Onyx Care of Natchitoches

Inspectors wroteBased on record review and interviews, the facility failed to act promptly upon the grievances voiced by residents during monthly Resident Council meetings.

Inspectors wroteBased on observations and interviews, the facility failed to ensure services were provided by the facility to meet quality professional standards. The facility failed to:ensure scheduled medications were administered timely for 1(Resident #14) resident; andfollow physician orders for Resident #40.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services that assured accurate disposition and/or administration of medications to meet the needs of each resident. The facility failed to: Ensure an accurate account for controlled medications was completed at the start of shift and time of administering narcotics on 1 (Cart A) of 4 medication/treatment carts for Resident #62; and Ensure proper nursing procedures for wasting of controlled substances were completed when Resident #46 and Resident #64's controlled medications were not administered.

Inspectors wroteBased on observation and interview, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with current accepted professional principles. This deficient practice has the potential to affect all 62 residents residing in the facility. The facility failed to ensure expired treatment supplies were not available for administration to residents in 1 (Cart C) of 3 medication/treatment carts.

Inspectors wroteBased on observation, interview and record review, the facility failed to administer its resources efficiently and effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This deficient practice had the potential to effect all 62 residents who resided in the facility. The facility failed to ensure the monthly Pharmacy Consultant Reports were utilized, reviewed, and/or addressed as it related narcotic medication reconciliation and documentation.

Inspectors wroteBased on interview and record reviews the facility failed to ensure a resident's electronic Medication Administration Record (eMAR) was accurately documented for 4 (Resident #5, Resident #9, Resident #15, and Resident #34) residents. This deficient practice had the potential to effect all 62 residents in the facility.

Inspectors wroteBased on record review and interview the facility failed to notify the Ombudsman in writing of resident transfer/discharge for 1 (Resident #71) of 1 resident reviewed for transfer/discharge. The total sample size was 30.

Inspectors wroteBased on record review and interview, the facility failed to complete an annual performance review at least once every 12 months for 2 (S12 CNA and S13 CNA) of 5 CNA personnel records reviewed.

Inspectors wroteBased on observation and interview, the facility failed to ensure infection control measures were practiced providing a safe, sanitary environment and prevent the development and transmission of communicable diseases and infections by failing to ensure medical equipment was cleaned in between uses with multiple residents during medication administration. This had to potential to affect all 62 residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide a diet/supplements to meet the resident's needs for 3 (Resident #R1, Resident #R2 and Resident #2) of 9 sampled residents. The facility failed to:Provide supplements and providing feeding assistance with meals for Resident #R1; Provide feeding assistance for meals for Resident #R2; and Provide a meal tray and feeding assistance for Resident #2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received reasonable accommodation of needs for 1 (#R2) of 9 sampled residents. The facility failed to ensure Resident #R2 had an appropriate call light within reach to call for assistance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 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 incontinent care in a timely manner for 1 (#2) of 9 residents reviewed for ADL care.

Inspectors wroteBased on observation, record review, and interview the facility failed to provide care and services that meet professional standards of quality, by failing to: 1. Ensure Resident #7's Suprapubic Indwelling Catheter was changed monthly according to physician's orders; and 2. Input and follow physician wound care clinic orders for wound care for 1 (#7) of 7 sampled residents.3. Follow physician wound care orders for wound care for 1 (#6) of 7 sampled residents.

Inspectors wroteFindings:Review of Resident #8's Clinical Record revealed an admit date of 10/12/2022 with diagnoses which included: Other Muscle Spasm; Quadriplegia, C5-C7 Complete; and Other Chronic Pain. Review of Resident #9's Clinical Record revealed an admit date of 11/19/2025 with diagnoses which included: Contracture, Right Shoulder; Contracture, Right Elbow; Limitation of Activities due to Disability; Quadriplegia; Other Muscle Spasm; Contracture, Left Shoulder; Chronic Pain Syndrome; Age-Related Nuclear Cataract, Unspecified Eye; Myopia, Unspecified Eye, Primary Generalized (Osteo) Arthritis. Review of Resident #10's Clinical Record revealed an admit date of 12/26/2025 with diagnoses which included: Unspecified Dementia; Muscle Weakness (Generalized); Unspecified Lack of Coordination; Other Symbolic Dysfunctions; Dysphagia; (Idiopathic) Normal Pressure Hydrocephalus. [...]

Inspectors wroteFindings: A review of Resident #4's Quarterly MDS with an ARD date of 11/24/2025 revealed Resident #4 had a BIMS of 15 which indicated the resident was cognitively intact. In an interview with Resident #4 on 01/13/2026 at 9:25 a.m., he revealed he was unable to get his money out of his trust fund. He stated he had been asking S11 Administrative Assistant/Office Manager for it since October 28, 2025, and was repeatedly told tomorrow. In an interview with S11 Administrative Assistant/Office Manager on 01/13/2026 at 9:55 a.m., she revealed Resident #4 wanted money from his trust fund to reimburse his family for wheelchair parts and other purchases made in October 2025. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive person-centered care plan consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #7) resident of 7 sampled residents. The facility failed to develop and/or initiate a care plan for Resident #7's suprapubic indwelling catheter.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infection by failing to ensure staff followed proper infection control practices during wound care for 1 (#7) of 1 resident observed during wound care.

Inspectors wroteBased on observation, record review and interview the facility failed to provide care and services that met professional standards of quality by failing to ensure x-ray results were followed up on in a timely manner for 1 (#1) of 3 (#1, #2, #3) sampled residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to implement, monitor, and modify interventions, consistent with the resident's assessed needs and current professional standards of practice, to maintain acceptable parameters of nutritional status for 2 (Resident #3, and Resident #36) of 3 (Resident #3, Resident #14, and Resident #36) residents sampled for nutrition. The facility failed to ensure: 1. Meal intake was recorded for every meal for Resident #3 as care planned; 2. Resident #3 was assisted with all meals as care planned; 3. The MD/NP was notified when Resident #3 refused to eat, as care planned; 4. The MD/NP was notified of a severe weight loss for Resident #3; and 5. Failing to ensure a resident was provided a meal tray during lunchtime. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the Quality Assessment and Assurance (QAA) committee meetings included the required staff members for the facility's quarterly committee meetings. The facility failed to ensure the Infection Preventionist (IP) was in attendance at each quarterly committee meetings. This deficient practice had the potential to affect all 58 residents residing in the facility.

Inspectors wroteResident #23 Based on record review and interview, the facility failed to develop a comprehensive person-centered care plan to meet the resident's medical, nursing, and mental and psychosocial needs for 1 (#23) of 24 sampled residents. The facility failed to ensure Resident #23 was care planned for discharge planning.

Inspectors wroteBased on interviews, and record review, the facility failed to ensure all services provided met professional standards of quality. The facility failed to notify the physician of 3+ edema for 1 (#26) of 58 sampled residents.

Inspectors wroteResident #59 Based on record review, observation, and interview, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal hygiene for 1 (#59) of 1 resident reviewed for ADLs (Activities of Daily Living).

Inspectors wroteBased on interview and record review the facility failed to provide an ongoing activities program to support residents in their choice of activities based on comprehensive assessments, care plans and preferences for 3 (Resident #23, Resident #25, and Resident #41) of 24 sampled residents. The facility failed to ensure an activities program occurred on the weekend. This deficient practice has the potential to effect all 58 residents currently residing in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Medical Director was notified when a hospice resident had an accident resulting in injury and pain that could not be relieved for 1 (#1) of 3 (#1, #2, and #3) sampled residents. The facility waited 14 hours for hospice to come assess Resident #1 before sending the resident to the emergency room.

Inspectors wroteBased on record review and interview, the facility failed to ensure pain management was provided to residents who required such services, consistent with professional standards of practice, and the comprehensive care plan for 1 (#1) of 3 (#1, #2, and #3) sampled residents. The facility failed to ensure Resident #1, who reported pain after a fall, and displayed nonverbal indicators of pain, received pain medication as ordered to alleviate pain.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that each resident was treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 2 (#R1 and #R4) of 8 (#1, #2, #3, #4, #R1, #R2, #R3, and #R4) sampled residents. The facility failed to maintain privacy for residents by allowing the shower door to remain open during resident care.

Inspectors wroteBased on observation, record review, and interview the facility failed to provide care and services that met professional standards of quality by failing to ensure physician's orders were implemented as ordered. The facility failed to administer a medication (antibiotic) when ordered for 1 (#3) of 8 (#1, #2, #3, #4, #R1, #R2, #R3, and #R4) sampled residents.

Inspectors wroteBased on observation and interview the facility failed to dispose of garbage and refuse properly. The total facility census was 63 residents.

Inspectors wroteBased on observation and interview the facility failed to ensure a safe, functional and comfortable environment for residents. The facility failed to: 1. Repair a toilet base in Room A; and 2. Repair the shower room door on X hall.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and residents' person centered care plans for 6 (#3, #4, #5, #9, #10 and #12) of 13 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, and #13) sampled Residents. The facility failed to have a system in place to: 1. Notify the physician of a low critical Hemoglobin level for Resident #5 and failed to document bleeding monitoring for Resident #5 and Resident #12; 2. Obtain ordered weekly PT/INR levels for 2 (Resident #5 and Resident #12) of 2 residents receiving Coumadin, (an anticoagulant) therapy; 3. Ensure medications that included anticoagulant, analgesics, and antidiuretics were administered for Residents #5 and #9; 4. Obtain and/or monitor blood glucose levels as ordered for Resident #9; 5. [...]

Inspectors wroteBased on record review and interview, the facility failed to administer its resources effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 6 (#3, #5, #4, #9, #10 and #12) of 13 sampled residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12 and #13). The Facility failed to: 1. Ensure there was a system in place to monitor the completion of laboratory draws and timely communication of abnormal lab results to the provider; and 2. Follow and implement physician's orders for residents who required bleeding and glucose monitoring, routine labs, medication administration and catheterization. [...]

Inspectors wroteBased on record review, observation, and interview, the facility failed to provide a private space for the Resident Council Meeting held 10/07/2024 and failed to act promptly upon the grievances voiced by the residents during monthly resident council meetings. The deficient practice had the potential to affect a total of 66 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were provided with a diet specific for his special dietary needs and preferences. The facility failed to ensure that an artificial sugar sweetener was available for use for Resident #1 who required a diabetic precautions diet. The total facility census was 62 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident #1, who had been assessed to be at risk for elopement, received adequate supervision to prevent him from exiting the facility without staff knowledge, for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. This deficient practice resulted in an Immediate Jeopardy situation for Resident #1 on 05/13/2024 at 11:30 a.m., when Resident #1, (a moderately cognitively impaired resident who was identified as an elopement risk), asked S5 Agency Nurse to unlock the facility's front door so he could go see his wife, while holding a clear trash bag containing clothing items. S5 Agency nurse did not notify any other staff of Resident #1's exit seeking behavior. [...]

Inspectors wroteBased on interview on record review, the facility failed to administer its resources effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. The Administration failed to have an effective system in place to ensure Resident #1, who was assessed as being at risk for elopement, was adequately supervised to prevent him from exiting the front door of the facility unattended. This deficient practice resulted in an Immediate Jeopardy situation for Resident #1 on 05/13/2024 at 11:30 a.m., when Resident #1, (a moderately cognitively impaired resident who was identified as an elopement risk), asked S5 Agency Nurse to unlock the facility's front door so he could go see his wife, while holding a clear trash bag containing clothing items. [...]

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plans. The facility failed to ensure physician orders to obtain lab work was followed (#11, #16, #17, #43 and #59), failed to ensure medication was administered in a timely manner (#59), and failed to ensure medication was administered as ordered by the physician (#11), for 5 (#11, #16, #17, #43, and #59) of 24 sampled residents. This deficient practice resulted in an Actual Harm for Resident #17. On 12/27/2023, S10 NP ordered to obtain a CBC, BMP, ESR, CRP, and UA with C-Reflex on 12/28/2023. According to interview with S2 DON, S10 NP, and review of Resident #17's medical record, the orders were never carried out. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to act promptly upon grievances and recommendations of the resident council concerning issues of resident care and life in the facility; and failed to demonstrate their response and rationale for such response. The facility census was 58.

Inspectors wroteResident #26 Review of Resident #26's medical record revealed Resident #26 was admitted to the facility on [DATE]. Resident #26 had diagnoses that included in part . Dementia, Kidney Failure, Urinary Incontinence, Anxiety, Dizziness and Giddiness, and Unsteadiness on feet. Review of Resident #26's Quarterly MDS with ARD of 12/07/2023 revealed Resident #26 had a BIMS of 13 (intact cognition). Resident required Substantial/Maximal assistance for toileting, showering/bathing, and dressing. Resident was always incontinent of Bowel/Bladder. Observation on 01/10/2024 at 9:41 a.m. of Resident #26's room revealed a strong urine odor within room. There was a heavily soiled pull up that contained urine lying on the floor beside the right side of Resident's bed. Interview with Resident #26 at time of observation revealed she called for help, but had to wait too long for assistance. [...]

Inspectors wroteBased on interview and record revealed the facility failed to develop and implement a comprehensive person-centered care plan for services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 5 (Resident #10, Resident #12, Resident #16, Resident #26, and Resident #28) of 24 sampled residents.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene for 5 (#5, #11, #12, #17, & #53) of 7 (#5, #11, #12, #17, #22, #30, & #53) residents reviewed for ADLs.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide sufficient numbers of CNAs to perform services on a 24-hour basis to provide nursing care to all residents in accordance to the resident care plans for all 58 residents in the facility

Inspectors wroteFACILITY Based on observation and interview the facility failed to dispose of garbage and refuse properly. This could affect all 58 residents in the facility. The total facility census was 58 residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain an infection prevention and control 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. Proper hand hygiene during wound care for Resident # 17. 2. Proper staff training of chemicals used for cleaning and disinfection of environment. 3. Proper handling of medical equipment during wound care for Resident # 28. This failed practice had the potential to affect all staff and the residents residing at the facility. The facility census was 58.

Inspectors wroteBased on observation and interview the facility failed to ensure cognitively impaired residents were treated with respect and dignity, and cared for in a manner that promoted enhancement of his or her own quality of life for 2 (#17, #59) of 4 (#17, #22, #53, and #59) Residents reviewed for dignity in a total sample of 24. The facility failed to: 1. Ensure Resident #17's hair was maintained in a manner of her preference. 2. Ensure Resident #59 was dressed appropriately.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received services in the facility with reasonable accommodation of resident needs for 1 (Resident #28) of 1 resident reviewed for environment. The facility failed to ensure Resident #28 had an adaptive call light in reach in order to call for assistance. The total facility census was 58 residents.

Inspectors wroteBased on interview and record review the facility failed to ensure their grievance policy and procedure was followed. The facility failed to inform the resident/resident's RP (responsible party) of investigation findings and actions taken to correct the identified problems for 1 (#17) of 24 sampled residents.

Inspectors wroteBased on observation, interview and record review the facility failed to provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition for 1 (Resident #10) of 1 sampled resident reviewed for foot care.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 (Resident #10) of 1 sampled resident receiving dialysis.

Inspectors wroteBased on observations, interview, and record review the facility failed to provide services with reasonable accommodation of needs for 1(Resident #2) of 3 (Resident #1, Resident #2, & Resident #3) sampled residents. The facility failed to ensure Resident #2's call light was answered within a timely manner after calling for assistance.

Inspectors wroteBased on observation, interview, 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 incontinent care to a dependent resident for 1(Resident #2) of 3 (Resident #1, Resident #2, & Resident #3) residents sampled for ADL's.

Inspectors wroteBased on observation, record review and interview, the facility to provide appropriate and sufficient services, treatment and care according to standards of professional practice for Resident #2 who was reviewed for urinary catheter or UTI (urinary tract infection) out of a total of 3 sampled residents. The facility failed to ensure Resident #2's Foley catheter care was performed as ordered by the physician.

Inspectors wroteBased on interview and record review, the facility failed to ensure restorative nursing services were implemented according to the resident's person-centered plan of care for 1 (Resident #1) of 7 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7) sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 3 (Resident #1, Resident #2, and Resident #4) of 7 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7) sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing staff were able to demonstrate competency in the skills and techniques necessary to provide tracheostomy care for 2 (S6 LPN and S7 LPN) of 3 (S6 LPN, S7 LPN and S8 LPN) facility staff, and 2 (S5 Agency LPN and S9 Agency LPN) of 3 (S5 Agency LPN, S9 Agency LPN, and S10 Agency LPN) agency staff. The facility had a total of 4 residents with tracheostomies.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide pharmaceutical services, to include the accurate administration of medication, for 1 (#R2) random sampled resident. The facility failed to reorder a blood pressure medication timely for #R2. The total sample was 7 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6 and Resident #7), and 4 random sampled residents (#R1, #R2, #R3 and #R4).

Inspectors wroteBased on interview and record review, the facility failed to maintain accurately documented resident medication administration records for 3 (Resident #1, Resident #2, Resident #3) of 7 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7) sampled residents and 2 (#R1 and #R2) of 4 (#R1, #R2, #R3, and #R4) random sampled residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a resident's right to be treated with respect and dignity, for 1 (#R1) of 4 (#R1, #R2, #R3, and #R4) random sampled residents, in a total sample of 7 residents (#1, #2, #3, #R1, #R2, #R3, and #R4).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs and preferences, by failing to ensure the resident had a call light within reach for 1 (Resident #4) of 7 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7) sampled residents.

Inspectors wroteBased on observation and interview, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 2 (Resident #1 and Resident #5) of 7 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7) sampled residents' rooms.

Inspectors wroteBased on record review and interview, the facility failed to provide services to meet professional standards of practice for 1 (Resident #2) of 7 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6 and Resident #7) sampled residents. The facility failed to perform Neurological checks on Resident #2 after finding the resident on the floor with a laceration to his head.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care consistent with professional standards of practice of 1 (Resident #1) of 7 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7) sampled residents.