Camelback Post Acute Care and Rehabilitation

Inspectors wroteBased on interviews, clinical record review, and review of facility policy and procedure, the facility failed to ensure two residents (#31 and #135) were provided written notice of discharge including contact information for the ombudsman prior to the discharge, and that the notice of discharge was sent to the ombudsman prior to the resident's discharge. The deficient practice could result in residents and their representatives being unaware of their appeal and advocacy rights and could prevent the ombudsman from reviewing and advocating for safe and appropriate discharge planning before the discharge occurred.

Inspectors wroteBased on observation, interview, review of clinical record, and review of facility policy and procedure, the facility failed to ensure care and services regarding oxygen therapy were provided to meet the needs of one of four sampled residents (Resident #3). The deficient practice could result in a resident not receiving necessary respiratory care, and could result in a worsening medical condition and physical harm.

Inspectors wroteBased on clinical record reviews, staff and resident interviews, facility documentation, and policy and procedures, the facility failed to protect the rights of one resident, resident (#1) to be free from verbal abuse by staff. The deficient practice could result in further abuse. Findings Include: Resident #1 was admitted on [DATE], with a diagnosis that included spinal stenosis, retention of urine, hypertension, fibromyalgia, obesity, muscle weakness, abnormalities of gait and mobility, need for assistance with personal care, and low back pain. The care plan dated November 26, 2025, had a focused care area for risk of impaired cognitive function/dementia or impaired thought process related to the new environment. [...]

Inspectors wroteBased on observations, staff interviews, and the facility policy and procedures, the facility failed to ensure that soiled linens and laundry were not stored in public areas and were covered to prevent the spread of infection. The deficient practice could result in the spread of infection to residents.

Inspectors wroteBased on observations, staff interviews, and the facility policy and procedures, the facility failed to ensure that soiled linens and laundry were not stored in public areas and were covered to prevent odor and ensure a comfortable environment. The deficient practice could impact the residents' safe, sanitary, and homelike environment.

Inspectors wroteBased on documentation, staff interviews, and the facility policy and procedures, the facility failed to assess one resident (#35) for pain and take vitals when admitted to the facility in a timely manner, and failed to administer pain medication with pain parameters for one resident (#27). The deficient practice could result in residents' pain not being identified and addressed, residents' being overmedicated or under-medicated.

Inspectors wroteBased on observations, staff interview, and policy review, the facility failed to ensure food items were labeled and dated, food items were not expired, temperature logs were maintained, equipment was sanitized, and food was served under sanitary conditions. The deficient practice could increase the risk of foodborne illness.

Inspectors wroteBased on observation, staff interviews, and the facility policy and procedures, the facility failed to ensure that dirty dishes were not left in a common areas where residents have access, and that common areas were cleaned and disinfected. The deficient practice could result in residents becoming ill or infected.

Inspectors wroteBased on clinical record review, staff interviews, and review of facility policies and procedures, the facility failed to ensure one resident's (#81) clinical record included the required information for transfer/discharge. The deficient practice could result in residents not having a safe and effective transition of care.

Inspectors wroteBased on clinical record review, staff and resident interviews and policy review, the facility failed to ensure one resident's (#44) representative was able to participate in the care planning process. The deficient practice could result in residents and representatives not participating in and understanding their plan of care.

Inspectors wroteBased on observation, staff interviews, and the facility policy and procedures, the facility failed to ensure that a potentially dangerous item was not left in a public area on one resident's (#1) mobile tray where other residents could access it. The deficient practice could result in residents injuring themselves.

Inspectors wroteBased on observations, staff interviews, and the facility policy and procedures, the facility failed to ensure that one resident (#1) was assessed for the risk of entrapment when using full size bedrails on both sides of the bed and to assess and document the ongoing need for bed rails. The deficient practice could result in residents being physically injured.

Inspectors wroteBased on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that a registered nurse (RN) provided eight hours of coverage in a 24 hour period.

Inspectors wroteBased on observation, staff interviews, and the facility policy and procedures, the facility failed to ensure that the daily staff posting reflected the correct information.

Inspectors wroteBased on clinical record review, staff interviews and review of policy and procedure, the facility failed to coordinate one resident's (#4) care/medications with hospital physician to ensure medications were given according to physician instructions. The deficient practice resulted in significant harm to the resident.

Inspectors wroteRegarding staff not wearing appropriate Personal Protective Equipment (PPE): -Observations were conducted of the DON (staff #53) on August 17, 2021 at 1:45 pm and 3:05 pm, and on August 18, 2021 at 7:45 am. The DON was observed on these occasions to be wearing a cloth face mask with no other face mask or covering. The cloth face mask was not well fitting and slid down when the DON was talking, exposing his nose. -An observation of a housekeeping staff was conducted on August 18, 2021 at 7:47 am. The housekeeping staff member was cleaning a room in the COVID-19 unknown unit. The staff member was wearing an N95 face mask, with only one strap secured behind her head. The other strap was hanging down below her chin. The staff member was not wearing any other face mask or covering. -An observation was conducted of an LPN (staff #50) on August 18, 2021 at 2:45 pm. [...]

Inspectors wroteBased on staff interviews, review of the clinical record, and policy and procedure, the facility failed to ensure one of two sampled residents (#22) with a diagnosis of a serious mental illness was referred to the appropriate state-designated mental health or intellectual disability authority for review. The deficient practice could result in necessary specialized services not being provided for residents who need it.

Inspectors wroteBased on clinical record review, staff interviews, and review of policy and procedure, the facility failed to ensure a Level I Pre-admission Screening and Resident Review (PASRR) was completed prior to or upon admission and a PASRR Level I screening was updated when required for one of two sampled residents (#22). The deficient practice increases the risk that individuals who have a mental disorder or intellectual disability may be inappropriately placed in nursing homes and/or they may not receive appropriate treatment or services.

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to ensure one of three sampled residents (#267) received the necessary services to maintain good grooming and hygiene. The deficient practice could result in grooming and hygiene needs of residents not being met.

Inspectors wroteBased on observations, clinical record reviews, resident and staff interviews, and review of policy and procedure, the facility failed to ensure two residents received treatment and care in accordance with professional standards of practice related to a peripheral intravenous (IV) catheter for one resident (#267) and related to treatment orders for a knee immobilizer for one resident (#59). The sample size was 19. The deficient practice could lead to residents not receiving appropriate care and treatment.

Inspectors wroteBased on observations, clinical record review, resident and staff interviews, and policy review, the facility failed to ensure one sampled resident (#317) had an order for oxygen use. The deficient practice could result in residents receiving oxygen without a physician order.

Inspectors wroteBased on observation, staff interviews, clinical record review, and review of policy, the facility failed to ensure one resident's (#39) clinical record accurately reflected a medication administration. The sample size was 7. The deficient practice increases the risk for medication error.