Courtyard Of Natchitoches

Based on observation, interview, and record review, the facility failed to honor and accommodate food preferences for 2 (Resident #5 and Resident #29) of the 7 residents reviewed for dining. The deficient practice had the potential to affect 87 residents who consumed meals from the kitchen.Review of facility policy titled Promoting/Maintaining Resident Self-Determination dated 04/2025 read in part. It is the practice of this facility to protect and promote resident rights by facilitating resident self-determination through support of resident choice. The facility will ensure that each resident has the opportunity to exercise his/her autonomy regarding those things that are important in his/her life such as interest and preferences. 9. The facility will accommodate the resident preferences to the extent possible and as agreed upon by the resident sponsor and physician. Resident #5Review of Resident #5's electronic medical record revealed an initial admission date of 06/09/2016 with diagnoses that included, in part, Type 2 Diabetes Mellitus without complications, Anxiety Disorder, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure the privacy and confidentiality of medical records for 1 (Resident R5) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident R5) sampled residents.Review of the facility's policy entitled Sanctions for (facility name) to Comply to HIPAA Privacy Standards revised 06/2016 revealed, in part.all workforce members are required to adhere to the HIPPA Privacy Standards and prevent unauthorized disclosure of Protected Health Information (PHI). Workforce members will protect health information from unauthorized disclosure. Leaving PHI in public areas is a violation of HIPPA Privacy Standards.Observation of Hall B on 09/16/2025 at 8:55 a.m. revealed Cart X was unattended, with the electronic medical record (EMR) screen open and Resident R5's PHI visible. The surveyor remained with Cart X until a staff member approached Cart X. The staff member identified herself as S7LPN.Interview with S7LPN on 09/16/2025 at 8:57 a.m. revealed she left Cart X unattended on Hall B, with Resident R5's PHI visible…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews, the facility failed to ensure drugs and biologicals were stored in accordance with currently accepted professional principles. The facility failed to ensure Cart X was locked and medications were stored in a safe and secure manner.Review of the facility's policy entitled Medication Storage revised 03/2025 revealed, in part.It is the policy of this facility to ensure all medications housed on our premises will be stored to ensure security. All drugs and biologicals will be stored in locked compartments. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.Observation of Hall B on 09/16/2025 at 8:55 a.m. revealed Cart X was unattended, and unlocked, with 3 of 8 drawers pulled open. This surveyor remained with Cart X until a staff member approached Cart X. The staff member identified herself as S7LPN.Interview with S7LPN on 09/16/2025 at 8:57 a.m. revealed Cart X was unattended and unlocked on Hall B, with 3 drawers pulled open. S7LPN…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews, and record reviews, the facility failed to maintain accurate medical records in accordance with accepted professional standards and practices. The facility failed to ensure documentation on the Medication Administration Report (MAR) was accurate for 2 (Resident #2 and Resident #4) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident R5) sampled residents. Review of the facility's policy entitled Administration of Medicines revised 03/2025 revealed, in part.the facility is to maintain a record of all medications administered. Staff is to time and initial each medication on the MAR after the medication is given.Review of the facility's policy entitled Medication Administration Electronic Documentation revised 03/2025 revealed, in part.Every resident has an electronic Medication Administration Record (E-MAR) for the purpose of proper administration and recording of all medications. The E-MAR is a permanent, legal document and is a part of the Electronic Health Record. Resident #2Review of Resident #2's medical record revealed an initial admission…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure a resident was free from misappropriation of property/funds for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents investigated for misappropriation. The facility failed to prevent misappropriation of Resident #1's funds by S7 Rehab Tech. Findings: Review of a facility policy on 06/09/2025 at 9:18 a.m. titled, Abuse Protection and Prevention Program with a revision date of 02/2013 revealed the following in part .Our residents have the right to be free from abuse, neglect and misappropriation of resident property. Misappropriation of property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. Review of Resident #1's medical record revealed a re-entry admission date of 05/07/2024, with diagnoses that included in part . Fusion of Spine of the Cervical Region, Seizures, Quadriplegia, and Depression. Review of Resident #1's Quarterly MDS with an ARD of 04/23/2025 revealed a BIMS score…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure an investigation of an allegation of misappropriation of resident property/funds was thoroughly investigated for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents reviewed for misappropriation. Findings: Review of a facility policy on 06/09/2025 at 9:18 a.m. titled, Abuse Protection and Prevention Program with a revision date of 02/2013 revealed the following in part . Our residents have the right to be free from abuse, neglect and misappropriation of resident property. D. Timely and thorough investigations of all reports and allegations of abuse. Misappropriation of property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. 10. Upon receiving information concerning a report of abuse, the director of nursing will designate an associate to monitor the resident's emotions concerning the incident as well as the resident's reactions to his/her involvement in the investigation to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to ensure residents were free from physical restraints imposed for the purpose of discipline or convenience for 2 (#1, #3) of 3 (#1, #2, #3) residents reviewed for restraints. The facility failed to ensure: 1. A physician's order was obtained, a consent was signed and a risk assessment was completed for a Geri-chair for Resident #1, 2. A physician's order was obtained, a consent was signed and a risk assessment was completed for a pommel cushion for Resident #3, and 3. A restraint policy was developed. Findings: Review of the facility's policy and procedures failed to reveal a policy for restraints and bed rails. Resident #1 Review of Resident #1's medical records revealed an admit date of 01/16/2025 with the following diagnoses, including in part: infection and inflammatory reaction due to internal left knee prosthesis/subsequent encounter, chronic kidney disease stage 2 (mild), and chronic thromboembolic pulmonary hypertension. Review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews, the facility failed to: 1) ensure residents had a physician's order for side rails, 2) obtain informed consent from the resident or resident's representative for side rail use, and/or 3) assess residents for the risk of entrapment from bed rails and 4) ensure a policy was developed for the use of bed rails prior to the installation of bed rails for 3 (#1, #2, #3) of 3 (#1, #2, #3) residents reviewed for bed rails. Findings: Review of the facility's policy and procedures failed to reveal a policy for bed rails. Resident #1 Review of Resident #1's medical records revealed an admit date of 01/16/2025 with the following diagnoses, including in part: infection and inflammatory reaction due to internal left knee prosthesis/subsequent encounter, chronic kidney disease stage 2 (mild), and chronic thromboembolic pulmonary hypertension. Review of Resident #1's MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 10…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record reviews and interviews, the facility failed to ensure 1 (#1) out of 2 (#1, #2, #3) sampled residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Findings: Review of Facility's Wound Care Documentation (reviewed 01/2025) revealed: .Wound documentation on all other existing and/or new wounds will be made once a week in the resident care notes. Review of Facility's Staging of Pressure Wounds (revised 03/2013 and reviewed 02/2025) revealed: Purpose: To manage impaired skin integrity as it relates to pressure ulcers. Policy: II. Status and condition of pressure ulcers should be assessed upon admission, if pressure ulcer noted, weekly assessment by treatment nurse. Location, stage, type of wound, width, length, depth, exudate, odor, presence of necrotic or granulation tissue, and condition of surrounding skin should be documented. VIII. Chart in patient's record, weekly. Review of Facility's Wound Care Procedure for Major…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure all medical records regarding the resident's code status consistently reflected the resident's current wishes for 1 (#2) of 3 (#1, #2, and #3) sampled residents reviewed for advance directives. Findings: Review of the facility's policy titled, Advance Medical Directives with a review date of 01/2024 read in part: Section II. General: 3) Documentation that addresses advance directives must be placed in the patient's medical record; 6) The physician must inform the patient . and seek agreement on a mutually acceptable plan of care. Section III. A.) At the time of admission via the admitting department or the emergency department, the patient and/or significant other will be: 2) Asked by the hospital personnel if he/she has an AMD (Advanced Medical Directive) . this response will be documented in the medical record . Review of Resident #2's medical record revealed an admission date of 10/21/2024, with diagnoses that included in part . Cerebral Infarction, Urinary Tract Infection, Dysphagia, Aphasia, Essential (Primary)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a resident's change in condition was immediately reported for 1 (#1) of 3 (#1, #2, & #3) sampled residents, as evidenced by S4CNA and S5CNA failing to timely notify the nurse when Resident #1's leg made an audible popping sound while being repositioned by staff. Findings: On 12/03/2024, a review of the facility's policy titled Accidents and Incidents last reviewed on 01/2024 revealed in part .Any employee witnessing an accident or incident involving a resident, employee, or visitor, must report such occurrence to the charge nurse as soon as possible regardless of how minor it may be, to include the following: a. Any resident fall, accident or injury . e. Any other unusual or unexpected event involving a resident. Review of Resident #1's medical record revealed an admit date of 03/10/2017 with diagnoses that included: Displaced Spiral Fracture of Shaft of Left Femur, Atrial Fibrillation, Unspecified Dementia, and Osteoporosis. Review of Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to use a mechanical lift, as determined necessary by the resident's person centered plan of care, during a transfer from bed to wheelchair for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. Findings: On 12/03/2024, a review of the facility's policy titled Proper Transferring of Non-Weight Bearing Residents last reviewed on 01/2024 revealed in part . In order to properly transfer any non-weight bearing resident (example: from bed to chair, chair to bed, or to whirlpool, etc.) a lift is to be utilized. As a matter of precaution, two people are required in order to safely move the resident. Review of Resident #1's medical record revealed an admit date of 03/10/2017 with diagnoses that include Displaced Spiral Fracture of Shaft of Left Femur, Atrial Fibrillation, Unspecified Dementia, and Osteoporosis. Review of Resident #1's Quarterly MDS with an ARD of 09/04/2024 revealed a BIMS score of 3, which indicated severe cognitive impairment. Review of the MDS revealed Resident #1 required…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to keep the residents' equipment in good repair. The facility failed to repair wheelchair arm rest cushions for 5 (#19, #40, #47, #49, #67) out of 44 total sampled residents. Findings: Observation of Resident #19 sitting in wheelchair on 09/23/2024 at 10:15 a.m. revealed both wheelchair arm cushions were peeling and in disrepair. Observation of Resident #40 on 09/23/2024 at 11:36 a.m. revealed the resident's wheelchair arm cushions in disrepair. Resident # 40's son stated the wheelchair had been like that for about 6-8 months. Observation of Resident #49's wheelchair on 09/23/2024 at 11:38 a.m. revealed Resident #49's arm chair cushions in disrepair. Observation of Resident #47 on 09/23/2024 at 12:06 p.m. sitting in wheelchair revealed Resident #47's arm cushions of wheelchair in disrepair. Observation of Resident #67's wheelchair on 09/23/2024 at 12:15 p.m. revealed a crack in one arm of Resident # 47's wheelchair cushion. Environmental rounds observed with S2 DON on 09/25/2024 at 2:45 p.m. revealed Residents…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to meet the nutritional needs of residents in accordance with established national guidelines. The facility failed to follow the menu in regard to portion size to ensure nutritional adequacy of the meal for 10 ( #10, #25, #34, #41, #51, #52, #78, #85, #92, and #295) out of 13 (#2, #10, #25, #34, #35, #41, #50, #51, #52, #78, #85, #92, and #295) residents who received pureed meals served by the facility kitchen. Findings: Review of the facility's approved Patient Menu revealed the facility was on week 4, cycle day 23. Lunch menu consisted of: Chicken Spaghetti, [NAME] Beans, Pineapple Tidbits, Honey Wheat Roll, and Unsweetened Iced Tea. Serving size for pureed meal read as follows: Pureed Chicken Spaghetti- ¾ cup (6oz) Ladle/Spoodle. Pureed [NAME] Beans- ½ cup (4oz) Ladle/Spoodle. Pureed Peaches- ½ cup (4oz) Ladle/Spoodle. Observation on 09/23/2024 at 10:45 a.m. of the lunch meal service revealed S7 Kitchen Lead obtained 4oz Ladles/Scoops to serve meal food items. Interview at time of observation with S7 Kitchen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) to a resident or his/her responsible party prior to the discontinuation of Medicare Part A services for 3 (#33, #44, & #197) of 3 residents reviewed for Beneficiary Notification. Findings: Review of the SNF Beneficiary Review forms completed by the facility for Residents #33, #44, and #197 revealed a NOMNC, Form CMS-10123 was not issued prior to their discharge from Medicare Part A services. In an interview at 9:34 a.m. on 09/24/2024, S4 SW (Social Worker) stated she did not issue a NOMNC/Form CMS-10123 to Residents #33, #44, and #197 prior to their discharge from Part A services. S4 SW confirmed the three residents all had benefit days remaining. S4 SW stated she was not aware the NOMNC/Form CMS-10123 needed to be issued to them.

Based on observation, record review, and interview the facility failed to develop the resident's comprehensive plan of care for 1 (#37) of 44 sampled residents by failing to develop a Hospice Care Plan for Resident #37. Findings: Review of Resident #37's clinical record revealed an admit date of 09/13/2016, with a Hospice admit date of: 07/22/2024. Resident #37's diagnoses included malignant neoplasm of unspecified lower limb, end stage renal disease, heart disease; cerebral infarction; dependence on renal dialysis; age-related physical debility; hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting unspecified side. Review of Resident #37's Significant Change MDS with an ARD of 07/31/2024, revealed a BIMS score that was not assessed because the resident was rarely or never understood. Resident #37 had impairment on both sides for lower and upper extremities; used a wheelchair. Resident #37 was dependent for eating, oral hygiene, toileting hygiene; showering/ bathing, upper body and lower body dressing and personal hygiene. Review of Resident #37's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to revise the care plan to include new fall interventions after a resident fell attempting to get in bed for 1 (#54) of 3 (#13, #54 and #59) resident's care plans reviewed. Findings: Review of Resident #54's medical record revealed he was admitted to the facility on [DATE]. Resident #54 had diagnoses that included in part . Dizziness and Giddiness, Chronic Obstructive Pulmonary Disease with Acute Exacerbation, Chronic Kidney Disease, Anemia in Chronic Kidney Disease, and Pain. Review of Resident #54's Quarterly MDS with ARD of 08/21/2024, revealed a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. Review of the MDS revealed Resident #54 used a wheelchair for mobility. Review of Resident #54's current comprehensive care plan with a target date of 11/13/2024, revealed Resident #54 is at moderate risk for falls related to gait and/or balance problems. The care plan included in part .Last fall 1/31/24 without…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview the facility failed to ensure services were provided to meet professional standards of practice for 1 (#28) of 44 sampled residents. The facility failed to ensure physician's orders for Resident #28 were followed. Findings: Review of resident #28's medical record revealed an admit date of 12/20/2022 with diagnoses that included in part .Osteoporosis, Unspecified Fracture of Right Wrist and Hand, Anemia, and Pain. Review of Resident #28's Quarterly MDS with an ARD of 06/26/2024 revealed a BIMS score of 15, which indicated the resident was cognitively intact. Review of Resident #28's Progress note dated 09/20/2024 by S16 MD revealed in part . Assessment Plan: 1. Back pain/Osteoarthritis: Patient wants to try to increase Duloxetine (Cymbalta) to help with pains. Review of Resident #28's medical record revealed a telephone order dated 09/20/2024 which read: Change Duloxetine to 60mg daily. The order was signed by S16 MD and S15 LPN on 09/20/2024. Review of Resident #28's MAR for September 2024 revealed the resident was not receiving Duloxetine 60 mg…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that a resident maintained acceptable parameters of nutritional status for 2 (#11, #195) of 5 (#2, #11, #37, #77, & #195) residents reviewed for nutrition by failing to follow or implement registered dietitian's recommendations. Findings: Resident #11 Review of Resident #11's medical record revealed an admit date of 08/19/2022 with diagnoses that included .Chronic kidney disease, Stage 3, COPD, Chronic Non-pressure Ulcers of Lower Legs and Left Foot and Heart Failure. Review of Resident #11's Quarterly MDS with an ARD of 09/02/2024 revealed a BIMS score of 6, which indicated severe cognitive impairment. Resident #11 required set up assistance with eating. Review of Resident #11's medical record revealed the resident was care planned for a heart healthy, regular texture diet. Interventions included: Refer to Dietician as needed, provide diet as ordered, and monitor and record weight per orders and/or policy. Review of Resident #11's progress…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure that nurse aides are able to demonstrate competency in skills necessary to care for residents' needs, as identified through observation of delayed call light response for 1 (#67) of 44 sampled residents. The facility failed to ensure timely call light response for Resident #67. Findings: Review of Resident #67's clinical record revealed an admit date of 06/20/2024, with diagnoses which included weakness, Dementia in other diseases; Benign Prostatic Hyperplasia without lower urinary tract symptoms; urinary tract infection; and anemia. Review of Resident #67's Significant Change MDS with an ARD date of 07/22/2024, revealed a BIMS score of 10; moderately impaired. Resident #67 uses a walker and wheelchair. Resident #67 required setup or clean up assistance with eating; Supervision or touching assistance with oral hygiene; substantial/maximal assist with toileting hygiene, shower/bathing; and partial moderate assist with personal hygiene. Resident #67 required Partial/Moderate assist with chair/bed to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to honor and accommodate resident food allergies, intolerances, and preferences by failing to ensure 1 Resident (#2) was not provided a supplement with milk containing products. This deficient practice had the potential to affect the 94 Residents that resided at the facility. Findings: Record Review of Resident #2's electronic medical record revealed an admit date of 04/03/2024. Resident #2 had diagnoses that included in part . Cough, Unspecified Bacterial Pneumonia, Dysphagia, Contracture of Muscle-Unspecified Site, and Cerebral Palsy. Record Review of Resident #2's Quarterly MDS with ARD of 06/19/2024 revealed Resident had impaired memory and severely impaired cognitive skills. Resident #2 was dependent on staff for all ADL's. Record Review of Resident #2's Comprehensive Person Centered Care Plan with initiated date of 07/09/2024 revealed in part . Food intolerance. Lactose/Dairy products with intervention of: provide nondairy alternatives. Record Review of Resident #2's Current Physician Orders revealed in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety by failing to ensure refrigerated food items were covered, labeled, and stored with an open date after opening. This deficient practice had the potential to affect the 92 Residents that received meals served in the kitchen. Findings: Review of the facility policy titled Food Storage dated 01/2024 read in part . Food is stored immediately after receipt and maintained in a manner that prevents damage, spoilage, infestation, and bacterial contamination. Observation of kitchen on 09/23/2024 at 8:45 a.m. accompanied by S7 Kitchen Lead revealed there was an open block of cheese on the refrigerator shelf that was uncovered, open to air, and undated, and a cup of oranges that was uncovered, open to air, and undated. Interview on 09/24/2024 at the time of the observations accompanied by S7 Kitchen Lead, confirmed the above findings. S7 Kitchen Lead confirmed all opened food items should be covered and dated, but had not been.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to ensure a resident maintained acceptable parameters of nutritional and hydration status consistent with the resident's comprehensive assessment and plan of care, for 1 (#1) of 3 (#1, #2, & #3) sampled residents reviewed for hydration and nutrition. The facility failed to: 1. Ensure Resident #1 received nutritional supplements as ordered; 2. Ensure the RD's (Registered Dietician) dietary recommendation to increase Resident #1's calories and protein through a nutritional supplement was implemented; and 3. Ensure Resident #1's meal intake was documented for each meal, as care planned. Findings: Review of Resident #1's medical record revealed an admit date of 12/29/2008, with diagnoses that included in part .Cerebral Palsy, Unspecified Bacterial Pneumonia, Dysphagia, Contracture of muscle, Altered Mental Status, Convulsions, Dehydration, Weight Loss, and Pain. Review of Resident #1's Quarterly MDS with an ARD of 01/31/2024, revealed a BIMS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a resident who was unable to carry out ADLs received the necessary services to maintain good oral hygiene for 1 (#1) of 3 (#1, #2, & #3) sampled residents reviewed for ADLs. Findings: Review of Resident #1's medical record revealed an admit date of 12/29/2008 with diagnoses that included in part .Cerebral Palsy, Unspecified Bacterial Pneumonia, Dysphagia, Contracture of Muscle, Altered Mental Status, Convulsions, and Pain. Review of Resident #1's Quarterly MDS with an ARD of 01/31/2024 revealed a BIMS was not conducted because the resident was rarely or never understood. Review of the MDS revealed Resident #1 required extensive assistance by two persons with bed mobility and transferring and was totally dependent on one person with eating and toilet use. Review of the MDS revealed Resident #1 was dependent with oral hygiene, the helper does all of the effort, and the resident does none of the effort to complete the activity. Review of Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to protect the resident's right to be free from verbal abuse by staff for 2 (#2, #4) of 4 (#1, #2, #3, & #4) residents reviewed for abuse. Findings: Review of the facility's Abuse Reporting Protocol revealed in part . Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm or pain or mental anguish, or deprivation by an individual, including a caretaker, of goods, or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Review of the facility's policy titled Abuse Identification, Protection, and Reporting revealed in part . 5. b. Verbal abuse is defined as any use of oral, written or gestured language that includes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability. Resident #2 Review of Resident #2's medical record revealed an admit date of 05/06/2022 with diagnoses that included…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure there was sufficient staff with appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to ensure that resident calls for help were answered timely, and that the need was met when a resident called for help. This deficient practice had the potential to affect all 97 residents residing in the facility. Findings: An interview on 08/14/2023 at 9:55 a.m. with Resident #90 revealed she had to wait for over an hour at times for help after using the call bell. Resident #90 stated weekend staff call in often and she felt the facility is short staffed at times. Resident #90 stated she had notified management about the call light issues in the past. A review of Resident #90's quarterly MDS dated [DATE] revealed Resident #90 had a BIMS score of 15, which indicated the resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

FACILITY Based on observation and interview, the facility failed to ensure medications were stored under proper temperature controls for 2 (Medication Refrigerator A, Medication Refrigerator B) of 2 medication refrigerators observed out of a total of 3 medication refrigerators. Findings: In an observation on 08/16/2023 at 7:45 a.m. of Medication Refrigerator A with S4 RN Charge Nurse revealed the refrigerator contained resident medications. Observation of Medication Refrigerator A's temperature log at that time revealed the temperatures were not monitored for 7 days in August of 2023. In an interview at that time, S4 RN Charge Nurse stated the night nurses are supposed to monitor the refrigerator temperatures each night and confirmed they had not. In an observation on 08/16/2023 at 7:50 a.m. of Medication Refrigerator B with S4 RN Charge Nurse revealed the refrigerator contained multiple resident medications. Observation and interview with S4 RN Charge Nurse at that time of Medication Refrigerator B's temperature log revealed the temperatures were not monitored for 7 days in August…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure the resident's right to formulate an advanced directive was properly reflected in the resident's record for 2 (#19, #57) of 3 (#19, #52,#57) residents reviewed for advance directives. The facility failed to ensure all records regarding code status consistently reflected the resident's wishes. Findings: Resident #19 Review of Resident #19's medical record revealed an admit date of [DATE] with diagnoses which included: Chronic Venous Hypertension, Chronic Obstructive Pulmonary Disease, Benign Prostatic Hyperplasia, Heart Failure, Chronic Kidney Disease, Myopathy, and Essential Hypertension. Review of Resident #19's 08/2023 Physician's orders revealed an order dated [DATE] read Do Not Resuscitate. Review of Resident #19's Face Sheet listed a resuscitation status of Full Code- Cardiopulmonary Resuscitation (CPR). Review of Resident #19's headboard on the Electronic Health Record (EHR) revealed a resuscitation status of CPR. An Interview on [DATE] at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to consult with the resident's physician timely when there was a change in the resident's physical condition after a recent fall, for 1 (#12) of 4 (#12, #18, #33, #93) residents reviewed for accidents. Findings: Review of the facility's policy titled Notification of Physician/Family revealed in part . Courtyard of Natchitoches will in effect notify the resident's physician/resident's legal representative when the following occurs: 1. An accident involving the resident which results in injury and has the potential for requiring physician intervention. 2. A significant change in the resident's physical, mental, or psychosocial status Review of Resident #12's medical record revealed an admit date of 04/27/2022, with diagnoses that included in part . Abnormal weight loss, Fracture of shaft of left femur, Anxiety disorder, Major Depressive Disorder, and Alzheimer's disease. Review of Resident #12's Annual MDS with an ARD of 06/07/2023 revealed a BIMS score of 0, which indicated severe cognitive impairment. Review of the MDS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to make prompt efforts to document and resolve grievances for 1 (#84) of 1 resident reviewed for grievances. Findings: Review of the facility's policy titled Filing Grievances/Complaints revealed in part . Our facility will assist residents, their representatives (sponsors); other interested family members, or resident advocates in filing grievances or complaints when such requests are made. 1. Any resident, his/her representative (sponsor), family member, or appointed advocate may file a grievance or complaint concerning treatment, medical care, behavior of other residents, staff members, theft of property, etc., without fear of threat or reprisal in any form. 2. . 3. Grievances and/or complaints may be submitted orally or in writing. A grievance log will be kept in the office of the Director of Nursing and all grievances will be recorded in this log. A brief notation of the intervention and the follow-up will also be recorded. 4. The Administrator and the Director of Nursing have the responsibility of grievance and/or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide care and services that met professional standards of quality, by failing to promptly assess a resident after she fell and hit her head, for 1 resident (#18) in a total sample of 25 residents. Findings: The Facility's Policy titled Fall Policy/Risk Assessment read in part .Post-fall management: (2) the nurse will notify the physician promptly and note and implement diagnostic or treatment interventions ordered. Review of Resident #18's medical record revealed she was admitted to the facility on [DATE] with diagnoses which included: Tremor unspecified, Repeated Falls, Pain in left foot, Chronic Migraine, Retention of Urine, Pain in the right shoulder and Subdural Hematoma. Review of Resident #18's DPE MDS with an ARD of 07/25/2023 revealed a BIMS score of 14 (indicating intact cognition). The MDS revealed Resident #18 was coded as requiring one person physical assistance for transfers, personal hygiene and bed mobility; and extensive assistance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews and record review, the Facility failed to ensure that Residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene. The Facility failed to provide trimmed fingernails to dependent Residents for 1 (Resident #67) of 5 (Resident #67, Resident #1, Resident #39, Resident #21 and Resident #84) Residents sampled for ADL's. Total sample size was 24. Findings: Review of Resident #67's clinical record revealed an admission date of 11/02/2021 with diagnoses which included: Parkinson's Disease, Dementia and repeated falls. Review of Resident #67's Quarterly MDS with an ARD of 07/26/2023 revealed Resident #67 had a BIMS score of 11 (indicating moderately impaired cognition), required one person physical assistance for bathing and one person extensive assistance for personal hygiene. Review of Resident #67's care plan with a review date of 10/26/2023 revealed a need for grooming and personal hygiene and the need for staff to assist with approaches to monitor and clean…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review the facility failed to provide respiratory care consistent with professional standards for 1 (Resident #63) of 1 Residents reviewed for respiratory care. The facility failed to ensure Resident #63's respiratory equipment was properly changed, labeled and stored. Total sample size was 24. Findings: Facility's Policy on Oxygen Administration read in part . change nebulizer tubing and delivery device on a weekly basis. Review of Resident #63's medical record revealed a diagnoses of Shortness of Breath and Resident #63 received Budesonide 0.25 MG/2 ML suspension one vial per nebulizer two times a day (breathing treatment). Observation and interview on 08/14/2023 at 9:30 a.m. revealed a nebulizer mouth piece lying in Resident #63's bedside drawer in a cup, uncovered and undated. Resident #63 stated she used the nebulizer daily. Observation on 08/15/2023 at 8:25 a.m. revealed a nebulizer mouth piece lying in Resident #63's bedside drawer in a cup, uncovered and undated. Observation and interview on 08/15/2023 at 9:50 a.m. accompanied by S3…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure residents who use psychotropic drugs received gradual dose reductions for 1 (#12) of 5 (#12, #18, #47, #84, #93) residents reviewed for unnecessary medications. Findings: Review of Resident #12's medical record revealed an admit date of 04/27/2022 with diagnoses that included in part .Abnormal weight loss, Fracture of shaft of left femur, Anxiety disorder, Major Depressive Disorder, and Alzheimer's disease. Review of Resident #12's physician' orders revealed the following: 08/10/2023: Norco 5-325 mg tablet, one tablet by mouth every 6 hours as needed 07/12/2023: Paroxetine HCL 40 mg by mouth every day 07/12/2023: Quetiapine Fumarate 25 mg by mouth daily 07/12/2023: Quetiapine Fumarate 50 mg by mouth at bedtime 07/12/2023: Trazodone 50 mg by mouth every night at bedtime 07/12/2023: Buspar 10 mg by mouth three times a day Review of Resident #12's medical record revealed the resident was care planned for the use of psychotropic drugs. Review of the care plan revealed interventions that included pharmacy consultant to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure each resident was free of significant medication errors for 1 (#86) of 4 residents observed during medication administration pass. The facility failed to ensure medication administered to Resident #86 was the correct medication as ordered by the physician. The facility had a total census of 97 residents residing in the facility. Findings: Review of the facility's policy titled Administration of Medicines revealed in part . Procedure: B. Administration of medication (5 rights) 1. Check physician's order for medication name, dosage, route, and frequency or time ordered. 2. Check medication label on unit dose pack or medication box for correct name and dosage. 3. Check MAR for time last dose given. 4. Identify patient before administering medication. During an observation of medication administration pass on 08/15/2023 at 8:00 a.m., S5 LPN administered Abiraterone (a hormone based chemotherapy used to treat prostate cancer) 250mg by mouth to Resident #86. Review of Resident #86's medical record revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.