Camelot Rehabilitation At Magnolia Park
Inspection history, citations, penalties and survey trends for this long-term care facility in Lafayette, Louisiana.
- Location
- 1511 Dulles Drive, Lafayette, Louisiana 70506
- CMS Provider Number
- 195573
- Inspections on file
- 34
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Camelot Rehabilitation At Magnolia Park during CMS and state inspections, most recent first.
The facility failed to maintain documentation for its QAPI program, as the DON could not locate the QAPI binder containing evidence of ongoing quality assurance and performance improvement efforts. This deficiency highlights a lack of oversight and documentation in maintaining the program.
The facility failed to provide documentation of its QAPI program, which is crucial for performance improvement activities. The facility could not present evidence of improvement projects addressing the services provided, potentially affecting 133 residents. The DON was unable to locate the QAPI binder during the survey.
The facility failed to provide evidence of its QAA committee meetings and ensure the committee was composed of required members, potentially affecting 133 residents. The DON could not locate the QAPI binder containing evidence of the ongoing QAPI program and meeting information.
The facility failed to maintain a safe and clean environment, with observations of damaged sheetrock, unfinished repairs, and detached call light units on Hall U. Additionally, a room was not cleaned after a resident's discharge, and on Hall Y, a light fixture was not working, a call light box was detached, and an electrical outlet cover was bent, exposing wiring. The Maintenance Supervisor confirmed these issues should have been addressed.
The facility failed to provide adequate care for two residents with pressure ulcers. One resident did not receive weekly wound assessments for their stage 3 pressure ulcers, while another resident's unstageable pressure ulcer was not identified in a timely manner. The DON confirmed that these assessments should have been conducted weekly by the Treatment Nurse and during bathing by CNAs.
Expired medications, including Sodium Chloride flushes and Heparin syringes, were found in Med Room C, confirmed by an LPN and the DON. These expired items, with dates ranging from July 2022 to November 2024, were not disposed of as per facility policy, potentially affecting 133 residents.
The facility failed to store food according to professional standards, with several opened items in the walk-in cooler not labeled with dates, and expired foods found in dry storage. The Dietary Supervisor confirmed these deficiencies, which could impact the 116 residents consuming food from the kitchen.
The facility failed to ensure proper PPE use for residents under Enhanced Barrier Precautions (EBP). A CNA and an LPN did not wear gowns while providing care to two residents with pressure ulcers and gastrostomy status, despite EBP signage. Additionally, two CNAs transferred a resident with a pressure sore without gowns. The DON confirmed the need for gowns and gloves during high-contact activities, indicating a pattern of non-compliance with infection control policies.
A facility failed to accurately code the MDS for a resident's use of Bipap therapy. The resident, with conditions including Sleep Apnea, had a physician's order for nightly Bipap use, which was confirmed by the care plan and MAR/TAR. However, the MDS did not reflect this use. The MDS coordinator confirmed the error during an interview and record review.
A resident with a urinary catheter was found with the drainage bag improperly placed on the floor, connected to their suprapubic catheter. The resident required assistance with transfers, and an LPN confirmed the improper placement, indicating a lapse in catheter care and infection control.
The facility failed to properly store respiratory equipment for two residents, leading to a deficiency in care. A resident with sleep apnea had her BiPAP mask left open to air without a storage bag, confirmed by an LPN. Another resident with multiple diagnoses had a CPAP mask and nasal cannula improperly stored, also confirmed by an LPN. Both instances violated the facility's policy requiring storage in labeled plastic bags.
The facility did not ensure daily staffing information was current and accessible, as staffing sheets were missing and stored in a closed binder in an infrequently used hallway. The Assistant Administrator confirmed the issue.
The facility failed to secure a handrail on Hall W, leaving it broken and detached with an exposed screw, as observed on multiple occasions. The Maintenance Supervisor confirmed the unsafe condition, which violated the facility's maintenance policy.
Facility Lacks Documentation for QAPI Program
Penalty
Summary
The facility failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) program was developed, implemented, and maintained in a comprehensive manner. During a review of the facility's policy, it was noted that all employees were expected to participate in ongoing QAPI efforts, which included continuous quality improvement and quality assurance processes. These processes involved analyzing clinical data, identifying opportunities for improvement, implementing interventions, and evaluating their effectiveness. However, the Director of Nursing (DON) was unable to provide documentation of the facility's ongoing QAPI program, as the QAPI binder containing this evidence was misplaced. Despite requests from the surveyor, the DON could not locate the binder or provide any evidence of the program, indicating a lack of documentation and oversight in maintaining the QAPI program.
Lack of QAPI Documentation
Penalty
Summary
The facility failed to provide documentation of its Quality Assurance and Performance Improvement (QAPI) program, which is essential for addressing performance improvement activities and projects. During the survey, the facility was unable to present evidence of the number and frequency of improvement projects that addressed the scope and complexity of the services provided. This deficiency had the potential to affect 133 residents residing in the facility. A review of the facility's policy revealed that all employees were expected to participate in ongoing QAPI efforts, which included continuous quality improvement and quality assurance processes. These processes involved analyzing clinical data, identifying opportunities for improvement, implementing interventions, and evaluating their effectiveness. However, the Director of Nursing (DON) was unable to locate the QAPI binder, which contained evidence of the facility's ongoing QAPI program, during the survey.
Failure to Document QAA Committee Meetings and Composition
Penalty
Summary
The facility failed to provide evidence that its Quality Assessment and Assurance (QAA) committee met at least quarterly and as needed. Additionally, the facility did not ensure that the QAA committee was composed of the required members, including the Director of Nursing (DON), Medical Director or designee, Infection Preventionist (IP), and at least three other staff members, one of whom must be the facility's administrator, owner, board member, or another individual in a leadership role with knowledge of facility systems and authority to change those systems. This deficiency had the potential to affect 133 residents residing in the facility. During a review of the facility's policy titled 'QAPI Program,' it was revealed that the facility was unable to present any documented evidence of the QAA committee meetings or documentation of who attended these meetings. The Director of Nursing (S2DON) was interviewed and stated that she could not locate the facility's QAPI binder, which contained evidence of the ongoing QAPI program and QAA committee meeting information. As a result, the facility could not provide evidence of its QAPI program due to the misplaced QAPI binder.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents. Observations on Hall U revealed multiple rooms with damaged sheetrock, unfinished repairs, and a call light unit detached from the wall. Additionally, housekeeping staff did not clean and sanitize a room after a resident was discharged to the hospital. On Hall Y, a light fixture was not functioning properly, a call light box was detached from the wall, and an electrical outlet cover plate was bent, exposing wiring. The facility's policy on maintenance service, revised on 10/30/24, states that the Maintenance Department is responsible for maintaining the building in a safe and operable manner. However, interviews with the Maintenance Supervisor confirmed that the issues identified should have been addressed. The observations and interviews indicate a failure to adhere to the facility's maintenance policy, resulting in an environment that does not meet the required standards for safety and cleanliness.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services for residents with pressure ulcers, consistent with professional standards of practice, leading to deficiencies in care. Resident #95, who was admitted with multiple diagnoses including morbid obesity and chronic heart failure, had three stage 3 pressure ulcers documented upon admission. However, the facility did not perform weekly wound assessments as required, with the last documented assessment occurring on 01/15/2025. This lapse was confirmed by the Director of Nursing (DON), who acknowledged that wound measurements should be conducted weekly and documented in the electronic health record. Similarly, the facility failed to conduct accurate skin assessments for Resident #108, who had multiple health issues including cerebral infarction and severe malnutrition. The resident's annual Minimum Data Set (MDS) did not initially reflect an unstageable pressure ulcer, which was later identified in a quarterly MDS. A wound evaluation revealed a new unstageable pressure ulcer on the resident's left elbow, which was not identified in a timely manner. The DON confirmed that skin assessments should be conducted weekly by the Treatment Nurse and during bathing by CNAs, indicating a failure in the facility's protocol to identify and document the pressure ulcer before it became unstageable.
Expired Medications Found in Med Room C
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in accordance with currently accepted professional principles, specifically in Med Room C. During an observation, it was found that expired medications, including Sodium Chloride flushes and Heparin pre-filled syringes, were available for administration. These expired items had expiration dates ranging from July 2022 to November 2024. The presence of these expired medications was confirmed by an LPN, who acknowledged that they should not have been available and should have been discarded. The Director of Nursing confirmed that expired medications should not have been present in Med Room C and should have been disposed of properly. This oversight had the potential to affect 133 residents residing in the facility, as expired medications were accessible for use. The facility's policy, revised in April 2019, mandates that discontinued, outdated, or deteriorated drugs or biologicals be returned to the dispensing pharmacy or destroyed, which was not adhered to in this instance.
Deficient Food Storage Practices in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food storage and handling, as evidenced by observations in the kitchen. During a tour of the kitchen, it was found that several opened food items in the walk-in cooler were not labeled with the date and time they were opened, nor with a use-by date. These items included large containers of Italian dressing, thousand island dressing, mayonnaise, mustard, pickles, a gallon of milk, cartons of almond milk, soy milk, pineapple juice, cranberry juice, apple juice, and a container of au jus prep. The Dietary Supervisor confirmed that these items were not labeled as required by the facility's policy. Additionally, the dry storage area contained expired food items, including a plastic gallon bag with an opened bag of powdered lemonade, fudge mix, and powdered chocolate pudding, all of which were past their expiration dates. The Dietary Supervisor acknowledged that these items were expired and should have been removed from storage and discarded. This deficiency in food storage practices had the potential to affect the 116 residents who consumed food from the kitchen.
Inadequate PPE Use in Infection Control
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper use of Personal Protective Equipment (PPE) by staff while providing care to residents under Enhanced Barrier Precautions (EBP). Resident #95, who had a stage 3 pressure ulcer, was observed to have care provided by a Certified Nursing Assistant (CNA) who did not wear a gown as required by the facility's policy. Similarly, Resident #118, with severe protein calorie malnutrition and gastrostomy status, received care from a Licensed Practical Nurse (LPN) who also failed to don a gown while changing the resident's incontinence brief, despite the presence of EBP signage indicating the need for gown use. Additionally, Resident #53, who was cognitively intact and had a pressure sore, was transferred using a mechanical lift by two CNAs who did not wear gowns, contrary to the EBP requirements. The Director of Nursing (DON) confirmed that gowns and gloves were necessary for high-contact activities for residents under EBP, yet staff failed to comply with these precautions. These observations highlight a consistent pattern of non-compliance with the facility's infection control policies, specifically regarding the use of PPE during high-contact care activities for residents requiring EBP.
Inaccurate MDS Coding for Bipap Use
Penalty
Summary
The facility failed to ensure the accurate coding of the Minimum Data Set (MDS) for a resident's use of Bipap (Bilevel Positive Airway Pressure) therapy. Resident #19, who was admitted with diagnoses including Type 2 Diabetes Mellitus, Major Depressive Disorder, and Sleep Apnea, had a physician's order for Bipap use at night. The resident's care plan and Medication Administration Record/Treatment Administration Record (MAR/TAR) for November 2024 confirmed nightly use of the Bipap as ordered. However, the MDS with an Assessment Reference Date (ARD) of 11/27/2024 did not reflect the use of Bipap. During an interview and record review, the MDS coordinator confirmed the oversight, acknowledging that the MDS should have been coded to indicate the resident's use of Bipap therapy.
Improper Catheter Care for Resident
Penalty
Summary
The facility failed to provide appropriate care for a resident with a urinary catheter, leading to a deficiency. The resident, who was admitted with diagnoses including Obstructive and Reflux Uropathy and Bladder Neck Obstruction, required partial/moderate assistance with transfers. During an observation, it was noted that the resident's urinary catheter drainage bag was improperly placed on the floor, connected by tubing to the resident's suprapubic catheter. This was confirmed by an LPN, who acknowledged that the drainage bag should not have been on the floor, indicating a lapse in proper catheter care and infection control practices.
Improper Storage of Respiratory Equipment for Two Residents
Penalty
Summary
The facility failed to ensure proper storage of respiratory equipment for two residents, leading to a deficiency in respiratory care. Resident #19, who has a history of Type 2 Diabetes Mellitus, Major Depressive Disorder, and Sleep Apnea, was observed with her BiPAP mask left open to air on her bedside table, contrary to the facility's policy requiring storage in a labeled plastic bag. The resident confirmed the absence of a storage bag, and an LPN verified the improper storage, acknowledging the lack of a bag for the mask. Similarly, Resident #41, diagnosed with congestive heart failure, chronic obstructive pulmonary disease, and obstructive sleep apnea, was found with a CPAP mask and nasal cannula improperly stored. The CPAP mask was left open to air in the machine's basket, and the nasal cannula was on the seat of the resident's wheelchair, both without storage bags. The resident confirmed staff assistance with the equipment, and an LPN acknowledged the improper storage, confirming the responsibility of nursing staff to ensure proper storage of respiratory equipment.
Failure to Post Current Staffing Information
Penalty
Summary
The facility failed to ensure that daily staffing information was posted in a current and accessible manner for residents and visitors. On February 4, 2025, at 2:00 PM, an observation revealed that staffing data sheets were stored in a closed binder placed in a window at the nurses' station, which was located in a hallway not frequently used by residents or visitors. Additionally, the staffing sheets for February 3 and February 4, 2025, were missing from the binder. During an interview at 2:09 PM on the same day, the Assistant Administrator confirmed the absence of the staffing sheets for the specified dates and acknowledged that the closed binder was not readily accessible to residents or visitors.
Unsafe Handrail on Hall W
Penalty
Summary
The facility failed to ensure that hallway handrails were securely affixed to the walls in one of the six hallways observed, specifically Hall W. This deficiency was identified through multiple observations on February 2, 2025, where a handrail outside of Room A on Hall W was found broken, with one end detached from the wall and pointing outward into the hallway. An exposed screw was also noted at the end of the detached portion of the handrail. During an interview, the Maintenance Supervisor confirmed the broken and detached handrail, acknowledging that it was unsafe and should have been repaired. The facility's maintenance policy, last revised in December 2009, mandates that maintenance personnel maintain the building in compliance with laws and regulations, ensuring safety and operability at all times.
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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