Chateau Napoleon Caring, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Napoleonville, Louisiana.
- Location
- 252 Hwy. 402, Napoleonville, Louisiana 70390
- CMS Provider Number
- 195498
- Inspections on file
- 36
- Latest survey
- November 25, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Chateau Napoleon Caring, Llc during CMS and state inspections, most recent first.
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 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.
Latest citations in Louisiana
A resident with Parkinson’s disease, essential tremor, dementia, and legal blindness, who was care planned as being at risk for burns from hot liquids and to receive hot beverages in lidded cups at temperatures not exceeding 130°F, sustained 2nd and 3rd degree burns to the left thigh after spilling coffee during a group activity. The facility’s policy required hot beverages to be cooled to 120–130°F and mandated temperature monitoring, but the coffee served at the time of the incident was reported by dietary staff to be 140°F, and the coffee temperature log did not include documentation for the 10:00 a.m. service when the spill occurred. This failure to adhere to the hot beverage policy and to consistently monitor and document beverage temperatures resulted in actual harm to the resident.
A resident with severe cognitive impairment, multiple chronic conditions, and hospice services required extensive assistance for transfers. During a transfer from wheelchair to bed performed by a CNA, the resident’s left lower leg rubbed against an enabler bar that had a missing end cap, creating a sharp edge. An LPN observed a large laceration on the leg and identified the defective enabler bar as the source of injury. The resident was sent to the ED, where a deep, 25.5 cm stellate laceration required extensive cleaning, internal and external sutures, a tetanus shot, and subsequent daily wound care and antibiotics due to delayed healing. The incident occurred despite facility policies and the Maintenance Supervisor’s responsibilities requiring regular inspection of bed rails and enabler bars for hazards.
The facility did not maintain the required 8 consecutive hours of daily RN coverage on multiple days, as time card records showed that the only scheduled RN worked less than 8 hours on several occasions. The administrator confirmed that this RN was the sole RN scheduled during the period reviewed and acknowledged that full daily RN coverage was not provided on the identified days.
The facility failed to maintain adequate supplies of clean bath towels and bed linens despite its own assessment identifying the need to keep sufficient PAR levels for these items. A resident with a history of traumatic brain injury and another with type 2 DM and asthma, both cognitively intact, reported that towels and linens were often unavailable, with one resident’s family providing personal linens due to frequent shortages. The grievance log documented a complaint about missing personal towels and sheets, and staff, including laundry personnel, a CNA, and the ADON, confirmed that clean towels and bed linens were frequently unavailable during multiple weeks, affecting all residents in the facility.
A resident with severe cognitive impairment, dementia, and multiple comorbidities, assessed as high risk for elopement due to prior exit-seeking and wandering, was found alone outside near the front entrance in a flower bed by an oncoming LPN. The LPN assisted the resident and notified staff inside, and the responsible party later reported the same event. Despite a written wandering and elopement policy requiring notification of regulatory agencies after such incidents, the Administrator acknowledged that this elopement was not reported to the State Survey Agency as required by state law.
A resident with multiple conditions, including type 2 DM, dementia with behavioral symptoms, gait abnormalities, and an anxiety disorder, was documented in progress notes as having eloped and been found outside in a flower bed, and later was found to have a diabetic ulcer on the right heel. Review of the comprehensive care plan showed it was not revised to address either the elopement or the new diabetic ulcer, and the MDS coordinator acknowledged that the care plan should have been updated to reflect these changes in condition.
A resident with type 2 DM, dementia, mobility impairments, and other comorbidities was admitted with a documented deep tissue injury on the right heel, but no corresponding MD wound care orders or treatments were recorded for approximately one month despite a care plan directive to assess for skin breakdown and treat as ordered. A NP note referenced treatment with gentian violet and foam, yet this was not supported by physician orders or the TAR. Later, a wound care nurse identified a diabetic ulcer on the same heel and initiated gentian violet and foam dressings after an order was finally obtained, with treatments documented on only a few dates. The resident was later seen in the ED for cellulitis related to the diabetic heel ulcer and discharged with antibiotics, and both the wound care nurse and NP confirmed gaps in assessment, ordering, and follow-up of the heel wound.
Staff failed to follow infection control protocols during incontinence care for two residents, including not performing required hand hygiene between glove changes and after contact with stool, and placing soiled items on clean linens. CNAs provided perineal care, handled residents’ clean clothing, body surfaces, wheelchairs, and room surfaces, and managed soiled briefs and pads without appropriate glove changes or hand sanitizing, contrary to facility policy. Both CNAs later acknowledged they should have performed hand hygiene and changed gloves correctly, and the DON confirmed that staff are expected to follow these infection prevention practices.
Two residents were not treated in a manner that promoted dignity and quality of life. One resident with left-sided weakness and a flaccid arm following a stroke requested a bedpan, but a CNA told her she was wearing a diaper and could use it instead, despite therapy having recommended bedpan use and the resident not wanting to use a diaper. Another resident with vascular dementia, a history of C. diff enterocolitis, heart failure, and depression, and a moderately impaired BIMS score continued to receive meals on disposable dishware in the dining room even though contact isolation precautions had been discontinued, and nursing leadership confirmed this should not have occurred.
A resident with paraplegia, severe cognitive impairment (BIMS 6), and dependence for mobility and hygiene was repeatedly observed in bed and in a Geri chair without access to a call light, despite facility policy requiring call lights to be within easy reach when residents are in bed or confined to a chair. On multiple occasions throughout the day, the call light was found on the floor or hanging on the side of the bed, out of the resident’s reach. The resident reported being unable to reach the call light, and both a CNA and the DON acknowledged that the call light was not within reach and should have been accessible.
Resident Burn from Overheated Coffee and Failure to Follow Hot Beverage Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure the environment was free from accident hazards and that residents received adequate supervision to prevent accidents, specifically related to serving hot beverages. The facility had a written policy titled “Serving Hot Beverages and Soup,” revised in 07/2007, which required the Food Service Department to monitor the temperature of all hot liquids to prevent burns if they contacted skin. The policy specified that coffee should be chilled to 120–130°F before being served and that the Food Service Department was responsible for ensuring all hot beverages, including those for activities, left the kitchen at the proper temperature. However, the coffee temperature log for March only included entries for 6:00 a.m. and 2:00 p.m., with no slot or documentation for 10:00 a.m. coffee temperatures, despite coffee being served at that time. Resident #1 was admitted with diagnoses including Parkinson’s disease, unspecified dementia, essential tremor, and legal blindness. A quarterly MDS with an ARD of 12/31/2025 showed a BIMS score of 13, indicating the resident was cognitively intact, and Section GG indicated no functional limitation in upper extremity range of motion. The resident’s care plan included a focus that the resident was at risk for burns from hot liquids, with interventions such as encouraging consumption of hot liquids while sitting at a table, requiring use of a cup with a lid for all hot beverages, and specifying that the temperature of hot liquids should not exceed 130°F. Another care plan focus addressed impaired visual function related to legal blindness, with interventions to provide activities adjusted to the resident’s visual disability. During a 10:00 a.m. group activity, Resident #1 spilled hot coffee on her lap. The dietary manager later confirmed that coffee was served at 6:30 a.m., 10:00 a.m., and 2:00 p.m., and that the dietary aide who prepared the coffee for the incident reported the coffee temperature as 140°F, which exceeded the facility’s policy limit of 130°F. Resident #1 reported that she spilled coffee on herself while sitting at a table in the activity room and that the coffee was hot and burned when it was spilled. Subsequent nursing and NP assessments documented two in-house–acquired wounds on the resident’s left upper thigh: one described as a blister and one as a burn, later characterized by the NP as a full-thickness (3rd degree) burn and a partial-thickness (2nd degree) burn. These findings, combined with the lack of documented 10:00 a.m. temperature monitoring and the reported serving temperature of 140°F, demonstrate that the facility did not follow its hot beverage policy and failed to protect the resident from an avoidable burn hazard.
Failure to Maintain Safe Enabler Bar Results in Severe Leg Laceration
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s enabler bar was free from accident hazards, resulting in an actual injury. The facility’s own Bed and Side Rails policy required a designee to inspect all bed frames, mattresses, and bed rails, including grab bars and assist bars, as part of a regular maintenance program. The Maintenance Supervisor job description also required daily tours of the property to identify and correct hazardous conditions and liability hazards. Despite these requirements, the enabler bar on one resident’s bed had a missing end cap, creating a sharp edge that was not identified or corrected prior to use. The affected resident had been admitted with multiple diagnoses, including Peripheral Vascular Disease, Malnutrition, Chronic Kidney Disease, Depression, and Alzheimer’s Disease, and had a BIMS score of 5, indicating severe cognitive impairment. The resident was receiving hospice services and required extensive assistance of one staff person with transfers, as documented in the care plan. On the date of the incident, a CNA assisted the resident with a transfer from a wheelchair to the bed. During this transfer, the resident’s left lower leg rubbed against the enabler bar that had the missing end cap and sharp edge. Nursing documentation recorded that the CNA called an LPN to the room and the LPN observed a large laceration on the resident’s left lower leg with bleeding, which the CNA reported had occurred during the transfer. The LPN noted that the enabler bar had a missing end cap, resulting in a sharp edge, and that the resident’s leg had contacted this area during the transfer. The resident was sent to the emergency department, where records described a very large stellate laceration measuring 25.5 cm on the lateral left lower leg, extending deep to the fascia and requiring extensive cleaning and a complicated repair with internal and external sutures, as well as a tetanus vaccination. Subsequent physician notes documented that the wound required ongoing assessment, daily wound care, and two courses of Bactrim DS due to the extent and depth of the laceration and delayed healing, with sutures removed in stages over several weeks.
Failure to Maintain Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for 8 consecutive hours per day, 7 days a week, as required. Review of the time card report for staff member S5RN from 02/22/2026 through 03/24/2026 showed that on five specific dates—02/25/2026, 02/26/2026, 02/27/2026, 02/28/2026, and 03/01/2026—there were fewer than 8 consecutive hours of RN coverage, with recorded work times of 6.50, 7.48, 6.48, 7.50, and 7.50 hours respectively. During an interview on 03/25/2026 at 9:35 a.m., the Administrator (S1) confirmed that S5RN was the only RN scheduled between 02/22/2026 and 03/21/2026 and acknowledged that the facility did not have 8 consecutive hours of RN coverage on the identified dates. No additional information was provided in the report regarding specific residents, their medical conditions, or any clinical events occurring during the periods without full RN coverage.
Failure to Maintain Adequate Supply of Clean Towels and Bed Linens
Penalty
Summary
The facility failed to provide residents with a safe, functional, sanitary, and comfortable environment by not ensuring the consistent availability of clean bath towels and bed linens. The facility’s own Facility Assessment Tool, updated on 03/23/2026, identified bed and bath linen as non-medical supplies for which PAR levels must be maintained at all times to ensure adequate supplies. Despite this, multiple interviews and record reviews showed that clean linens and towels were often unavailable. One resident, admitted on 12/05/2022 with diagnoses including diffuse traumatic brain injury and allergic rhinitis and a BIMS score of 15 (no cognitive impairment), reported that bath towels and bed linens were often unavailable, most recently during the week of 03/15/2026 through 03/21/2026. Another resident, admitted on 07/12/2023 with diagnoses including type 2 diabetes mellitus and asthma and a BIMS score of 15, had filed a grievance on 01/10/2026 reporting that personal bath towels and sheets were missing from the laundry and later reported that family had to provide personal linens because the facility frequently lacked bath towels and bed linens. Staff interviews corroborated these reports: a laundry staff member stated the facility frequently did not have clean bath towels and bed linens available for residents; a CNA reported that clean bath towels and bed linens were unavailable for residents during the week of 03/08/2026 through 03/14/2026; and the ADON confirmed that the facility did not have clean bath towels and bed linens available for residents on 03/23/2026. This pattern of unavailability affected the facility’s census of 58 residents.
Failure to Report Resident Elopement to State Survey Agency
Penalty
Summary
The deficiency involves the facility’s failure to report a resident elopement to the State Survey Agency as required by state law and by the facility’s own Wandering and Elopement Policy dated 11/15/2023. That policy directs that when a resident returns after an elopement, the DON or charge nurse must examine the resident, notify the attending physician, complete an incident/accident report, document the event in the medical record, and notify regulatory agencies per state guidelines. Record review showed that one resident, admitted on 01/09/2026, had multiple diagnoses including type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy, gait and mobility abnormalities, disorientation, unspecified dementia with anxiety, psychotic and mood disturbance, anxiety disorder, and essential hypertension. A Quarterly MDS documented a BIMS score of 4, indicating severely impaired cognition, and the resident was assessed as an elopement risk level 3 due to a history of attempted elopement at home, wandering with purpose in the facility, and exit-seeking behavior. Progress notes and interviews confirmed that on 02/08/2026 the resident was found outside the facility alone in the flower bed at the front of the building, bent over with hands in the dirt, by an oncoming nurse arriving for her shift. The LPN reported she parked her car, went to assist the resident, and alerted staff inside that the resident was outside alone. The resident’s responsible party similarly reported that the resident had been found outside alone in front of the facility on that date. During interview, the Administrator confirmed that the resident, who had dementia and a BIMS score of 4, had been found outside in the flower bed in front of the facility and acknowledged that this incident was not reported to the State Survey Agency, constituting a failure to report the elopement in accordance with state law and facility policy.
Failure to Revise Care Plan After Elopement and Development of Diabetic Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive care plan following significant changes in condition, specifically an elopement and the development of a diabetic ulcer. The resident was admitted with multiple diagnoses, including type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy at multiple sites, gait and mobility abnormalities, disorientation, unspecified dementia with associated anxiety, psychotic and mood disturbances, an anxiety disorder, and essential hypertension. Progress notes documented that the resident was found outside the facility in a flower bed, bent over with hands in the dirt, after having eloped from the building. Further review of the resident’s progress notes showed that a diabetic ulcer was identified on the resident’s right heel the day after the elopement. Despite these documented changes in condition, review of the resident’s comprehensive care plan revealed no revisions to address the actual elopement event or the new diabetic ulcer on the right heel. During an interview, the MDS Coordinator confirmed that the resident’s care plan should have been revised to reflect both the elopement and the development of the diabetic ulcer, but it was not.
Failure to Implement and Document Diabetic Foot and Heel Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and the comprehensive care plan for a resident with diabetes and multiple comorbidities. The resident was admitted with type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy, gait and mobility abnormalities, disorientation, unspecified dementia with associated psychiatric symptoms, anxiety disorder, and hypertension. On admission, the Minimum Data Set and skin assessment documented a deep tissue injury on the right heel. A nurse practitioner’s progress note dated shortly after admission described a deep tissue injury on the right heel being treated with gentian violet and foam and noted the heel was tender to touch. However, there were no corresponding physician’s orders for wound care treatment on the January and early February physician order sheets, and the treatment administration records for that same period showed no wound care treatments provided. The resident’s care plan for diabetes included an approach to check the body for breaks in the skin and treat promptly as ordered by the physician, but the facility did not develop and implement specific approaches addressing the documented right heel injury. A wound care nurse’s progress note later identified a diabetic ulcer on the right heel, described as tender and spongy, and documented application of gentian violet–soaked gauze and foam dressing. Only then was a physician’s order written to monitor the right heel and apply gentian violet dampened gauze and a protective dressing on specified days, with the treatment administration record showing documentation of these treatments on only three dates. The resident’s responsible party reported that the resident was discharged and subsequently required emergency department treatment for cellulitis due to a diabetic ulcer on the right heel, for which antibiotics were prescribed. The wound care nurse confirmed the initial documentation of a deep tissue injury without any physician’s orders for treatment and that the diabetic ulcer was not identified until nearly a month after admission, and the nurse practitioner confirmed he examined the right heel only once during that period.
Failure to Follow Hand Hygiene and Glove Protocols During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain an infection prevention and control program during incontinence care, specifically related to hand hygiene, glove use, and handling of soiled linens. The facility’s own policy for bladder incontinence care requires staff to perform handwashing or use alcohol gel, don disposable gloves, cleanse the perineal and anal areas, then remove and discard gloves and perform hand hygiene before proceeding. During observed incontinence care for one resident, a CNA donned clean gloves and used perineal wipes to remove bowel movement from the resident’s buttocks, then, without changing gloves or performing hand hygiene, placed a clean incontinence pad and brief under the resident. The CNA placed a soiled brief and urine-soaked bed pad at the foot of the bed on top of the resident’s clean comforter, then disposed of the soiled brief in the trash, spread a clean incontinence pad on the bed, and secured a clean brief, all without changing gloves or performing hand hygiene. The same CNA continued to touch the resident’s clean clothing, body, wheelchair armrests, and room door, transferred the resident to the wheelchair, and moved the resident into the hallway, then returned to retrieve the soiled incontinence pad and carried it down the hall to the soiled linen barrel before finally disposing of gloves, again without any observed hand hygiene during the entire episode of care. In a separate observation involving another resident, two CNAs provided incontinence care without performing hand hygiene before donning gloves. One CNA removed bowel movement from the resident’s buttocks, discarded the soiled brief, removed soiled gloves, and donned clean gloves without hand hygiene, then touched the resident’s extremities, bed linens, and applied a clean brief and incontinence pad. The CNA again changed gloves and dressed the resident in a clean gown, touching multiple body areas, without hand hygiene. The second CNA unfastened the brief, confirmed the resident remained soiled, wiped remaining stool, and helped secure the clean brief without changing soiled gloves or performing hand hygiene. Both CNAs later confirmed in interviews that they should have performed hand hygiene and changed gloves appropriately, and the DON confirmed staff are expected to change gloves when soiled or moving from contaminated to clean areas, sanitize hands between glove changes and between residents, and avoid placing soiled linen on clean linen.
Failure to Honor Resident Dignity and Discontinue Unnecessary Isolation Practices
Penalty
Summary
The deficiency involves failure to honor residents' rights to dignity and self-determination. One resident, who was lying in bed and requested a bedpan, was observed on 03/25/2026 at 8:59 a.m. using the call light with surveyor assistance. When the CNA entered the room, she stated the resident was wearing a diaper, could not get up due to left-sided weakness from a stroke, and said the resident "can go in her diaper" instead of providing a bedpan as requested. A COTA later reported that therapy had recommended the resident use a bedpan and had removed the bedside commode the previous day, and that the resident did not want to use a diaper. The COTA also stated the resident’s left arm was flaccid and that she required maximum assistance of two people. A second deficiency involved another resident who continued to receive meals on disposable dishware in the dining room after contact isolation precautions had been discontinued. This resident had diagnoses including vascular dementia, enterocolitis due to Clostridium difficile, hyperlipidemia, heart failure, and depression, and had a BIMS score of 9, indicating moderately impaired cognition. A physician order for single room isolation with contact precautions had been discontinued on 02/17/2026, yet on 03/23/2026 at 11:20 a.m., the resident was observed receiving a lunch tray on disposable dishware while seated in the dining room. The ADON confirmed the resident was no longer on contact precautions and should not have been receiving meals on disposable dishware.
Failure to Keep Call Light Within Reach for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was accessible as required by facility policy and necessary to reasonably accommodate the resident’s needs. The facility’s policy on answering call lights, dated 01/16/2026, states that when a resident is in bed or confined to a chair, the call light must be within easy reach. Resident #3 was admitted on 12/07/2023 with diagnoses including mononeural disorder, paraplegia, epilepsy, and peripheral vascular disease. A quarterly MDS with an ARD of 03/03/2026 documented a BIMS score of 6, indicating severe cognitive impairment, and showed the resident required setup assistance with eating, was dependent for toileting and personal hygiene, and needed substantial/maximal assistance to roll left to right. On multiple observations on 03/24/2026, surveyors found the resident’s call bell out of reach despite the resident’s reliance on it to express needs. At 10:12 a.m., the resident was lying in bed with eyes closed and the call bell was on the floor on the right side of the bed, not within reach. At 12:24 p.m., the resident was awake and alert in bed, and again the call bell was on the floor and not reachable; the resident stated he could not reach it. During an interview at 12:45 p.m., a CNA familiar with the resident confirmed the resident could express needs with short responses and used the call bell. At 12:48 p.m., with the CNA present, the call bell was still on the floor and not within reach, and the CNA acknowledged it should have been accessible. Later observations at 1:41 p.m. and 3:00 p.m. found the resident awake and alert in a reclined position in a Geri chair, with the call bell hanging on the side of the bed and again out of reach; the DON, present at 3:00 p.m., confirmed the call bell was not within reach and should have been.
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