Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
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.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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| Louisiana Extended Care Hospital Of Lafayette | 0.6 mi | — | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.