Inspection Reports for
Camelot Leisure Living
6818 HIGHWAY 84 WEST, FERRIDAY, LA, 71334
Back to Facility Profile8 Reports
Inspection Report — Jul 16, 2025
Complaint Investigation CMS
Date: Jul 16, 2025
Visit Reason
The inspection was conducted to investigate complaints related to inadequate ileostomy care and failure to develop a person-centered care plan for feeding assistance for sampled residents.
Complaint Details
The investigation was initiated due to complaints from Resident #1's responsible party about leaking ileostomy bags and inadequate care. The complaints were substantiated as the facility failed to initiate grievances and delayed ileostomy care. Additionally, a grievance filed by Resident #2's family about feeding assistance was substantiated due to lack of appropriate care planning.
Findings
The facility failed to ensure prompt resolution of grievances regarding ileostomy care for Resident #1 and failed to develop a comprehensive care plan for feeding assistance for Resident #2. Additionally, the facility did not provide ileostomy care to Resident #1 in a timely manner consistent with professional standards.
Deficiencies (3)
F 0585: The facility failed to ensure prompt resolution of an allegation of improper ileostomy care for Resident #1 by not initiating a grievance despite multiple complaints from the resident's responsible party.
F 0656: The facility failed to develop a person-centered care plan reflecting the feeding assistance required for Resident #2, despite evidence that the resident needed moderate assistance with eating.
F 0691: The facility failed to provide appropriate ileostomy care for Resident #1, resulting in the resident having feces on her skin due to delayed changing of the ileostomy bag contrary to care orders.
Report Facts
Residents sampled: 3
Frequency of ileostomy bag changes ordered: 6
Grievance filing date: Jun 23, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S1 ADON | Assistant Director of Nursing | Confirmed responsibility for ileostomy care and acknowledged complaints from Resident #1's responsible party. |
| S5 RN/ADON | Treatment Nurse/Assistant Director of Nursing | Admitted not providing ileostomy care to Resident #1 on 07/14/2025 and not reporting care needs to CNA. |
| S6 LPN | Licensed Practical Nurse | Provided ileostomy care to Resident #1 after 2:00 p.m. on 07/14/2025 and confirmed delayed care. |
| S2 MDS Nurse | Minimum Data Set Nurse | Confirmed Resident #2 required feeding assistance that was not care planned. |
| S3 Administrator | Facility Administrator | Confirmed that department heads decide what is considered a grievance and that no grievances were filed for Resident #1. |
Inspection Report — Feb 20, 2025
Annual Inspection CMS
Date: Feb 20, 2025
Visit Reason
Annual inspection of Camelot Leisure Living nursing home to assess compliance with regulatory standards including resident care, dietary services, infection control, and safety.
Findings
The facility had multiple deficiencies including failure to ensure resident dignity, timely meal service, proper medication storage and documentation, infection control lapses, and unsafe dietary practices. An immediate jeopardy was identified related to improper dishwashing with bleach in the kitchen but was removed after corrective actions.
Deficiencies (16)
F0550: Facility failed to ensure residents were treated with dignity; Resident #19 had long facial hair not removed despite requests, and Resident #32 was served lunch late compared to others at the same table.
F0580: Facility failed to notify physician of significant change in Resident #72's condition after syncope episode on 12/21/2024.
F0583: Facility failed to ensure confidentiality of medical records; EMR screen left visible and unattended on medication cart.
F0636: Facility failed to complete Discharge MDS assessment timely for Resident #28, submitted more than 14 days late.
F0637: Facility failed to complete Significant Change MDS within 14 days for Resident #7 admitted to hospice.
F0658: Facility failed to revise care plan to prevent wound development for Resident #43 with contracted hand and skin tear.
F0689: Facility failed to maintain safe environment; cracked parking lot caused fall for Resident #13 and was not repaired timely.
F0695: Facility failed to provide safe respiratory care; oxygen tubing and nebulizer masks were improperly stored, unlabeled, or missing humidifiers for Residents #10, #17, and #273.
F0732: Facility failed to post daily nurse staffing information including census and hours worked by staff.
F0761: Facility failed to ensure proper medication storage and documentation including unlabeled insulin vial, inaccurate emergency kit log, loose pills in medication cart, expired eye drops, undocumented controlled substance administration, missing medication strength on narcotic record, and failure to remove discontinued controlled substances.
F0802: Facility failed to provide sufficient support personnel for timely meal service; lunch consistently served late affecting multiple residents.
F0804: Facility failed to ensure pureed foods were prepared according to recipes conserving nutritional value; dietary staff did not measure ingredients or follow recipes.
F0812: Facility failed to maintain clean and sanitary kitchen environment, used bleach improperly for dishwashing causing immediate jeopardy, failed to label and date food items, maintain freezer, cover hot foods, wear hair/beard restraints, practice hand hygiene, and monitor food temperatures.
F0835: Facility failed to administer resources effectively; dietary staff lacked training and competency documentation, poor management oversight, and unsafe food handling practices.
F0814: Facility failed to dispose of garbage properly; dumpsters were open, lids broken, and litter present around dumpster area.
F0880: Facility failed to implement infection prevention and control program; reusable equipment not decontaminated between residents, staff failed hand hygiene, Enhanced Barrier Precautions not used for Resident #9, and oxygen tubing improperly stored.
Report Facts
Residents affected: 2
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 11
Residents affected: 64
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S3 Dietary | Dietary Cook | Observed using bleach for dishwashing and improper pureed food preparation |
| S11 Dietary | Dietary Cook | Observed with long beard hair without beard net, untrained |
| S12 Dietary Aide | Dietary Aide | Observed with beard hair without beard net and poor glove hygiene |
| S10 LPN | Licensed Practical Nurse | Failed to decontaminate BP cuffs and wash hands between residents |
| S7 LPN | Licensed Practical Nurse | Failed to decontaminate BP cuffs and wash hands between residents |
| S5 ADON | Assistant Director of Nursing | Confirmed multiple medication storage and infection control deficiencies |
| S2 DON | Director of Nursing | Confirmed infection control and respiratory care deficiencies |
| S1 Administrator | Administrator | Managed dietary department during manager absence, intervened on bleach use |
| S4 Maintenance Supervisor | Maintenance Supervisor | Assisted with kitchen oversight and confirmed environmental deficiencies |
| S13 RD | Registered Dietitian | Reported concerns about kitchen sanitation and staff training |
Inspection Report — Dec 19, 2024
Complaint Investigation CMS
Date: Dec 19, 2024
Visit Reason
The inspection was conducted due to complaints alleging sexual abuse and failure to report a fracture of unknown origin at the facility.
Complaint Details
The complaint involved allegations of sexual abuse for Resident #1 and failure to report a fracture of unknown origin for Resident #2. The sexual abuse allegation was not reported within the required 2-hour timeframe and was not investigated. The fracture was also not reported to the State Survey Agency.
Findings
The facility failed to timely report an allegation of sexual abuse and a fracture of unknown origin to the State Survey Agency. Additionally, the facility did not thoroughly investigate the sexual abuse allegation and failed to develop a comprehensive care plan with appropriate interventions after a resident fall.
Deficiencies (3)
F0609: The facility failed to timely report an allegation of sexual abuse and a fracture of unknown origin to the State Survey Agency for two residents.
F0610: The facility failed to thoroughly investigate an allegation of sexual abuse for one resident.
F0656: The facility failed to develop and implement a comprehensive care plan with appropriate interventions after a resident fell from a wheelchair.
Report Facts
Residents sampled: 4
BIMS score: 13
BIMS score: 0
Date of Resident #1 fall: Nov 12, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S1 Administrator | Administrator | Confirmed failure to report sexual abuse and fracture, and failure to investigate sexual abuse allegation. |
| S2 DON | Director of Nursing | Reported fracture discovery and confirmed no fall interventions were implemented after Resident #1's fall. |
| S3 LPN | Licensed Practical Nurse | Called to Resident #2's room due to bruising and edema. |
| S4 CNA | Certified Nursing Assistant | Reported bruising and edema to Resident #2's left foot. |
Inspection Report — Jan 10, 2024
Routine CMS
Date: Jan 10, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, notification procedures, assessment transmissions, care planning, activities of daily living assistance, and equipment safety at Camelot Leisure Living.
Findings
The facility was found deficient in multiple areas including failure to update advance directives consistently, untimely issuance of Medicare Non-Coverage notices, delayed transmission of MDS assessments, incomplete implementation of care plans, inadequate assistance with activities of daily living such as nail care, and failure to maintain kitchen equipment safely.
Deficiencies (6)
F 0578: The facility failed to ensure a resident's advance directive and code status were consistently updated in medical records, resulting in conflicting documentation for Resident #38.
F 0582: The facility failed to issue Notice of Medicare Non-Coverage at least two days prior to Medicare Part A discharge for Residents #164 and #165, limiting their right to appeal.
F 0640: The facility failed to transmit a Minimum Data Set assessment within 14 days of completion for Resident #53, delaying required reporting.
F 0656: The facility failed to implement a comprehensive care plan by not providing a hand roll to Resident #33 as directed for right hand contracture.
F 0677: The facility failed to provide adequate nail care for Residents #40 and #33, resulting in untrimmed toenails and fingernails with debris.
F 0908: The facility failed to maintain the walk-in freezer in safe operating condition, with excessive frost and ice buildup and a door that did not seal properly, potentially affecting 52 residents.
Report Facts
Residents reviewed for advance directives: 32
Residents reviewed for Beneficiary Notification: 3
Residents affected by NOMNC deficiency: 2
Residents sampled for MDS transmission: 1
Residents sampled for care plan implementation: 32
Residents affected by care plan deficiency: 1
Residents sampled for ADL assistance: 4
Residents affected by ADL deficiency: 2
Residents potentially affected by freezer issue: 52
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S1 DON | Director of Nursing | Confirmed Resident #38's advance directives were not updated properly |
| S3 LPN | Licensed Practical Nurse | Interviewed regarding Resident #38's DNR status and nail care documentation |
| S8 Admissions/Marketing Director | Admissions/Marketing Director | Confirmed failure to issue NOMNC notices timely |
| S2 ADON | Assistant Director of Nursing | Responsible for transmitting MDS assessments; confirmed delay for Resident #53 |
| S7 LPN | Licensed Practical Nurse | Confirmed Resident #33 did not have hand roll and nails were not trimmed |
| S4 CNA | Certified Nursing Assistant | Assigned to Resident #40; confirmed toenails not trimmed |
| S5 CNA | Certified Nursing Assistant | Responsible for non-diabetic nail care; last trimmed Resident #40's toenails on 11/23/2023 |
| S9 Dietary Manager | Dietary Manager | Confirmed freezer frost and ice issues |
| S10 Administrator | Administrator | Discussed freezer repair quotes and facility status |
Inspection Report — Oct 24, 2023
CMS
Date: Oct 24, 2023
Visit Reason
The inspection was conducted to evaluate compliance with care plan requirements and resident safety following a fall incident involving a resident who required a winged mattress.
Findings
The facility failed to ensure that Resident #1's person-centered care plan for use of a winged mattress was followed. Resident #1 was found using a regular mattress without wings despite the care plan specifying a winged mattress to prevent falls.
Deficiencies (1)
F 0656: The facility failed to develop and implement a complete care plan that meets all the resident's needs, including the use of a winged mattress for Resident #1. The winged mattress was not provided after room transfer, increasing fall risk.
Report Facts
Residents Affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN ADON | Confirmed the winged mattress was not transferred with Resident #1 and should have been |
Inspection Report — Jul 12, 2023
Complaint Investigation CMS
Date: Jul 12, 2023
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to provide appropriate pressure ulcer care and to ensure weekly assessment and documentation of a resident's pressure wound.
Complaint Details
The complaint investigation found that the facility did not complete weekly wound assessments for Resident #2's pressure ulcer, and the responsible nurse was unaware of the requirement to document weekly measurements and characteristics of the wound. The Director of Nursing confirmed the deficiency.
Findings
The facility failed to ensure that Resident #2 received necessary care to promote healing of a pressure ulcer and that a registered nurse assessed and documented the stage of the pressure wound on a weekly basis as required.
Deficiencies (1)
F 0686: The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing. The weekly wound assessment and documentation for Resident #2's left buttock pressure ulcer were not completed as required.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2 Treatment Nurse | Provided wound care for Resident #2 and confirmed lack of weekly wound assessment documentation. | |
| S1 Director of Nursing | Confirmed that weekly wound assessments for Resident #2 were not completed as required. |
Inspection Report — Jun 1, 2023
Complaint Investigation CMS
Date: Jun 1, 2023
Visit Reason
The investigation was conducted due to a complaint regarding resident-to-resident physical abuse involving Resident #1 and Resident #5, and a failure to provide timely discharge notification to Resident #1.
Complaint Details
The complaint investigation substantiated that Resident #5 was physically abused by Resident #1 on 02/28/2023, resulting in injuries and hospital treatment. The facility failed to provide constant observation as required. The investigation also found failure to notify Resident #1 in writing at least 30 days before involuntary emergency discharge.
Findings
The facility failed to protect Resident #5 from physical abuse by Resident #1, resulting in actual harm. Additionally, the facility failed to notify Resident #1 in writing at least 30 days prior to involuntary emergency discharge. Corrective actions and staff training were implemented following the incident.
Deficiencies (2)
F 0600: The facility failed to protect Resident #5 from resident-to-resident physical abuse by Resident #1, resulting in actual harm including abrasions and pain requiring hospital evaluation and treatment.
F 0623: The facility failed to provide timely written notification to Resident #1 of involuntary emergency discharge at least 30 days prior to discharge, violating resident rights.
Report Facts
Incident time: 820
Pain rating: 6
Tylenol dosage: 650
Ultram dosage: 50
Flexeril dosage: 10
Correction date: Mar 13, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S4 LPN | Licensed Practical Nurse | Provided care for Resident #5, reported on abuse incident and monitoring |
| S6 CNA | Certified Nursing Assistant | Provided care for Resident #5, reported on wandering and monitoring |
| S5 Clerk/CNA | Clerk / Certified Nursing Assistant | Witnessed abuse incident and intervened |
| S8 CNA | Certified Nursing Assistant | Provided care for Resident #5, reported on monitoring frequency |
| S9 CNA | Certified Nursing Assistant | Provided care for Resident #5, reported on monitoring frequency |
| S2 DON | Director of Nursing | Confirmed care plan and monitoring failures, and discharge process |
| S3 ADON/MDS Coordinator | Assistant Director of Nursing / MDS Coordinator | Confirmed care plan and monitoring failures |
| S1 Administrator | Administrator | Instructed previous administrator to issue discharge notice |
Inspection Report — Nov 30, 2022
Annual Inspection CMS
Date: Nov 30, 2022
Visit Reason
The inspection was conducted as a comprehensive annual survey of Camelot Leisure Living to assess compliance with federal and state regulations regarding resident rights, safety, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including resident dignity and privacy, failure to promote resident self-determination, inadequate mail delivery practices, missing privacy curtains, unclean patient care equipment, untimely transmission of resident assessments, failure to post nurse staffing information, lack of COVID-19 signage, untrained infection preventionist, and malfunctioning kitchen equipment.
Deficiencies (10)
F 0550: The facility failed to ensure a resident's urinary catheter drainage bag was covered to ensure privacy for 1 of 1 residents reviewed for dignity.
F 0561: The facility failed to promote and facilitate resident self-determination by not assisting a resident in obtaining her birth certificate timely due to payment issues.
F 0576: The facility failed to ensure residents received mail on Saturdays, affecting 66 residents.
F 0583: The facility failed to respect a resident's right to privacy by not providing a privacy curtain around the bed for 1 resident.
F 0584: The facility failed to maintain cleanliness of patient care equipment, with dried tube feeding residue observed on feeding pump equipment for 1 resident.
F 0640: The facility failed to transmit a Minimum Data Set (MDS) assessment within 14 days of completion for 1 resident.
F 0732: The facility failed to post nurse staffing information daily and make it accessible to residents and visitors.
F 0880: The facility failed to maintain infection prevention and control by not posting COVID-19 signage at facility entrances.
F 0882: The facility failed to ensure the designated Infection Preventionist completed specialized training in infection prevention and control.
F 0908: The facility failed to keep essential kitchen equipment working safely, with an oven door and walk-in freezer door not closing tightly, risking food safety for 60 residents.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 66
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 60
Fine/fee amount: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S1 Administrator | Administrator | Named in failure to assist resident with birth certificate and failure to post staffing information |
| S2 DON | Director of Nursing | Named as Infection Preventionist without completed training and confirmed deficiencies in equipment cleaning and staffing postings |
| S3 CNA | Certified Nursing Assistant | Confirmed catheter bag was uncovered |
| S4 SSD | Social Services Director | Completed birth certificate application for resident |
| S5 CNA | Certified Nursing Assistant | Reported missing privacy curtain |
| S6 Bookkeeper | Bookkeeper | Reported mail delivery and holding practices |
| S7 Clerk | Clerk | Reported staffing pattern location and COVID-19 signage absence |
| S10 Dietary Manager | Dietary Manager | Reported malfunctioning oven and freezer doors |
| S11 Dietary Worker | Dietary Worker | Reported oven door issues affecting cooking |
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