Camden Postacute Care, Inc

Inspectors wroteBased on interview and record review, the facility failed to re-admit one of three sampled residents (Resident 1) following hospitalization when Resident 1 was ready to be discharged from an acute care hospital on 7/13/26 and facility indicated there was no available isolation room. Facility staff did not review Resident 1's current clinical information to determine the appropriate infection control precautions and did not explore alternative room placement options. This failure delayed Resident 1's return to the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen when: 1 One can of grape juice in the dry storage room was dented and was not removed to prevent use; and 2. One pack of open cereal with no date when it was opened and no expiration date; 3. Refrigerator #2 had the following: 12 pieces of tomatoes inside a plastic bag container, three pieces of carrots inside a plastic bag, four pieces of white onions inside a plastic bag, 2 bunches of lettuce inside a plastic bag and one bunch of celery inside a plastic bag were not labeled and no date when it was delivered to the facility; and 4. Freezer #2 in front of the kitchen, there was one pack of cauliflower, and one pack of chopped spinach with no opened date or expiration date. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure their policy and procedure (P&P) for an advance directive (AD, a written instruction, such as a living will or durable power of attorney [ a document that authorizes to act on behalf of resident] for healthcare when the individual is incapacitated) for six of 8 sampled residents (Resident 10, 13,18,19,27, and 37). This failure could lead to the delivery of unnecessary or inappropriate medical services against sampled residents' goals and wishes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their bed rails (side rails, bed rails, safety rails, grab/assist bars: adjustable metal or rigid plastic bars that attached to the bed) policy for six of 15 sampled residents (Resident 39,19,27,33,17, and 5) when: 1. There was no documentation that alternatives for side rails were attempted prior to installing bed rails; 2. There was no informed consent (IC, the process of communication between health care provider and resident that often leads to agreement or permission for care, treatment or services or interventions) from resident or responsible parties (RP, individual designated to make decisions on behalf of the residents) including risks and benefits explained prior to installing bed rails; and 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to adhere with their infection prevention and control program to ensure proper hand hygiene and personal protective equipment (PPE, is equipment used to prevent or minimize exposure to hazards such as gown and gloves ) were implemented during delivery of care to residents in the facility when: 1. Facility staff did not follow the Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs, is a germ that is resistant to many antibiotics] in nursing homes) wearing personal protective equipment (PPE, is equipment used to prevent or minimize exposure to hazards such as gown and gloves) during wound dressing change to Resident 12 and during Foley catheter (F/C: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat four of 15 sampled residents (Resident 1, Resident 18, Resident 23 and Resident 28) with dignity and respect when: 1. Housekeeping (HK) N and the dietary staff were speaking in their own language other than English in the presence of Resident 1; 2. Resident 18 and 28 urinary catheter drainage bags (a urinary catheter is a thin, flexible tube used to drain urine from the bladder) were left uncovered; and 3. Staff did not assist Resident 23 during lunch while other residents in the same dining room were already eating with staff assistance. These failures had the potential to negatively affect resident's emotional and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform interdisciplinary team (IDT, staff from different departments who coordinate the residents care) assessment and obtain a physician order for self-administration of medication for two of eight sampled residents (Resident 27 and 37) when: 1. Resident 27 had over the counter (OTC, can be purchased without a prescription from medical doctor) bottle of isopropyl alcohol (used for cleaning wounds and as disinfectant) on the bedside tray table unattended; and 2. Resident 37 had a bottle of OTC hydrogen peroxide (used for cleaning wounds and as disinfectant), and a bottle folic acid (vitamin supplement) medication on the bedside table unattended. This failure had the potential for unsafe and improper administration of OTC and medication supplement for Residents 27 and 37.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a clean and homelike environment was provided for two of 14 sampled residents (Resident 1 and Resident 25) when: 1. The privacy curtain in Resident 25's room was left sticky, had brownish dry food particles, and dirty; and 2. In Resident 1's room, the floor was sticky when walked on and Resident 1 complained that her room was not cleaned by the housekeeper daily. These failures increased the potential for Resident 1 and Resident 25 not attaining their highest practicable well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR, screening for residents with mental disorder and residents with intellectual disability) Level 1 and Level II screening was completed for two of 15 sampled residents (Resident 9 and 13). This failure had the potential for mentally ill sampled residents not to receive benefit from specialized health care and services.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive person-centered care plan with measurable objectives, goal and person-centered interventions, for one out of 15 sampled residents (Resident 5). This deficient practice had the potential to result in not meeting the residents' needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to update and revise the individualized and comprehensive care plans for two of 15 sampled residents (Resident 12 and Resident 40) when: 1. A care plan to address Resident 12's dementia (memory loss) was not updated and revised; and 2. A care plan to address Resident 40's end stage of renal disease (ESRD, a severe and irreversible condition where the kidneys have lost most of their function and are no longer able to adequately filter waste products from the blood) on hemodialysis (HD, is a life-saving treatment for kidney failure that removes waste and extra fluids from the blood and regulates blood pressure) was not updated and revised after increasing HD from three times per week to four times per week. These failures had the potential to result in not meeting the residents' needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the safety of one of four residents (Residents 29) who smoke without oversight staff supervision. This failure had the potential to put Resident 29 at risk of harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure there was sufficient direct care nursing staff to provide nursing and related care and services to meet resident's needs safely for 24 hours a day during the weekend. This failure had the potential to compromise care, health, and well-being of the 55 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure the consultant pharmacist (CP, a licensed pharmacist provides expert clinical advice and guidance on medication use) identified and reported the lack of blood work related to use of anticoagulant (AC, used to treat prevent or delays blood clots forming in blood vessels) medication to the facility during the monthly medication regimen review (MRR, a thorough evaluation of resident's medications) for one of three sampled resident (Resident 10); and the facility failed to follow up MRR recommendations for one of two sampled resident (Resident 156). These failures resulted in Resident 10 not receiving a baseline and periodical blood work, and Resident 156's medication orders not clarified.

Inspectors wroteBased on observation, interview, and record review, the facility had a 5.56% medication error rate when two medication errors out of 36 opportunities were identified during medication pass for two residents (Resident 16 and 41). These failures had the potential to result in ineffective drug therapy and possible adverse effects for the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were labeled and stored accordance with currently accepted professional standards for two of 15 sampled Residents( 5 and 25) when: 1. A bottle of oral liquid lorazepam (a controlled medication used to relieve anxiety [persistent worry and fear about everyday situations]) without legible expiration date was stored in the medication room for Resident 25 to be used; and 2. An unlabeled normal saline solution (NSS, 0.9% sodium chloride in water ) in a bottle was found at Resident 5's bedside table unattended. These deficient practices could lead to unsafe and ineffective medication use for the residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure a resident's room accommodated no more than four residents when room [ROOM NUMBER] had six beds, and six residents and room [ROOM NUMBER] had five beds and five residents. Having more than four residents per room had the potential of compromising the quality of life and quality of care the residents received.

Inspectors wroteBased on observation, interview and record review, the following multi-resident rooms were less than 80 square feet per resident.

Inspectors wroteBased on interview and record review the facility improperly transferred Resident 20 to board and care facility (a smaller, more intimate living option for residents who need assistance but not 24/7 nursing care), failed to notify responsible party (RP, a person empowered to make decisions for the resident/ person legally responsible and liable for a decision or action) in writing at least 30 days prior to the transfer, and failed to advise the RP of Resident 20's of their rights to appeal. The transfer/discharge was improper and violated Resident 20's resident rights.

Inspectors wroteBased on interview and record review, the facility Administrator (ADMN) failed to provide consistent administrative oversight to ensure that the Social Services Department and interdisciplinary team (IDT, facility staff members from different departments who coordinate care provided to residents) implemented the facility's policy and procedure (P&P) for safe transfer and discharge for one of three residents (Resident 20) when Resident 20 was discharged to a board and care facility (smaller more intimate living option for residents who need assistance with daily activities but not nursing care 24/7). This failure had resulted in Resident 20's having eloped (run away secretly) from the board and care facility.

Inspectors wroteBased on interview and record review, the facility failed to perform a thorough investigation and report for six of six residents (Residents 1, 2, 3, 4, 5, and 6). This failure had the potential to compromise the facility's ability to determine the circumstances surrounding the incidents and could have compromised the residents' safety.

Inspectors wroteBased on interview and record review, the facility failed to assist one of three residents (Resident 1) with getting insurance when their insurance stopped. This failure had the potential to compromise Resident 1's ability to obtain quality of care and admission.

Inspectors wroteBased on interview and record review, the facility failed to provide care and services in accordance with professional standard of practice for one of one resident (Resident 1) when the Licensed Vocational Nurse (LVN) did not follow the physician order regarding out on pass (leave the premises) for therapeutic therapy. This failure had the potential to compromise the resident's safety.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from sexual abuse when Resident 1 and Resident 2 were left alone in the activity room and Resident 2 touched Resident 1's inner thigh. This failure had the potential to endure emotional and psychological harm for Resident 1.

Inspectors wroteBased on observation and interviews, the facility failed to ensure residents' rooms measured at least 80 square (sq) feet (ft) per resident in 23 (Rooms 1 through 21, [NAME] 1, and [NAME] 2) of 23 resident rooms in the facility.

Inspectors wroteBased on observations, interviews, and facility document review, the facility failed to ensure residents' rooms accommodated no more than four residents when 1 (Ward 1) of 23 resident rooms was occupied by six residents, and 1 (Ward 2) of 23 resident rooms was occupied by four residents but had six beds available for use when at full occupancy.

Inspectors wroteBased on interview and record review, the facility failed to provide supervision to prevent one out of three residents (Resident 1) from leaving the facility without staff's knowledge and permission. 1. The facility did not implement the care plan to provide enough supervision for Resident 1's mobility; 2. The facility did not update Resident 1's care plan to provide adequate supervision post-event. These failures compromised Resident 1's health and safety, as he was found by the police and, was admitted to the acute hospital for treatment and evaluation on 9/20/23, and had a potential risk for Resident 1's elopement in the future.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen when: 1. Dietary staff did not cover their hair completely with a hairnet; 2. The uncleaned fan blew air directly onto the clean meal trays, plates, plate covers and food preparation area (area to prepare for hot food); 3. There were opened liquid eggs stored with other food items in the refrigerator; 4. Toaster had multi-colored substances; 5. The can opener had multi-colored substances; 6. Kitchen staff did not correctly check the sanitizer concentration level; 7. Dietary manager (DM) did not wash his hands or perform the hand hygiene when he was in the kitchen. These failures had the potential to cause food-borne illness for the residents. There were 49 of 51 residents consuming the food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff implemented proper infection control practices when: 1. Licensed vocational nurse A (LVN A) did not follow infection control practice during residents' wound treatment for sampled Residents 8 and 28; 2. The janitor/Housekeeper did not know the environmental disinfectant contain time (wet time, disinfectant maintain wet on the surface in order to kill the micro-organism) when cleaning the resident's room; 3. The facility did not implement the effective infection control practice when Resident 8 refused to do the wound treatment and shared the room with four residents; 4. Multiple residents did not wear mask or did not properly wear masks when leaving their room; multiple residents did not keep social distancing of at least six feet apart in the hallway; 5. COVID-19 screen concerns for visitor/staff; 6. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respect and dignity was maintained for five of 13 sampled residents (46, 7, 31, 33, and 198) when: 1. Resident 46's urinary catheter drainage bag (urinary catheter a thin, flexible tube used to drain urine from the bladder) was left uncovered; 2. Residents 7 and 31's body parts were exposed to public view; 3. Resident 33's name were written on the back of his clothes and 4. Resident 198 wore only an incontinent brief while walking in the hallway. This failure resulted to residents rights not being maintained.

Inspectors wroteBased on interview and record review, the facility failed to submit the completed Minimum Data Set (MDS, an assessment tool) data to the Centers for Medicare & Medicaid Services (CMS, oversees federal healthcare programs) for one of three sampled (Resident 2). This failure resulted in non-compliance with regulatory requirements.

Inspectors wroteBased on interview and record review, the facility failed to ensure an interdisciplinary team (IDT) meeting was held to start the discharge planning of four of four residents. This failure could potentially affect the residents' health and wellness upon discharge from the facility. During the initial tour on 5/17/21 at 10:23 a.m., Resident 40 stated the facility staff wanted to send him home, but he said he was not ready. Resident 40 stated he just started to walk a few days ago. Resident 40 stated he had filed an appeal, because his insurance ran out. During an interview on 5/20/21 at 3:04 p.m. with the social services staff (SS), the SS stated there was not an IDT note about Resident 40's future discharge. The SS stated no IDT meeting was held to discuss Resident 40's discharge plan. During an interview on 5/20/21 at 3:08 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure treatment for limited range of motion (ROM, the full movement potential of a joint) was implemented consistently for one of 13 sampled (Resident 197) when a carrot/hand roll was not applied to both of Resident 197's hands every shift. This failure had the potential to decrease the range of motion and function of Resident 197's hands.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the gastrostomy tube (GT, a device surgically inserted into the stomach through the abdomen used to supply food, fluids, and medications) placement was checked prior to administering medications for one out of 28 opportunities (Resident 20). This failure had the potential to compromise the residents's care and could cause health complications.

Inspectors wroteBased on interview and record review the facility failed to ensure communication with the dialysis facility was properly coordinated when dialysis communication records (DCR) for one of four (Resident 46) was not completed. This failure may affect the quality of dialysis care being provided to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from unnecessary psychotropic medication (drugs that affects brain activities associated with mental processess and behavior) for two of five residents (21 and 5) who receives psychotropic medications when: 1. Resident 21 received Ambien (prescription medicine for the short-term treatment of adults who have trouble falling asleep) 2.5 mg (mg, unit of measurement of mass) without monitoring hours of sleep, as indicated in the care plan; and 2. Resident 5 received prn (as needed) Lorazepam Intensol (used to treat anxiety) beyond 14 days without documentation of its rationale and specific duration in the resident's clinical record. [...]

Inspectors wroteBased on observation, interview, and record review, the facility had a 7.14 percent medication error rate when two medication errors out of 28 opportunities were identified during medication pass for one resident (Resident 30). These failures had the potential to result in ineffective drug therapy and possible adverse effects for the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and label medications in accordance with the manufacturer's instructions when: 1. Resident 14's Incruse Ellipta (an oral inhaler, used to prevent airflow obstruction and reduce flare-ups in adults with chronic obstructive pulmonary disease) was opened without an open date; 2. Two of two Xalatan (or Latanoprost, to treat high pressure inside the eye due to glaucoma) eye drops for Residents 13 and 23 were being used past the discard date; and 3. Lorazepam Intensol (medication used to treat anxiety) 2mg/ml (mg/ml, measurement of a solution's concentration) bottle for Resident 5 did not have an open date and was being used past the discard date. These deficient practices had the potential for residents to receive medications from two out of two medication carts. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure a resident room accommodated no more than four residents when Room A had six beds and six residents, and Room B had five beds and five residents. Having more than four residents per room has the potential of compromising the quality of life and quality of care the residents receive.

Inspectors wroteBased on observation, interview and record review, the following multi-resident rooms provided less than 80 square feet per resident.