Camelot Leisure Living

F-F812

Review of a facility policy on 02/20/2025 at 1:15 p.m. titled, Dietary Staff Competency with a date of 01/15/2025 revealed in part .Purpose: All dietary staff will be trained according to policy. 1. Provide all dietary employees with training upon hire and as needed. 2. Staff should be made aware of all safety precautions, nursing home policies, and necessary in-services regarding dietary equipment and meal services. 3. Dietary Supervisor will provide in-services to dietary staff as needed .

Review of an undated facility policy on 02/20/2025 at 1:15 p.m. titled, Dietary Competency revealed in part .

the Dining Services Manager will review each skill, observe staff demonstration, and sign each item on this list annually with each evaluation. The completed form will be placed in the employee file competencies included in part .Skill: purpose, emergency preparedness, food storage and handling, procedures, handwashing, food preparation, meal services, safety procedures, sanitary procedures, proper temperatures and recordings, storage, washing dishes, trash containers, operation, cleaning, and safety .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 35 195516 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 195516 B. Wing 02/20/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Camelot Leisure Living 6818 Highway 84 West Ferriday, LA 71334

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 In an interview on 02/17/2025 at 8:40 a.m., S4 Maintenance Supervisor revealed the dietary manager had been out for several months so he had been helping S1 Administrator oversee the kitchen and dietary staff. Level of Harm - Immediate jeopardy to resident health or In an observation of and interview in the kitchen area of S11 Dietary [NAME] on 02/17/2025 at 12:03 p.m., safety revealed S11 Dietary [NAME] had long curly goatee/facial hair and no usage of a beard net. S11 Dietary [NAME] confirmed he does not wear a beard net and he had not been made aware that he needed to wear a Residents Affected - Many beard net since he was hired 4 months ago. S11 Dietary [NAME] stated no one has ever spoke to him about covering his beard/goatee hair. S11 Dietary [NAME] stated that no one has properly trained him. S11 Dietary [NAME] revealed that he was 'self-taught' and stated, To be completely honest, it's a s!@# show every day in

this kitchen! S11 Dietary [NAME] stated that S1 Administrator nor S4 Maintenance Supervisor had ever trained him. S11 Dietary [NAME] stated he did not feel comfortable asking them for help because they do not listen and do not help the kitchen staff. S11 Dietary [NAME] stated that S14 Part-Time Dietary Manager comes weekly but had never taught him anything regarding his duties. S11 Dietary [NAME] reported that he worked by himself sometimes and often had little to no help.

In an interview and observation on 02/17/2025 at 12:13 p.m., S3 Dietary [NAME] was observed preparing pureed meals in the kitchen blender. S3 Dietary [NAME] was observed free-pouring and unmeasured amount of powdered thickener. S3 Dietary [NAME] revealed this was how she normally prepares her pureed meals and she just eye-balls it. S3 Dietary [NAME] stated no one had taught her differently.

In an interview on 02/17/2025 at 1:33 p.m., S3 Dietary [NAME] stated prior to today, she was unaware she was not to use Clorox/Bleach for dishwashing.

Review of facility dietary staff personnel files revealed there was no documentation indicating dietary staff had received training upon hire. Findings included in part .

S1 Administrator was hired on 09/01/2024 with no documentation of dietary staff competencies or duties check-off.

S3 Dietary [NAME] was hired on 12/11/2024 with no documentation of dietary cook competencies or duties check-off.

S4 Maintenance Supervisor was hired on 10/29/2001 with no documentation of dietary staff competencies or duties check-off.

S11 Dietary [NAME] was hired on 11/22/2024 with no documentation of dietary cook competencies or duties check-off.

S12 Dietary Aide was hired on 05/09/2024 with no documentation of dietary aide competencies or duties check-off.

In an interview on 02/18/2025 at 2:25 p.m., S13 RD stated there was no current Dietary Manager overseeing

the kitchen and that S1 Administrator was overseeing the kitchen daily. S13 RD stated she was made aware today that the kitchen staff had never received training and had never had competency check offs completed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 35 195516 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 195516 B. Wing 02/20/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Camelot Leisure Living 6818 Highway 84 West Ferriday, LA 71334

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 In an interview on 02/17/2025 at 9:26 a.m., S1 Administrator revealed the dietary manager had been out since July 2024 due to an injury. S1 Administrator stated he completed his self-serve certification and was Level of Harm - Immediate ultimately responsible for managing the kitchen and dietary staff. S1 Administrator stated recently corporate jeopardy to resident health or had allowed him to hire S14 Part-Time Dietary Manager who came once a week to assist in the kitchen. S1 safety Administrator stated S13 RD monitored the kitchen monthly. S1 Administrator confirmed that he was responsible for daily duties, hiring/firing of dietary staff, education, and daily monitoring. Residents Affected - Many Plan of Removal:

All 65 residents have the potential for illness or serious harm from the alleged deficiency

F-F835.

The dietary staff allegedly was not properly trained on dishwashing practices. After a review of policies and procedures they did not require updating. The training of new dietary staff will be done on hire, and continuing education will be provided at monthly in-services for all dietary staff to improve the knowledge, and basic skills of the dietary staff to ensure regulatory compliance. The training and continuing education of current and new dietary staff will be done by the administrator, the administrator's designee, or the dietary consultant.

On 02/17/2025 the administrator immediately verbally in-serviced dietary staff present not to use bleach to sanitize equipment and instructed staff how to use the 3 compartment sink and check for the proper amount of sanitizer. On 02/17/2025 the administrator called the dietary consultant to come 02/18/2025 to in-service and train dietary staff on sanitation in the kitchen and how to set up and check the sanitizer in the 3 compartment sink to ensure regulatory compliance. On 02/18/2025 the administrator called 2 off duty dietary staff to verbally in-service them about not using bleach, and how to setup the 3 compartment sink and check

the sanitizer. All dietary staff have been in-serviced as of 02/18/2025. Continuing education will be provided by the administrator, the administrator's designee, or the dietary consultant at monthly in-services for all dietary staff.

The training of each new hire in dietary will be monitored using a check list to orient them to the kitchen and dietary policies and procedures, and all dietary staff will receive monthly in-servicing training. The administrator will monitor the training of new dietary staff and the monthly in-services, both will be ongoing.

The dietary consultant will monitor the administrator to ensure new hire training and monthly in-servicing is taking place during their monthly visit. This monitoring will be included in the current QAPI being done in the kitchen and reported quarterly in the QA meeting.

Correction Date: 02/19/2025 at 1:29 p.m.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 35 195516 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 195516 B. Wing 02/20/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Camelot Leisure Living 6818 Highway 84 West Ferriday, LA 71334

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 51596 potential for actual harm Based on observation, interview and record review, the facility failed to maintain an infection prevention and Residents Affected - Some control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infection by:

1. failing to ensure staff decontaminated reusable medical equipment between residents,

2. failing to ensure staff washed their hands or applied an alcohol-based hand rub before and after direct contact with residents,

3. failing to ensure Enhanced Barrier Precautions (EBP) were utilized for 1 (Resident #9) of 1 resident sampled for Dialysis,

4. failing to ensure oxygen was properly stored in a sanitary manner that prevented the transmission of infection.

Findings:

Review of the facility's policy entitled Cleaning and Disinfection of Resident-Care Items and Equipment dated 01/13/2025 revealed, in part .Reusable resident care equipment will be decontaminated between residents.

Review of the facility's undated policy entitled Infection Control Guidelines for All Nursing Procedures revealed, in part . Employees must wash their hands before and after direct contact with residents. If hands are not visibly soiled, use an alcohol-based hand rub before and after direct contact with residents, after contact with a resident's intact skin, and after contact with medical equipment in the immediate vicinity of a resident.

Observation on 02/18/2025 from 8:15 a.m. until 9:20 a.m. revealed S10LPN using a wrist blood pressure (BP) cuff and an arm BP cuff to monitor the blood pressures of multiple residents. The BP cuffs were not decontaminated between uses on different residents. S10LPN did not wash her hands or apply hand sanitizer before or after direct contact with the residents.

An interview on 02/18/2025 at 9:20 a.m. with S10LPN confirmed she did not decontaminate the wrist BP cuff or the arm BP cuff between uses on residents, but should have. S10LPN confirmed she did not wash her hands or use hand sanitizer before or after direct contact with the residents.

Observation on 02/19/2025 at 9:02 a.m. revealed S7LPN used a wrist BP cuff to monitor the blood pressure of a resident. S7LPN then placed the wrist BP cuff onto Cart A without decontaminating the cuff. S7LPN then continued with dispensing of medications without washing her hands or using hand sanitizer.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 35 195516 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 195516 B. Wing 02/20/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Camelot Leisure Living 6818 Highway 84 West Ferriday, LA 71334

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 An interview on 02/19/2025 at 9:15 a.m. with S7LPN confirmed she did not decontaminate the wrist BP cuff

after using the cuff on a resident, but should have. S7LPN confirmed she did not always decontaminate the Level of Harm - Minimal harm or BP cuff after use, but did so when she thought about it. S7LPN confirmed she did not wash her hands or use potential for actual harm hand sanitizer before or after direct contact with a resident, but should have.

Residents Affected - Some An interview on 02/19/2025 at 9:40 a.m. with S6ADON confirmed blood pressure cuffs should be decontaminated between uses on residents. S6ADON confirmed staff should wash hands or use hand sanitizer before and after direct contact with residents.

An interview on 02/19/2025 at 10:09 a.m. with S5ADON confirmed blood pressure cuffs should be decontaminated between uses on residents. S5ADON confirmed staff should wash hands or use hand sanitizer before and after direct contact with residents.

Resident #9

Record review revealed Resident #9 was admitted on [DATE REDACTED] with diagnoses including, in part .End Stage Renal Disease (ESRD).

Review of Resident #9's Quarterly MDS with ARD of 01/04/2025 revealed, in part .BIMS score of 12 with indication for Dialysis.

Review of current physician orders for Resident #9 revealed and order dated 01/21/2025 for Dialysis on Tuesday, Thursday and Saturday related to ESRD. An order dated 01/15/2025 revealed EBP to be used

during resident high contact activities related to ESRD.

An observation on 02/18/2025 at 11:56 a.m. revealed no EBP sign on Resident #9's door and no EBP equipment outside Resident #9's room.

An observation on 02/18/2025 at 3:00 p.m. revealed no EBP sign on Resident #9's door and no EBP equipment outside Resident #9's room.

An observation on 02/19/2025 at 10:04 a.m. revealed no EBP sign on Resident #9's door and no EBP equipment outside Resident #9's room.

An interview was conducted with S5ADON on 02/19/2025 at 10:09 a.m. S5ADON confirmed EBP were not in place or maintained for Resident #9, but should have been. S5ADON confirmed residents receiving dialysis should have EBP in place.

51503

Resident #17

Review of Resident #17's medical record revealed an admitted [DATE REDACTED] with diagnoses that included in part . Persistent Asthma With (Acute) Exacerbation, Anxiety Disorder, Hemiplegia And Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, and Acute Respiratory Failure with Hypercapnia .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 35 195516 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 195516 B. Wing 02/20/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Camelot Leisure Living 6818 Highway 84 West Ferriday, LA 71334

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Review of Resident #17's Quarterly and State Optional MDS with ARD of 01/07/2025 revealed a BIMS score of 15, which indicated cognition was intact, and resident received oxygen therapy. Resident #17 required Level of Harm - Minimal harm or total dependence with one person physical assist for bed mobility and required total dependence with two potential for actual harm persons physical assist for transfers.

Residents Affected - Some Review of Resident #17's current physician orders revealed in part . -Change oxygen and nebulizer tubing weekly on Thursday every night shift with a start date of 01/30/2025 . -Oxygen per nasal cannula at 2LPM continuously every twelve hours related to severe persistent asthma with acute exacerbation with a start date of 09/03/2024 .

Review of Resident #17's care plan with an initial date of 01/18/2025 and a next review date of 04/18/2025 revealed in part .a focus of impaired gas exchange with interventions that included administer oxygen therapy as ordered .

On 02/17/2025 at 10:15 a.m., observed Resident #17's oxygen tubing/nasal prongs directly on the resident's bedroom floor.

In an interview and observation on 02/17/2025 at 10:20 a.m., S10 LPN confirmed Resident #17's oxygen tubing was directly on the floor and should have been stored in a labeled bag and was not.

In an interview on 02/19/2025 at 9:35 a.m., S2 DON revealed that nursing staff are ordered to change/label/store the oxygen tubing in bags weekly on Thursdays. S2 DON confirmed that all oxygen tubing should be labeled and stored in a bag when not in use.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 35 195516