Natchitoches Community Care Center

F-F692

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 22 195405 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 195405 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Natchitoches Community Care Center 781 Highway 494 Natchitoches, LA 71457

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 Review of the facility's policy titled, Medication Orders (Revised November 2014) revealed the following, in part: The purpose of this procedure is to establish uniform guidelines in the receiving and recording of Level of Harm - Immediate medication orders. jeopardy to resident health or safety 2. A current of orders must be maintained in the clinical record for each resident.

Residents Affected - Some Review of the facility's Info: Orders Communication Methods Explained (Updated January 31, 2024) revealed the following, in part: When adding a new order, users may select any of the following communication methods:

Phone-means the physician called on the phone and communicated an order to the user and it will pend signature.

Verbal-means the physician was present and verbally communicated an order to the user and it will pend signature.

Prescriber Written-means the physician wrote the order on a prescription pad and signed it, then handed it to

the user. There is no electronic signature trail of a prescriber written order. It is assumed the facility scanned

the hard copy with a signature on it.

Review of the facility's policy titled, Dietician (Revised October 2017) revealed the following, in part:

1. A qualified Dietician or other clinically qualified nutrition professional will help oversee food and nutritional services provided to the residents .

9. Our facility's Dietician is responsible for, but not necessarily limited to: a. Assessing nutritional needs of residents;

An observation and interview on 07/15/2024 at 10:26 a.m., revealed Resident #26 had a feeding pump infusing Diabetisource AC at 25 ml/hr., with the water flush set at 150 ml/6hrs. At that time, Resident #26 typed I'm hungry, I'm losing weight on her phone, then typed I'm getting one capful of feeding an hour.

During that time, Resident #26's daughter entered the room, and said her mother's tube feeding was not enough, and she had lost weight. Resident #26's daughter explained she was here today to talk to someone about her mother's tube feeding, and being hungry.

An interview on 07/16/2024 at 2:49 p.m. with S4 RN Clinical Coordinator, revealed she was responsible for carrying out dietary recommendations for Resident #26 on 07/05/2024. She indicated that Resident #26 was NPO with tube feedings, and getting bolus feedings of Diabetisource AC 250ml every 8 hours, and flush with 150ml of water every 8 hours. S4 RN Clinical Coordinator said that Resident #26 was assessed by S19 RD

on 07/04/2024, with recommendations to increase Diabetisource to 250ml carton every 6 hours, and flush with 150 ml of water every 6 hours, to increase Resident #26's caloric intake from 900Kcals to 1200Kcals. S4 RN Clinical Coordinator stated that on 07/05/2024, S7 ADON requested S19 RD give her the rate for continuous feeding on a pump because Resident #26 was staying long-term. She stated that the S19 RD sent an email on 7/05/2024 recommending Diabetisource AC at 45 ml/hr. S4 RN Clinical Coordinator stated that she called S10 NP and misread the recommendation to S10 NP. S4 RN Clinical Coordinator indicated that she entered the order as 25 ml/hr., instead of the recommended 45 ml/hr. S4 RN Clinical Coordinator stated I read the recommendation wrong.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 22 195405 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 195405 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Natchitoches Community Care Center 781 Highway 494 Natchitoches, LA 71457

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 During an observation and interview of Resident #26 on 07/16/2024 at 3:12 p.m., when asked how she was feeling today, Resident #26 typed I feel better. Before I was hungry and nauseous after taking medicine on Level of Harm - Immediate an empty stomach. Resident #26 then typed It felt like they were starving me and there was nothing I could jeopardy to resident health or do. I asked the nurse practitioner if I'm gonna die. safety

An interview on 07/16/2024 at 4:00 p.m. with S2 DON and S20 QI Nurse, revealed there was not one Residents Affected - Some standard facility process for obtaining, communicating and carrying out dietary recommendations. S2 DON stated the clinical coordinator for each house was responsible for obtaining and carrying out the dietary recommendations for their residents. S2 DON reported that the facility did not have a system for ensuring recommendations from the Registered Dietician were accurately communicated and accurately entered. S20 QI Nurse, stated We don't have one, but we will have one today.

An interview on 07/16/2024 at 4:55 p.m. with S7 ADON revealed that she was the direct supervisor for S4 RN Clinical Coordinator. S7 ADON reported she amended the order for Resident #26 on 07/09/2024 to reflect on the EMAR for the day and night shift. However, she reported that she did not review the rate of the infusion, and did not compare the order to the dietary recommendations. S7 ADON confirmed Resident #26 should have been getting 45 ml/hr of Diabetisource instead of the 25 ml/hr she received from 07/05/2024 through 07/15/2024.

A telephone interview on 07/17/2024 at 09:09 a.m. with S19 RD, revealed she made recommendations on 07/04/2024 to increase Resident #26's PEG feeding from Diabetisource 250ml every 8 hours to provide 900 Kcals, to Diabetisource 250ml every 6 hours to provide 1200 Kcals to increase her caloric intake. S19 RD reported that S7 ADON emailed her and requested a continuous rate recommendation on 07/05/2024. S19 RD reported she recommended Diabetisource AC to be infused at 45 ml/hr, and flushed with 150 ml of water every 6 hours, or flush at 25 ml/hr if Resident #26 was on a continuous infusion. S19 RD confirmed that Resident #26 should have received 45 ml/hr instead of 25 ml/hr, as recommended on 07/05/2024. S19 RD confirmed that receiving 25 ml/hr contributed to Resident #26's weight loss.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 22 195405 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 195405 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Natchitoches Community Care Center 781 Highway 494 Natchitoches, LA 71457

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 47004 potential for actual harm Based on observation and interview, the facility failed to maintain an infection prevention and control Residents Affected - Few program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections. The facility failed to ensure the following:

1. Staff performed proper hand hygiene during meal service.

2. Staff followed proper infection control practices during wound care.

This deficient practice had the potential to affect all residents who reside in the facility. The total resident census was 108.

Findings:

1. Observation on 07/15/2024 at 11:45 a.m. of meal service on X Hall dining room revealed S11 CNA assisted Resident #12, and Resident #33 whom were seated together at a table. Review of Resident #12's dietary card revealed she was a full assist with all meals. Review of Resident #33's dietary card revealed she required adaptive equipment: Sippy Cup, Weighted Utensils, and Divider Plate for every meal. Observation revealed S11 CNA assisted Resident #12, and Resident #33 while seated between each resident. S11 CNA physically touch assisted each resident, and did not perform hand hygiene between assisting the residents.

Interview on 07/15/2024 at 12:00 p.m. with S11 CNA revealed Resident #12 and Resident #33 were to be assisted by staff with meals. S11 CNA revealed she did not perform hand hygiene between assisting Resident #12 and Resident #33, but should have.

Interview on 07/15/2024 at 12:07 p.m. with S12 LPN confirmed staff were to perform hand hygiene between assisting residents during meal service.

2. Observation on 07/17/2024 at 10:04 a.m. revealed S9 Treatment Nurse performed wound care on Resident #19 while S13 Treatment Nurse assisted. S9 Treatment Nurse and S13 Treatment Nurse donned gown and gloves as Resident #19 required Enhanced Barrier Precautions. Wound care supplies were set up

on a bedside table next to Resident #19's bed. The treatment cart remained parked on X Hall, outside of Resident #19's room door. S9 Treatment Nurse performed wound care and requested S13 Treatment Nurse obtain cal zinc ointment from the treatment cart on X Hall. S13 Treatment Nurse then exited Resident #19's room and entered hallway without doffing gown and gloves that were used during high contact resident care.

Interview on 07/17/2024 at 10:20 a.m. with S13 Treatment Nurse confirmed she should have removed gown and gloves prior to exiting Resident #19's room to gather supplies from the treatment cart on X Hall that contained clean supplies.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 22 195405