Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Chateau Napoleon Caring, Llc during CMS and state inspections, most recent first.
A resident with bipolar disorder, depression, anxiety, and other mood disorders was discharged from a behavioral health hospital with orders for Aripiprazole 7.5 mg at bedtime, but the LTC facility failed to implement this order. Instead, an earlier Aripiprazole 5 mg daily order was reactivated, and the 7.5 mg order was discontinued in error. EMAR review showed the resident received only the 5 mg dose on multiple days, with no documented administration of the prescribed 7.5 mg bedtime dose, as confirmed by the unit manager and DON.
A resident did not receive their prescribed Brivaracetam 75mg oral tablet for several days because the medication was not available in the facility. The MAR showed missed doses with codes indicating unavailability or that the medication was on hold, and there was no documentation in the progress notes explaining the missed doses. Staff did not report the medication discrepancy to the DON as required by facility policy.
A resident developed a red/purple discoloration on the neck/chest area, which was identified by a CNA and assessed by an LPN. The LPN attempted to notify the physician's nurse via text, but the message was not successfully sent, resulting in a significant delay before the physician was informed. The issue was only discovered when another nurse prepared to send the resident to the ER and realized the physician had not been notified.
The DON instructed an LPN to ignore and not report a resident's bruise, an injury of unknown origin, contrary to the facility's abuse prevention policy that requires immediate reporting of suspicious injuries. This was confirmed through a recorded conversation and staff interviews.
A resident with moderate cognitive impairment and a history of multiple unwitnessed falls experienced another fall, but the care plan was not updated with new interventions to address the continued fall risk. The omission was confirmed by the DON, who acknowledged the care plan should have been revised.
An LPN left her assigned halls at the end of her shift without ensuring another nurse had accepted responsibility for resident care, resulting in a gap where no nurse was assigned to those residents. Documentation and staff interviews confirmed that no nurse accepted the assignment until later in the evening, leaving residents without an assigned nurse for several hours.
Wound care was not completed as ordered for multiple residents, with documentation falsely indicating that care was provided by a nurse who was not present. Staff interviews and record reviews confirmed that required wound treatments for various wounds, including ulcers and surgical sites, were not performed as documented.
A resident with dementia, abnormal posture, and mobility issues was found partially in bed and partially in a wheelchair. A CNA moved the resident fully into bed and removed the wheelchair from the bedside, which the administrator later stated should not have occurred, as it deprived the resident of an essential assistive device to reduce fall risk.
The facility did not ensure an RN was on duty for at least 8 hours on one reviewed day, with no documentation available to show RN presence as required. The Medical Director confirmed an RN should have been present.
A medication cart containing controlled substances was not reconciled by the off-going LPN with another nurse at shift change, as confirmed by surveillance footage and staff interviews. The DON acknowledged that reconciliation should occur between off-going and oncoming nurses.
The facility did not document the involvement of an RN, LPN, CNA, a resident or resident's representative, and a governing body member in the development of its facility-wide assessment, as required. The administrator was unaware of the need for these individuals' participation, and no evidence was provided to show their involvement.
A CNA did not have documented evidence of completing the required 12 hours of annual in-service training, and the DON confirmed that no such documentation was available.
A facility failed to develop and implement a baseline care plan within 48 hours for a newly admitted resident at risk for pressure ulcers. The facility's policy mandates individualized interventions to prevent pressure ulcers, but no baseline care plan was documented. Interviews with the MDS nurse and DON confirmed the oversight.
The facility failed to provide necessary medications for two residents, leading to a deficiency in pharmaceutical services. One resident did not receive medications for chronic conditions due to pharmacy delivery delays, while another missed doses of ondansetron for nausea. The DON confirmed the issues, highlighting a lack of timely medication procurement.
The facility failed to maintain cleanliness in two shower rooms, with observations of black/gray substances on floors, base moldings, and shower curtains, as well as cracked tiles and missing moldings. A resident, who was cognitively intact, refused to use the shower room due to its condition. Staff interviews confirmed that housekeeping was responsible for daily cleaning, but the administrator acknowledged the deficiencies.
A resident developed a blister on their finger from a cigarette burn, and the facility failed to promptly notify the physician as required by policy. Although a fax was sent, there was no evidence of timely follow-up or confirmation of receipt. Interviews indicated that the LPN attempted to contact the physician, but no orders were received, and the Staff Development Coordinator did not follow up. The DON acknowledged the lapse in timely notification.
A resident with chronic osteomyelitis and diabetes mellitus with polyneuropathy missed a scheduled podiatry appointment due to the facility's failure to document the appointment and place the resident on the podiatry list. The resident, who was cognitively intact, was not seen by the in-house podiatrist, resulting in inadequate foot care.
A facility failed to ensure a resident was seen by a physician in a timely manner, as required by policy. The resident, who was cognitively intact, was not seen by a physician or NPP within the required 10-day period between visits. This was confirmed by the DON and the resident, who expressed concerns about irregular visits.
A resident with multiple health conditions did not receive scheduled CBC and CMP tests as ordered by their physician. The facility lacked documentation for these tests on several occasions, and the DON confirmed that the tests were not conducted by the laboratory company or the facility's nursing staff.
The facility failed to provide privacy for residents during ADL and incontinence care in two rooms. In Room A, two residents, one with moderate cognitive impairment and the other cognitively intact, received care without a privacy curtain. In Room B, two residents with cognitive impairments also lacked privacy during care. Staff confirmed the absence of privacy curtains and acknowledged that privacy should have been provided.
A facility failed to verify the CNA Registry status for a newly hired CNA before they began working with residents. The CNA worked several days before the registry verification was completed, and there was no documented evidence of a certification check prior to hire. This was confirmed by the HR Business Partner.
A facility failed to report an allegation of verbal abuse involving a resident who required supervision with toilet transfer. The resident experienced an episode of diarrhea and received an inappropriate response from a CNA. The grievance was reported to the Director of Social Services but was not escalated to the DON or Administrator, violating the facility's abuse policy.
A resident reported verbal abuse by a CNA after requesting assistance during an episode of diarrhea. Despite the facility's policy requiring a thorough investigation of abuse allegations, there was no documented evidence of an investigation into this incident. The CNA Coordinator, Director of Nursing, and Administrator all confirmed the absence of documentation, indicating a failure to adhere to the facility's abuse policy.
A resident with Major Depressive Disorder and Bipolar Disorder was not referred for a required PASARR Level II evaluation. Despite the diagnoses, there was no documented evidence of the evaluation in the resident's EMR. Interviews with the Director of Social Services and the Administrator confirmed the oversight.
A resident did not receive Tramadol 50mg for pain management as ordered by the physician due to the medication's unavailability in the facility. The LPN who received the order failed to contact the pharmacy to obtain the medication, and the DON confirmed this oversight.
A resident requiring extensive assistance for transfers was improperly transferred by a single CNA using a mechanical lift, contrary to the care plan requiring two staff members. This resulted in the resident sustaining an abrasion on the leg. The incident was confirmed by interviews with staff and the DON.
Failure to Administer Prescribed Antipsychotic Dose After Behavioral Health Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with multiple mental health diagnoses received the prescribed behavioral health medication regimen following a behavioral health hospitalization. The resident, who had bipolar disorder, depression, anxiety, and an unspecified mood disorder, was discharged from a behavioral health hospital with diagnoses including recurrent major depressive disorder with psychosis and impulse control disorder. The hospital discharge orders dated 03/24/2026 directed that the resident receive Aripiprazole 7.5 mg at bedtime for treatment of bipolar disorder. However, the resident’s April 2026 physician orders only showed an active order for Aripiprazole 5 mg once daily related to bipolar disorder dated 03/25/2026, and there was no active order for the 7.5 mg bedtime dose as specified in the discharge instructions. Review of the March and April 2026 EMAR showed the resident received Aripiprazole 5 mg on multiple dates, but there was no documented evidence that the resident ever received Aripiprazole 7.5 mg at bedtime as ordered on 03/24/2026. The EMAR also showed an order for Aripiprazole 7.5 mg at bedtime with a start date of 03/24/2026 and a discontinue date of 03/25/2026. The unit manager, who was responsible for reviewing medications on admission and after hospitalizations, stated that the 7.5 mg order was discontinued in error on 03/25/2026 and that the previous 5 mg order was incorrectly reactivated. The DON confirmed that the discharge orders required Aripiprazole 7.5 mg at bedtime and that the EMAR contained no documentation that the resident received this ordered dose.
Failure to Provide Ordered Medication Due to Unavailability and Lack of Reporting
Penalty
Summary
The facility failed to ensure that a resident received their routine medication, Brivaracetam 75mg oral tablet, as ordered by the physician. According to the Medication Administration Record (MAR), the medication was not administered for several days, with various codes such as '9' (other, such as medication not available), '2', and 'H' (on hold) documented for multiple scheduled doses. There was also a lack of documentation for one of the scheduled doses. The facility's policy requires that any discrepancies related to medication orders be corrected and reported to the nurse manager, but this was not done in this case. Interviews with the Director of Nursing (DON) and an LPN confirmed that the medication was not available and was not administered for several days. The DON also confirmed that there were no progress notes documenting the reason for the missed doses, and that staff did not report the medication discrepancy to her as required by policy. The medication was only issued to the facility by the pharmacist several days after the start date of the physician's order, resulting in the resident missing multiple doses.
Failure to Notify Physician of Resident's Skin Change
Penalty
Summary
Staff failed to ensure timely physician notification regarding a change in a resident's skin condition. A Certified Nursing Assistant observed a red/purple discoloration on the resident's right neck/chest area, which was assessed and documented by a nurse. The nurse attempted to notify the resident's physician's nurse via text message, but the message was not sent successfully. This failure was not discovered until later in the day when another nurse was preparing to send the resident to the emergency room and realized the physician had not been notified. The physician was ultimately informed of the skin alteration several hours after it was first identified. Interviews confirmed that the nurse did not realize the notification had failed until contacted by another staff member, and facility administration acknowledged that the physician should have been notified promptly when the skin change was first observed.
Failure to Follow Abuse Reporting Policy by DON
Penalty
Summary
The facility failed to ensure that the Director of Nursing (DON) followed the established abuse prevention policy regarding the reporting of injuries of unknown origin. According to the facility's policy, staff are required to immediately report any suspicious injuries, which are considered potential signs of abuse, to the Administrator and appropriate agencies. However, the DON instructed a Licensed Practical Nurse (LPN) that she should have acted as though she did not see a bruise on a resident's chest, which was an injury of unknown origin. This instruction was given during a recorded conversation, where the DON explicitly stated that, in her position, she would have denied seeing the injury and would not have taken any action. Interviews with staff confirmed the content of the recorded conversation, and the DON acknowledged making these statements when questioned. The Administrator also confirmed that the DON should not have advised the LPN to refrain from reporting the injury. The DON's actions were in direct violation of the facility's policy, which mandates immediate reporting of any signs of abuse or suspicious injuries.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to revise the care plan for a resident with a history of falls after the resident experienced another unwitnessed fall. The resident, who had moderate cognitive impairment as indicated by a Brief Interview for Mental Status score of 9, had previously experienced unwitnessed falls on three separate occasions. Despite documentation of these incidents and the most recent fall being reported by a CNA and noted in the nursing progress notes, the resident's care plan was not updated with any new interventions to address the ongoing risk of falls. This omission was confirmed by the Director of Nursing, who acknowledged that the care plan should have been revised following the latest fall.
LPN Left Facility Without Ensuring Nursing Coverage
Penalty
Summary
A licensed practical nurse (LPN) assigned to two halls left the facility at the end of her shift without ensuring that another nurse had assumed responsibility for her resident assignment. The facility's schedule and time sheets confirmed that the outgoing LPN clocked out at 6:15PM, while the incoming agency LPN did not clock in until 9:36PM, leaving a gap in nursing coverage. During this period, there was no documented evidence that any nurse was assigned to or accepted responsibility for the residents on those halls. Multiple staff interviews confirmed that the outgoing LPN left only a written report and did not provide a verbal handoff, and that the incoming nurses did not accept the assignment until later in the evening. Text message exchanges between the staff development nurse, the former assistant director of nursing, and the outgoing LPN further corroborated that the outgoing LPN left the facility without a proper handoff, citing unwillingness to argue with another nurse. The director of nursing confirmed that the LPN should not have left without ensuring coverage, and there was no evidence presented that the residents had an assigned nurse during the gap. This lapse had the potential to affect all 28 residents residing on the two affected halls during the time in question.
Failure to Complete Wound Care as Ordered
Penalty
Summary
The facility failed to ensure that wound care was completed as ordered for eight residents. Review of facility time sheets showed that the wound care nurse scheduled to work on the relevant date was still in training and did not perform wound care, while another wound care nurse, who was documented in the electronic Treatment Administration Reports (eTAR) as having provided wound care to multiple residents, confirmed she did not work that day and had not performed the care. Documentation in the eTAR indicated that wound care procedures, including cleaning wounds, applying medications and dressings, were recorded as completed for several residents with various types of wounds, such as non-pressure ulcers, surgical sites, venous ulcers, and moisture-associated dermatitis. However, interviews with the involved staff confirmed that the documented wound care was not actually performed on the specified date, and there was no evidence presented by the facility to show that the required wound care was completed for the affected residents. The medical director acknowledged that it was unacceptable for residents' wound care to not be completed as per physician orders. The deficiency was identified through review of records and staff interviews, which revealed discrepancies between documentation and actual care provided.
Failure to Ensure Availability of Assistive Device Increases Fall Risk
Penalty
Summary
The facility failed to ensure that a resident's assistive device, specifically a wheelchair, was available for use to decrease the risk of falls. The resident, who had diagnoses including unspecified dementia, abnormal posture, difficulty in walking, muscle weakness, and lack of coordination, was found by a former CNA lying in bed with the upper half of his body in the bed and the lower half in his wheelchair. The CNA then placed the resident fully back in bed and removed the wheelchair from the bedside, which upset the resident. The administrator later confirmed that the CNA should not have taken the wheelchair away from the resident's bedside.
Failure to Provide Required RN Coverage for 8 Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least 8 hours on one of the fourteen days reviewed for staffing requirements. Specifically, on 02/09/2025, there was no documented evidence in the Nursing/Ancillary Personnel Staffing Pattern Report Form or the facility's time sheets that an RN worked that day. The provider was unable to present any documentation to show that an RN was present for the required hours. During an interview, the Medical Director confirmed that an RN should have been on duty as required on that date. No information was provided regarding any residents' medical history or condition at the time of the deficiency.
Failure to Reconcile Controlled Drugs at Shift Change
Penalty
Summary
The facility failed to maintain a system for reconciling controlled drugs on one of three medication carts reviewed. Surveillance footage showed that Medication Cart c, which contained controlled substances for residents on two halls, was not reconciled by the off-going LPN with another nurse before she left the facility. The LPN confirmed in an interview that she did not perform the required reconciliation at the end of her shift. The Director of Nursing also acknowledged that the facility's protocol requires off-going and oncoming nurses to reconcile controlled drugs at shift change.
Lack of Required Stakeholder Involvement in Facility Assessment
Penalty
Summary
The facility failed to ensure that its facility-wide assessment included documented involvement from key stakeholders, including direct care staff such as a Registered Nurse (RN), a Licensed Practical Nurse (LPN), a Certified Nursing Assistant (CNA), as well as a resident and/or a resident's representative, and a member of the facility's governing body. Review of the most recent facility assessment showed no evidence that these individuals participated in its development. During an interview, the administrator stated he was unaware that these parties were required to be involved in the assessment process. There was no documentation provided to demonstrate their participation.
Failure to Document Annual CNA In-Service Training
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) received the required 12 hours of in-service training annually. Review of the CNA's personnel file, who was hired on 07/17/2014, showed no documented evidence of completion of the annual in-service training requirement. During an interview, the Director of Nursing (DON) confirmed that the facility was unable to provide any documentation verifying that the CNA had completed the mandated training hours.
Failure to Implement Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident identified as being at risk for developing pressure ulcers. The facility's policy requires individualized interventions to prevent pressure ulcers, which should be monitored for effectiveness and reflected in the resident's care plan. However, upon review of the resident's electronic medical record, it was found that no baseline care plan was developed or implemented. Interviews with the MDS nurse and the Director of Nursing confirmed the absence of a baseline care plan for the resident, which should have been completed according to the facility's policy.
Medication Availability Deficiency
Penalty
Summary
The facility failed to ensure the availability of medications for two residents, leading to a deficiency in pharmaceutical services. Resident #1, who was admitted with chronic kidney disease, hypertension, and gout, did not receive prescribed medications including potassium chloride, allopurinol, and lisinopril-hydrochlorothiazide on the morning of 11/16/2024. The medications were not available because they had not arrived from the pharmacy, and the facility did not utilize an on-call pharmacist or another local pharmacy to obtain them. This was confirmed by the Director of Nursing, who noted that medications ordered after 3:00 p.m. would only arrive the next day. Resident #3, admitted to the facility with a prescription for ondansetron hydrochloride to treat nausea, also experienced medication unavailability. The medication was not administered on multiple occasions in December 2024 due to delays in receiving it from the pharmacy. Nursing progress notes indicated that the facility was waiting for the medication to arrive, and the Director of Nursing confirmed the issue, stating that the floor nurses and pharmacist were responsible for ordering medications. This resulted in Resident #3 not receiving the prescribed medication as needed.
Unsanitary Conditions in Facility Shower Rooms
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in two shower rooms, identified as shower room y and shower room z. Observations revealed an unknown black/gray substance on the floor, base moldings, and shower curtains in both rooms. Additionally, cracked tiles with black discoloration were noted, and missing tile moldings exposed sheet rock in shower room y. An unknown orange/red substance was also observed on the metal ceiling supports in shower room y. These conditions were confirmed by the facility's administrator, who acknowledged that the shower curtains should not have the unknown substance and should be cleaned or disposed of by housekeeping staff. A resident, who was cognitively intact with a Brief Interview of Mental Status (BIMS) score of 15, expressed refusal to use the shower room due to its unsanitary condition. Interviews with facility staff, including a Certified Nursing Assistant (CNA) and the administrator, indicated that housekeeping staff were responsible for cleaning the shower rooms daily. However, the presence of the substances and the resident's refusal to use the facilities highlight a failure in maintaining a safe and clean environment for residents.
Failure to Notify Physician of Resident's Condition Change
Penalty
Summary
The facility failed to promptly notify a resident's physician of a change in condition, specifically a blister on the resident's left hand index finger caused by a cigarette burn. The facility's policy requires immediate notification of the resident, their physician, and a representative in the event of an accident resulting in injury. On the date of the incident, the resident's wife reported the blister, and a facsimile was sent to the physician's office. However, there was no documented evidence of the time the fax was sent, whether the physician was present to receive it, or if any follow-up occurred to confirm receipt and obtain new orders. Interviews revealed that the LPN responsible for notifying the physician claimed to have sent a fax and attempted to call and text the physician, but no orders were received by the end of her shift. The medical receptionist confirmed the fax was sent in the evening, but there was no evidence the physician reviewed it. Additionally, the Staff Development Coordinator did not follow up with the physician, and the Director of Nursing acknowledged that the nursing staff should have ensured timely notification and follow-up with the physician.
Failure to Provide Adequate Foot Care
Penalty
Summary
The facility failed to assist a resident in attending a scheduled podiatry appointment and did not provide necessary foot care. The resident, who was cognitively intact and had a history of chronic osteomyelitis and diabetes mellitus with polyneuropathy, had a podiatry appointment scheduled but did not attend. The appointment was not documented in the facility's appointment book, and the resident was not placed on the podiatry list for in-house rounds. Interviews revealed that the ward clerk was unaware of the appointment, and the Director of Nursing confirmed the oversight. Despite the resident's request for podiatry assessment, the facility did not reschedule the missed appointment or ensure the resident was seen by the in-house podiatrist, resulting in a failure to provide adequate foot care as required by the resident's rights.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to ensure that a resident was seen by a physician in a timely manner, as required by their policy. According to the facility's policy, a physician visit is considered timely if it occurs no later than 10 days after the required date, and this requirement can be fulfilled by a Non Physician Practitioner (NPP) as well. Resident #1, who was cognitively intact with a Brief Interview of Mental Status (BIMS) score of 15, was admitted to the facility and was supposed to have regular physician visits. However, the resident was seen by the physician on 08/27/2024 and not again until 10/08/2024, which exceeded the 10-day requirement. This was confirmed by the Director of Nursing, who acknowledged the lack of documented evidence of a timely visit. The resident also expressed concerns about not being seen regularly by their primary physician.
Failure to Conduct Ordered Laboratory Tests
Penalty
Summary
The facility failed to obtain laboratory services per physician's order for a resident diagnosed with chronic myeloid leukemia, chronic osteomyelitis, diabetes mellitus with polyneuropathy, hypertension, and hyperlipidemia. The resident was admitted to the facility with a physician's order for weekly Complete Blood Count (CBC) and Comprehensive Metabolic Panel (CMP) tests to be drawn on Mondays. However, the facility did not have documented evidence that these tests were conducted on several specified dates. The Director of Nursing (DON) confirmed that the laboratory testing company did not draw the laboratory tests as scheduled, and the facility's nursing staff did not perform the tests when the company failed to do so. The DON acknowledged the lack of evidence for the completion of the CBC and CMP tests on the specified dates, indicating a failure to adhere to the physician's orders for the resident's laboratory testing needs.
Failure to Provide Privacy During Personal Care
Penalty
Summary
The facility failed to ensure privacy for residents during activities of daily living (ADL) and incontinence care in their rooms. In Room A, there was no curtain to provide privacy between the beds of two residents, one with moderate cognitive impairment and the other cognitively intact. Both residents required assistance with bed mobility, transfers, and toileting, with varying levels of incontinence. Interviews revealed that care was provided without privacy, and staff confirmed the absence of a privacy curtain, acknowledging that privacy should have been provided. Similarly, in Room B, there was no curtain to provide privacy between the beds of two residents, both with cognitive impairments and requiring extensive assistance with bed mobility, transfers, and toileting. Observations and staff interviews confirmed that care was provided without privacy, and the absence of a privacy curtain was acknowledged by the housekeeping supervisor and the Director of Nursing. The facility's failure to provide privacy during personal care activities was evident in both rooms, as confirmed by staff and resident interviews.
Failure to Verify CNA Registry Before Employment
Penalty
Summary
The facility failed to verify the Certified Nurse Aide (CNA) Registry status for a newly hired CNA, identified as S11CNA, before allowing them to work with residents. S11CNA was hired on January 9, 2024, and worked on several dates before the CNA Registry verification was completed on January 15, 2024. The personnel record of S11CNA lacked documented evidence of a CNA certification check prior to their hire date. This deficiency was confirmed during an interview with the Human Resources Business Partner, who acknowledged that the facility did not complete the necessary certification check to ensure S11CNA was active on the registry before they began working.
Failure to Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of staff-to-resident verbal abuse to the required State Survey Agency. The incident involved a resident who required supervision with toilet transfer and had an episode of diarrhea during the night. When the resident called for assistance, a Certified Nursing Assistant (CNA) responded inappropriately by making a derogatory comment. This grievance was reported to the Director of Social Services and was supposed to be investigated by the Certified Nursing Assistant Coordinator. However, the Certified Nursing Assistant Coordinator did not report the allegation of verbal abuse to the Director of Nursing (DON) or the Administrator. Interviews with the Director of Social Services, the Certified Nursing Assistant Coordinator, the DON, and the Administrator confirmed that the allegation was not reported as required. The facility's failure to report the incident violated their Abuse Policy and Procedure, which mandates reporting allegations to appropriate authorities within required timeframes.
Failure to Investigate Alleged Verbal Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation following an allegation of verbal abuse by a staff member towards a resident. The facility's Abuse Policy and Procedure, last revised in March 2023, mandates that upon identifying abuse, the facility should take immediate steps to remediate noncompliance and protect residents from further abuse. Additionally, the policy requires a thorough investigation of the allegation, with documentation and reporting of the investigation's results. However, in this case, there was no documented evidence of an investigation into the alleged verbal abuse incident involving Resident #64. Resident #64, who requires supervision with toilet transfer, reported an incident where a CNA responded inappropriately after the resident called for assistance following an episode of diarrhea. The resident alleged that the CNA made a derogatory comment. Despite the report of this incident to the CNA Coordinator and the Director of Nursing, both confirmed that there was no documented evidence of an investigation. The facility's Administrator also acknowledged the lack of documentation, indicating that the allegation was not thoroughly investigated as required by the facility's policy.
Failure to Conduct PASARR Level II Evaluation for Resident
Penalty
Summary
The facility failed to ensure that a resident with diagnoses of Major Depressive Disorder and Bipolar Disorder was referred for a Preadmission Screening and Resident Review (PASARR) Level II evaluation, as required. The resident was admitted with a diagnosis of Major Depressive Disorder, and later received a new diagnosis of Bipolar Disorder. Despite these diagnoses, there was no documented evidence in the resident's Electronic Medical Record (EMR) that a Level II PASARR evaluation was completed. Interviews with the Director of Social Services and the Administrator confirmed that the evaluation was not conducted, and both acknowledged that it should have been completed for the resident.
Medication Unavailability for Resident
Penalty
Summary
The facility failed to ensure that a medication, Tramadol 50mg, was available for a resident as ordered by the physician. The deficiency involved a resident who was prescribed Tramadol to be administered twice daily for pain management. However, the medication was not available in the facility from the time it was ordered on September 3, 2024, through September 9, 2024. The electronic Medication Administration Record (eMAR) documented that the medication was not administered on multiple occasions due to its unavailability. Interviews conducted with facility staff revealed that the Licensed Practical Nurse (LPN) who received the verbal order from the physician did not contact the pharmacy to obtain the medication. The Director of Nursing (DON) confirmed the lack of medication availability and acknowledged that the nurse should have taken steps to acquire the medication. This oversight resulted in the resident not receiving the prescribed pain management medication as ordered by the physician.
Inadequate Assistance During Resident Transfer
Penalty
Summary
The facility failed to ensure that a resident received adequate assistance during a transfer, which resulted in an accident. Resident #1, who required extensive assistance from two or more persons for transfers, was transferred by a single CNA using a mechanical lift. This action was contrary to the resident's care plan, which specified the need for two staff members to assist with transfers. The incident led to Resident #1 sustaining an abrasion on his leg. Interviews conducted during the investigation revealed that the CNA, identified as S4, did not follow the facility's practice by attempting the transfer alone. Another CNA, S5, confirmed that when she entered the room, Resident #1 was already suspended in the mechanical lift sling over his gerichair, with no other staff present. The Director of Nursing also confirmed that the care plan required two staff members for all transfers, indicating a clear deviation from the established protocol.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Napoleonville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Chateau D'ville Rehab And Retirement | 9.6 mi | — | 1 | 0 |
| Legacy Nursing And Rehabilitation Of Lafourche | 17 mi | — | 0 | 0 |
| Audubon Health And Rehab | 18.6 mi | — | 2 | 0 |
| Thibodaux Healthcare And Rehabilitation Center | 19.2 mi | — | 0 | 0 |
| Legacy Nursing And Rehabilitation Of Morgan City | 19.9 mi | — | 1 | 0 |
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