Camellia Gardens Care Center

In the surveyor’s words

From the most serious findings on record at Camellia Gardens Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jun 29, 2021

  Based on observation, interview, and record review, the facility failed to identify hazards in the environment (the hand sanitizers, an alcohol based liquid used to minimize the spread of infection) and eliminate them to provide a safe environment and provide adequate supervision (an intervention to mitigate the risk of an accident) for one of 8 sampled residents with a behavior of grabbing items (Resident 159) in accordance with the facility's policies and procedures by failing to: 1. Provide visual monitoring as recommended and documented on the Situation-Background-Assessment-Recommendation (SBAR, a communication tool), dated 6/21/2021, due to Resident 159's behavior of grabbing staff and other people's belongings. 2. […]

• No harm, potential for more than minimal, widespreadF880Mar 1, 2024

  Based on observation, interview, and record review, the facility failed to observe infection control measures as indicated on the facility policy when facility failed to: 1. Establish and maintain an effective water management program to prevent the development and transmission of Legionnaire's disease (LD, a serious and often deadly form of lung infection [pneumonia], acquired by breathing in water droplets caused by the bacteria, legionella [the bacteria that causes LD]). This deficient practice placed 70 of 70 residents in the facility at risk for developing severe respiratory infection (pneumonia). 2. […]

• No harm, potential for more than minimal, patternF686Apr 23, 2026

  Based on observation, interview, and record review, the facility failed to ensure the low air loss mattresses (LALMs, designed to distribute a resident's body weight over a broad surface area and help prevent skin breakdown) for two (2) of 2 sampled residents (Residents 13 and 81) reviewed for pressure ulcers (injuries to the skin and underlying tissue resulting from prolonged pressure) were set at the correct settings in accordance with the facility's policy and procedure (P&P) and the physician's orders:Resident 13, who weighed 90 pounds (lbs.), had a LALM setting of 50 lbs.Resident 81, who weighed 103 lbs., had a LALM setting of 120 lbs.This deficient practice had the potential for Resident 13 to develop a pressure ulcer and placed Resident 81 at risk for deterioration of the resident's… […]

• No harm, potential for more than minimal, patternF812Apr 23, 2026

  Based on observation, interview, and record review, the kitchen staff (Cook 3) failed to follow the facility's food preparation policy by not using serving utensils and not changing gloves during the lunch tray line assembly (organized process in a healthcare or food service setting where staff assemble meal trays for residents) on 4/22/2026. This deficient practice had the potential to expose residents to pathogens (germs), placing them at risk for developing foodborne illness, which may cause symptoms such as upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever, and could lead to serious medical complications or hospitalization. […]

• No harm, potential for more than minimal, patternF584Mar 7, 2025

  Based on observation, interview and record review, the facility failed to provide a safe, clean, and homelike environment for two (2) of 17 sampled residents (Resident 36 and 37) when facility failed to: 1. Ensure Resident 36 and Resident 37's room did not have used gloves left on the floor. 2. Ensure Resident 36 and Resident 37's trashcan in the room was not overflowing with used disposable gowns. These deficient practices resulted in unsanitary conditions placing Resident 36 and 37 at risk for infection and uncomfortable living. Findings 1. […]