Calera Manor

Inspectors wroteBased on record review and interview, the facility failed to ensure an RN was on duty for 8 consecutive hours per day. The DON identified 74 residents who resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents did not receive antipsychotic medications for the diagnosis of dementia for 2 (#14 and #25) of 6 sampled residents reviewed for unnecessary medications. The DON stated 22 residents were prescribed antipsychotic medications at the facility. 1. A significant change MDS assessment, dated 03/09/25, showed in section C Res #14 had a BIMS score of 3 [this indicated the resident's cognition was severely impaired]. A policy titled Antipsychotic Medication Use, dated April 2007, read in part, Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. A prescription order, dated 03/04/25, showed Res #14 had been prescribed one tablet of Seroquel [an antipsychotic medication] 50 mg every day for dementia with mood disturbance. [...]

Inspectors wroteBased on record review and interview, the facility failed to notify the physician of a significant weight change for 1 (#71) of 3 sampled residents reviewed for nutrition. A weight variance report, dated 06/09/25, showed 4 residents with significant weight loss.

Inspectors wroteBased on record review and interview, the facility failed to implement a comprehensive care plan intervention regarding smoking safety assessments for 1 (#25) of 18 sampled residents reviewed for care plans. The DON stated there were 74 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident that smoked cigarettes was assessed for the ability to safely smoke for 1 (#25) of 4 sampled residents reviewed for accidents. The DON stated 15 residents at the facility smoked tobacco products.

Inspectors wroteBased on record review and interview, the facility failed to report an allegation of physical abuse to local law enforcement for 1 (#80) of 1 sampled resident reviewed for abuse. The assistant administrator reported the census in the facility was 74.

Inspectors wroteBased on record review and interview, the facility failed to ensure sufficient staff to provide supervision for one (#35) of 17 sampled residents reviewed for sufficient staffing. The administrator identified 67 residents resided in the facility and 23 resident were dependent on staff for assistance with activities of daily living.

Inspectors wroteBased on record review and interview, the facility failed to ensure RN coverage for eight consecutive hours per day. The administrator identified 67 residents resided in the facility. On 01/09/24 at 2:56 pm., RN coverage time sheets were reviewed with the Adm. Asst. from 10/01/23 through 10/31/23. There was no RN coverage for eight consecutive hours per day for the following dates: 10/03/23, 10/04/23, 10/05/23, 10/07/23, and 10/09/23 through 10/14/23. The Administrator acknowledged there was no RN coverage. A staff schedule, dated 12/25/23 through 01/13/24 did not have a Registered Nurse scheduled on 01/07/24. On 01/09/24 at 3:22 p.m., the Adm. Asst. was shown the staff schedule dated 12/25/23 through 01/13/23 and asked if there had been registered nurse coverage on 01/07/24. They reviewed the the payroll time on the computer and stated no RN had clocked in on that date. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure: a. staff did not carry two resident's medications (#126 and #59) to administer at the same time, b. staff counted controlled medications every shift per policy, and c. controlled medications had accurate narcotic count sheets for two (#70 and #46) of four sampled residents reviewed for medications. The administrator identified 67 residents resided in the facility. The DON identified 35 residents received narcotics.

Inspectors wroteBased on record review and interview, the facility failed to ensure snacks were offered to one [#8] of three sampled residents reviewed for snacks. The administrator identified 67 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure informed consent was obtained for the use of an antipsychotic medication for one (#47) of five sampled residents reviewed for unnecessary meds. The Administrator identified 67 residents resided in the facility and the DON identified 22 residents who received psychotropic medications.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure privacy by preventing wandering residents from going in other residents' rooms uninvited for two (#23 and #25) of three sampled residents reviewed for privacy. The administrator identified 67 residents resided in the facility and the ADON identified seven residents that wandered.

Inspectors wroteBased on record review and interview, the facility failed to report allegations of abuse to the State agencies for two (#36 and #63) of three sampled residents reviewed for abuse. The Administrator reported there were 67 residents residing in the facility.

Inspectors wroteBased on record review and interview, the facility failed to investigate allegations of inappropriate sexual behavior for two (#36 and #63) of three sampled residents reviewed for abuse. The Administrator identified there were 67 residents residing in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure showers were provided for one (#8) of two sampled residents reviewed for ADL assistance. The administrator identified 67 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure supervision for a resident who was on a mechanically altered diet for one (#60) of 17 sampled residents. The administrator identified 67 residents resided in the facility and the DON reported four residents received a pureed diet and nineteen residents received a mechanical soft diet.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain infection control during wound care for one (#19) of one sampled resident reviewed for wound care. The administrator identified 67 residents resided in the facility. The DON identified eight residents received wound care.

Inspectors wroteBased on record review and interview, the facility failed to transmit resident assessments to CMS within 14 days of completion. The Resident Census And Conditions Of Residents report documented 67 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to staff a registered nurse eight hours a day, seven days a week. The Residents Census And Conditions Of Residents documented 67 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure comprehensive assessments were completed in a timely manner on three (#4, 11, and #185) of 37 residents reviewed for comprehensive assessments. The Resident Census And Conditions Of Residents documented 67 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure quarterly assessments were performed in a timely manner on three (# 12, 145, and #187) of 37 residents reviewed for quarterly assessments. The Resident Census And Conditions Of Residents documented 67 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to perform annual skills competencies for nursing staff. The Resident Census And Conditions Of Residents documented 67 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to revise a comprehensive person centered care plan for one (#48) of two residents sampled for care plans. The Resident Census And Conditions Of Residents documented 67 residents resided in the facility.

Inspectors wroteBased on record review, observation, and interview, the facility failed to obtain a physician's order for gastrostomy care on one (#180) of two residents sampled for a gastrostomy tube. The Resident Census And Conditions Of Residents documented two residents received tube feedings.