Pontchartrain Health Care Center

Inspectors wroteBased on record review, observation, and interviews, the facility failed to ensure it provided medications, as ordered by the prescriber, to meet the needs of 1 (#4) of 6 residents reviewed for medications.

Inspectors wroteBased on observation and interviews, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles. The facility failed to ensure 1 (Medication Cart #1) of 3 Medication Carts observed were kept locked when not under direct observation of authorized staff. Review of the facility's policy titled, Medication Labeling and Storage with a revised date of February 2026 revealed the following, in part:Medication Storage:4. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes) containing medications and biological are locked when not in use and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. On 07/14/2026 at 11:16 a.m., an observation was made of Med Cart #1 unlocked and unattended near resident rooms. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure resident assessments accurately reflected the resident status by failing to ensure a resident Minimum Data Set (MDS) was accurately coded for Pre-admission Screening and Resident Review (PASRR) for 1 (#102) of 3 sampled residents reviewed for PASRR.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding by failing to:1. Ensure free water bags were changed in appropriate timeframe for 1 (#2) of 2 residents reviewed for tube feedings; and2. Ensure free water flushes were administered per physician's orders for 1 (#59) of 2 residents reviewed for tube feedings.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to provide fluids sufficient to maintain adequate hydration. The facility failed to provide a water pitcher or any fluid for hydration within reach for 1 (#3) of 2 residents reviewed for UTI's.

Inspectors wroteBased on observation and interviews the facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety by failing to ensure staff with facial hair wore a beard restraint. This deficient practice had the potential to affect any of the 98 residents who received nourishment from the facility's kitchen. On 07/13/2026 at 08:10 a.m. an observation of the facility's kitchen food preparation area was conducted with S4DM. An observation of two male employees both with beards and mustaches not wearing beard restraint while serving morning meal. On 07/14/2026 at 8:18 a.m., an interview was conducted with S4DM. S4DM confirmed S5DS and S6DS were not wearing a beard restraint over their facial hair and should have. On 07/14/25 at 8:18 a.m., an interview was conducted with S1ADM. [...]

Inspectors wroteBased on record review, observation, and interviews, the facility failed to ensure grievances were entered into the grievance log and followed through to resolution for 1 (#2) of 3 residents sampled for grievances, resulting in the potential for unresolved care concerns. Review of the facility's policy titled Grievance Policy and Procedure - Voicing and Resolution, revised date 11/2025, revealed the following, in part:Policy:Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents and other concerns regarding their stay. Procedure:3. Grievance will be written on the home's grievance/complaint report form.6. The home will keep a grievance/complaint log outlining each grievance/complain and the disposition of the complaint. 8. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the resident's status for 1 (#2) resident of 3 sampled residents. Review of Resident #2's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #2's Quarterly MDS with an Assessment Reference Date (ARD) of 01/12/2026 revealed Section C, question C0100 should brief interview for mental status be conducted, coded as 0 - no (resident is rarely/never understood). On 02/18/2026 at 11:50 a.m., an interview was conducted with Resident #2. Resident interview revealed Resident #2 was able to hear and understand my questions with no issue. Resident interview further revealed Resident #2 was able to voice answers to my questions with no issue. On 02/19/2026 at 9:51 a.m., an interview was conducted with S7SW. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the Quality Assurance and Performance Improvement (QAPI) committee failed to provide sufficient evidence ongoing monitoring and evaluations were implemented to ensure corrective actions were put in place after identifying residents were not receiving showers. This deficient practice had the potential to affect all residents who required assistance with showering/bathing.

Inspectors wroteBased on record review and interviews, the provider failed to implement a comprehensive person-centered care plan to meet the needs of 2 (#61 and #84) of 25 sampled residents. The facility failed to ensure: 1. Staff consistently implemented an intervention of sitters at bedside for supervision for Resident #61; and 2. Staff scheduled an order neurology consultation for Resident #84. This deficient practice resulted in an Immediate Jeopardy situation on 05/12/2025 when Resident #61, a cognitively impaired resident with a history of falls, recent brain bleed, poor safety awareness, and impulsiveness, had an unwitnessed fall when staff left him unsupervised. Resident #61 was assessed to need staff supervision at bedside on 05/03/2025. On 05/18/2025, the resident had another unwitnessed fall when S22CNA left his bedside leaving the resident unsupervised. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents received adequate supervision to prevent avoidable falls for 1 (#61) of 4 (#6, #61, #85, and #103) residents reviewed for falls. This deficient practice resulted in an Immediate Jeopardy situation on 05/12/2025 when Resident #61, a cognitively impaired resident with a history of falls, recent brain bleed, poor safety awareness, and impulsiveness, had an unwitnessed fall when staff left him unsupervised. Resident #61 was assessed to need staff supervision at bedside on 05/03/2025. On 05/18/2025, the resident had another unwitnessed fall when S22CNA left his bedside leaving the resident unsupervised. Resident #61 was sent to the emergency room for evaluation and head CT revealed a new subacute subdural hematoma. Resident #61 was then admitted to the neurological Intensive Care Unit through 05/27/2025. [...]

Inspectors wroteThe facility failed to ensure it was administered in a manner that effectively used its resources for 1 (#61) of 4 (#6, #61, #85, and #103) residents reviewed for falls. The facility failed to have an effective system in place to ensure a care plan intervention of sitter at bedside was continuously implemented for Resident #61 to prevent falls. This deficient practice resulted in an Immediate Jeopardy situation on 05/12/2025 when Resident #61, a cognitively impaired resident with a history of falls, recent brain bleed, poor safety awareness, and impulsiveness, had an unwitnessed fall when staff left him unsupervised. Resident #61 was assessed to need staff supervision at bedside on 05/03/2025. On 05/18/2025, the resident had another unwitnessed fall when S22CNA left his bedside leaving the resident unsupervised. [...]

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure all medical records regarding the residents' code status reflected the residents' wishes for 2 (#18 and #14) of 34 residents reviewed in the initial screening for advanced directives.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to implement and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to ensure staff: 1. Properly utilized Enhanced Barrier Precaution (EBP) Personal Protective Equipment (PPE) during direct care with Peripherally Inserted Central Catheter (PICC) line for 1 of 1 (#206) residents whom required PICC line care; and 2. Performed appropriate Standard PPE glove precautions during incontinence care for 1 of 1 (#18) residents observed for incontinence care.

Inspectors wroteBased on interviews and record review, the facility failed to ensure resident's assessments accurately reflected the resident's status by failing to ensure a resident's Minimum Data Set (MDS) was accurately coded for Pre-admission Screening and Resident Review (PASRR) for 1 (#90) of 2 (#29 and #90) sampled residents reviewed for PASRR.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident with an identified mental health diagnosis was referred for a Preadmission Screening Resident Review (PASRR) Level II evaluation as required for 1 (#29) of 2 (#29 and #90) sampled residents records reviewed for PASRR.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure services were provided to meet quality professional standards by failing to follow physician orders for 1 (#84) of 25 residents reviewed in the final sample.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure a resident's Medication Administration Record (MAR) was accurately documented and complete for 1 (#17) of 25 residents reviewed in the final sample.

Inspectors wroteBased on interviews and record review, the facility failed to meet the following Hospice requirements by failing to maintain a system to ensure a Hospice resident's Hospice Binder contained the most recent Hospice Plan of Care and a current Recertification of Terminal Illness for 1 of 1 (#56) residents reviewed for Hospice care. This deficient practice had the potential to affect any of the 10 residents receiving Hospice services in the facility.

Inspectors wroteBased on observations and interview, the facility failed to: 1. Post the names, addresses, and telephone numbers of pertinent state agencies and advocacy groups, such as the State Survey Agency, the State licensure office, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit; and 2. Post a statement for how a resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulation for all required postings reviewed. This deficient practice had to the potential to affect all 109 residents residing in the facility.

Inspectors wroteBased on observations and interviews, the facility failed to ensure the facility was a functional, sanitary, and comfortable environment for residents. The facility failed to ensure: 1.) The floor tiles were cleaned and without debris, the wall adjacent to the bed was without chipped/missing paint, the shower was functional and sanitary, and the bed's mechanical parts were cleaned in Room a; and 2.) The air conditioner units in Room b and Room c were cleaned. This deficient practice had the potential to effect the 113 residents residing in the facility.

Inspectors wroteBased on observations, and interviews the facility failed to ensure a safe, functional, sanitary and comfortable environment. The facility failed to ensure: 1.) Ceiling tiles were in good repair for Room b, Room c, Room d, Room f, and Hall b; 2.) The vent above the ice machine on Hall c was clean; 3.) The gutters of the building remained intact; and 4.) Hall a's bathroom toilet was maintained in a sanitary and functional condition. This deficient practice had the potential to effect the 114 residents residing in the facility.

Inspectors wroteBased on interviews and record review, the facility failed to ensure an allegation of physical abuse was reported to the state agency in the required time frame for 1 (#1) of 3 (#1, #2, and #3) residents reviewed for abuse.

Inspectors wroteBased on interviews and record review, the facility failed to ensure a resident's comprehensive plan of care was implemented for 1(#1) of 3(#1, #2 and #3) residents reviewed in the sample. The facility failed to ensure Resident #1 had daily meal intake percentage documented.

Inspectors wroteBased on observations and interviews, the facility failed to ensure housekeeping and maintenance services were provided and maintained a safe, clean, comfortable, and homelike environment for the residents for 3 of 3 (Hall A, Hall B, Hall C) areas observed for environmental concerns. This deficient practice had the potential to affect a census of 110 residents currently residing in the facility.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an effective pest control program to ensure residents had a pest free environment. The deficient practice affected 2 (#1 and #3) of 3 (#1, #2, and #3) sampled residents and had the potential to affect all 110 residents that resided in the facility.

Inspectors wroteBased on record reviews and interviews, the facility failed to maintain accurate records in accordance with accepted professional standards for 2 (#2 and #3) of 3 (#1, #2, and #3) sampled residents reviewed for baths.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment to help prevent the development and transmission of infection for 2 ( #2 and #3) of 2(#2 and #3) residents reviewed for infection control. The facility failed to ensure staff wore proper Personal Protective Equipment (PPE) while providing peri-care and catheter care to residents who were on Enhanced Barrier Precautions (EBP).

Inspectors wroteBased on interviews and record review, the facility failed to ensure a resident's assessment accurately reflected the resident's status for 1 (#3) of 3 (#1, #2, and #3) residents reviewed for resident assessment. The facility failed to code the resident's Minimum Data Set (MDS) correctly for antipsychotic and antidepressant use.

Inspectors wroteBased on record review and interviews, the facility failed to ensure services were provided to meet quality professional standards by failing to ensure physician's orders were accurately transcribed for 1 (#2) of 3 (#1, #2 and #3) residents reviewed for physician's orders.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide necessary care and services for the provision of respiratory care in accordance with professional standards. The facility failed to ensure: 1. Oxygen tubing and humidifier bottle were properly labeled for 1 of 1 (#3) resident; and 2. Oxygen was administered at the ordered rate for 1 of 1 (#3) resident reviewed for oxygen therapy.

Inspectors wroteBased on interviews and record reviews, the facility failed to maintain accurate records in accordance with accepted professional standards and practices for 3 of 3 (#1, #2 and #3) sampled residents reviewed for activities of daily living. The facility failed to ensure staff documented completed baths or showers in the Residents' record.

Inspectors wroteBased on observations and interview, the facility failed to store food under sanitary conditions by failing to do the following: 1. Ensure food was properly labelled and stored in unit refrigerators; and 2. Ensure kitchen equipment was maintained in safe operating condition. This deficient practice had the potential to affect 101 residents who were capable of storing and consuming food in the facility's unit refrigerators.

Inspectors wroteBased on record review and interviews, the facility failed to have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. This deficient practice had the potential to affect 101 residents who were capable of storing and consuming food in the facility.

Inspectors wroteBased on observation and interviews, the facility failed to dispose of garbage and ensure waste was properly contained in the outdoor dumpster

Inspectors wroteBased on interviews and record review, the facility failed to ensure resident assessments accurately reflected the resident's status for 3 (#50, #54, and #78) of 22 sampled residents reviewed for MDS.

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents were given the right to rescind the arbitration agreement within 30 calendar days for 3 (#50, #109, and #114) of 3 (#50, #109, and #114) residents reviewed for arbitration.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident with an identified mental health diagnosis was referred for a PASARR Level II evaluation as required for 1 (#72) of 4 (#34, #49, #72, and #114) sampled residents records reviewed for PASARR Level II.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents' drug regimens were free from unnecessary psychotropic medications for 2 (#19 and #51) of 6 (#9, #12, #19, #34, #51 and #58) residents reviewed for unnecessary psychotropic medications. The facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days.

Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. The facility failed to ensure staff used appropriate hand hygiene after incontinent care for 1 (#101) of 1 (#101) residents observed for incontinent care.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure all complaint surveys since the last annual survey were available for resident review.

Inspectors wroteBased on observations and interview, the facility failed to ensure nurse staffing data, including resident census, and total number and actual hours worked for licensed and unlicensed nursing staff, was posted in a prominent location readily accessible to residents and visitors. This deficient practice had the potential to affect any of the 110 residents residing in the facility.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents, who were unable to carry out ADLs, received the necessary services to maintain personal hygiene for 2 (#1 and #3) of 3 (#1, #2, and #3) residents reviewed for ADLs.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection control program designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infection. The facility failed to ensure staff practiced proper hand hygiene and cleaning techniques during incontinence care for 2 (Resident #2, Resident #3) of 3 (Resident #2, Resident #3 and R2) residents reviewed for incontinent care.