Camelot Nursing and Rehabilitation Center

Inspectors wroteBased on interview and record review, the facility failed to ensure residents with orders for psychotropic (medication used to treat mental health conditions by affecting mood, behavior, thoughts and perception) medications were informed about the medication before its use for two residents (Residents #5 and #12) out of five sampled residents. The facility's census was 74. [...]

Inspectors wroteBased on interview and record review, the facility failed to inform of and provide a free basic haircut for two residents (Residents #14 and #75) out of four sampled Medicaid residents. This had the potential to affect all Medicaid residents. The facility's census was 74. Review of the Missouri Department of Social Services, MO Health Net Division State Regulations for Medicaid Reimbursement for Long Term Care Facilities, showed:- 13 CSR 70-10.010 (5) Covered Supplies, Items and Services. All supplies, items and services covered in the per-diem rate must be provided to the resident as necessary. Supplies and services which would otherwise be covered in a per diem rate, but which also are billable to the Title XVIII Medicare program must be billed to that program for facilities participating in the Title XVIII Medicare program. [...]

Inspectors wroteBased on interview and record review, the facility failed to document an accurate Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) for two residents (Residents #8 and #10) out of 18 sampled residents. The facility census was 74. The facility did not provide a policy regarding MDS coding for accuracy. Review of the Resident Assessment Instrument (RAI) Manual, dated October 2025, showed:- J1400: Code 1, yes: if the medical record includes physician documentation: 1) that the resident is terminally ill; or 2) the resident is receiving hospice services;- H0300: Code 9, not rated: if during the seven-day look-back period the resident had an indwelling bladder catheter (a flexible tube inserted into the bladder to continuously drain urine into an external bag) for the entire seven days.1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician's orders for three residents (Residents #6, #10, and #62) and failed to obtain orders for three residents (Residents #10, #15, and #62) out of 18 sampled residents. The facility's census was 74. Review of the facility's policy, Physician's Orders, reviewed 09/28/22, showed: - Physician orders shall be provided by licensed practitioners (Physicians, Nurse Practitioners, and Physician's Assistants) authorized to prescribe orders; - Orders must be recorded in the medical record by the licensed nurse authorized to transcribe such orders; - Physician orders must be documented clearly in the medical record; - Physician orders that are missing required components, are illegible or unclear must be clarified before implementation; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain proper infection control practices to prevent the development and transmission of infections when staff did not utilize appropriate Personal Protective Equipment (PPE - equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) and Enhanced Barrier Precautions (EBP - an infection control strategy used in nursing homes requiring staff to use gloves and gowns during high-contact activities). The facility also failed to properly handle potentially contaminated sharps, failed to sanitize a glucometer (a small, portable device used to measure the sugar level in blood) per manufacturer's directions, and failed to perform hand hygiene during medication administration and at appropriate times during resident care. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an error rate of less than five percent when medications were administered. There were 28 opportunities with three medication errors made, for an error rate of 10.7%. Out of six residents observed, this affected two residents (Resident #1 and #47) out of 16 sampled residents and one resident (Resident #10) outside the sample. The facility's census was 64. Review of the facility's policy titled, Specific Medication Administration Procedures/Injectable Medication Administration, revised September 2018, showed: - Pen Devices: dial dose as instructed and prime pen needle per manufacturer guidelines. Review of NovoLog Flex Pen (insulin in a pen-type device) instructions showed: - Remove cap; - Attach needle; - Prime pen by turning dose selector to select two units; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to label medication in a safe and effective manner. This affected one resident (Resident #10) outside of the 16 sampled residents. The facility's census was 64. Review of the facility's policy titled, Medication Storage in the Facility/Storage of Medications, revised November 2018, showed: - Certain medications or package types, such as IV solution, multiple dose injectable vials, opthalmics, nitroglycerin tablets, blood sugar testing solutions and strips, once opened, require an expiration date shorter than the manufacturer's expiration date to insure medication purity and potency. Review of the manufacturer's recommendations for Fiasp Flextouch insulin pen showed the medication is to be discarded after eight weeks of being opened. 1. Observation on 10/23/24 at 11:10 A.M. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a comprehensive Minimum Data Set (MDS, a federally mandated assessment completed by the facility) within the required time frames for seven residents (Resident #6, #34, #50, #58, #61, #65, and #68) out of 18 sampled residents. The facility's census was 72. Review of the facility's policy titled MDS 3.0, revised 04/26/23, showed: - MDS assessments will be completed per the 3.0 Resident Assessment Instrument (RAI) User's Manual guidelines. Review of the RAI Manual showed: - For the admission assessment, the MDS Completion Date (Z0500B) must be no later than 13 days after the Entry Date (A1600); - The ARD (Assessment Reference Date) of an assessment drives the due date of the next assessment. The next comprehensive assessment is due within 366 days after the ARD of the most recent comprehensive assessment; [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a quarterly Minimum Data Set (MDS, a federally mandated assessment completed by the facility) within the required timeframe for six residents (Resident #7, #8, #44, #47, #61, and #63) out of 18 sampled residents. The facility's census was 72. Review of the facility's policy titled, MDS 3.0, revised 04/26/23, showed: - MDS assessments will be completed per the 3.0 Resident Assessment Instrument (RAI) User's Manual guidelines. Review of the Resident Assessment Instrument (RAI) Manual showed: - The ARD (Assessment Reference Date) of an assessment drives the due date of the next assessment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to document an accurate Minimum Data Set (MDS- a federally mandated assessment) for three residents (Resident #7, #16, and #44) out of 18 sampled residents. The facility's census was 72. Review of the facility's policy titled, MDS 3.0, revised 04/26/23, showed: - MDS assessments will be completed per the 3.0 Resident Assessment Instrument (RAI) User's Manual guidelines. 1. Review of Resident #7's Medical Record showed: - admitted on [DATE]; - Physician's Order Sheets, dated September 2023 and October 2023, showed no orders for parenteral/interavenous (IV) feeding or feeding tube; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess residents for the risk of entrapment and review possible risks and benefits of side rails prior to installation or use. The facility also failed to care plan specific monitoring and supervision provided during the use of the bed rails and to obtain informed consent for use of the side rails prior to use for 11 residents (Residents #6, #7, #8, #27, #44, #47, #50, #58, #61, #65, and #68) out of 18 sampled residents. The facility's census was 72. Review of the FDA (Federal Drug Administration) documents entitled, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, dated [DATE], showed 413 people died as a result of entrapment events in the United States. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to conduct regular inspections of all bed frames, mattresses and side rails as part of a regular maintenance program for 11 residents with side rails (Residents #6, #7, #8, #27, #44, #47, #50, #58, #61, #65, and #68) out of 18 sampled residents. The facility's census was 72. Review of the facility's policy titled, Bed Safety and Bed Rails, revised [DATE], showed: - Bed frames, mattresses and bed rails are checked for compatibility and size prior to use; - Maintenance staff routinely inspects all beds and related equipment to identify risks and problems including potential entrapment risks; - Maintenance provides a copy of inspections to the administrator and reports results to the quality assurance committee; [...]