Pointe Coupee Healthcare

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure a hearing impaired resident was provided with an alternate means of communication for 1 (#97) of 2 (#36 and #97)hearing impaired residents reviewed in the sample. Review of the facility Policy, dated 01/23/2023, Translation/Interpreting Services Policy and Procedure for Hearing and Visually Impaired and Foreign Language Speaking Residents revealed the following, in part: Purpose: to ensure the facility provides appropriate auxiliary aids and services when necessary to ensure effective communication for residents with disabilities who have a hearing impairment, reasonable accommodations must be provided. Policy: 1. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure services provided by the facility met professional standards of quality for 1 (#1) of 5 (#1, #2, #3, #R1, and #R2) residents reviewed for professional standards. The facility failed to ensure nursing staff:1. Accurately transcribed Resident #1's Lantus insulin order;2. Clarified blood glucose monitoring orders with the physician for Resident #1, a Diabetic resident receiving Insulin; and3. Obtained a blood glucose level when Resident #1 experienced a change in condition. This deficient practice resulted in an immediate jeopardy situation on 08/05/2025 when Resident #1's insulin order was inaccurately transcribed into his electronic medical record and MAR. Resident #1 admitted to the facility from a local hospital on [DATE] with an order for Lantus 100 unit/mL inject 5 units subcutaneously daily. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure a resident was free from a significant medication error by failing to transcribe the accurate insulin order in the electronic medical record for 1 (#1) of 3 (#1, #2, and #3) residents reviewed receiving insulin. This deficient practice resulted in an immediate jeopardy situation on the morning of 08/06/2025 when Resident #1, a Diabetic resident, began receiving the incorrect dose of Lantus 100 unit/mL insulin. Resident #1 admitted to the facility from a local hospital on [DATE] with an order for Lantus 100 unit/mL inject 5 units subcutaneously daily. S4LPN transcribed the order into Resident #1's electronic medical record as Lantus 100 unit/mL inject 30 units subcutaneously daily. From 08/06/2025 through 08/11/2025, Resident #1 received 30 units of Lantus 100 unit/mL subcutaneously daily. [...]

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure a resident's physician was notified of significant changes that required treatment to be altered for 1(#76) of 3 (#54, #76, and #77) residents reviewed for Orthopedic braces. The facility failed to ensure: 1. The treating physician was notified when Resident #76 constantly removed an ordered LUE immobilizer brace due to a Left Distal Humerus Fracture; and 2. The physician was notified when Resident #76 showed signs of pain when receiving ADL care. This deficient practice resulted in an Immediate Jeopardy situation on 09/13/2024 for Resident #76, a severely cognitively impaired resident, removed an immobilizing splint ordered for treatment of a Left Humerus Fracture and the nursing staff did not reapply it from 09/13/2024 through present. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to implement a resident's comprehensive person-centered care plan for 2 (#76 and #86) of 22 sampled residents reviewed for comprehensive care plan by failing to ensure: 1. Resident #76's left upper extremity immobilizing splint was applied according to the Physicians order; and 2. Resident #76 and Resident #86 attended follow up care physician's appointments as ordered This deficient practice resulted in an Immediate Jeopardy situation on 09/13/2024 for Resident #76, a severely cognitively impaired resident, when the resident removed an immobilizing splint ordered for treatment of a Left Humerus Fracture and the nursing staff did not reapply it. From 09/13/2024 through present, nursing staff did not implement the physician's order which caused the fractured left arm to remain mobile. [...]

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure services provided by the facility to meet professional standards of quality. The facility failed to ensure medications were administered safely by leaving medications at bed side for 1 (#81) of 22 residents observed in the final sample.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide pain management for a resident following diagnosis of the Left Humerus Fracture at the Elbow consistent with the comprehensive person-centered care plan and professional standards of practice for 1 (#76) of 2 (#76 and #86) residents reviewed for pain. This deficient practice resulted in an Immediate Jeopardy situation on 09/16/2024 when Resident #76, a severely cognitively impaired resident, received her last dose of pain medication following a fall that resulted in a Left Humerus Fracture at the Elbow. Resident #76 was treated by an Orthopedic Specialist on 10/01/2024 and returned with an order to wear an immobilizing brace to the LUE at all times to prevent further injury and to decrease pain. Staff did not apply Resident #76's immobilizing splint to her LUE from 10/02/2024 through present. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to provide sufficient nursing staff to attain or maintain each resident's highest practicable physical, mental, and psychosocial well-being, as determined by resident assessments and individual plans of care and considering the acuity and diagnoses of the facility's resident population by failing to respond to a resident's requests for assistance with ADLs timely for 1 (#59) of 22 residents reviewed in the final sample. Review of the facility's PBJ Staffing Data Report for Fiscal Year Quarter 3 revealed a one-star staffing rating. Review of the facility's Daily Assignment Sheet revealed the facility required 8 regularly staffed CNA's assigned per shift. Review of the facility's census dated 12/01/2024 revealed there was a total census of ninety-two residents and four hallways. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to promote and facilitate resident self-determination through support of a resident's choice to participate in activities for 1 (#61) of 2 (#22 and #61) residents reviewed for self-determination. This deficient practice had the potential to affect any of the 92 residents currently residing in the facility.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to maintain a resident's mattress in a sanitary manner for 1 (#4) of 2 (#4 and #36) residents reviewed for environment in the final sample. Review of the facility's Maintenance Log dated October 2024 through December 2024 revealed no entries for Resident #4's mattress. Review of Resident #4's Clinical Record revealed an admission date of 01/06/2020. Review of Resident #4's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 11/20/2024 revealed she was always incontinent of bladder. An observation was made of Resident #4's room on 12/02/2024 at 1:40 p.m. There was a mattress on the bed frame with a cloth covering, which contained multiple brown rings. There was a strong urine odor in the room. An interview was conducted with S4CNA on 12/02/2024 at 12:05 p.m. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure a resident's MDS assessment accurately reflected the PASARR status for 1 (#59) of 2 (#59 and #61) residents reviewed with Level II PASARRs. Review of the facility's policy titled, MDS Policy and Procedure dated 06/25/2015 revealed the following, in part: Policy: All MDS are to be completed and transmitted according to the most current Resident Assessment Instrument manual. Review of Resident #59's Clinical Record revealed an admission date of 04/05/2024 and diagnoses, which included Bipolar Disorder and Major Depressive Disorder. Review of Resident #59's BHSF Form 142 revealed she was approved for admission by Level II Authority with an effective period of 02/02/2024 through 01/31/2025. Review of Resident #59's OBH-PASARR Level II Evaluation Summary & Determination Notice revealed the following, in part: [...]

Inspectors wroteBased on observations, interviews and record reviews 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 staff failed to provide hair hygiene for 1 (Resident # 46) of 2 (#46 and #63) residents sampled for ADL's. This deficiency had the potential to affect all 92 residents in the facility who required assistance with ADL's.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure residents received care, consistent with professional standards of practice to promote prevention and healing of pressure ulcers for 1 (#22) of 1 residents reviewed for pressure ulcers.

Inspectors wroteBased on interviews and record reviews, the facility failed to meet the following Hospice requirements by failing to: 1. Designate a member of the facility's interdisciplinary team (IDT) to be responsible for working with Hospice representatives to coordinate care of the resident provided by facility and Hospice staff for 1 of 1 (#10) residents reviewed for Hospice care; and 2. Maintain a system to ensure a Hospice resident's Hospice Binder contained the most current Hospice orders, most recent Hospice plan of care and a current Recertification of Terminal Illness for 1 of 1 (#10) residents reviewed for Hospice care. This deficient practice had the potential to affect any of the 5 residents receiving Hospice services in the facility.

Inspectors wroteBased on observation and interviews the facility failed to maintain resident's bed equipment in safe operating condition for 1 of 1 (#36) residents observed with care equipment concerns. This failure had the potential to affect all 92 residents in the facility who sleep in a bed.

Inspectors wroteBased on record review, interviews and observations the facility failed to ensure a resident's Medication Administration Record (MAR) was accurately documented for 1(#76) of 3(#54, #76, and #77) sampled residents reviewed for use of orthopedic devices.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure each resident was treated with dignity and respect for 1 (#1) of 3 (#1, #2, and #3) sampled residents reviewed.