Camelot Leisure Living

Inspectors wroteBased on observation, record review, and interview the facility failed to provide care and services that met professional standards. The facility failed to:Obtain PT/INR for Resident #2; andDocument medications and/or treatments on the EMAR and ETAR for 5 (Resident #1, Resident #6, Resident #8, Resident #37, and Resident #59) of 26 sampled residents. Review of Resident #37's medical record revealed an admission date of 06/20/2022 with diagnoses that included in part. Type 2 Diabetes Mellitus with Diabetic Neuropathy, Methicillin Resistant Staphylococcus, Mild Protein-Calorie Malnutrition, GERD, Dysphagia, COPD, Chronic Hypertension, Diverticulitis of Intestine, Constipation, HTN, and Depressive Episodes, and Atherosclerotic Heart Disease of Native Coronary Artery. [...]

Inspectors wroteBased on observation and interview the facility failed to ensure nurse staffing data requirements were completed and posted appropriately. This deficient practice had the potential to affect all 65 residents residing in the facility. Observation on 03/16/2026 at 9:10 a.m. revealed a facility form titled, Daily Nursing Census posted on a clipboard (on the wall-near the front desk) with a date of 03/15/2026. No observation of the completed form for the current date, 03/16/2026. Observation on 03/17/2026 at 9:00 a.m. revealed a facility form titled, Daily Nursing Census posted on a clipboard (on the wall-near the front desk) with a date of 03/15/2026. No observation of the current date, 03/17/2026, were noted. Further observation of the previous facility forms titled, Daily Nurse Census revealed several missing dates. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to meet the nutritional needs of residents in accordance with established national guidelines. The facility failed to follow the recipe while mixing ingredients to ensure nutritional adequacy for the 7 residents receiving pureed meals prepared by the facility's kitchen.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that each Resident was treated with respect and dignity in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 2 (#3 and #38) of 26 residents sampled for dignity, by failing to ensure they were free of facial hair.

Inspectors wroteBased on record review and interview the facility failed to notify the Ombudsman in writing of resident transfer/discharge for 1 (Resident #68) of 3 residents reviewed for transfer/discharge. The total sample size was 26.

Inspectors wroteBased on interview and record review the facility failed to ensure that a resident with an identified mental disorder had a completed Preadmission Screening and Resident Review (PASRR) Level II form as required for 1 (#11) of 26 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services for the provision of respiratory care in accordance with professional standards. The facility failed to ensure respiratory equipment/nebulizer was stored properly for 1 (Resident #8) of 1 residents reviewed for respiratory care. The total sample size was 26 residents.

Inspectors wroteBased on observation, record review and interview the facility failed to maintain a medication error rate of less than 5% for 2 (Resident #12 and Resident #50) of 3 residents observed during medication administration. A total of 27 opportunities were observed which included 2 medication errors for a medication error rate of 7.41%

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with current accepted professional principles. The facility failed to: Ensure medications were not left at the bedside for 1 (Resident #8) of 26 sampled residents; and Ensure controlled substances were properly stored in a permanently affixed compartment in the medication refrigerator. Facility census was 65.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure infection control measures were practiced to provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections for 1 (#1) of 1 residents observed for wound care.

Inspectors wroteBased on interview and record review the facility failed to ensure prompt resolution of an allegation of not providing proper Ileostomy care for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents by failing to initiate a grievance for Resident #1.

Inspectors wroteBased on interview and record review, the facility failed to develop a person-centered care plan for 1 (Resident #2) of 3 (Residents #1, #2, and #3) sampled residents. The facility failed to develop a care plan related to feeding assistance for Resident #2. On 07/16/2025 at 10:39 a.m., review of facility policy titled, Care Plans, Comprehensive Person- Centered, with revision date of 01/15/25, revealed in part. A Comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. A comprehensive, person-centered care plan will. describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. [...]

Inspectors wroteBased on Observation, interview and record review the facility failed to ensure that a resident who required Ileostomy services received such care consistent with professional standards of practice for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents by failing to change Resident #1's ileostomy bag as needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a clean and sanitary kitchen to prevent the likelihood of foodborne illnesses and failed to store, prepare, and serve food in accordance with professional standards for food service safety. This deficient practice had the potential to effect all 64 residents who resided in the facility. The facility failed to ensure: 1. Staff used approved chemicals/sanitizers during dishwashing; 2. Food items in the refrigerators were labeled and dated; 3. Maintenance of a clean freezer, in a safe operating condition, and food stored appropriately; 4. Food items in the pantry were labeled with an open date, stored in a sealed container, and expired foods were not available for use; 5. Food items in hot-warmer were covered and labeled until ready for serving; 6. Maintenance of a clean and sanitary kitchen at all times; 7. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to administer its resources effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This deficient practice had the potential to effect all 64 residents who resided in the facility. The facility failed to ensure the dietary department was practicing professional standards for food services. This deficient practice resulted in an immediate jeopardy situation on 02/17/2025 at 12:17 p.m. when S3 Dietary [NAME] was observed using a Clorox/Bleach solution for dishwashing of the blender, used during pureed meal preparation. S3 Dietary [NAME] stated this was how she washed dishes normally to save time. S3 Dietary [NAME] was advised by Surveyor to dispose of meats/beef patties on two occasions during meal preparation. [...]

Inspectors wroteBased on observation, interview and record review the Facility failed to provide respiratory care consistent with professional standards for 3 (Resident #10, Resident #17 and Resident #273) of 35 residents reviewed for respiratory care. The Facility failed to ensure respiratory equipment was properly changed, labeled and stored.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure drugs were stored in accordance with currently accepted professional principles by: 1. Failing to ensure an insulin vial was labeled with the date it was opened; 2. Failing to maintain accurate and complete documentation for medications in the emergency kit; 3. Having a loose pill in 1 (Cart A) of 1 medication cart checked for safe and secure storage; 4. Failing to ensure expired medications were not available for use; 5. Failing to document administration of controlled substances; 6. Failing to ensure a narcotic record included the strength of the medication; and 7. Failing to discard a controlled substance when it was discontinued.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide sufficient support personnel to effectively carry out the functions of the food and nutrition services. The facility failed to ensure meals were served timely according to the meal times posted. This deficient practice had the potential to affect the 62 residents that received meals from the facility kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that pureed foods were prepared by methods which conserved nutritional value for 11 (#6, #7, #10, #12, #15, #26, #30, #45, #55, #61, and #224) of 11 Residents who were ordered and served pureed diets.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infection by: 1. failing to ensure staff decontaminated reusable medical equipment between residents, 2. failing to ensure staff washed their hands or applied an alcohol-based hand rub before and after direct contact with residents, 3. failing to ensure Enhanced Barrier Precautions (EBP) were utilized for 1 (Resident #9) of 1 resident sampled for Dialysis, 4. failing to ensure oxygen was properly stored in a sanitary manner that prevented the transmission of infection.

Inspectors wroteBased on observation and interview the facility failed to ensure that each Resident was treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 2 (#32 and #19) of 2 Residents reviewed for dignity. The facility failed to ensure: 1. Resident #32, who was seated at a table with another Resident, was served his meal at the same time; and 2. Resident #19 was free from facial hair.

Inspectors wroteBased on interview and record review, the facility failed to consult with the resident's physician when there was a significant change in the resident's physical status for 1 (#72) of 3 (#49, #71, and #72) closed records reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the security and confidentiality of medical records.

Inspectors wroteBased on interview and record review, the facility failed to complete a Discharge Minimum Data Set (MDS) assessment upon discharge for 1 (Resident #28) of 1 resident sampled for Resident Assessment.

Inspectors wroteBased on record review and interview the facility failed to complete a significant change MDS within 14 calendar days after determining there was a significant change in residents status for 1 (#7) of 35 sampled resident's.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide services that meet professional standards of quality. The facility failed to revise the care plan interventions to prevent development of a wound for 1 (Resident #43) of 3 residents (Resident #10, Resident #43, and Resident #223) sampled for skin conditions.

Inspectors wroteBased on observation, interviews and record review the facility failed to ensure the resident's environment remained as free of accidents/ hazards as possible for 1 (#13) resident reviewed for accidents. The facility failed to repair a crack in the parking lot's concrete which resulted in a fall for Resident #13. Total sample size was 35.

Inspectors wroteBased on observation and interview the facility failed to post nurse staffing information on a daily basis that included the resident census, and total number and actual hours worked by RNs, LPNs and CNA staff directly responsible for resident care per shift. The facility census was 64.

Inspectors wroteBased on observation and interview the facility failed to ensure garbage and refuse were disposed of properly. This deficient practice had the potential to affect all 64 residents who resided in the facility.

Inspectors wroteBased on record review and interview the facility failed to ensure an allegation of sexual abuse was reported to the State Survey Agency immediately but not later than 2 hours after the sexual abuse was reported for 1 (Resident #1) of 4 (Resident #1, Resident #2, Resident #3 and Resident #4) sampled residents. The facility also failed to report a fracture of unknown origin for 1 (Resident #2) of 4 (Resident #1, Resident #2, Resident #3, and Resident #4) sampled residents.

Inspectors wroteBased on interview and record review the facility failed to thoroughly investigate and allegation of sexual abuse for 1 (Resident #1) of 4 (Resident #1, Resident #2, Resident #3 and Resident #4) of 4 sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to develop a comprehensive care plan with appropriate interventions after a fall for 1 (Resident #1) of 4 (Resident #1, Resident #2, Resident #3, and Resident #4) sampled residents.

Inspectors wroteBased on interviews and observations the facility failed to ensure all mechanical, electrical, and patient care equipment were maintained in a safe operating condition. The facility failed to ensure the walk-in freezer was functioning properly. The deficient practice had the potential to affect the 52 residents that received meals prepared in the kitchen.

Inspectors wroteBased on record review and interview the facility failed to ensure a resident's right to formulate an advanced directive was properly reflected in the resident's medical record for 1 (#38) of 1 resident reviewed for advance directives. The facility failed to ensure all medical records regarding code status consistently reflected the resident's wishes to be a DNR (Do Not Resuscitate). The total sample size was 32.

Inspectors wroteBased on record review and interview the facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) in a timely manner to residents or his or her responsible parties for 2 (Resident #164 and Resident #165) of 3 (Resident #2, Resident #164 and Resident #165) residents reviewed for Beneficiary Notification. The facility failed to issue NOMNC at least two days prior to the end of Medicare Part A coverage to allow the right to appeal the discharge.

Inspectors wroteBased on record review and interview, the facility failed to transmit a MDS (Minimum Data Set) Assessment within 14 days of completion for 1 (Resident #53) of 1 sampled residents with MDS record over 120 days old.

Inspectors wroteBased on observations, record review and interviews the facility failed to implement a comprehensive person-centered care plan for 1 (#33) of 32 sampled residents. The facility failed to ensure Resident #33 was provided a hand roll as directed in the plan of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene. The facility failed to provide nail care for 2 (Resident #40 and Resident #33) of 4 (Resident #2, Resident #29, Resident #33, and Resident #40) residents sampled for ADLs.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident's person-centered plan of care for use of a winged mattress to his bed was followed for 1 (#1) of 3 (#1, #2, and #3) sampled residents. The facility had a total census of 63.