Camelot Of Broussard
Inspection history, citations, penalties and survey trends for this long-term care facility in Broussard, Louisiana.
- Location
- 418 Albertson Parkway, Broussard, Louisiana 70518
- CMS Provider Number
- 195592
- Inspections on file
- 27
- Latest survey
- March 13, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Camelot Of Broussard during CMS and state inspections, most recent first.
The facility failed to maintain effective infection control, with staff not performing proper hand hygiene during medication administration and not wearing appropriate PPE for a resident on Enhanced Barrier Precautions. Observations showed an LPN did not sanitize hands after removing a wristband and before handling medications, and another LPN used a pen from the floor without sanitizing hands. Additionally, staff provided wound care to a resident without gowns, despite EBP requirements.
The facility did not maintain professional standards for food service safety, as observed when the Dietary Manager was without a beard restraint and the Maintenance Director's hair was not fully covered by a hair net. This oversight could potentially affect the 124 residents consuming food from the kitchen.
A resident's dignity was compromised when a sign indicating their need for feeding assistance was placed outside their door, visible to the public. This action violated the facility's policy on maintaining resident dignity and confidentiality. The resident, with severe cognitive impairment and requiring assistance due to hemiplegia, had not requested the sign to be placed publicly. The DON confirmed the sign's presence, which was contrary to the responsible party's wishes.
A resident with dementia and at moderate risk for falls was not rounded on for six hours, leading to a fall. Despite guidelines for two-hour checks, staff failed to enter the resident's room during this period, as confirmed by video footage. The DON acknowledged the lapse in care.
The facility failed to accurately maintain and reconcile narcotic records for one of two medication carts. Discrepancies were found in the counts of Oxycodone and Lorazepam pills between the lockbox and narcotic record sheets. The ADON noted that a nurse did not sign out medications on the record sheet after administration, leading to these discrepancies.
An LPN in an LTC facility borrowed Zofran from another resident's supply to administer to a resident with nausea, despite the medication being available in the facility's pyxis machine. The LPN prioritized quick symptom relief over proper medication dispensing procedures, as confirmed by the DON.
A facility failed to document the administration of Zofran and the resident's response, as required by policy. The resident, with multiple health conditions, was prescribed Zofran for nausea, but the LPN did not record the administration or follow-up on the MAR. The DON confirmed the lapse in procedure, highlighting a deficiency in pharmaceutical services.
A facility failed to maintain accurate medical records when an LPN did not document the administration of Zofran for a resident who experienced nausea and vomiting. The EMAR lacked entries for the medication administration and the resident's response, as confirmed by the DON. This deficiency had the potential to impact the care of all residents.
A facility failed to protect a resident from verbal and mental abuse by a CNA, who used derogatory language and refused assistance, causing distress to the resident with cognitive impairment. Another resident was not protected from physical abuse by a fellow resident with a history of aggression, who struck her in the dining area. Both incidents were confirmed through video surveillance, highlighting a breach in the facility's responsibility to ensure resident safety.
A resident with moderate cognitive impairment and muscle weakness was exposed during personal care when a CNA left the door open, violating privacy policies. The facility's DON confirmed the door should have been closed to protect the resident's dignity.
A resident with moderate cognitive impairment was verbally abused by a CNA, as captured on video. The CNA made derogatory remarks while the resident was on the floor, and neither the RN nor the LPN present reported the incident to the facility's administration, despite acknowledging the unprofessional conduct. The facility's policy mandates reporting such incidents, which was not followed.
Two residents experienced deficiencies in care due to failures in reporting changes in their conditions. One resident, with severe cognitive impairment, suffered a leg fracture after her leg slipped off a wheelchair footrest, but the CNA did not report her pain to the nursing staff. Another resident, with a high fever and low oxygen levels, was placed on supplemental oxygen by an RN, but the resident's family and physician were not notified of the condition change. These communication lapses were confirmed by staff and family interviews.
The facility failed to implement a comprehensive care plan and physician's orders for two residents. One resident, with severe cognitive impairment, was not monitored as ordered after a fall, resulting in a lack of documentation for two shifts. Another resident, with mobility issues, fell and sustained a head injury, but no new non-pharmacological interventions were added to prevent future falls, despite the fall being linked to a urinary tract infection.
A facility failed to monitor a resident's fluid intake and output, leading to a deficiency in maintaining hydration status. The resident, with conditions including Overactive Bladder and Acute Cystitis, showed acute creatinine elevation. Despite a care plan requiring monitoring, there was no specific documentation for fluid intake, as confirmed by the DON and Quality Insurance Nurse.
Infection Control Lapses in Hand Hygiene and PPE Use
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene practices during medication administration. On March 10, 2025, observations revealed that an LPN did not sanitize her hands after removing a wristband from a resident and before continuing medication preparation. Additionally, the same LPN failed to perform hand hygiene before and after donning gloves to remove pills from a medicine cup. Another LPN was observed picking up a pen from the floor and using it without sanitizing her hands. Both LPNs acknowledged their lapses in hand hygiene during interviews. The facility also failed to adhere to Enhanced Barrier Precautions (EBP) for a resident with a Stage 3 pressure ulcer. The resident's care plan required the use of gowns and gloves during high-contact care activities due to the risk of multidrug-resistant organism (MDRO) transmission. Despite a sign indicating the need for EBP, the Assistant Director of Nursing and an LPN were observed providing wound care to the resident without wearing gowns. Both staff members confirmed their awareness of the EBP requirement but did not comply during the care session. Interviews with the facility's Infection Preventionist confirmed the lapses in infection control practices, emphasizing the necessity of hand hygiene and appropriate PPE use. The deficiencies highlight the facility's failure to implement its own policies on hand hygiene and EBP, potentially compromising the safety and well-being of residents and staff.
Failure to Maintain Food Service Safety Standards
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by not ensuring that staff wore appropriate hair restraints. During an observation, the Dietary Manager (S1DM) was seen in the kitchen without a beard restraint, leaving his facial hair exposed. Additionally, the Maintenance Director (S2MD) was observed wearing a hair net that did not fully cover his hair, allowing a large amount of hair to hang down to his shoulders. Both staff members acknowledged the oversight, confirming that they should have been wearing proper hair restraints as per the facility's policy on preventing foodborne illness through employee hygiene and sanitary practices. This deficiency had the potential to affect the 124 residents who consumed food prepared in the kitchen, as the lack of proper hair restraints could lead to contamination of food, equipment, utensils, and linens.
Resident Dignity Compromised by Public Display of Care Needs
Penalty
Summary
The facility failed to maintain the dignity of a resident by placing a sign outside the resident's door, visible to the public, indicating that the resident required feeding assistance. This action was contrary to the facility's policy on Quality of Life-Dignity, which specifies that signs indicating a resident's clinical status or care needs should not be openly posted. The resident in question, identified as Resident #14, had severe impaired cognition and required partial to moderate assistance with eating due to hemiplegia and hemiparesis following a cerebral infarction. Observations on two separate occasions confirmed the presence of the sign outside the resident's door. The resident's responsible party (RP) stated that she did not request the sign to be placed outside the door, but rather inside the room to assist with care, especially when agency staff were working. The Director of Nursing (DON) confirmed the presence of the sign and mentioned that the RP had requested it to be placed outside the door previously. This failure to adhere to the facility's policy could have led to decreased feelings of self-worth, embarrassment, and a diminished quality of life for the resident.
Failure to Conduct Regular Rounding Leads to Resident Fall
Penalty
Summary
The facility failed to provide care and services that met professional standards of quality by not ensuring that rounding was conducted every two hours for a resident. The resident, who was at moderate risk for falls due to psychoactive drug use and had impaired cognitive function related to Alzheimer's and dementia, was not checked on for a period of six hours. This lapse in care occurred despite the facility's guideline of conducting rounds every two hours to ensure resident safety and positioning. The deficiency was highlighted by an incident where the resident fell from her bed and was found on the floor after being unattended for several hours. Video footage from the resident's electronic monitoring device confirmed that staff did not enter the resident's room between 11:00 PM and 5:16 AM, during which time the fall occurred. The Director of Nursing acknowledged the failure in staff rounding, confirming that the expected two-hour checks were not performed, which contributed to the resident's fall.
Discrepancies in Narcotic Records for Medication Cart
Penalty
Summary
The facility failed to maintain and reconcile individual resident narcotic records accurately for one of the two medication carts reviewed. During a narcotic count review of Cart A, discrepancies were identified. For one resident, the count of Oxycodone APAP 10-325mg pills in the lockbox was 72, while the narcotic record sheet indicated 73 pills. For another resident, the count of Lorazepam 2mg pills in the lockbox was 17, whereas the narcotic record sheet showed 16 pills. The Assistant Director of Nursing (S6ADON) acknowledged that the nurse who administered the medications that morning did not sign them out on the narcotic record sheet, which should have been done immediately after administration to ensure accurate reconciliation.
LPN Borrows Medication from Another Resident
Penalty
Summary
The facility failed to ensure that services were provided to meet professional standards of quality when an LPN borrowed medication from one resident to administer to another resident. This incident was identified during a complaint survey. The LPN, identified as S2LPN, borrowed Zofran, a nausea medication, from another resident's supply instead of obtaining it from the facility's medication pyxis machine, which is an automated dispensing system designed to provide the right medications to the right patient at the right time. This action was taken despite the availability of Zofran in the pyxis machine, as confirmed by the Director of Nursing (S1DON). The resident involved, referred to as Resident #1, had been admitted with diagnoses including Generalized Osteoarthritis, Morbid Obesity, Muscle Weakness, Essential Hypertension, and Benign Prostatic Hyperplasia with lower urinary tract symptoms. The resident had an active order for Zofran 4mg to be administered three times a day for nausea. During an interview, S2LPN admitted to borrowing the medication because she was focused on quickly relieving the resident's symptoms. The Director of Nursing confirmed that the LPN should have used the medication from the pyxis machine and not borrowed from another resident's supply.
Failure to Document Medication Administration and Resident Response
Penalty
Summary
The facility failed to ensure the accurate administration and documentation of a medication for one resident during a complaint survey. The resident, who had a history of Generalized Osteoarthritis, Morbid Obesity, Muscle Weakness, Essential Hypertension, and Benign Prostatic Hyperplasia, was prescribed Zofran for nausea. However, there was no documentation on the Medication Administration Record (MAR) that the medication was administered after the Licensed Practical Nurse (LPN) called the Nurse Practitioner (NP) for the order. Additionally, there was no documentation of the resident's response to the medication. The Director of Nursing (DON) confirmed that the LPN failed to document the administration of Zofran and the resident's response in the clinical record, which was against the facility's policy. The LPN admitted to administering the medication as ordered but acknowledged not following the correct procedure for documentation on the MAR and in the nurse's notes. This lack of documentation and follow-up on the resident's symptoms constituted a deficiency in the facility's pharmaceutical services.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to maintain accurate medical records in accordance with accepted professional standards and practices for one of the sampled residents. Specifically, an LPN did not document the administration of a medication, Zofran, on the Electronic Medication Administration Record (EMAR) or in the nurse's notes. This oversight occurred after the resident complained of nausea and vomited twice, prompting the LPN to contact the Nurse Practitioner and receive a new order for Zofran 4 mg to be administered every 8 hours for 3 days. However, the EMAR for October 2024 did not reflect that the medication was administered on the specified date, nor did it include any follow-up documentation regarding the resident's response to the medication. During an interview and record review with the Director of Nursing (DON), it was confirmed that the LPN failed to document the administration of Zofran and the resident's response in the clinical record. The DON acknowledged that the LPN should have recorded this information either on the EMAR or in the nurse's notes, as per the facility's policy on medication administration documentation. This deficiency in documentation had the potential to affect the care of all 127 residents in the facility.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect Resident #2 from verbal and mental abuse by a Certified Nursing Assistant (CNA), identified as S6CNA. Resident #2, who has a moderately impaired cognitive status due to conditions such as Disease of Basal Ganglia and Depression, was subjected to derogatory and intimidating language by S6CNA on multiple occasions. Video surveillance captured instances where S6CNA used disparaging terms and refused to assist Resident #2 adequately, causing the resident to struggle physically and emotionally. The resident's responsible party reported increased anxiety and nervous tics in Resident #2, which were attributed to the verbal abuse experienced at the facility. The facility also failed to protect Resident #1 from physical abuse by another resident, Resident #3. Resident #1, who has severe cognitive impairment due to Alzheimer's Disease, was struck by Resident #3 in the dining area. Video surveillance confirmed that Resident #3, who also has severe cognitive impairment and a history of aggressive behavior, wheeled by Resident #1 and slapped her on the arm. Despite Resident #1's inability to recall the incident, the facility's staff confirmed the aggressive act through video review. The facility's policy on abuse and neglect emphasizes the responsibility to ensure residents' safety and freedom from abuse. However, the incidents involving Resident #2 and Resident #1 demonstrate a failure to uphold these standards. The facility's administration and nursing staff acknowledged the unprofessional behavior of S6CNA and the aggressive actions of Resident #3, indicating a lapse in maintaining a safe and respectful environment for all residents.
Privacy Violation During Personal Care
Penalty
Summary
The facility failed to ensure privacy for a resident during personal care, violating the resident's rights to dignity and respect. The facility's policy on Quality of Life - Dignity, which emphasizes the importance of maintaining and protecting resident privacy during personal care, was not adhered to. This deficiency was identified through video surveillance and interviews, revealing that a Certified Nursing Assistant (CNA) left the door open while changing the resident's brief, exposing the resident's lower body to the hallway. The resident involved had a history of muscle weakness, Parkinson's Disease, and moderate cognitive impairment, requiring extensive assistance with personal hygiene. Despite these needs, the CNA did not close the door during personal care on two separate occasions, leaving the resident exposed. The Director of Nursing confirmed that the door should have been closed to ensure the resident's privacy, as per the facility's policy.
Failure to Report Verbal Abuse Incident
Penalty
Summary
The facility failed to report an incident of verbal abuse involving a resident, which was captured on video surveillance. The incident occurred when a CNA, along with an RN and an LPN, entered the resident's room and found her sitting on the floor. The CNA made derogatory remarks about the resident, suggesting that the resident was playing games and did not need assistance. The RN and LPN present did not report the incident to the ADON, DON, or the administrator, despite acknowledging that the CNA's behavior was unprofessional and could have caused the resident to feel humiliated. The resident involved had a history of conditions including Disease of Basal Ganglia, Muscle Weakness, Parkinson's Disease, and Tremor, with a moderately impaired cognitive status as indicated by a BIMS score of 12. The failure to report the incident was confirmed during interviews with the RN and LPN, who admitted they should have reported the CNA's mistreatment of the resident. The facility's manual requires that any evidence of mistreatment, exploitation, neglect, or abuse be reported to the administrator, which was not adhered to in this case.
Failure to Report Changes in Resident Conditions
Penalty
Summary
The facility failed to ensure immediate reporting of a change in condition for two residents, leading to deficiencies in care. For the first resident, who had severe cognitive impairment and a history of Alzheimer's Disease and pain, the issue arose when the resident's leg slipped off the wheelchair footrest, causing pain and a subsequent fracture. Despite the resident's complaints of pain, the van driver, who was also a CNA, did not report the incident to the nursing staff. This lack of communication resulted in a delay in addressing the resident's injury, as the nurse was not informed until later, after the resident had already communicated her pain to other staff members. In the case of the second resident, who had diagnoses including overactive bladder and cognitive communication deficit, the deficiency involved a failure to notify the resident's family and physician of a significant change in condition. The resident experienced a high fever and low oxygen levels, prompting the RN to administer Tylenol and place the resident on supplemental oxygen. However, the RN did not notify the resident's family or physician about these changes, leaving them unaware of the resident's condition until after the resident was hospitalized. Interviews with staff and family members confirmed these lapses in communication and reporting. The Director of Nursing acknowledged that the van driver should have reported the first resident's pain, and the RN should have informed the family and physician about the second resident's condition. These failures to follow the facility's policy on notifying relevant parties of changes in residents' conditions contributed to the deficiencies identified in the report.
Failure to Implement Care Plans and Physician's Orders
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan and physician's orders for two residents. For Resident #1, the facility did not follow the physician's order to monitor the resident for changes in condition, range of motion, and pain every shift for 72 hours following an incident. The resident, who has severe cognitive impairment due to Alzheimer's Disease, experienced a fall from her wheelchair, resulting in a nondisplaced fracture of the proximal tibia. Despite the order for acute charting and monitoring, there was no documentation of assessments on the evening shifts of two consecutive days, indicating non-compliance with the physician's directive. For Resident #3, the facility did not develop appropriate interventions to prevent future falls after the resident experienced a fall. The resident, who has a history of cerebral infarction and mobility issues, fell while attempting to get into a chair, resulting in a head injury. Although the fall was potentially linked to a urinary tract infection, the only interventions implemented were lab tests and a urinalysis, followed by a course of antibiotics. No non-pharmacological, person-centered interventions were added to the care plan to address the risk of future falls, as confirmed by the Director of Nursing.
Failure to Monitor Resident's Fluid Intake and Output
Penalty
Summary
The facility failed to effectively monitor a resident's fluid intake and output, which was necessary to maintain acceptable hydration parameters. The resident, who was admitted with diagnoses including Overactive Bladder, Cognitive Communication Deficit, and Acute Cystitis without Hematuria, was found to have an acute elevation of creatinine, indicating potential acute kidney injury. The care plan for this resident included interventions to monitor intake and output, but there was no documented evidence in the resident's health record that this monitoring was being carried out effectively. During an interview with the Director of Nursing and the Quality Insurance Nurse, it was confirmed that there was no specific area in the resident's medical record for documenting the number of times the resident voided or the number of brief changes. The Director of Nursing stated that the resident's intake was monitored through the percentage of meal intake, which included fluids with meals, but there was no specific documentation for fluid intake throughout each shift. This lack of specific documentation and monitoring led to the deficiency in maintaining the resident's hydration status.
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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