Courtyard Of Natchitoches
Inspection history, citations, penalties and survey trends for this long-term care facility in Natchitoches, Louisiana.
- Location
- 708 Keyser Avenue, Natchitoches, Louisiana 71457
- CMS Provider Number
- 195213
- Inspections on file
- 27
- Latest survey
- January 7, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Courtyard Of Natchitoches during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, multiple chronic conditions, and a care plan noting vaccine refusal due to allergies received a high-dose influenza vaccine without documented prior education or signed consent from the resident or health care proxy, as required by facility policy. An LPN administered the vaccine based on a list of residents reported to have consented, without verifying consent in the record, and the only documented refusal form from the responsible party was signed several days after the vaccine had already been given.
A resident with intact cognition and multiple chronic conditions was assessed and care planned to self-administer only eye drops, with no orders permitting bedside storage of other medications. However, surveyors observed Diclofenac arthritis cream, Nystatin cream, and Hydrocortisone cream left unattended in the resident’s room and bathroom, and the resident reported self-administering these creams after receiving them from a nurse. The ADON confirmed that the resident was authorized only for self-administration of eye drops and that the topical creams should not have been left in the room, demonstrating the facility’s failure to follow its own self-administration assessment and policy.
A resident with quadriplegia, central cord syndrome, edema, and intact cognition, who relied on a wheelchair for mobility and required extensive assistance with ADLs, repeatedly reported that her wheelchair was too small and causing hip discomfort. CNAs confirmed the complaints and notified the administrator, and staff observed that the resident had gained weight and sometimes had edema. Surveyors observed the resident seated with her hips tightly pressed against the wheelchair sides and later noted redness and indentations on both hips after transfer, which an LPN confirmed were from the wheelchair. Therapy staff reported they had not been informed by nursing that the wheelchair was too small, and despite awareness of the issue, no effective action was taken to provide an appropriately sized wheelchair.
A resident's protected health information (PHI) was left visible on an unattended EMR cart, as observed by surveyors. An LPN admitted to leaving the cart unattended without securing the computer screen, and the DON confirmed that staff are required to lock screens when not present. This incident violated the facility's HIPAA privacy policy.
Surveyors found a medication cart left unattended and unlocked in a hallway, with several drawers open and medications accessible. An LPN confirmed the cart should have been locked and secured when not in use, in accordance with facility policy. The DON also stated that medication carts are required to be locked when unattended.
Staff failed to accurately document the administration of medications and completion of ordered care tasks on the MAR for two residents with complex medical needs. Despite performing the required tasks, LPNs did not consistently record times and initials as required by facility policy, resulting in incomplete and inaccurate medical records.
A resident with intact cognition and significant medical needs entrusted a staff member with a large sum of settlement money for safekeeping and distribution to family. The staff member failed to safeguard the funds, claiming they were stolen from her home, did not report the theft, and did not return the money. Facility investigation confirmed the misappropriation of the resident's property by the staff member.
A resident with intact cognition and complex medical needs reported that a staff member misappropriated a significant sum of money. Although the staff member admitted to the misappropriation, the facility did not conduct a thorough investigation, failed to interview all relevant residents, and did not provide comprehensive in-service education to all staff. Additionally, the resident was not consistently monitored for safety or emotional well-being during the investigation, and several staff members lacked awareness of misappropriation as a form of abuse.
Two residents were placed in physical restraints, including a Geri-chair and a pommel cushion, without required physician orders, consents, or risk assessments. Staff interviews confirmed that the facility lacked both the necessary documentation and a policy for restraints or bed rails.
The facility did not obtain physician's orders, informed consent, or conduct risk assessments before installing bed rails for three residents with significant medical and cognitive impairments. Staff confirmed the absence of required documentation and policies related to bed rail use.
A resident with pressure ulcers did not receive the required weekly skin assessments and wound measurements, as confirmed by interviews with the Wound Care Nurse and RN Charge. This failure to document care is contrary to the facility's policies, which mandate weekly documentation to manage pressure ulcers effectively.
A facility failed to ensure consistent documentation of a resident's code status. Despite having a physician's order and signed consent for DNR status, the resident's care plan incorrectly indicated Full code status. Staff were aware of the DNR status through the resident's dashboard and hard chart, but the care plan was not updated accordingly, leading to a discrepancy.
A resident with severe cognitive impairment and osteoporosis experienced a leg injury during repositioning by two CNAs, who failed to report an audible pop immediately. The resident later complained of leg pain, prompting a nurse to investigate and send the resident for an x-ray, which revealed a spiral fracture. The facility's administrator confirmed the CNAs should have reported the incident immediately.
A facility failed to use a mechanical lift for transferring a non-weight bearing resident, as required by the care plan. Two CNAs used a lift pad instead, citing issues with finding a functional lift. The resident, with severe cognitive impairment and osteoporosis, was transferred without the necessary equipment, contrary to facility policy.
The facility failed to maintain wheelchairs in good repair, affecting five residents. Observations showed peeling and cracked armrest cushions, with one resident's family member noting the issue had persisted for months. The DON confirmed the need for replacement during environmental rounds.
The facility failed to meet residents' nutritional needs by not adhering to prescribed portion sizes for pureed meals. Kitchen staff used a 4oz scoop that was not filled to capacity, resulting in residents receiving less than the required portions. This affected multiple residents, including those needing double portions, and was confirmed by staff observations and interviews.
The facility did not provide a Notice of Medicare Non-Coverage (NOMNC) to three residents before discontinuing their Medicare Part A services, despite having benefit days remaining. The social worker acknowledged not issuing the required notice and was unaware of the necessity to do so.
A facility failed to develop a comprehensive Hospice Care Plan for a resident admitted to hospice care, despite the resident's serious health conditions and a physician's order. Interviews confirmed the resident was receiving hospice services, but the care plan did not reflect this, indicating a lapse in care planning.
A resident with a history of dizziness and balance issues fell while trying to get into bed without assistance. The facility failed to update the care plan with new fall prevention strategies after the incident. The MDS coordinator was unaware of the fall due to a lack of communication, resulting in the care plan not being revised.
A resident with a history of osteoporosis and pain did not receive the prescribed Duloxetine dosage due to a failure in entering a physician's order. The resident was supposed to receive 60 mg daily, but the order was not processed, and the resident missed the medication from 09/16/2024 to 09/24/2024. The ADON confirmed the oversight during an interview.
The facility failed to implement a dietitian's recommendations for two residents, leading to deficiencies in maintaining their nutritional status. One resident experienced significant weight loss without receiving recommended dietary supplements, while another resident with mild malnutrition did not receive suggested nutritional supplements or vitamins for wound healing. The ADON confirmed that necessary orders were not entered.
A resident with a history of falls and multiple diagnoses, including dementia and incontinence, experienced a significant delay in receiving assistance after using the call light. Despite being informed that help would arrive soon, the resident waited approximately 35 minutes for assistance to use the restroom. The facility's policy requires call light responses within 15 minutes, but this was not adhered to, indicating a deficiency in staff competency and response time.
A resident with a milk allergy and lactose intolerance was given Ensure, a supplement containing milk protein, three times daily due to weight loss. Despite the care plan requiring nondairy alternatives, staff confirmed the administration of Ensure. The RD admitted to the oversight, assuming the resident only had lactose intolerance.
The facility did not follow professional standards for food service safety by failing to cover, label, and date refrigerated food items after opening. An open block of cheese and a cup of oranges were found uncovered and undated in the refrigerator, confirmed by the kitchen lead. This oversight could impact the 92 residents receiving meals from the kitchen.
Failure to Obtain and Document Consent and Education Prior to Influenza Vaccination
Penalty
Summary
The facility failed to follow its policy requiring education and signed consent prior to administering influenza and pneumonia vaccinations. The written policy titled “Pneumonia/Influenza Vaccinations” directed staff to contact the resident and family to explain the importance of vaccinations and to obtain signed consent from the resident and/or family. For one resident, admitted with chronic kidney disease stage 5, end stage renal disease, pneumonia, schizophrenia, and bipolar disorder, the record identified a health care proxy as the responsible party and a care plan focus of refusing vaccines due to allergy to some components, with an intervention to assess for consent or refusal upon admission and periodically with the resident and responsible party. The resident’s MDS showed a BIMS score of 3, indicating severely impaired cognition. Despite these requirements and the resident’s cognitive status and care plan, the physician’s order for a high-dose influenza vaccine was implemented and the vaccine was administered on a documented date and time without any documented evidence of prior education, consent, or refusal from the resident or health care proxy. The eMAR confirmed the vaccine was given, while the medical record lacked a signed consent form or documentation of education about risks and benefits before administration. A subsequent influenza vaccination request and consent form, signed by the responsible party several days after the vaccine was given, documented a refusal of the influenza vaccine on an ongoing basis. Staff interviews confirmed that an LPN administered the vaccine based on a list of residents purported to have consented, without personally verifying a signed consent, and the infection control nurse and ADON acknowledged that consent/refusal and education should have been obtained and documented before the vaccine was administered, but this did not occur for this resident.
Failure to Follow Self-Administration Assessment Limits for Topical Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure the interdisciplinary team assessed and determined clinical appropriateness for self-administration of medications in accordance with its policy for one resident. The facility’s policy required that if a resident desired to self-administer medications, the interdisciplinary team would assess the resident’s cognitive, physical, and visual abilities and document the results on a Self-Administration Assessment form in the medical record. The resident in question had diagnoses including COPD, primary insomnia, depression, and nicotine dependence, and a BIMS score of 15 indicating intact cognition. The resident’s care plan documented a physician’s order for unsupervised self-administration of carboxymethylcellulose eye drops only, and the Self-Administration of Medication assessment form indicated the resident was fully capable to self-administer eye drops, but topical medications (including patches) were not selected as medications the resident was capable of self-administering. There were no physician’s orders allowing the resident to store medications at the bedside. Despite this, surveyor observations and interviews showed that multiple topical medications were present and left unattended in the resident’s room and bathroom, and the resident reported self-administering them. Diclofenac arthritis cream was observed on the bedside table, and later Diclofenac arthritis cream, Nystatin cream, and Hydrocortisone cream were observed on a table next to the resident’s toilet. The resident stated she administered the creams herself and that a nurse had given her the cream in a medicine cup, although she could not recall which nurse. The ADON confirmed during the survey that these topical medications should not have been left unattended in the resident’s bathroom and that, per the self-administration assessment, the resident was only allowed to self-administer eye drops and not topical creams. This discrepancy between the documented assessment/physician orders and the actual practice of allowing the resident to self-administer and keep topical medications in the room led to the cited deficiency.
Failure to Provide Appropriately Sized Wheelchair for Resident
Penalty
Summary
The facility failed to reasonably accommodate a resident’s needs and preferences by not providing a wheelchair appropriate for her size. The resident, admitted with diagnoses including edema, unspecified quadriplegia, acute pain, muscle spasm, central cord syndrome of the cervical spinal cord, and seizures, had intact cognition with a BIMS score of 15 and used a wheelchair for mobility. Her MDS and care plan documented limited physical mobility, bilateral upper and lower extremity impairments, and dependence on staff for transfers, toileting, and personal hygiene, as well as risk for pressure ulcers and the need to avoid striking extremities on hard surfaces. During observation, the resident was seen sitting in a wheelchair with no space between her hips and the sides of the chair, and she reported that the wheelchair was too small, rubbed against her hips, and that she had previously informed the administrator of this issue over a month earlier after gaining weight. Multiple CNAs confirmed that the resident had complained that her wheelchair was too small and was hurting her hips, and that they had notified the administrator and shown her that the wheelchair did not fit properly. Another staff member reported noticing that the resident’s wheelchair was too small and that the resident had edema at times and had gained weight. On a subsequent observation, three CNAs were seen transferring the resident from the wheelchair to bed via Hoyer lift, and redness and indentations were observed on both hips where they had been pressed against the sides of the wheelchair; an LPN confirmed these findings. Therapy staff stated that residents are screened every three months and as needed, but nursing had not notified therapy that this resident’s wheelchair was too small. The administrator acknowledged that a requisition for a larger wheelchair had been cancelled and confirmed that no other measures had been implemented to obtain an appropriately sized wheelchair for the resident.
Failure to Protect Resident PHI Due to Unattended EMR Cart
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of medical records for one resident. During an observation on Hall B, an unattended medical cart was found with the electronic medical record (EMR) screen left open, displaying a resident's protected health information (PHI). The cart remained unattended until a staff member, identified as an LPN, returned. Upon interview, the LPN acknowledged leaving the cart unattended with the resident's PHI visible and admitted not ensuring the privacy and confidentiality of the information. The Director of Nursing confirmed that staff are expected to lock computer screens when leaving them unattended to protect resident PHI. This deficiency was identified through observation, interview, and record review, and was found to be in violation of the facility's policy requiring all workforce members to adhere to HIPAA Privacy Standards and prevent unauthorized disclosure of PHI.
Unattended and Unlocked Medication Cart Found During Survey
Penalty
Summary
Surveyors observed that Cart X, containing medications, was left unattended and unlocked in Hall B, with three of its eight drawers open. This occurred during a medication pass and was witnessed at 8:55 a.m. The cart remained unsecured until a staff member, identified as an LPN, returned. Upon interview, the LPN confirmed that the cart was supposed to be locked and all drawers closed when not attended, acknowledging that the medications were not stored in a safe and secure manner. The facility's policy requires all medications to be stored in locked compartments and for medication carts to be locked when unattended, which was not followed in this instance. The Director of Nursing also confirmed that medication carts are to be locked when unattended to ensure security.
Failure to Accurately Document Medication Administration and Care Tasks
Penalty
Summary
The facility failed to maintain accurate and complete medical records in accordance with accepted professional standards and its own policies. Specifically, staff did not consistently document the administration of medications and completion of ordered care tasks on the Medication Administration Record (MAR) for two residents. The facility's policies require that all medications administered be recorded with time and staff initials on the MAR, and that the electronic MAR (E-MAR) serves as a permanent, legal document within the electronic health record. For one resident with multiple diagnoses including severe cognitive impairment, repeated falls, malnutrition, and dementia, there were multiple instances where staff failed to record the administration of medications such as Levothyroxine, Donepezil, Atorvastatin, Latanoprost, Memantine, and topical creams, as well as the completion of care tasks like applying an overlay on the mattress and ensuring the use of pillow heel boots. These omissions occurred across several dates and shifts, with missing documentation for both day and night shifts. Another resident, with diagnoses including diabetes and hypothyroidism and intact cognition, also had missing documentation for medication administration (Levothyroxine, Novolin R), blood glucose monitoring, and other ordered care tasks over several days. Interviews with administrative and nursing staff confirmed that while medications and care tasks were performed as ordered, the required documentation was not completed on the MARs for the affected residents. Staff acknowledged that the records were not accurate and should have been properly documented according to facility policy.
Staff Misappropriation of Resident Funds
Penalty
Summary
A deficiency occurred when a staff member, S7 Rehab Tech, misappropriated a resident's funds by agreeing to hold a large sum of money for the resident and subsequently failing to safeguard or return the funds. The resident, who had intact cognition as indicated by a BIMS score of 15 and diagnoses including cervical spine fusion, seizures, quadriplegia, and depression, received a settlement check and entrusted S7 Rehab Tech with approximately $12,000 in cash. The staff member was supposed to distribute portions of the money to the resident's family and hold the remainder for the resident, as per the resident's instructions. After the money was given to S7 Rehab Tech, the staff member reported to the resident that the funds were stolen from her home during a break-in. S7 Rehab Tech did not file a police report regarding the alleged theft and did not return the funds to the resident. The staff member admitted to holding the money and acknowledged that she should not have agreed to the arrangement. The resident attempted to recover the funds and communicate with S7 Rehab Tech, but the staff member avoided contact and blocked the resident's phone number. The facility's investigation, prompted by a rumor and subsequent interviews, confirmed that the staff member had misappropriated the resident's funds. The staff member admitted to the actions during interviews with facility administration and the rehab director. The incident was substantiated as misappropriation of property/funds, as the staff member wrongfully used the resident's money without proper consent or protection, in violation of facility policy and resident rights.
Failure to Thoroughly Investigate Misappropriation of Resident Property
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of misappropriation of resident property involving a resident with intact cognition and significant medical conditions, including quadriplegia and depression. The resident reported that a staff member was asked to hold a large sum of money, which was later reported stolen from the staff member's home. The staff member admitted to taking the money, and the incident was substantiated by the facility. Despite the admission, the investigation was not comprehensive. Not all cognitively intact residents were interviewed regarding similar issues, and not all facility and therapy staff received in-service education on misappropriation of resident property or funds. Several staff members, including CNAs and therapy staff, demonstrated a lack of understanding about misappropriation and its classification as a form of resident abuse. Some staff members were unaware of the incident or had not received any related training or education following the event. Additionally, the resident who reported the incident did not receive consistent monitoring or safety checks during the investigation process. The facility's own policy required timely and thorough investigations and monitoring of the resident's emotional well-being during such incidents, but these steps were not fully implemented. The administrator acknowledged that the investigation was limited due to the staff member's admission and confirmed that key investigative and monitoring actions were not completed.
Failure to Obtain Orders, Consents, and Assessments for Physical Restraints
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints imposed for discipline or convenience, as evidenced by the lack of required physician orders, consents, and risk assessments for two residents. One resident, admitted with multiple diagnoses including chronic kidney disease and impaired cognition, was observed using a Geri-chair for mobility without documentation of a physician's order, signed consent, or completed risk assessment. The resident's care plan indicated the use of the Geri-chair, but the necessary regulatory steps were not followed. Another resident, with a history of dementia, falls, and severely impaired cognition, was observed using a pommel cushion in a wheelchair. The medical record did not contain a physician's order, consent, or risk assessment for this device, despite its use being documented in the care plan. Interviews with facility staff, including the DON and Administrator, confirmed that the facility had not obtained the required documentation for these restraints and did not have a policy in place for restraints or bed rails.
Failure to Obtain Orders, Consent, and Assessments for Bed Rail Use
Penalty
Summary
The facility failed to ensure proper procedures were followed regarding the use of bed rails for three residents. Specifically, there was no evidence of physician's orders, informed consent from the residents or their representatives, risk assessments for entrapment, or care plan documentation related to the use of assist rails. Observations confirmed that all three residents were using bed rails, and staff interviews acknowledged that required assessments, consents, and orders had not been obtained. Additionally, the facility did not have a policy in place for the use of bed rails. The residents involved had significant medical histories, including chronic conditions such as chronic kidney disease, heart failure, dementia, and a history of falls. Cognitive assessments indicated that at least two of the residents had moderate to severe cognitive impairment. Despite these factors, the facility did not document any individualized assessment or planning for the use of bed rails, nor did it obtain the necessary authorizations or consents prior to their installation and use.
Failure to Document Weekly Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with pressure ulcers, as required by professional standards of practice. The resident, who was admitted with multiple diagnoses including stage 3 pressure ulcer of the right hip and stage 2 pressure ulcer of the sacral region, did not receive the mandated weekly skin assessments and wound measurements on specified dates. The facility's wound care documentation policy requires weekly documentation of all existing and new wounds, including detailed assessments of the wound's status and condition. Interviews with the Wound Care Nurse and the Registered Nurse Charge confirmed the absence of documentation for the required weekly skin evaluations and measurements for the resident on the specified dates. This lack of documentation indicates a failure to adhere to the facility's policies and procedures for managing pressure ulcers, which are crucial for promoting healing and preventing further complications.
Inconsistent Documentation of Resident's Code Status
Penalty
Summary
The facility failed to ensure that all medical records regarding a resident's code status consistently reflected the resident's current wishes. The resident, who had multiple diagnoses including cerebral infarction and type II diabetes mellitus, had a physician's order for Do Not Resuscitate (DNR) status created and confirmed on 11/11/2024. The resident had also signed a consent form for DNR status on 10/22/2024, which was confirmed by the physician. However, the resident's care plan, which should have been updated to reflect the DNR status, incorrectly indicated a Full code status as of 10/23/2024. During interviews and record reviews, it was revealed that the facility's staff, including an LPN and the MDS Coordinator, were aware of the DNR status as indicated in the resident's dashboard on Point Click Care (PCC) and the hard chart. Despite this, the care plan was not updated to reflect the DNR status, leading to a discrepancy between the resident's documented wishes and the care plan. The MDS Coordinator confirmed that the care plan should have been updated when the new DNR order was received, but it was not, resulting in the deficiency.
Failure to Report Change in Condition Immediately
Penalty
Summary
The facility failed to ensure immediate reporting of a change in condition for a resident, which is a deficiency in their care protocol. The incident involved a resident with severe cognitive impairment and multiple diagnoses, including a displaced spiral fracture of the left femur, atrial fibrillation, unspecified dementia, and osteoporosis. The resident required substantial assistance with daily activities and was care planned for osteoporosis, with specific interventions for safety and transfer assistance. On the morning of the incident, two CNAs were repositioning the resident when they heard an audible popping sound from the resident's leg. Despite hearing the pop, the CNAs did not report the incident to the nurse immediately, as the resident did not show any immediate signs of pain or distress. The resident was then placed in a wheelchair and taken to the dining room. It was only after the resident complained of leg pain while sitting at the dining table that the CNAs informed the nurse about the earlier popping sound. The nurse, upon being informed, examined the resident and, after consulting with the charge nurse and the resident's doctor, decided to send the resident to the emergency room for further evaluation. An x-ray confirmed a spiral fracture in the resident's left femur. The delay in reporting the initial incident by the CNAs was acknowledged by the facility's administrator as a failure to adhere to the facility's policy on reporting accidents and incidents immediately, regardless of the perceived severity.
Failure to Use Mechanical Lift for Resident Transfer
Penalty
Summary
The facility failed to adhere to its policy for transferring non-weight bearing residents, resulting in a deficiency. The policy requires the use of a mechanical lift with two-person assistance for transferring residents who are non-weight bearing. However, on 11/19/2024, two CNAs transferred a resident from bed to wheelchair using a lift pad instead of the mechanical lift, as outlined in the resident's care plan. The CNAs reported that they opted for the lift pad because it was quicker and mechanical lifts were often unavailable due to being hidden or having dead batteries. The resident involved had a history of severe cognitive impairment, osteoporosis, and other medical conditions, necessitating careful handling during transfers. The resident's care plan specifically required the use of a Hoyer lift with two-person assistance for all transfers to ensure safety. Despite this, the CNAs proceeded with the transfer using the lift pad, which was confirmed by the facility's administrator through interviews and camera footage review. This action was contrary to the care plan and facility policy, leading to the deficiency finding.
Wheelchair Armrest Cushions in Disrepair
Penalty
Summary
The facility failed to maintain residents' wheelchairs in good repair, compromising the residents' right to a safe and comfortable environment. Observations revealed that the armrest cushions of wheelchairs for five residents were peeling and in disrepair. Specifically, Resident #19 was observed sitting in a wheelchair with both arm cushions in disrepair. Resident #40's wheelchair arm cushions were also in disrepair, with the resident's son noting that the condition had persisted for 6-8 months. Similar conditions were observed for Residents #47, #49, and #67, with cracked and non-intact surfaces on their wheelchair arm cushions. During environmental rounds with the Director of Nursing (DON), these deficiencies were confirmed, indicating a need for replacement of the damaged equipment.
Failure to Adhere to Prescribed Portion Sizes for Pureed Meals
Penalty
Summary
The facility failed to meet the nutritional needs of residents by not adhering to the prescribed portion sizes for pureed meals, as observed during a survey. The lunch menu for residents on pureed diets specified serving sizes of 3/4 cup for pureed chicken spaghetti and 1/2 cup for pureed green beans. However, the kitchen staff used a 4oz scoop for all food items, which was not filled to capacity, resulting in residents receiving less than the required portion sizes. This discrepancy was confirmed through observations and interviews with kitchen staff, including the Kitchen Lead and Kitchen Assistant Manager, who acknowledged the failure to serve the correct portion sizes. The deficiency affected multiple residents, including those who required double portions as per their meal cards. Observations revealed that residents often received inadequate amounts of food, as confirmed by CNAs assisting them during meals. The Dietary Manager also confirmed that the staff should have followed the serving sizes indicated on the approved menus. The lack of a menu with serving sizes posted in the kitchen contributed to the staff's inability to serve the correct portions, leading to the nutritional inadequacy of meals provided to residents.
Failure to Issue Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) to three residents or their responsible parties before discontinuing Medicare Part A services. This deficiency was identified during a review of the Skilled Nursing Facility (SNF) Beneficiary Review forms for the residents. It was found that the NOMNC, Form CMS-10123, was not provided to the residents prior to their discharge from Medicare Part A services, despite having benefit days remaining. In an interview, the social worker (S4 SW) admitted to not issuing the NOMNC to the residents and was unaware of the requirement to do so.
Failure to Develop Hospice Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive Hospice Care Plan for a resident who was admitted to hospice care. The resident, who had multiple serious health conditions including malignant neoplasm, end-stage renal disease, and heart disease, was admitted to hospice on July 22, 2024. Despite the resident's significant health needs and the physician's order to admit the resident to hospice care, the care plan did not include hospice care, which is a critical component of the resident's treatment and support. Interviews with facility staff, including an LPN and MDS coordinators, confirmed that the resident was receiving hospice services, with a hospice nurse visiting weekly and aides visiting twice a week. However, the MDS coordinators acknowledged that the resident's care plan should have included hospice care but did not. This oversight indicates a lapse in ensuring that the resident's care plan was comprehensive and reflective of their current health care needs, as required by regulatory standards.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to revise the care plan for a resident after a fall incident, which is a deficiency in care planning. The resident, who had a history of dizziness, chronic obstructive pulmonary disease, chronic kidney disease, and anemia, was at moderate risk for falls due to gait and balance problems. Despite these risks, the care plan was not updated with new interventions after the resident fell while attempting to get into bed without assistance. The fall occurred on September 16, 2024, and was documented in the progress notes, but the care plan remained unchanged. The MDS coordinator responsible for the resident's care plan was unaware of the fall incident, as it was not reported in the morning meeting following the event. This lack of communication resulted in the care plan not being revised to include new fall prevention strategies. The resident acknowledged the fall during an interview, stating that he attempted to get into bed without help, believing he could manage on his own. The oversight in updating the care plan highlights a failure in the facility's process for addressing and preventing falls among residents.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to ensure that physician's orders for a resident were followed, leading to a deficiency in meeting professional standards of practice. The resident, who was cognitively intact with a BIMS score of 15, had a medical history that included osteoporosis, an unspecified fracture of the right wrist and hand, anemia, and pain. On 09/20/2024, a physician's order was made to change the resident's Duloxetine dosage to 60 mg daily to help manage back pain and osteoarthritis. However, the order was not entered into the system, and the resident did not receive the prescribed medication. Further review of the resident's Medication Administration Record (MAR) for September 2024 revealed that the resident had not been receiving the previously prescribed 30 mg of Duloxetine daily from 09/16/2024 through 09/24/2024. The resident's care plan included the use of antidepressant medication for pain management, with interventions to ensure the resident was free from discomfort or adverse reactions related to the therapy. During an interview on 09/24/2024, the Assistant Director of Nursing (ADON) confirmed that the order was not entered, and the resident did not receive the medication as prescribed.
Failure to Implement Dietitian's Recommendations for Nutritional Support
Penalty
Summary
The facility failed to ensure that two residents maintained acceptable nutritional status by not implementing the registered dietitian's recommendations. Resident #11, who had severe cognitive impairment and required assistance with eating, experienced significant weight loss over a six-week period. Despite the dietitian's recommendation to encourage supplements for improved nutrition, there were no physician's orders for dietary supplements, and the Medication Administration Records (MARs) showed no documentation of supplements being provided. The Assistant Director of Nursing (ADON) confirmed that an order for supplements was not entered, which should have been done. Similarly, Resident #195, who had a history of metabolic encephalopathy, vitamin deficiency, and other conditions, was identified as having mild malnutrition with a BMI less than 22. The dietitian recommended supplements between meals and specific vitamins for wound healing. However, there were no physician's orders for these supplements or vitamins, and the MARs did not document their provision. The resident confirmed not receiving any supplements, and the ADON acknowledged that the necessary orders were not entered, which should have been carried out by the floor nurse.
Delayed Call Light Response for Resident with High Fall Risk
Penalty
Summary
The facility failed to ensure that nurse aides demonstrated competency in responding to residents' needs, as evidenced by a delayed call light response for a resident. The resident, who had a history of falls and was at high risk due to confusion and gait/balance problems, required prompt assistance. Despite using the call light to request help to use the restroom, the resident waited approximately 35 minutes before receiving assistance. This delay occurred even after an LPN informed the resident that help would arrive soon and notified another staff member of the resident's need. The resident's clinical record indicated multiple diagnoses, including dementia and frequent urinary and bowel incontinence, necessitating timely assistance. The care plan emphasized the importance of anticipating and meeting the resident's needs promptly, with specific instructions for call light accessibility and response. However, the staff failed to adhere to the facility's policy of responding to call lights within 15 minutes, as confirmed by the Director of Nursing. This incident highlights a deficiency in the facility's ability to provide timely care, potentially compromising the resident's well-being.
Failure to Accommodate Resident's Milk Allergy
Penalty
Summary
The facility failed to honor and accommodate a resident's food allergies and intolerances, specifically by providing a supplement containing milk protein to a resident with a documented milk allergy and lactose intolerance. The resident, who had diagnoses including cerebral palsy and severely impaired cognitive skills, was dependent on staff for all activities of daily living. Despite the resident's care plan indicating a need for nondairy alternatives, the resident was given Ensure, a supplement containing milk protein, three times daily due to weight loss. Interviews with facility staff, including a CNA, LPN, and the Assistant Director of Nursing (ADON), confirmed the administration of Ensure to the resident. The Registered Dietitian (RD) responsible for the resident's dietary plan admitted to recommending Ensure, mistakenly assuming the resident only had lactose intolerance and not a milk allergy. This oversight led to the administration of a product containing milk protein, contrary to the resident's documented allergies and care plan requirements.
Failure to Properly Store and Label Refrigerated Food Items
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by not ensuring that refrigerated food items were properly covered, labeled, and dated after opening. During an observation of the kitchen, an open block of cheese and a cup of oranges were found on the refrigerator shelf, both uncovered, exposed to air, and undated. This observation was confirmed by the S7 Kitchen Lead, who acknowledged that all opened food items should be covered and dated, but this protocol was not followed. This deficiency had the potential to affect the 92 residents who received meals served from the kitchen.
Latest citations in Louisiana
The facility failed to maintain an effective pest control program when multiple live roaches, roach feces, and dead roach carcasses were observed in a room shared by two residents, including on and under a personal refrigerator and beneath items placed on top of it. Housekeeping, maintenance, and a CNA each reported seeing roaches in the room on the prior day, and subsequent observations by maintenance and the administrator confirmed ongoing roach activity in the same area.
A resident with end stage renal disease, bone density disorder, chronic pain, and osteoarthritis was care planned and assessed as totally dependent for chair/bed transfers, requiring a mechanical lift with two-person assist. On one occasion after dialysis, an LPN and a CNA brought a mechanical lift into the room but, after the resident reportedly expressed not wanting to use it, the CNA manually transferred the resident from wheelchair to bed by lifting under the resident’s arms while the resident held the CNA’s waist. During this non–care-planned manual transfer, a popping sound was heard from both shoulders and the resident complained of arm pain; subsequent x‑rays and hospital evaluation confirmed acute fractures of the left clavicle and right humerus. The facility’s investigation, including review of camera footage and staff interviews, established that the mechanical lift was not used as required by the resident’s care plan, and that the injury occurred during this improper manual transfer rather than during a clothing change as initially reported.
A staff member in Social Services routinely emailed detailed resident information, including face sheets and a full census listing names, dates of birth, payer sources, room numbers, diagnoses, allergies, and advance directive details, to a contracted outside provider so the provider could identify which residents were not receiving their services and then approach them. These disclosures involved all residents in the facility and were made without obtaining or documenting any resident or responsible party consent, despite a facility policy requiring protection and confidential handling of medical, financial, and social records.
A resident with an order for Glucerna 1.2 at a specified rate and duration was instead observed receiving Isosource at 60 ml/hour. Record review confirmed the physician’s order for Glucerna 1.2, while observation and interview with an LPN verified that Isosource, a different enteral formula, was being administered. The DON later stated that the LPN should have verified the physician’s order before administering the tube feeding.
Surveyors found that the facility failed to keep its medication error rate below 5%, identifying a 29% error rate during one observed medication pass. A resident had multiple medications ordered for 9:00 AM, including aspirin, calcium carbonate, vitamin C, carvedilol, furosemide, potassium chloride ER, thiamin, timolol ophthalmic drops, and docusate sodium. An LPN administered all of these medications at 11:24 AM, outside the facility’s policy window of one hour before to one hour after the scheduled time, and did so without a physician order to change the administration times. The DON confirmed that this timing did not comply with the facility’s medication administration policy.
A resident was readmitted from the hospital with handwritten physician orders for multiple medications, including acetaminophen, Eliquis, buspirone, losartan, mirtazapine, quetiapine, senna, and Vistaril, to be given on specific schedules and as needed. Review of the eMAR showed that none of these medications were administered for an extended period after readmission. In interviews, the DON stated that nurses are responsible for clarifying orders upon a resident’s return from the hospital, and an LPN acknowledged that the medications should have been restarted and administered as ordered but were not.
A resident with physician orders for Glucerna 1.2 via enteral feeding at a specified rate and duration did not have the administration of this feeding documented in the eMAR on two days, even though surveyors directly observed the feeding being administered at the ordered rate on both days. The DON acknowledged that nursing staff should have recorded the enteral feeding administration in the medication administration record, but this documentation was missing, resulting in incomplete medical records.
A treatment nurse performed wound care on a resident with a diabetic toe wound without following the facility’s hand hygiene policy. The facility’s policy required staff to wash hands after removing gloves and clarified that gloves do not replace handwashing. During the observed dressing change, the nurse removed the old dressing and gloves, did not perform hand hygiene, donned new gloves, cleansed the wound, then again removed gloves and applied new ones without hand hygiene before applying calcium alginate and a dry dressing. The nurse later stated she had not cleaned her hands between glove changes because there was no hand sanitizer available in the room and she did not wash her hands instead, and the DON confirmed that hand hygiene should have been performed between each glove change.
Surveyors found that a CNA’s personnel file lacked documentation of the required 12 hours of annual in-service education, including dementia care and abuse prevention. The CNA had been employed for over a year, and facility leadership confirmed there was no evidence that the mandated annual training had been completed.
A resident sustained burns after spilling hot coffee from a lidded Styrofoam cup while using an over-bed table. The incident review and interviews showed kitchen staff did not check coffee temperatures before sending it to the floor, and an observed canister of coffee measured 158.1 degrees F. The facility policy stated hot liquids should be monitored to prevent scalding.
Failure to Maintain Effective Pest Control in Resident Room
Penalty
Summary
The facility failed to maintain an effective pest control program to ensure the environment was free of pests and insects, affecting a room shared by Resident #1 and Resident #3 and having the potential to affect 89 residents in the facility. On 04/30/2026 at 8:30 a.m., during an observation with the housekeeping staff member (S3Housekeeping) in this room, a live roach was seen crawling on the wall, on top of Resident #1’s personal refrigerator, and underneath the desk-style phone on top of the refrigerator. S3Housekeeping stated she had seen one roach in the same room the previous day. Around 8:40 a.m., the maintenance staff member (S2Maintenance) reported that a CNA (S4Certified Nurse Aide) had informed him the previous afternoon about a roach on the wall in that room. At 8:45 a.m., further observation of the same room with S2Maintenance revealed roach feces and dead roach carcasses on top of Resident #1’s refrigerator, and when S2Maintenance lifted the phone and a book from the top of the refrigerator, live roaches ran out from underneath. At 8:53 a.m., the CNA (S4Certified Nurse Aide) confirmed she had noticed a roach in the room the day before. Later, at 12:45 a.m., the administrator (S1Administrator) reported that when he accompanied maintenance to the room and the refrigerator was lifted, a couple of live roaches ran out from underneath it. In a subsequent interview at 4:30 p.m., S1Administrator confirmed there were live roaches in the room of Resident #1 and Resident #3 and acknowledged they should not have been present.
Failure to Follow Care-Planned Mechanical Lift Transfer Resulting in Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received adequate assistance during transfers by not following the resident’s care plan, which required use of a mechanical lift with two-person assistance. The resident had been admitted with diagnoses including end stage renal disease with dependency on renal dialysis, other specified disorders of bone density and structure, chronic pain, and osteoarthritis. The resident’s annual and quarterly MDS assessments documented intact cognition with a BIMS score of 15 and indicated the resident was totally dependent for chair/bed transfers. The care plan, initiated at admission, specified that transfers were to be performed using a mechanical lift with two staff assisting. On the date of the incident, the resident had returned from dialysis and required assistance transferring from a wheelchair to a bed. According to interviews, a CNA and an LPN were involved in the transfer. The LPN reported that a mechanical lift was rolled into the resident’s room, but the CNA stated the resident did not want to use the lift. Despite knowing that the resident was care planned for mechanical lift use, the CNA proceeded to transfer the resident manually by placing her arms under the resident’s arms while the resident wrapped her arms around the CNA’s waist. During this manual transfer from wheelchair to bed, a popping sound was heard from the resident’s shoulders and the resident immediately complained of pain in both arms. Progress notes from that day documented that staff heard an audible pop from both shoulders while assisting the resident and that the resident complained of pain. The physician was notified, x-rays of both upper extremities were ordered, and the resident was transferred to a local emergency room at the family’s request. Facility x-rays and hospital records confirmed acute fractures of the left clavicle and right humerus, described in the hospital record as an acute mildly displaced left distal clavicular fracture and an acute mildly displaced fracture of the right proximal humeral diaphysis. The facility’s incident report later documented that the LPN and CNA did not utilize a mechanical lift during the transfer from wheelchair to bed, and the administrator confirmed through interviews and review of camera footage that the transfer had been performed without the mechanical lift, contrary to the resident’s assessed needs and care plan. Initially, the resident, the LPN, and the CNA all reported that the injury occurred while staff were assisting the resident with a change of clothing. The hospital record also reflected the resident’s report that the injury occurred while staff were assisting her with changing clothes while she was in the mechanical lift. However, during the facility’s subsequent investigation, the administrator reviewed camera footage showing the mechanical lift being brought into and then removed from the room within a short period of time, and questioned whether that time frame was sufficient to complete a lift transfer. Both the LPN and CNA acknowledged that it was not enough time and ultimately admitted that the lift had not been used and that the injury occurred during a manual transfer from wheelchair to bed, not during clothing change. This sequence of actions and inactions—specifically, the decision to disregard the care-planned mechanical lift transfer and instead perform a manual transfer—led directly to the resident’s bilateral upper extremity fractures and constituted the cited deficiency.
Unauthorized Disclosure of Resident Medical Information to Outside Provider
Penalty
Summary
The facility failed to maintain residents' right to confidentiality of their medical records when a staff member in Social Services transmitted resident information to a contracted outside provider without obtaining consent. Review of the facility’s Resident Rights and Dignity policy, revised 03/07/2011, showed the facility was to safeguard all resident records and handle release of information in a manner that protected resident rights. Contrary to this policy, review of an email dated 10/15/2025 from the Social Services staff member to a contracted provider showed that face sheets for multiple residents were attached. These face sheets contained residents’ names, dates of birth, Social Security numbers, admit dates, Medicare/Medicaid numbers, drug allergies, care providers, pharmacy names, emergency contacts, diagnoses, and advance directive information. Further review of another email dated 03/20/2026 from the same Social Services staff member to the contracted provider showed that a facility census for a specific date was sent, which included information on all 80 residents in the facility. The census listed each resident’s room number, name, date of birth, status in the facility, primary payer source, and room rate designation. In interviews, the Social Services staff member stated that every month to every quarter she sent a daily census to the contracted provider so they could identify residents not receiving their services and then approach those residents about services. When surveyors requested evidence of resident consent for release of medical records to this provider, the Social Services staff member and the Chief Operating Officer both confirmed that the facility had no documentation of consent obtained prior to releasing the residents’ information, and acknowledged that the information had been sent on at least two occasions.
Incorrect Enteral Feeding Formula Administered Contrary to Physician Order
Penalty
Summary
The facility failed to ensure a resident received the correct enteral feeding formula as ordered by the physician. Review of the resident’s April 2026 physician orders showed an order for Glucerna 1.2 to be administered at 50 ml/hour for 12 hours per day, with an increase to 60 ml/hour for 21 hours per day if tolerated. During observation on 04/21/2026 at 1:20 PM, the resident was noted to be receiving Isosource at a rate of 60 ml/hour instead of the ordered Glucerna 1.2. In a subsequent interview and observation at 1:31 PM, an LPN confirmed that Isosource was being administered at 60 ml/hour and acknowledged that this was the wrong enteral feeding type compared to the physician’s order for Glucerna 1.2. Later, the DON stated that the LPN should have verified the physician’s order for the resident’s enteral feeding prior to administration. This deficiency centers on the administration of an incorrect enteral feeding product despite a clear physician order specifying a different formula and rate, as confirmed through record review, direct observation of the feeding in progress, and staff interviews.
Medication Error Rate Exceeded Due to Late Administration of Scheduled Medications
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5 percent, as required, resulting in a calculated error rate of 29 percent during a medication pass for one resident. Facility policy stated that medications were to be administered within one hour of their prescribed time unless otherwise specified. Review of the resident’s April 2026 physician orders and eMAR showed multiple medications scheduled for 9:00 AM, including aspirin EC 81 mg daily, calcium carbonate 600 mg twice daily, ascorbic acid 500 mg daily, carvedilol 25 mg twice daily, furosemide 20 mg daily, potassium chloride ER 20 mEq daily, thiamin HCl 100 mg daily, timolol maleate ophthalmic 0.5% one drop to both eyes daily, and docusate sodium 100 mg daily. On the observed medication pass, the LPN administered all of these medications at 11:24 AM, outside the facility’s accepted administration window of one hour before to one hour after the scheduled 9:00 AM time. The LPN acknowledged that the medications were scheduled for 9:00 AM and should have been given between 8:00 AM and 10:00 AM. The DON confirmed that medications were to be administered within that one-hour-before to one-hour-after window and that the LPN should not have administered the medications at 11:24 AM without a physician order to change the medication times. Based on 31 opportunities for error and 9 errors identified, surveyors calculated a medication error rate of 29 percent.
Failure to Restart and Administer Physician-Ordered Medications After Hospital Readmission
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when nursing staff did not administer multiple physician-ordered medications following the resident’s readmission from the hospital. The resident was readmitted on 03/09/2026, and the handwritten physician order sheet dated that day directed that the resident receive acetaminophen 500 mg, 2 tablets every 6 hours as needed; Eliquis 2.5 mg, 1 tablet twice daily; buspirone 5 mg, 1 tablet three times daily; losartan 25 mg, 2 tablets daily; mirtazapine 7.5 mg, 1 tablet nightly; quetiapine 25 mg, 2 tablets nightly; senna 8.6 mg, 1 tablet twice daily; and Vistaril every 8 hours as needed. Review of the March 2026 eMAR showed no evidence that any of these ordered medications were administered between 03/09/2026 and 03/19/2026. In interviews, the DON stated that nurses were responsible for clarifying orders with the physician when a resident returned from the hospital, and a clinical support LPN confirmed that the resident’s medications should have been restarted and administered per the written orders on 03/09/2026 but were not.
Failure to Document Enteral Feeding Administration in eMAR
Penalty
Summary
The facility failed to ensure nursing staff documented the administration of ordered enteral feeding in accordance with professional standards for one resident receiving tube feedings. The resident had physician orders in April 2026 for Glucerna 1.2 at 50 ml/hour for 12 hours daily, with instructions to increase to 60 ml/hour for 21 hours daily if tolerated. Review of the resident’s April 2026 electronic medication administration record (eMAR) showed no documentation that Glucerna 1.2 was administered at 60 ml/hour for 21 hours on 04/21/2026 and 04/22/2026. However, surveyor observations on 04/21/2026 at 9:40 AM and on 04/22/2026 at 2:41 PM confirmed the resident was receiving Glucerna 1.2 at 60 ml/hour at those times. In an interview, the DON stated that when nurses administered the Glucerna 1.2, they should have documented the administration in the medication administration record. This lack of documentation of enteral feeding administration, despite direct observation of the feeding being provided, constituted the deficiency in maintaining medical records in accordance with accepted professional standards.
Failure to Perform Hand Hygiene Between Glove Changes During Wound Care
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a treatment nurse failed to perform required hand hygiene during wound care for Resident #1. The facility’s “Using Gloves” policy, revised 03/10/2011, stated that employees were to wash hands after removing gloves and that gloves did not replace handwashing. Resident #1 had a physician’s order in April 2026 for treatment of a diabetic wound on the left second toe, including cleansing with normal saline or wound cleanser, patting dry, applying silver alginate to the wound bed, and covering with a clean dry dressing three times weekly and as needed. During an observation on 04/21/2026 at 10:43 AM, the treatment nurse removed the existing dressing, removed her gloves, did not perform hand hygiene, and then applied new gloves. She then cleaned the resident’s left second toe wound, again removed her gloves, did not perform hand hygiene, and applied new gloves before placing the calcium alginate and dry dressing. In an interview immediately afterward, the treatment nurse stated she had completed hand hygiene before and after the wound care but had not done so between glove changes because there was no hand sanitizer in the room and she did not wash her hands as an alternative. The DON later confirmed that the nurse should have performed hand hygiene between every glove change. This sequence of observations, interviews, and record review showed that the nurse’s actions during wound care did not follow the facility’s hand hygiene and glove-use policy, resulting in the cited infection control deficiency.
Failure to Provide Required Annual In-Service Training for CNA
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA), identified as S12CNA, received at least 12 hours of in-service training annually as required. Review of S12CNA’s personnel file showed that this CNA was hired on 03/23/2025 and did not have documentation demonstrating completion of the required 12 hours of annual in-service education, including topics such as dementia care and abuse prevention. During an interview on 04/23/2026 at 4:23 PM, the Chief Operations Officer (S1) confirmed that the facility had no documented evidence that S12CNA had completed the mandated 12 hours of in-service training for the year.
Hot Coffee Served Without Temperature Monitoring
Penalty
Summary
The facility failed to have a system in place to ensure coffee was served at a safe temperature to prevent scalds and burns for one resident. The report states that 112 residents consumed meals and beverages prepared by the facility's kitchen. A review of the facility policy on hot liquids stated that residents with risk factors for injury from hot liquids should have precautions implemented, and that food service staff should monitor and maintain food temperatures that comply with food safety requirements but do not exceed recommended temperatures to prevent scalding. Resident #79 was involved in an incident on 02/24/2026 when the resident spilled coffee while in bed and sustained redness to the left arm and buttocks area. The incident report stated that the resident was trying to get coffee from the table when the cup fell, and that a non-spill cup would be given to the resident. During an interview, the resident stated she had burns on her left forearm and left hip after spilling hot coffee from a Styrofoam cup with a lid while placing it on the over-bed table. The dietary manager stated that staff did not check coffee temperatures before sending coffee to the floor, and a brewed canister of coffee was observed at 158.1 degrees F.
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