dementia, left hip pain, and previous fractures. After an unwitnessed fall, the resident complained of left hip pain, prompting a nurse practitioner to order a STAT x-ray. The x-ray was performed, and the results, which showed a nondisplaced intertrochanteric fracture, were electronically signed and available the same evening. However, the results were not reviewed or acted upon until the following morning. Nursing staff on the evening and overnight shifts were aware that the x-ray results were pending but did not follow up with the imaging center or check for the results within the expected timeframe. The LPN on the night shift acknowledged that she did not call to check on the results, despite knowing that STAT results are typically received within a few hours. The Director of Nursing Services confirmed that the nurse assigned to the resident should have followed up on the x-ray results that night. As a result, there was a delay in identifying and responding to the resident's fracture.
Nutritional Care Deficiencies for Two Residents
Penalty
Summary
The facility failed to adequately monitor and address the nutritional needs of two residents, leading to significant deficiencies in their care. Resident #3, who has dementia and Alzheimer's disease, experienced a severe weight loss of 7.7% over a three-month period. The facility did not consistently record meal intake for Resident #3, failed to assist with all meals as care planned, and did not notify the MD/NP when the resident refused to eat or exhibited severe weight loss. Interviews revealed that the CNAs did not document meal intake in the medical record or report it to the nurse, and the dietary staff discarded meal tickets without recording intake information. Resident #36, who has multiple diagnoses including Type 2 Diabetes Mellitus and morbid obesity, was not provided a meal tray during lunchtime. The resident was observed sitting alone without a lunch tray while other residents were served. The CNA responsible for Resident #36's meal service mistakenly believed the resident had refused the meal and discarded the lunch tray without offering an alternative. Interviews with staff confirmed that Resident #36 typically eats in the day area and does not refuse meals, indicating a failure in communication and adherence to care protocols. The facility's policies on meal time observation and food acceptance were not followed, resulting in harm to Resident #3 and a failure to provide adequate nutrition to Resident #36. The Director of Nursing acknowledged the lapses in documentation and communication, which contributed to the deficiencies in care. The Registered Dietician's recommendations and weight records were not effectively communicated to the medical staff, delaying necessary interventions for Resident #3's weight loss.
Infection Preventionist Absence in QAA Meetings
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) committee meetings included the required staff members, specifically the Infection Preventionist (IP), for the facility's quarterly meetings. The facility's policy, revised in October 2022, mandates that the QAA committee should include the Director of Nursing Services (DNS), Medical Director or designee, and three other staff members, one of whom must be in a leadership role, and the IP. However, a review of the facility's QAA Committee list and sign-in sheets for meetings held in 2024 and 2025 revealed that the IP was not present at any of the quarterly meetings. The absence of the IP from these meetings was confirmed during an interview with the facility's Administrator. The QAA Committee meetings were attended by various staff members, including the Executive Director, Director of Rehab, Activities Director, Dietary Manager, Housekeeping, Unit Manager-LPN, LPN-MDS, Medical Records, and Medical Director, among others. Despite the presence of these members, the lack of the IP's attendance was a significant oversight, as the IP plays a crucial role in infection control and prevention, which is vital for the health and safety of all 58 residents in the facility.
Failure to Notify Physician of Resident's 3+ Edema
Penalty
Summary
The facility failed to meet professional standards of quality by not notifying the physician of a resident's 3+ edema, as required by the physician's orders. The resident, who was admitted with a diagnosis of edema, had physician orders to monitor edema every shift and notify the physician if the edema reached 3+ or 4+. Despite this, the resident's medical records showed multiple instances of 3+ edema documented over several months, from January to March, without any notification to the physician. Interviews and observations confirmed the oversight. An LPN admitted to documenting 3+ edema on two consecutive days in March but did not notify the physician, as required. The Director of Nursing also confirmed that the physician was not notified of the resident's 3+ edema on these dates, acknowledging that the notification should have occurred. This failure to notify the physician of significant changes in the resident's condition represents a deficiency in the facility's adherence to professional standards of care.
Failure to Maintain Resident's Personal Hygiene
Penalty
Summary
The facility failed to provide necessary services for a resident who was unable to perform activities of daily living independently. Resident #59, who was admitted with diagnoses including polyosteoarthritis, type 2 diabetes mellitus, and hypertension, was cognitively intact with a BIMS score of 15. The resident required partial to moderate assistance with various movements and had an ADL self-care performance deficit related to activity intolerance, fatigue, impaired balance, and stroke. The care plan included interventions such as checking and trimming nails on bath day and as necessary. Despite these interventions, observations on two consecutive days revealed that Resident #59 had long, dirty fingernails, and the resident expressed a desire to have them cut. The resident stated that no one had offered to cut the nails, and he had never refused such care. The Director of Nursing confirmed the need for nail trimming and indicated that the Treatment Nurse should have performed this task, highlighting a lapse in the facility's adherence to the care plan for maintaining the resident's personal hygiene.
Failure to Develop Comprehensive Care Plan for Discharge Planning
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident, identified as Resident #23, who was admitted with diagnoses including schizophrenia, diabetes mellitus, and chronic pain syndrome. Despite having a BIMS score indicating intact cognition and being involved in active discharge planning, the resident's care plan lacked any evidence of discharge planning. The facility's policy requires each resident to have a person-centered care plan that includes discharge planning, but this was not adhered to in the case of Resident #23. Interviews revealed that the resident had expressed a desire to move to another facility and had communicated this to the Director of Nursing and the Administrator, but had not received any feedback. The MDS coordinator confirmed that the resident was not care planned for either remaining in the facility long-term or for discharge planning, attributing the oversight to the care plan being completed by someone else before her employment. The Administrator acknowledged that the resident should have been care planned for discharge planning, which was not done.
Lack of Weekend Activities for Residents
Penalty
Summary
The facility failed to provide an ongoing activities program that supports residents' choices based on comprehensive assessments, care plans, and preferences. This deficiency was identified for three residents out of a sample of 24, with the potential to affect all 58 residents in the facility. The facility's policy requires daily activities, including weekends and holidays, but the activities calendar and interviews revealed a lack of activities on weekends. Specifically, on the weekend of March 8th and 9th, 2025, scheduled activities did not occur, and residents reported a lack of organized activities. Resident #41, with diagnoses including cerebral infarction and diabetes, expressed dissatisfaction with the facility's activities, noting that bingo was the only organized activity and that no activities occurred on the weekend in question. The resident's care plan emphasized the importance of group activities and personal preferences, which were not met. Interviews with staff confirmed the absence of activities on weekends, and the Activity Director's time card showed no logged hours on the days in question, indicating she was not present to conduct activities. Resident #25, with conditions such as paraplegia and major depressive disorder, also reported that no activities were offered on weekends since admission. Similarly, Resident #23, diagnosed with schizophrenia and chronic pain syndrome, stated that the facility lacked weekend activities and had insufficient activities during the week. The resident's care plan highlighted the need for activities that empower and engage the resident, which were not provided. The facility's failure to adhere to its policy and provide adequate activities led to this deficiency.
Failure to Notify Medical Director and Delay in Emergency Care for Hospice Resident
Penalty
Summary
The facility failed to notify the Medical Director when a hospice resident experienced an accident resulting in injury and unrelieved pain. The incident involved a resident with Alzheimer's Disease, Major Depressive Disorder, and other conditions, who was under hospice care. The resident was found on the floor with a raised area on her left knee, indicating potential injury. Despite the presence of aides and the resident's daughter, the facility did not immediately send the resident to the emergency room but instead waited for hospice to assess the situation. The facility's policy required notification of the physician or responsible party in cases of abnormal pain complaints or ineffective pain relief. However, the hospice nurse advised against sending the resident to the ER, suggesting that the absence of immediate bruising indicated no fracture. The resident was given Lorazepam and Hydromorphone for pain, but these medications did not alleviate her discomfort. The hospice nurse was unable to visit promptly, and the facility delayed further action until the following day, resulting in prolonged pain for the resident. Interviews with staff and the resident's responsible party revealed that the resident was in severe pain throughout the night and into the next day. The facility's Director of Nursing acknowledged that further action should have been taken when hospice did not arrive as expected. The resident was eventually sent to the ER, where her hip was repositioned, and an immobilizer was applied to her broken leg. The failure to notify the Medical Director and the delay in sending the resident to the ER contributed to the deficiency identified in the report.
Inadequate Pain Management for Resident Post-Fall
Penalty
Summary
The facility failed to provide adequate pain management for a resident who required such services, as per professional standards and the resident's comprehensive care plan. The resident, who had a history of Alzheimer's Disease, Major Depressive Disorder, and was under hospice care, experienced a fall and reported pain. Despite having orders for Hydromorphone and Lorazepam to be administered every four hours for pain management, the resident did not receive these medications as prescribed. On the night of the incident, a nurse found the resident on the floor, displaying signs of pain with a swollen knee. The nurse contacted the hospice nurse, who advised administering the existing pain medications and scheduling an x-ray for the following morning. The resident received the medications approximately 20-30 minutes after the fall, which were effective in allowing the resident to sleep. However, the resident did not receive any further pain medication for nearly 12 hours, despite the order for administration every four hours. The following morning, another nurse assessed the resident's pain as significant, based on facial expressions, but delayed administering additional pain medication due to the previous nurse's report. The resident's daughter was consulted but declined further medication at that time. The resident was eventually sent to the ER for further evaluation and pain management. The facility's Director of Nursing acknowledged the lapse in administering pain medication as ordered.
Failure to Maintain Resident Privacy During Showering
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity by not maintaining privacy during showering. Observations on two separate occasions revealed that the shower room door was propped open while residents were receiving care, allowing staff, residents, and visitors to pass by and potentially see inside. This was contrary to the facility's policy, which required the door to be closed for warmth and privacy during resident care. Interviews with staff confirmed that the door should have been closed, but it was not. Two residents were directly affected by this deficiency. One resident, who had intact cognition, expressed a preference for the door to be closed while showering, indicating a lack of respect for his personal preferences and dignity. The other resident had moderately impaired cognition, which may have affected his ability to advocate for his privacy needs. The facility's failure to adhere to its own policies and procedures resulted in a breach of the residents' rights to privacy and dignity.
Failure to Administer Prescribed Antibiotic
Penalty
Summary
The facility failed to provide care and services that met professional standards of quality by not implementing a physician's order for a resident. Specifically, the facility did not administer the prescribed antibiotic, Augmentin, to a resident who was diagnosed with a urinary tract infection, among other conditions. The resident, who had severe cognitive impairment and required extensive assistance with daily activities, was supposed to receive the medication starting on October 18, 2024, as per the physician's order. Upon review of the resident's Medication Administration Record (MAR), it was found that the antibiotic was not administered from October 18 to October 23, 2024, and there were no documented refusals of the medication. This oversight was confirmed during an interview with the Director of Nursing and a Corporate Registered Nurse, who acknowledged that the medication should have been administered as ordered. The facility's policy on medication administration emphasizes the responsibility of licensed nursing personnel to administer medications according to physician's orders, which was not adhered to in this case.
Improper Garbage Disposal
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed during a survey. The facility's policy on garbage and rubbish disposal requires that all outside dumpsters be maintained in a clean and sanitary condition, with storage areas kept clean to discourage pests and outdoor trash receptacles kept covered. However, during an observation of the area outside the facility's kitchen, a blue dumpster was found with its sliding door left open, allowing a cat to jump out. Trash was observed on the ground in front of the dumpster, and a torn mattress and two walkers were found outside the dumpster area. Despite signage instructing that the dumpster door be closed at all times, the door remained open during a subsequent observation. An interview with the Housekeeping Supervisor confirmed that housekeeping was responsible for maintaining the cleanliness of the area and acknowledged that the sliding door should be closed and the area free of litter, which was not the case.
Facility Fails to Repair Toilet and Shower Door
Penalty
Summary
The facility failed to maintain a safe, functional, and comfortable environment for its residents, as evidenced by two specific deficiencies. Firstly, the toilet base in Room A was found to be in disrepair, with broken pieces of solid material observed underneath the toilet on two separate occasions. A resident occupying Room A reported that the toilet had been in disrepair since moving into the room the previous year. The resident's Quarterly MDS indicated a BIMS score of 15, suggesting intact cognitive function. Secondly, the shower room door on X Hall was observed to have a hole approximately 6 inches in width near the bottom. The maintenance staff confirmed the presence of the hole and acknowledged that the toilet base in Room A had rebroke, necessitating repair. These observations and interviews highlight the facility's failure to address and repair these issues in a timely manner.
Deficiencies in Lab Monitoring and Medication Administration
Penalty
Summary
The facility failed to ensure residents received treatment and care in accordance with professional standards of practice and residents' person-centered care plans. This deficiency was identified for six out of thirteen sampled residents. The facility did not have a system in place to notify physicians of critical lab results, obtain ordered lab tests, and ensure medications were administered as prescribed. Specifically, the facility failed to notify the physician of a critically low hemoglobin level for a resident and did not document bleeding monitoring for two residents receiving anticoagulant therapy. Additionally, the facility did not obtain ordered weekly PT/INR levels for these residents. One resident, who had a history of Coumadin toxicity and gastrointestinal bleeding, was not monitored appropriately. The facility failed to obtain a PT/INR level and did not notify the primary care physician of a critically low hemoglobin level. Despite these critical lab results, the resident continued to receive Coumadin, leading to hospitalization for Coumadin toxicity. The resident required a blood transfusion and Vitamin K injection. This situation resulted in an Immediate Jeopardy finding due to the potential for more than minimal harm to residents requiring lab monitoring and physician notification. Other residents were also affected by the facility's deficiencies. One resident did not have their PT/INR levels drawn due to refusals and a lack of follow-up by staff. Another resident did not receive their prescribed medications and had missing documentation for blood glucose levels and vital signs. Additionally, routine laboratory draws were not completed for two residents, and a suprapubic catheter was not changed as ordered for another resident. These failures highlight the facility's lack of adherence to physician orders and monitoring protocols, leading to potential harm to residents.
Deficiencies in Lab Monitoring and Communication
Penalty
Summary
The facility failed to effectively administer its resources to ensure the highest practicable well-being of its residents, as evidenced by multiple deficiencies in monitoring and communication of laboratory results. Specifically, the facility did not have a system in place to ensure the completion of laboratory draws and timely communication of abnormal lab results to the provider. This failure affected several residents, including one who experienced an Immediate Jeopardy situation due to the facility's negligence in obtaining and communicating critical lab results. Resident #5, who had a history of Coumadin toxicity and gastrointestinal bleeding, was particularly affected. The facility failed to obtain a PT/INR level as ordered and did not notify the primary care physician of a critically low hemoglobin level. Despite these critical lab results, the resident continued to receive Coumadin, leading to a hospital transfer for a blood transfusion and Vitamin K injection. This oversight was discovered during a routine visit by the resident's PCP, highlighting the facility's failure to monitor and communicate critical lab results. Other residents were also impacted by similar deficiencies. Resident #12 did not have a PT/INR level drawn for over a month, yet continued to receive Coumadin without proper monitoring. Resident #9 had missed documentation of vital signs and medication administration, while Resident #10 and Resident #3 had lab tests that were not conducted as ordered. Additionally, Resident #4's suprapubic catheter was not changed according to the physician's schedule. These failures were acknowledged by the facility's Director of Nursing, who cited high turnover in leadership positions as a contributing factor to these care issues.
Failure to Provide Privacy and Address Resident Grievances
Penalty
Summary
The facility failed to provide a private space for the Resident Council Meeting held on 10/07/2024, which was conducted in the day room near the front entrance, nurses' station, and dining room. This area was open to anyone entering the facility, compromising the privacy of the meeting. During the meeting, a staff member conversed with the social services staff, and a visitor stood in the day room area, listening to part of the meeting. This lack of privacy was acknowledged by the facility's administrator and director of nursing. Additionally, the facility did not act promptly upon grievances voiced by residents during monthly Resident Council meetings. Residents consistently complained about staff not rounding every two hours, call lights not being answered timely, beds not being made, and CNAs being too loud at night. These issues were reported as ongoing problems that had not been addressed effectively, despite being raised in meetings from July to October 2024. The facility's response was limited to monthly in-service training for staff, with no other documented interventions.
Failure to Provide Diabetic Dietary Needs
Penalty
Summary
The facility failed to provide a resident with a diet specific to their special dietary needs and preferences, particularly for a diabetic precautions diet. Resident #1, who has a medical history including diabetes, diabetic neuropathy, hyperlipidemia, hypertension, schizophrenia, mood disorder, and intellectual disabilities, was not provided with an artificial sugar sweetener, Sweet'n Low, which is part of their dietary requirements. The resident reported not having access to Sweet'n Low for several days, which affected their ability to consume certain foods like grits and water with ice cubes. The deficiency was due to the dietary management's oversight in ordering and maintaining an adequate supply of artificial sweeteners. The dietary aide confirmed the absence of alternative sweeteners until the supply truck's arrival. The dietary manager admitted to overlooking the need to replenish the Sweet'n Low supply and failing to notify the office to purchase it locally. The administrator acknowledged that the dietary manager should have taken steps to ensure the availability of sugar substitutes for residents on diabetic precaution diets.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident, who was assessed to be at risk for elopement, from exiting the facility without staff knowledge. The resident, who had moderate cognitive impairment and a history of wandering, was able to leave the facility unnoticed. This incident occurred when the resident asked an agency nurse to unlock the front door, expressing a desire to see his wife, while holding a trash bag with clothing items. The nurse did not notify other staff of the resident's exit-seeking behavior, and the resident was later found 0.4 miles away from the facility by staff from his Intensive Outpatient Program (IOP). The resident's medical records indicated a history of wandering and a risk for elopement, with interventions such as door alarms and hourly location monitoring in place. However, the agency nurse, who was not properly oriented to the facility's procedures or informed of the resident's elopement risk, failed to increase supervision or alert other staff members. The nurse signed off on the resident's location monitoring without accurately verifying his whereabouts, contributing to the resident's unsupervised departure. Interviews with facility staff revealed a lack of communication and awareness regarding the resident's elopement risk. The facility's administrator acknowledged that the resident was not included in the elopement binder until after the incident, and there was no policy for training all staff, including agency staff, on elopement risks. The situation was further complicated by another resident's family moving belongings out of the facility, which may have distracted staff and allowed the resident to leave unnoticed.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to effectively administer its resources to ensure the safety and well-being of its residents, specifically for a resident identified as being at risk for elopement. This resident, who was moderately cognitively impaired, managed to exit the facility unattended after asking an agency nurse to unlock the front door. The nurse did not inform other staff members of the resident's intention to leave. The resident was last seen at the nurses' station and was later found 0.4 miles away on a busy roadway by staff from the resident's Intensive Outpatient Program (IOP). The IOP staff notified the facility's Director of Nursing (DON), who then arranged for the resident's return to the facility. The incident highlighted a lack of effective supervision and communication among staff regarding residents at risk for elopement. The facility's administrator acknowledged that the resident was not placed in the elopement binder until after the incident, indicating a failure in the system to identify and monitor at-risk residents adequately. Additionally, there was no policy in place to ensure that all staff, including agency staff, were trained on identifying and managing residents at risk for elopement. This deficiency resulted in an Immediate Jeopardy situation, as the resident was able to leave the facility without proper supervision.
What surveyors are citing around you — mapped
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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 20 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
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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 | 0 mi | ★★★★★ | 14 | 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 |
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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.