Camelot Brookside
Inspection history, citations, penalties and survey trends for this long-term care facility in Jennings, Louisiana.
- Location
- 3330 Frontage Road, Jennings, Louisiana 70546
- CMS Provider Number
- 195550
- Inspections on file
- 19
- Latest survey
- March 27, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Camelot Brookside during CMS and state inspections, most recent first.
A CNA failed to follow infection control protocols by exiting a resident's room with soiled gloves and using them to open another room's door. This action violated the facility's policy requiring glove removal and hand hygiene before leaving a resident's room, as confirmed by the CNA and the Infection Preventionist.
A facility failed to maintain a clean environment for a resident, as evidenced by repeated observations of a large red stain on the floor and multiple red stains on the bedside table. Despite documentation indicating the room was cleaned, the housekeeping supervisor confirmed it was not cleaned as required, revealing a lapse in housekeeping procedures.
A resident filed a grievance about her colostomy bag not being changed, and the facility failed to document and conduct the promised in-service training for staff on colostomy care. The grievance was marked as resolved, but no evidence of follow-up training was provided by the staff responsible.
Two residents requiring oxygen therapy did not receive the prescribed oxygen flow rates as per their care plans. One resident's oxygen concentrator was set below the ordered 3 liters per minute, causing shortness of breath, while another resident's oxygen settings varied from the prescribed 3 liters, with observations showing 2, 3.5, and 4 liters at different times. LPNs confirmed the residents could not adjust the settings themselves.
A facility failed to invite a resident and their Responsible Party (RP) to a care planning meeting, as required by policy. The resident, with moderate cognitive impairment and multiple health conditions, reported never being invited to such meetings. The Social Service Director claimed invitations were sent, but the sign-in sheet lacked signatures from the resident or RP, and the RP confirmed not receiving an invitation.
A resident with Parkinson's disease and impaired mobility did not receive necessary assistance with personal hygiene, specifically in trimming and cleaning fingernails. Despite a care plan requiring extensive assistance and a physician's order for nail care, observations showed the resident's nails were long and dirty. An LPN confirmed the neglect, indicating a deficiency in the facility's nail care procedures.
A facility failed to conduct an activity program for a resident with severe cognitive impairment, as required by their policy. Despite the resident's care plan indicating a need for regular 1:1 visits, no documented activities were found over a 30-day period. Observations showed the resident lying in bed with the TV on, without staff engagement. Interviews confirmed a lack of documented interactions, and the resident's daughter reported not observing any staff interactions during her visits.
The facility failed to properly store and label medications as per professional standards. An LPN observed loose pills in Medication Cart A, which were confirmed to be improperly stored. The DON also confirmed that medications should not be left loose in the carts. The facility's policy mandates that drugs be stored in their original packaging, with only the issuing pharmacy authorized to transfer medications.
The facility failed to provide a clean and homelike environment for three residents. A resident's urinal was improperly stored, another's room had soiled bedpans and a dirty bathroom, and a shared bathroom had unlabeled urinals and a soiled bedpan. These issues were confirmed by staff, including a CNA and the DON.
A resident with moderate cognitive impairment did not receive nine doses of prescribed Hydrocodone-APAP due to staff oversight. The medication was marked as 'hold' or 'other' while awaiting pharmacy delivery, despite being available in the facility's emergency drug kit. Staff interviews revealed a lack of awareness or utilization of the emergency kit, which led to the deficiency.
Infection Control Breach: Improper Glove Use
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by staff actions that did not adhere to established protocols. During an observation, a Certified Nursing Assistant (CNA) was seen exiting a resident's room while wearing soiled gloves and carrying soiled linens. The CNA then used the soiled gloves to open the door of another room, Room A. This action was contrary to the facility's policy, which mandates that gloves be removed and hand hygiene performed before leaving a resident's room. Interviews with the CNA and the Infection Preventionist confirmed that the CNA did not follow the required procedures, acknowledging that gloves should have been removed and hand hygiene performed before exiting the room and that soiled gloves should not have been used to open doors.
Failure to Maintain Clean Environment in Resident's Room
Penalty
Summary
The facility failed to maintain a clean and homelike environment for a resident, as evidenced by multiple observations of unclean conditions in the resident's room. On three separate occasions, a large red stain was noted on the floor next to the right side of the resident's bed, and multiple red circular stains were observed on the bedside table. These observations were made over the course of two days, indicating a lack of adherence to the facility's cleaning policy. The housekeeping supervisor confirmed that the room should have been cleaned daily, including mopping the floors and cleaning the bedside table. Despite the housekeeping checkoff list indicating that the room was cleaned, the supervisor acknowledged that the room was not cleaned as required. This discrepancy between the documented cleaning and the actual condition of the room highlights a failure in the facility's housekeeping procedures.
Failure to Document and Follow Up on Grievance Regarding Colostomy Care
Penalty
Summary
The facility failed to ensure proper documentation and follow-up on a grievance filed by a resident regarding colostomy care. The resident, who had a colostomy, filed a grievance on 03/04/2025, stating that her colostomy bag was not changed the previous night. The Director of Nursing (DON) apologized to the resident and assured her that staff would be in-serviced on colostomy care. The grievance was marked as resolved on 03/05/2025. However, upon review, it was found that there was no evidence of in-service training conducted after the grievance was reported. The Social Service Director confirmed the grievance resolution date, but the Staff Developer could not provide evidence of any in-service training related to colostomy care after the grievance was filed. The DON also failed to provide evidence of such training occurring on or after the grievance resolution date, indicating a lapse in the facility's grievance resolution process.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for two residents requiring oxygen therapy. Resident #55, who was admitted with chronic obstructive pulmonary disease, acute and chronic respiratory failure, and congestive heart failure, had a physician's order for oxygen at 3 liters per minute via nasal cannula. However, during an observation, it was found that the oxygen concentrator was set at 2.5 liters per minute, which was confirmed by the resident and an LPN. The resident reported experiencing slight shortness of breath while on the incorrect oxygen setting. Similarly, Resident #102, who was admitted with chronic obstructive pulmonary disease, hypertensive heart disease with heart failure, and emphysema, and was under hospice care, had a physician's order for continuous oxygen at 3 liters per minute. Observations revealed discrepancies in the oxygen flow rate, with settings found at 2 liters, 3.5 liters, and 4 liters at different times, none of which matched the physician's order. An LPN confirmed that the resident was not capable of changing the oxygen settings herself, indicating a failure in adhering to the prescribed care plan.
Failure to Invite Resident and RP to Care Planning Meeting
Penalty
Summary
The facility failed to ensure that a resident and/or the resident's Responsible Party (RP) was invited to the care planning meeting, which is a requirement for developing and revising a resident's care plan. This deficiency was identified for one resident out of a sample of 32, with the potential to affect a census of 112 residents. The facility's policy encourages the participation of the resident, their family, or legal representative in care plan development, and if participation is not practicable, an explanation should be documented in the medical record. However, in this case, there was no documentation of such an explanation. Resident #111, who has a history of colostomy, congestive heart failure, anxiety, cognitive communication deficits, depression, Diabetes Mellitus II, and chronic kidney disease, was not invited to the care plan meeting. The resident, with a BIMS score indicating moderate cognitive impairment, stated she had never been invited to a care plan meeting. The Social Service Director, responsible for care planning meetings, claimed that residents and their RPs are invited, but the sign-in sheet for the meeting showed only staff signatures, with no indication of the resident or RP's participation. Additionally, the resident's RP confirmed not receiving any invitation to the meeting.
Failure to Maintain Resident's Personal Hygiene
Penalty
Summary
The facility failed to provide necessary services for a resident who was unable to perform activities of daily living, specifically in maintaining good grooming by trimming and cleaning fingernails. The resident, who was admitted with diagnoses including Parkinson's disease and major depressive disorder, had a care plan indicating a self-care performance deficit related to Parkinsonism and impaired mobility. The care plan required extensive assistance with personal hygiene, yet observations revealed that the resident's fingernails were long and had brown debris underneath, indicating neglect in nail care. Despite having a physician's order allowing licensed nurses to clip and trim diabetic finger and toenails, the resident's fingernails remained untrimmed and uncleaned over multiple observations. An LPN confirmed that the treatment nurse was responsible for trimming residents' fingernails, but any nurse could perform this task. The failure to trim and clean the resident's fingernails was observed on two separate occasions, highlighting a deficiency in the facility's adherence to its own policy and procedure for nail care.
Failure to Conduct Activity Program for Resident
Penalty
Summary
The facility failed to ensure an activity program was conducted for a resident with severe cognitive impairment and multiple medical conditions, including unspecified dementia and aphasia following a cerebral infarction. The facility's policy required individual activities for residents unable to participate in group activities, with a minimum of three room visits per week documented on the Bed Bound Activity Assessment. However, a review of the resident's records over a 30-day period revealed no documented activities or 1:1 interactions, despite the resident's care plan indicating a need for regular 1:1 visits and cues to improve orientation. Observations on multiple occasions showed the resident lying in bed with the TV on, without staff engaging in any activities. Interviews with the Activity Director and the resident's daughter confirmed a lack of documented interactions and activities, despite claims of reading scripture to the resident. The resident's daughter, who visited weekly, also reported not observing any staff interactions such as reading, massaging, or playing music for her mother. This lack of engagement and documentation indicates a failure to meet the resident's activity needs as outlined in the facility's policy and care plan.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications in accordance with accepted professional standards. During an observation of Medication Cart A, conducted with an LPN, a loose oval orange pill was found in the bottom of the second drawer, and a loose round peach pill was found in the bottom of the third drawer. The LPN confirmed that medications should not be loose in the medication carts. Additionally, during an interview, the Director of Nursing confirmed that medications should not be left loose in any of the medication carts. The facility's policy on the storage of medications, last reviewed on 11/15/2024, states that drugs and biologicals should be stored in the packaging or containers in which they are received, and only the issuing pharmacy is authorized to transfer medications between containers.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for three residents, as observed during a survey. For Resident #1, a urinal without a lid was found hanging on the safety bar of the toilet, not stored in a bag, and remained in the same position upon subsequent observations. This was confirmed by a Licensed Practical Nurse, who acknowledged that the urinal should have been stored in a bag. Resident #2's room was found with a bedpan on the floor under the bed, which should have been stored in a bag in the bathroom. Further observations revealed two soiled bedpans on the bathroom floor, a trash can without a liner containing soiled incontinence items, and a strong urine odor. The toilet seat and rim were also soiled. These findings were confirmed by a Certified Nursing Assistant and the Director of Nursing, who both acknowledged the improper storage and cleanliness issues. For Resident #3, a shared bathroom contained three unlabeled urinals and a bedpan with stool and toilet paper in the shower, causing a strong odor. These issues were confirmed by a CNA and the DON, with a resident reporting the bathroom was often dirty.
Failure to Administer Prescribed Medication Due to Staff Oversight
Penalty
Summary
The facility failed to implement the comprehensive care plan for a resident by not administering nine doses of a prescribed medication, Hydrocodone-Acetaminophen, as ordered by the resident's physician. The resident, who was admitted with diagnoses including Osteomyelitis of the Vertebra and had a moderately impaired cognitive status, was supposed to receive this medication three times a day. However, the medication was not administered on multiple occasions due to it being marked as 'hold' or 'other' in the electronic health record, with notes indicating the medication was awaiting delivery from the pharmacy. Interviews with nursing staff revealed that the facility had an emergency drug kit containing the prescribed medication, which could have been used while waiting for the pharmacy delivery. However, the staff were either unaware of the availability of the medication in the emergency kit or did not utilize it. The Director of Nursing confirmed that the secured drug dispensing system was available for such situations, and the nurses should have been aware and used it to ensure the resident received the medication as ordered.
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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