Camelot Brookside
Inspection history, citations, penalties and survey trends for this long-term care facility in Jennings, Louisiana.
- Location
- 3330 Frontage Road, Jennings, Louisiana 70546
- CMS Provider Number
- 195550
- Inspections on file
- 21
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Camelot Brookside during CMS and state inspections, most recent first.
A resident sustained burns after spilling hot coffee from a lidded Styrofoam cup while using an over-bed table. The incident review and interviews showed kitchen staff did not check coffee temperatures before sending it to the floor, and an observed canister of coffee measured 158.1 degrees F. The facility policy stated hot liquids should be monitored to prevent scalding.
Failure to Honor Documented Food Dislike: A resident with dementia and malnutrition had a documented dislike for breakfast sausage on the meal ticket, yet sausage was served on breakfast trays during two observations. The resident stated she did not eat breakfast sausage, and dietary staff and the ADM confirmed it should not have been served.
Soiled plate warmers were observed stacked on an open shelf next to the food serving line, with grease, egg, crumbs, and other food debris present. Styrofoam plates were also stored face up on the shelf, and one unused plate contained a piece of egg inside it. The S2DM confirmed the items should have been sanitized and stored face down.
A CNA failed to follow infection control protocols by exiting a resident's room with soiled gloves and using them to open another room's door. This action violated the facility's policy requiring glove removal and hand hygiene before leaving a resident's room, as confirmed by the CNA and the Infection Preventionist.
A facility failed to maintain a clean environment for a resident, as evidenced by repeated observations of a large red stain on the floor and multiple red stains on the bedside table. Despite documentation indicating the room was cleaned, the housekeeping supervisor confirmed it was not cleaned as required, revealing a lapse in housekeeping procedures.
A resident filed a grievance about her colostomy bag not being changed, and the facility failed to document and conduct the promised in-service training for staff on colostomy care. The grievance was marked as resolved, but no evidence of follow-up training was provided by the staff responsible.
Two residents requiring oxygen therapy did not receive the prescribed oxygen flow rates as per their care plans. One resident's oxygen concentrator was set below the ordered 3 liters per minute, causing shortness of breath, while another resident's oxygen settings varied from the prescribed 3 liters, with observations showing 2, 3.5, and 4 liters at different times. LPNs confirmed the residents could not adjust the settings themselves.
A facility failed to invite a resident and their Responsible Party (RP) to a care planning meeting, as required by policy. The resident, with moderate cognitive impairment and multiple health conditions, reported never being invited to such meetings. The Social Service Director claimed invitations were sent, but the sign-in sheet lacked signatures from the resident or RP, and the RP confirmed not receiving an invitation.
A resident with Parkinson's disease and impaired mobility did not receive necessary assistance with personal hygiene, specifically in trimming and cleaning fingernails. Despite a care plan requiring extensive assistance and a physician's order for nail care, observations showed the resident's nails were long and dirty. An LPN confirmed the neglect, indicating a deficiency in the facility's nail care procedures.
A facility failed to conduct an activity program for a resident with severe cognitive impairment, as required by their policy. Despite the resident's care plan indicating a need for regular 1:1 visits, no documented activities were found over a 30-day period. Observations showed the resident lying in bed with the TV on, without staff engagement. Interviews confirmed a lack of documented interactions, and the resident's daughter reported not observing any staff interactions during her visits.
The facility failed to properly store and label medications as per professional standards. An LPN observed loose pills in Medication Cart A, which were confirmed to be improperly stored. The DON also confirmed that medications should not be left loose in the carts. The facility's policy mandates that drugs be stored in their original packaging, with only the issuing pharmacy authorized to transfer medications.
The facility failed to provide a clean and homelike environment for three residents. A resident's urinal was improperly stored, another's room had soiled bedpans and a dirty bathroom, and a shared bathroom had unlabeled urinals and a soiled bedpan. These issues were confirmed by staff, including a CNA and the DON.
A resident with moderate cognitive impairment did not receive nine doses of prescribed Hydrocodone-APAP due to staff oversight. The medication was marked as 'hold' or 'other' while awaiting pharmacy delivery, despite being available in the facility's emergency drug kit. Staff interviews revealed a lack of awareness or utilization of the emergency kit, which led to the deficiency.
Hot Coffee Served Without Temperature Monitoring
Penalty
Summary
The facility failed to have a system in place to ensure coffee was served at a safe temperature to prevent scalds and burns for one resident. The report states that 112 residents consumed meals and beverages prepared by the facility's kitchen. A review of the facility policy on hot liquids stated that residents with risk factors for injury from hot liquids should have precautions implemented, and that food service staff should monitor and maintain food temperatures that comply with food safety requirements but do not exceed recommended temperatures to prevent scalding. Resident #79 was involved in an incident on 02/24/2026 when the resident spilled coffee while in bed and sustained redness to the left arm and buttocks area. The incident report stated that the resident was trying to get coffee from the table when the cup fell, and that a non-spill cup would be given to the resident. During an interview, the resident stated she had burns on her left forearm and left hip after spilling hot coffee from a Styrofoam cup with a lid while placing it on the over-bed table. The dietary manager stated that staff did not check coffee temperatures before sending coffee to the floor, and a brewed canister of coffee was observed at 158.1 degrees F.
Failure to Honor Documented Food Dislike
Penalty
Summary
The facility failed to honor and accommodate a resident’s food preference by serving breakfast sausage despite the resident’s documented dislike for it. Resident #68 was admitted with diagnoses including unspecified dementia and unspecified protein-calorie malnutrition, and her most recent MDS showed a BIMS score of 12, indicating moderately impaired cognition. Her meal ticket listed a special note that she disliked breakfast sausage. During observations on two separate mornings, Resident #68 was seen with a breakfast sausage patty cut up on her breakfast plate, and she stated both times that she did not eat breakfast sausage. During the second observation, the dietary staff member confirmed that breakfast sausage was listed as a dislike on the meal ticket and should not have been served. The administrator also confirmed that because breakfast sausage was listed as a dislike, it should not have been served to the resident.
Soiled Dishware Stored Unsafely in Kitchen
Penalty
Summary
The facility failed to ensure dishware was clean and stored under sanitary conditions. During a kitchen observation, an open shelf next to the food serving line was found with stacked plate warmers that were soiled, including grease, pieces of egg, crumbs, and fragments of other food items. Styrofoam plates were also observed stacked on the top shelf facing up, and the first plate contained a piece of egg inside it. During the observation and interview, the S2DM stated that dishwashing staff were responsible for stacking the plates and plate warmers on the shelf for the lunch meal. The S2DM confirmed that the plate warmers should have been sanitized before being stacked on the clean shelf and that the Styrofoam plates should have been stored face down. The report also states this had the potential to affect the 112 residents who ate meals from the facility's kitchen.
Infection Control Breach: Improper Glove Use
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by staff actions that did not adhere to established protocols. During an observation, a Certified Nursing Assistant (CNA) was seen exiting a resident's room while wearing soiled gloves and carrying soiled linens. The CNA then used the soiled gloves to open the door of another room, Room A. This action was contrary to the facility's policy, which mandates that gloves be removed and hand hygiene performed before leaving a resident's room. Interviews with the CNA and the Infection Preventionist confirmed that the CNA did not follow the required procedures, acknowledging that gloves should have been removed and hand hygiene performed before exiting the room and that soiled gloves should not have been used to open doors.
Failure to Maintain Clean Environment in Resident's Room
Penalty
Summary
The facility failed to maintain a clean and homelike environment for a resident, as evidenced by multiple observations of unclean conditions in the resident's room. On three separate occasions, a large red stain was noted on the floor next to the right side of the resident's bed, and multiple red circular stains were observed on the bedside table. These observations were made over the course of two days, indicating a lack of adherence to the facility's cleaning policy. The housekeeping supervisor confirmed that the room should have been cleaned daily, including mopping the floors and cleaning the bedside table. Despite the housekeeping checkoff list indicating that the room was cleaned, the supervisor acknowledged that the room was not cleaned as required. This discrepancy between the documented cleaning and the actual condition of the room highlights a failure in the facility's housekeeping procedures.
Failure to Document and Follow Up on Grievance Regarding Colostomy Care
Penalty
Summary
The facility failed to ensure proper documentation and follow-up on a grievance filed by a resident regarding colostomy care. The resident, who had a colostomy, filed a grievance on 03/04/2025, stating that her colostomy bag was not changed the previous night. The Director of Nursing (DON) apologized to the resident and assured her that staff would be in-serviced on colostomy care. The grievance was marked as resolved on 03/05/2025. However, upon review, it was found that there was no evidence of in-service training conducted after the grievance was reported. The Social Service Director confirmed the grievance resolution date, but the Staff Developer could not provide evidence of any in-service training related to colostomy care after the grievance was filed. The DON also failed to provide evidence of such training occurring on or after the grievance resolution date, indicating a lapse in the facility's grievance resolution process.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for two residents requiring oxygen therapy. Resident #55, who was admitted with chronic obstructive pulmonary disease, acute and chronic respiratory failure, and congestive heart failure, had a physician's order for oxygen at 3 liters per minute via nasal cannula. However, during an observation, it was found that the oxygen concentrator was set at 2.5 liters per minute, which was confirmed by the resident and an LPN. The resident reported experiencing slight shortness of breath while on the incorrect oxygen setting. Similarly, Resident #102, who was admitted with chronic obstructive pulmonary disease, hypertensive heart disease with heart failure, and emphysema, and was under hospice care, had a physician's order for continuous oxygen at 3 liters per minute. Observations revealed discrepancies in the oxygen flow rate, with settings found at 2 liters, 3.5 liters, and 4 liters at different times, none of which matched the physician's order. An LPN confirmed that the resident was not capable of changing the oxygen settings herself, indicating a failure in adhering to the prescribed care plan.
Failure to Invite Resident and RP to Care Planning Meeting
Penalty
Summary
The facility failed to ensure that a resident and/or the resident's Responsible Party (RP) was invited to the care planning meeting, which is a requirement for developing and revising a resident's care plan. This deficiency was identified for one resident out of a sample of 32, with the potential to affect a census of 112 residents. The facility's policy encourages the participation of the resident, their family, or legal representative in care plan development, and if participation is not practicable, an explanation should be documented in the medical record. However, in this case, there was no documentation of such an explanation. Resident #111, who has a history of colostomy, congestive heart failure, anxiety, cognitive communication deficits, depression, Diabetes Mellitus II, and chronic kidney disease, was not invited to the care plan meeting. The resident, with a BIMS score indicating moderate cognitive impairment, stated she had never been invited to a care plan meeting. The Social Service Director, responsible for care planning meetings, claimed that residents and their RPs are invited, but the sign-in sheet for the meeting showed only staff signatures, with no indication of the resident or RP's participation. Additionally, the resident's RP confirmed not receiving any invitation to the meeting.
Failure to Maintain Resident's Personal Hygiene
Penalty
Summary
The facility failed to provide necessary services for a resident who was unable to perform activities of daily living, specifically in maintaining good grooming by trimming and cleaning fingernails. The resident, who was admitted with diagnoses including Parkinson's disease and major depressive disorder, had a care plan indicating a self-care performance deficit related to Parkinsonism and impaired mobility. The care plan required extensive assistance with personal hygiene, yet observations revealed that the resident's fingernails were long and had brown debris underneath, indicating neglect in nail care. Despite having a physician's order allowing licensed nurses to clip and trim diabetic finger and toenails, the resident's fingernails remained untrimmed and uncleaned over multiple observations. An LPN confirmed that the treatment nurse was responsible for trimming residents' fingernails, but any nurse could perform this task. The failure to trim and clean the resident's fingernails was observed on two separate occasions, highlighting a deficiency in the facility's adherence to its own policy and procedure for nail care.
Failure to Conduct Activity Program for Resident
Penalty
Summary
The facility failed to ensure an activity program was conducted for a resident with severe cognitive impairment and multiple medical conditions, including unspecified dementia and aphasia following a cerebral infarction. The facility's policy required individual activities for residents unable to participate in group activities, with a minimum of three room visits per week documented on the Bed Bound Activity Assessment. However, a review of the resident's records over a 30-day period revealed no documented activities or 1:1 interactions, despite the resident's care plan indicating a need for regular 1:1 visits and cues to improve orientation. Observations on multiple occasions showed the resident lying in bed with the TV on, without staff engaging in any activities. Interviews with the Activity Director and the resident's daughter confirmed a lack of documented interactions and activities, despite claims of reading scripture to the resident. The resident's daughter, who visited weekly, also reported not observing any staff interactions such as reading, massaging, or playing music for her mother. This lack of engagement and documentation indicates a failure to meet the resident's activity needs as outlined in the facility's policy and care plan.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications in accordance with accepted professional standards. During an observation of Medication Cart A, conducted with an LPN, a loose oval orange pill was found in the bottom of the second drawer, and a loose round peach pill was found in the bottom of the third drawer. The LPN confirmed that medications should not be loose in the medication carts. Additionally, during an interview, the Director of Nursing confirmed that medications should not be left loose in any of the medication carts. The facility's policy on the storage of medications, last reviewed on 11/15/2024, states that drugs and biologicals should be stored in the packaging or containers in which they are received, and only the issuing pharmacy is authorized to transfer medications between containers.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for three residents, as observed during a survey. For Resident #1, a urinal without a lid was found hanging on the safety bar of the toilet, not stored in a bag, and remained in the same position upon subsequent observations. This was confirmed by a Licensed Practical Nurse, who acknowledged that the urinal should have been stored in a bag. Resident #2's room was found with a bedpan on the floor under the bed, which should have been stored in a bag in the bathroom. Further observations revealed two soiled bedpans on the bathroom floor, a trash can without a liner containing soiled incontinence items, and a strong urine odor. The toilet seat and rim were also soiled. These findings were confirmed by a Certified Nursing Assistant and the Director of Nursing, who both acknowledged the improper storage and cleanliness issues. For Resident #3, a shared bathroom contained three unlabeled urinals and a bedpan with stool and toilet paper in the shower, causing a strong odor. These issues were confirmed by a CNA and the DON, with a resident reporting the bathroom was often dirty.
Failure to Administer Prescribed Medication Due to Staff Oversight
Penalty
Summary
The facility failed to implement the comprehensive care plan for a resident by not administering nine doses of a prescribed medication, Hydrocodone-Acetaminophen, as ordered by the resident's physician. The resident, who was admitted with diagnoses including Osteomyelitis of the Vertebra and had a moderately impaired cognitive status, was supposed to receive this medication three times a day. However, the medication was not administered on multiple occasions due to it being marked as 'hold' or 'other' in the electronic health record, with notes indicating the medication was awaiting delivery from the pharmacy. Interviews with nursing staff revealed that the facility had an emergency drug kit containing the prescribed medication, which could have been used while waiting for the pharmacy delivery. However, the staff were either unaware of the availability of the medication in the emergency kit or did not utilize it. The Director of Nursing confirmed that the secured drug dispensing system was available for such situations, and the nurses should have been aware and used it to ensure the resident received the medication as ordered.
Latest citations in Louisiana
The facility failed to maintain an effective pest control program when multiple live roaches, roach feces, and dead roach carcasses were observed in a room shared by two residents, including on and under a personal refrigerator and beneath items placed on top of it. Housekeeping, maintenance, and a CNA each reported seeing roaches in the room on the prior day, and subsequent observations by maintenance and the administrator confirmed ongoing roach activity in the same area.
A resident with end stage renal disease, bone density disorder, chronic pain, and osteoarthritis was care planned and assessed as totally dependent for chair/bed transfers, requiring a mechanical lift with two-person assist. On one occasion after dialysis, an LPN and a CNA brought a mechanical lift into the room but, after the resident reportedly expressed not wanting to use it, the CNA manually transferred the resident from wheelchair to bed by lifting under the resident’s arms while the resident held the CNA’s waist. During this non–care-planned manual transfer, a popping sound was heard from both shoulders and the resident complained of arm pain; subsequent x‑rays and hospital evaluation confirmed acute fractures of the left clavicle and right humerus. The facility’s investigation, including review of camera footage and staff interviews, established that the mechanical lift was not used as required by the resident’s care plan, and that the injury occurred during this improper manual transfer rather than during a clothing change as initially reported.
A staff member in Social Services routinely emailed detailed resident information, including face sheets and a full census listing names, dates of birth, payer sources, room numbers, diagnoses, allergies, and advance directive details, to a contracted outside provider so the provider could identify which residents were not receiving their services and then approach them. These disclosures involved all residents in the facility and were made without obtaining or documenting any resident or responsible party consent, despite a facility policy requiring protection and confidential handling of medical, financial, and social records.
A resident with an order for Glucerna 1.2 at a specified rate and duration was instead observed receiving Isosource at 60 ml/hour. Record review confirmed the physician’s order for Glucerna 1.2, while observation and interview with an LPN verified that Isosource, a different enteral formula, was being administered. The DON later stated that the LPN should have verified the physician’s order before administering the tube feeding.
Surveyors found that the facility failed to keep its medication error rate below 5%, identifying a 29% error rate during one observed medication pass. A resident had multiple medications ordered for 9:00 AM, including aspirin, calcium carbonate, vitamin C, carvedilol, furosemide, potassium chloride ER, thiamin, timolol ophthalmic drops, and docusate sodium. An LPN administered all of these medications at 11:24 AM, outside the facility’s policy window of one hour before to one hour after the scheduled time, and did so without a physician order to change the administration times. The DON confirmed that this timing did not comply with the facility’s medication administration policy.
A resident was readmitted from the hospital with handwritten physician orders for multiple medications, including acetaminophen, Eliquis, buspirone, losartan, mirtazapine, quetiapine, senna, and Vistaril, to be given on specific schedules and as needed. Review of the eMAR showed that none of these medications were administered for an extended period after readmission. In interviews, the DON stated that nurses are responsible for clarifying orders upon a resident’s return from the hospital, and an LPN acknowledged that the medications should have been restarted and administered as ordered but were not.
A resident with physician orders for Glucerna 1.2 via enteral feeding at a specified rate and duration did not have the administration of this feeding documented in the eMAR on two days, even though surveyors directly observed the feeding being administered at the ordered rate on both days. The DON acknowledged that nursing staff should have recorded the enteral feeding administration in the medication administration record, but this documentation was missing, resulting in incomplete medical records.
A treatment nurse performed wound care on a resident with a diabetic toe wound without following the facility’s hand hygiene policy. The facility’s policy required staff to wash hands after removing gloves and clarified that gloves do not replace handwashing. During the observed dressing change, the nurse removed the old dressing and gloves, did not perform hand hygiene, donned new gloves, cleansed the wound, then again removed gloves and applied new ones without hand hygiene before applying calcium alginate and a dry dressing. The nurse later stated she had not cleaned her hands between glove changes because there was no hand sanitizer available in the room and she did not wash her hands instead, and the DON confirmed that hand hygiene should have been performed between each glove change.
Surveyors found that a CNA’s personnel file lacked documentation of the required 12 hours of annual in-service education, including dementia care and abuse prevention. The CNA had been employed for over a year, and facility leadership confirmed there was no evidence that the mandated annual training had been completed.
A resident sustained burns after spilling hot coffee from a lidded Styrofoam cup while using an over-bed table. The incident review and interviews showed kitchen staff did not check coffee temperatures before sending it to the floor, and an observed canister of coffee measured 158.1 degrees F. The facility policy stated hot liquids should be monitored to prevent scalding.
Failure to Maintain Effective Pest Control in Resident Room
Penalty
Summary
The facility failed to maintain an effective pest control program to ensure the environment was free of pests and insects, affecting a room shared by Resident #1 and Resident #3 and having the potential to affect 89 residents in the facility. On 04/30/2026 at 8:30 a.m., during an observation with the housekeeping staff member (S3Housekeeping) in this room, a live roach was seen crawling on the wall, on top of Resident #1’s personal refrigerator, and underneath the desk-style phone on top of the refrigerator. S3Housekeeping stated she had seen one roach in the same room the previous day. Around 8:40 a.m., the maintenance staff member (S2Maintenance) reported that a CNA (S4Certified Nurse Aide) had informed him the previous afternoon about a roach on the wall in that room. At 8:45 a.m., further observation of the same room with S2Maintenance revealed roach feces and dead roach carcasses on top of Resident #1’s refrigerator, and when S2Maintenance lifted the phone and a book from the top of the refrigerator, live roaches ran out from underneath. At 8:53 a.m., the CNA (S4Certified Nurse Aide) confirmed she had noticed a roach in the room the day before. Later, at 12:45 a.m., the administrator (S1Administrator) reported that when he accompanied maintenance to the room and the refrigerator was lifted, a couple of live roaches ran out from underneath it. In a subsequent interview at 4:30 p.m., S1Administrator confirmed there were live roaches in the room of Resident #1 and Resident #3 and acknowledged they should not have been present.
Failure to Follow Care-Planned Mechanical Lift Transfer Resulting in Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received adequate assistance during transfers by not following the resident’s care plan, which required use of a mechanical lift with two-person assistance. The resident had been admitted with diagnoses including end stage renal disease with dependency on renal dialysis, other specified disorders of bone density and structure, chronic pain, and osteoarthritis. The resident’s annual and quarterly MDS assessments documented intact cognition with a BIMS score of 15 and indicated the resident was totally dependent for chair/bed transfers. The care plan, initiated at admission, specified that transfers were to be performed using a mechanical lift with two staff assisting. On the date of the incident, the resident had returned from dialysis and required assistance transferring from a wheelchair to a bed. According to interviews, a CNA and an LPN were involved in the transfer. The LPN reported that a mechanical lift was rolled into the resident’s room, but the CNA stated the resident did not want to use the lift. Despite knowing that the resident was care planned for mechanical lift use, the CNA proceeded to transfer the resident manually by placing her arms under the resident’s arms while the resident wrapped her arms around the CNA’s waist. During this manual transfer from wheelchair to bed, a popping sound was heard from the resident’s shoulders and the resident immediately complained of pain in both arms. Progress notes from that day documented that staff heard an audible pop from both shoulders while assisting the resident and that the resident complained of pain. The physician was notified, x-rays of both upper extremities were ordered, and the resident was transferred to a local emergency room at the family’s request. Facility x-rays and hospital records confirmed acute fractures of the left clavicle and right humerus, described in the hospital record as an acute mildly displaced left distal clavicular fracture and an acute mildly displaced fracture of the right proximal humeral diaphysis. The facility’s incident report later documented that the LPN and CNA did not utilize a mechanical lift during the transfer from wheelchair to bed, and the administrator confirmed through interviews and review of camera footage that the transfer had been performed without the mechanical lift, contrary to the resident’s assessed needs and care plan. Initially, the resident, the LPN, and the CNA all reported that the injury occurred while staff were assisting the resident with a change of clothing. The hospital record also reflected the resident’s report that the injury occurred while staff were assisting her with changing clothes while she was in the mechanical lift. However, during the facility’s subsequent investigation, the administrator reviewed camera footage showing the mechanical lift being brought into and then removed from the room within a short period of time, and questioned whether that time frame was sufficient to complete a lift transfer. Both the LPN and CNA acknowledged that it was not enough time and ultimately admitted that the lift had not been used and that the injury occurred during a manual transfer from wheelchair to bed, not during clothing change. This sequence of actions and inactions—specifically, the decision to disregard the care-planned mechanical lift transfer and instead perform a manual transfer—led directly to the resident’s bilateral upper extremity fractures and constituted the cited deficiency.
Unauthorized Disclosure of Resident Medical Information to Outside Provider
Penalty
Summary
The facility failed to maintain residents' right to confidentiality of their medical records when a staff member in Social Services transmitted resident information to a contracted outside provider without obtaining consent. Review of the facility’s Resident Rights and Dignity policy, revised 03/07/2011, showed the facility was to safeguard all resident records and handle release of information in a manner that protected resident rights. Contrary to this policy, review of an email dated 10/15/2025 from the Social Services staff member to a contracted provider showed that face sheets for multiple residents were attached. These face sheets contained residents’ names, dates of birth, Social Security numbers, admit dates, Medicare/Medicaid numbers, drug allergies, care providers, pharmacy names, emergency contacts, diagnoses, and advance directive information. Further review of another email dated 03/20/2026 from the same Social Services staff member to the contracted provider showed that a facility census for a specific date was sent, which included information on all 80 residents in the facility. The census listed each resident’s room number, name, date of birth, status in the facility, primary payer source, and room rate designation. In interviews, the Social Services staff member stated that every month to every quarter she sent a daily census to the contracted provider so they could identify residents not receiving their services and then approach those residents about services. When surveyors requested evidence of resident consent for release of medical records to this provider, the Social Services staff member and the Chief Operating Officer both confirmed that the facility had no documentation of consent obtained prior to releasing the residents’ information, and acknowledged that the information had been sent on at least two occasions.
Incorrect Enteral Feeding Formula Administered Contrary to Physician Order
Penalty
Summary
The facility failed to ensure a resident received the correct enteral feeding formula as ordered by the physician. Review of the resident’s April 2026 physician orders showed an order for Glucerna 1.2 to be administered at 50 ml/hour for 12 hours per day, with an increase to 60 ml/hour for 21 hours per day if tolerated. During observation on 04/21/2026 at 1:20 PM, the resident was noted to be receiving Isosource at a rate of 60 ml/hour instead of the ordered Glucerna 1.2. In a subsequent interview and observation at 1:31 PM, an LPN confirmed that Isosource was being administered at 60 ml/hour and acknowledged that this was the wrong enteral feeding type compared to the physician’s order for Glucerna 1.2. Later, the DON stated that the LPN should have verified the physician’s order for the resident’s enteral feeding prior to administration. This deficiency centers on the administration of an incorrect enteral feeding product despite a clear physician order specifying a different formula and rate, as confirmed through record review, direct observation of the feeding in progress, and staff interviews.
Medication Error Rate Exceeded Due to Late Administration of Scheduled Medications
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5 percent, as required, resulting in a calculated error rate of 29 percent during a medication pass for one resident. Facility policy stated that medications were to be administered within one hour of their prescribed time unless otherwise specified. Review of the resident’s April 2026 physician orders and eMAR showed multiple medications scheduled for 9:00 AM, including aspirin EC 81 mg daily, calcium carbonate 600 mg twice daily, ascorbic acid 500 mg daily, carvedilol 25 mg twice daily, furosemide 20 mg daily, potassium chloride ER 20 mEq daily, thiamin HCl 100 mg daily, timolol maleate ophthalmic 0.5% one drop to both eyes daily, and docusate sodium 100 mg daily. On the observed medication pass, the LPN administered all of these medications at 11:24 AM, outside the facility’s accepted administration window of one hour before to one hour after the scheduled 9:00 AM time. The LPN acknowledged that the medications were scheduled for 9:00 AM and should have been given between 8:00 AM and 10:00 AM. The DON confirmed that medications were to be administered within that one-hour-before to one-hour-after window and that the LPN should not have administered the medications at 11:24 AM without a physician order to change the medication times. Based on 31 opportunities for error and 9 errors identified, surveyors calculated a medication error rate of 29 percent.
Failure to Restart and Administer Physician-Ordered Medications After Hospital Readmission
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when nursing staff did not administer multiple physician-ordered medications following the resident’s readmission from the hospital. The resident was readmitted on 03/09/2026, and the handwritten physician order sheet dated that day directed that the resident receive acetaminophen 500 mg, 2 tablets every 6 hours as needed; Eliquis 2.5 mg, 1 tablet twice daily; buspirone 5 mg, 1 tablet three times daily; losartan 25 mg, 2 tablets daily; mirtazapine 7.5 mg, 1 tablet nightly; quetiapine 25 mg, 2 tablets nightly; senna 8.6 mg, 1 tablet twice daily; and Vistaril every 8 hours as needed. Review of the March 2026 eMAR showed no evidence that any of these ordered medications were administered between 03/09/2026 and 03/19/2026. In interviews, the DON stated that nurses were responsible for clarifying orders with the physician when a resident returned from the hospital, and a clinical support LPN confirmed that the resident’s medications should have been restarted and administered per the written orders on 03/09/2026 but were not.
Failure to Document Enteral Feeding Administration in eMAR
Penalty
Summary
The facility failed to ensure nursing staff documented the administration of ordered enteral feeding in accordance with professional standards for one resident receiving tube feedings. The resident had physician orders in April 2026 for Glucerna 1.2 at 50 ml/hour for 12 hours daily, with instructions to increase to 60 ml/hour for 21 hours daily if tolerated. Review of the resident’s April 2026 electronic medication administration record (eMAR) showed no documentation that Glucerna 1.2 was administered at 60 ml/hour for 21 hours on 04/21/2026 and 04/22/2026. However, surveyor observations on 04/21/2026 at 9:40 AM and on 04/22/2026 at 2:41 PM confirmed the resident was receiving Glucerna 1.2 at 60 ml/hour at those times. In an interview, the DON stated that when nurses administered the Glucerna 1.2, they should have documented the administration in the medication administration record. This lack of documentation of enteral feeding administration, despite direct observation of the feeding being provided, constituted the deficiency in maintaining medical records in accordance with accepted professional standards.
Failure to Perform Hand Hygiene Between Glove Changes During Wound Care
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a treatment nurse failed to perform required hand hygiene during wound care for Resident #1. The facility’s “Using Gloves” policy, revised 03/10/2011, stated that employees were to wash hands after removing gloves and that gloves did not replace handwashing. Resident #1 had a physician’s order in April 2026 for treatment of a diabetic wound on the left second toe, including cleansing with normal saline or wound cleanser, patting dry, applying silver alginate to the wound bed, and covering with a clean dry dressing three times weekly and as needed. During an observation on 04/21/2026 at 10:43 AM, the treatment nurse removed the existing dressing, removed her gloves, did not perform hand hygiene, and then applied new gloves. She then cleaned the resident’s left second toe wound, again removed her gloves, did not perform hand hygiene, and applied new gloves before placing the calcium alginate and dry dressing. In an interview immediately afterward, the treatment nurse stated she had completed hand hygiene before and after the wound care but had not done so between glove changes because there was no hand sanitizer in the room and she did not wash her hands as an alternative. The DON later confirmed that the nurse should have performed hand hygiene between every glove change. This sequence of observations, interviews, and record review showed that the nurse’s actions during wound care did not follow the facility’s hand hygiene and glove-use policy, resulting in the cited infection control deficiency.
Failure to Provide Required Annual In-Service Training for CNA
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA), identified as S12CNA, received at least 12 hours of in-service training annually as required. Review of S12CNA’s personnel file showed that this CNA was hired on 03/23/2025 and did not have documentation demonstrating completion of the required 12 hours of annual in-service education, including topics such as dementia care and abuse prevention. During an interview on 04/23/2026 at 4:23 PM, the Chief Operations Officer (S1) confirmed that the facility had no documented evidence that S12CNA had completed the mandated 12 hours of in-service training for the year.
Hot Coffee Served Without Temperature Monitoring
Penalty
Summary
The facility failed to have a system in place to ensure coffee was served at a safe temperature to prevent scalds and burns for one resident. The report states that 112 residents consumed meals and beverages prepared by the facility's kitchen. A review of the facility policy on hot liquids stated that residents with risk factors for injury from hot liquids should have precautions implemented, and that food service staff should monitor and maintain food temperatures that comply with food safety requirements but do not exceed recommended temperatures to prevent scalding. Resident #79 was involved in an incident on 02/24/2026 when the resident spilled coffee while in bed and sustained redness to the left arm and buttocks area. The incident report stated that the resident was trying to get coffee from the table when the cup fell, and that a non-spill cup would be given to the resident. During an interview, the resident stated she had burns on her left forearm and left hip after spilling hot coffee from a Styrofoam cup with a lid while placing it on the over-bed table. The dietary manager stated that staff did not check coffee temperatures before sending coffee to the floor, and a brewed canister of coffee was observed at 158.1 degrees F.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
