Camelot Rehabilitation at Magnolia Park

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to ensure that services were provided to meet professional standards of quality for safe administration of medications evidenced by the staff nurse leaving 20 medications unattended at the bedside for 1 (#74) out of 32 initial pool residents.

Inspectors wroteBased on observations, interviews, and policy and procedure reviews, the facility failed to:1. Maintain a clean and sanitary kitchen; and 2. Store food in accordance with professional standards for food service safety;This had the potential to affect 101 residents who ate meals prepared from the facility's kitchen. The facility's census was 125.

Inspectors wroteBased on record review and interviews, the facility failed to ensure individual financial records were provided to the resident through quarterly statements for 1 (Resident #68) out of 1 (Resident #68) resident investigated for personal funds.

Inspectors wroteBased on record review and interview, the facility failed to ensure the resident's Minimum Data Set (MDS) assessment was completed accurately for 3 (Resident #12, Resident # 74, and Resident #91) out of 37 sampled residents, as evidenced by:Inaccurate coding of administration of Insulin injections and orders for insulin in Section N- Medications for Resident #12 and Resident #74, and Inaccurate coding for serious mental illness in Section A for Resident #91.

Inspectors wroteBased on record review and interview, the facility failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) program was developed, implemented, and/or maintained in an effective and comprehensive manner. The facility failed to maintain documentation of evidence of its ongoing facility QAPI program. This deficient practice has the potential to affect 133 residents residing in the facility.

Inspectors wroteBased on record review and interview, the facility failed to provide documentation of the Quality Assurance and Performance Improvement (QAPI) program that addresses the facility's performance improvement activities and projects. The facility failed to provide evidence of the number and frequency of improvement projects conducted, which addressed the scope and complexity of the facility's provided services. This deficient practice had to potential to affect 133 residents residing in the facility.

Inspectors wroteBased on record review and interview, the facility failed to: 1. Provide evidence that Quality Assessment and Assurance (QAA) committee met at least quarterly and as needed; and 2. Provide evidence that ensured the QAA committee was composed of at a minimum: the DON (Director of Nursing, Medical Director or his/her designee, the Infection Preventionist (IP), and at least three other staff, one of whom must be the facility's administrator, owner, board member, or other individual in a leadership role who has knowledge of facility systems and the authority to change those systems. This deficient practice had to potential to affect 133 residents residing in the facility.

Inspectors wroteBased on record review, observations and interviews the facility failed to provide a safe, clean, comfortable, and homelike environment. This was evidenced by: 1. Observations made on 02/05/2025 on Hall U of multiple rooms walls with damaged sheetrock, unfinished sheetrock repair, and a call light unit detached from wall; 2. Housekeeping staff failing to clean and sanitize room [ROOM NUMBER] on Hall U after a resident was discharged to the hospital; 3. Observation made on 02/02/2025 at 2:50 PM of a light fixture that was not working properly in room [ROOM NUMBER] on Hall Y; 4. Observation made on 02/02/2025 at 1:07 PM of a call light box that was detached from the wall in room [ROOM NUMBER] on Hall Y; and 5. Observation made on 02/02/2025 at 2:01 PM of an electrical outlet cover plate that was bent away from wall making electrical wiring visible in room [ROOM NUMBER] on Hall Y.

Inspectors wroteBased on record review and interview, the facility failed to ensure a residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent the development of new pressure ulcers for 2 (#95 and #108) out of 6 (#8, #10, #53, #95, #108 and #112) residents investigated for pressure ulcers by: 1. Filing to perform weekly wound assessments for pressure ulcers for Resident # 95; and 2. Failing to conduct accurate skin assessments for Resident # 108 Resident #95 Review of Resident #95's electronic health record revealed an admission date of 01/14/2025 with diagnoses which included, but were not limited to, Morbid Severe Obesity Due To Excess Calories, Chronic Diastolic Congestive Heart Failure, Cirrhosis Of Liver, and Diarrhea. Review of Resident #95's Nurses' Notes dated 01/15/2025 revealed in part: [...]

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 currently accepted professional principles. The facility failed to ensure expired medications were not available for administration to residents in 1 (Med Room C) of 4 (Med Room A, Med Room B, Med Room C, and Med Room D) medication rooms. This deficient practice had to potential to affect 133 residents residing in the facility.

Inspectors wroteBased on observations, and interview, the facility failed to store food in accordance with professional standards for food service, and ensure sanitary conditions were maintained in the kitchen as evidenced by: 1. opened food items in the walk in cooler not labeled with the date and time; and 2. expired foods in the dry storage area. This deficient practice had the potential to affect the 116 residents who consumed food from the kitchen.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. The facility failed to ensure proper PPE (Personal Protective Equipment) was worn while proving care for 3 (#53, #95, #118) out of 36 sampled residents.

Inspectors wroteBased on interview and record review the facility failed to ensure the MDS (Minimum Data Set) was coded accurately for use of Bipap (Bilevel Positive Airway Pressure) for 1 (#19) resident of 5 (#19, #41, #78, #95 and #112) residents investigated for respiratory care. Resident #19 Review of Resident #19's electronic medical record revealed she was admitted to the facility on [DATE] with diagnoses that included in part, Type 2 Diabetes Mellitus with unspecified complications, Major Depressive Disorder and other, Sleep Apnea. Review of Resident #19's current physician's orders read, RCU (Respiratory Care Unit): Bipap (Bilevel Positive Airway Pressure) S/T (Spontaneous/Timed) 16/12 RR (Respiration Rate) = 12 @ 21% at HS (Hour of Sleep) six times a day. Review of Resident #19's care plan read in part, Focus: The resident has Bipap related to sleep apnea. [...]

Inspectors wroteBased on record review, observations and interviews, the facility failed to provide appropriate and sufficient services, treatment, and care according to standards of professional practice for 1 (#3) of 4 (#3, #38, #62, and #78) residents that were reviewed for urinary catheter or UTI (urinary tract infection). The facility failed to ensure Resident #3's urinary catheter drainage tubing was properly secured off of the floor.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident's respiratory equipment was stored properly for 2 (Resident #19 and Resident #41) out of 5 (Resident #19, #41, #78, #95 and #112) 36 sampled residents reviewed for respiratory care. On 02/04/2025 review of the facility's policy titled Departmental (Respiratory Therapy) - Prevention Infection with a review date of 10/30/2024 read in part, Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol: 7. Store the circuit in plastic bag marked with date and resident's name, between uses. On 02/04/2025 at 4:17 PM, S2DON (Director of Nursing) confirmed that this is the policy used for proper storage of all respiratory equipment. [...]

Inspectors wroteBased on observations and interview, the facility failed to ensure staffing information posted daily was current and in a prominent place readily accessible to residents and visitors. The facility's census was 133.

Inspectors wroteBased on observation and interview the facility failed to ensure hallway hand rails were securely affixed to the walls on 1 (Hall W) of 6 (Hall U, Hall V, Hall W, Hall X, Hall Y, and Hall Z) hallways observed in the facility. This failed practice had the potential to affect all mobile residents that reside on Hall W.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that services were provided as outlined in the comprehensive plan of care for 2 (#28 and #63) out of 45 sampled residents by failing to ensure that: 1. Resident #28 had appropriate interventions for ADL (Activities of Daily Living) self-care related to Amputation. 2. Resident #63's physician orders were followed.

Inspectors wroteBased on observation, and interview, the facility failed to store food in accordance with professional standards for food service and failed to ensure sanitary conditions were maintained in the kitchen by failing to: 1. Ensure compromised cans in the dry storage room were disposed; 2. Failed to ensure food products were discarded on or before the expiration date; 3. Failed to ensure the kitchen was maintained in sanitary condition.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess 2 residents (#56 and #70) out of 45 sampled residents for self-administration of medications.

Inspectors wroteBased on record review and interview, the facility failed to investigate and take corrective actions for a grievance made by 1 (#56) out of a total sample of 45 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the assessment accurately reflected the status of 2 (#130 and #14) residents out of a total of 45 sampled residents by failing to ensure that: 1. Resident #130 was coded correctly for weight loss on discharge assessment. 2. Resident #14 was coded correctly for discharge on discharge assessment.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain personal hygiene for 1 (Resident #129) of 2 (Resident #129 and Resident #183) investigated for activities of daily living out of a sample of 45.

Inspectors wroteBased on record review and interview, the facility failed to ensure a RN (Registered Nurse) was on duty for 8 consecutive hours per day for 7 days per week.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that pharmaceutical services provided to meet the needs of each resident were consistent with state and federal requirements and reflect current standards of practice for 1 (#2) of 3 residents (#1, #2, and #483) observed during medication pass. This had the potential to affect all the residents residing in the facility. The facility census was 122.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a homelike environment for 1 (#1) out of 6 residents (#1, #24, #109, #110, #112 and #129) investigated for environment, by failing to ensure that the resident's wheelchair and wheelchair pad were cleaned. This had the potential to affect all residents in the facility who used a wheelchair. The Facility's census was 122.

Inspectors wroteBased on record review and interviews, the facility failed to update the facility wide assessment as evidenced by failing to: 1. Identify the resident population acuity levels, specifically ventilator dependent residents and residents requiring tracheostomy care 2. Include facility staff competencies regarding mechanical ventilator alarms 3. Include Respiratory Therapy Director or Respiratory Therapists as facility resources needed to provide competent support and care for the facility's resident population daily and during emergencies 4. Include how respiratory therapists were staffed on the mechanical ventilator and tracheostomy unit 5. Update the facility wide electronic medical record system to reflect the current system used This deficient practice had the potential to affect the 135 residents who resided in the facility.

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement a comprehensive plan of care for 3 (#1 #2, and #4) residents out of a total sample of 4 residents as evidenced by: 1. Failing to implement a tracheostomy/ventilator plan of care for residents #1 and #4 and 2. Failing to implement physician's orders to obtain vital signs for resident #2.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that residents with a urinary catheter had a privacy bag or covering over their urinary catheter collection bag to promote dignity for 2 (#1 and #4) of 4 (#1, #2, #3, and #4) sampled residents.

Inspectors wroteBased on policy review, record review, and interview, the facility failed to ensure each resident's plan of care and clinical record accurately reflected their advanced directives for 1 (#4) out of 4 sampled residents (#1, #2, #3 and #4).

Inspectors wroteBased on record review, observation and interviews, the facility failed to maintain accurately documented medical records in accordance with accepted professional standards and practices. The facility failed to ensure Resident # 1's EHR (Electronic Health Record) tracheostomy supplies were accurately documented for 1 (#1) out of 4 (#1-#4) sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good personal hygiene by failing to provide bathing on 08/18/2023, 08/19/2023, 08/23/2023, 08/25/2023, 08/28/2023, and 08/29/2023 for 1 (#3) of 2 (#2 and 3) residents who were dependent on staff for bathing, out of 3 (#1-3) sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure that residents who require urostomy services, receive such care consistent with professional standards of practice as evidenced by the facility failing to assess a new Suprapubic catheter insertion site and failing to change the dressing to the Suprapubic catheter site from 08/21/2023 until the resident was discharged on 08/31/2023, for 1 (#3) of 3 (#1-3) sampled residents, out of a census of 135.