Cameron Nursing Center

Inspectors wroteBased on observations and interviews, the facility failed to maintain a clean, neat and orderly environment in the resident room [ROOM NUMBER] and shared resident restrooms for room numbers 201, 202, 203, and 204. restrooms. The facility census was 75. Review of the facility's undated Resident Rooms Cleaning policy showed:-Staff are to pick up any trash off the floors and counters, take out trash;-Look around room from ceiling down for cobwebs/dust, wipe off windowsills, night stands, dressers, TV stands, TVs and picture frames;-Use clean rag to wipe off door knobs and light switches, clean off counters beside and around sink, clean sink and faucet, clean mirror;-Sweep and mop floor, ring out mop pads, change mop x2 for each room, if there is a fall mat, clean/mop under the fall mat; -Clean bathroom, handrails, toilet, mop floor, wipe off walls.1. [...]

Inspectors wroteBased on observations and interviews, the facility failed to provide appropriate and adequate methods for residents to call for staff while the call light system is being repaired. Resident #1 experienced shortness of breath when being required to use a whistle to summon staff while the call system is malfunctioning. Other residents (Residents #2, #3, #4) experienced anxiety and emotional distress related to the call system not functioning. Facility census was 75. The facility did not provide a policy on the call light system.1. Review of Resident #1's electronic medical record on November 3, 2025 showed:-The resident has the diagnoses of acute and chronic congestive heart failure (CHF; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Dietary Manager (DM) had the appropriate competencies and skills sets to carry out the functions of the food and nutritional services. The facility census was 67. Review of the facility job description titled, Dietary Supervisor/Manager, revised December 2023, showed: -Responsible for supervising functions and personnel within the dietary department. Safely and efficiently provides nutritionally appropriate food to residents for the purpose of maintaining, and enhancing their overall health. Ensures the provision of quality food service and nutrition care in accordance with Federal, State, and Local regulations; -Upon admission and periodically thereafter, visits residents regarding menus, food service, food preferences, and dining information; -Ensures physician's orders are followed; [...]

Inspectors wroteBased on observation, record review, and interview the facility failed to prepare and serve food in accordance with professional standards for food service safety when staff did not practice sanitary hand washing skills, used hand sanitizer during meal preparation failed to wear proper hair coverings, did not dispose of expire food waste, did not label and date all foods, did not test dishwasher for proper sanitation before running dishes, properly sanitize all food preparation surfaces in the kitchen, and failed to maintain a clean and sanitary kitchen. The facility census was 67. 1. The Facility did not provide a policy on dietary handwashing, gloving, or sanitizer use. Review of facility policy, Safe Minimum Internal Temperature chart, undated, showed: -Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. [...]

Inspectors wroteBased on interviews and record review, the facility failed to consider the views of resident council and act promptly upon grievances and recommendations made by the group when the facility failed to demonstrate their response to the council on follow up actions. This affected all the residents serving on the resident counsel and potentially other residents of the facility. The facility census was 67. Review of facility policy, Nursing Home Resident Rights, undated, showed residents can organize and participate in resident and family groups; Review of Resident Council Reports, showed: - 3/13/25 Issues brought up included bed sheets not being changed during shower days, staff not passing medications, and no fruit. There was no response from the facility to the resident council on past issues or grievances; [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure they informed residents of their rights periodically during the residents' stay both orally and in writing. This affected all residents at the facility. The facility census is 67. Review of facility Nursing Home Resident's Rights policy, undated, showed: - The law requires nursing homes to promote and protect the rights of each resident; - All residents have the right to be fully informed of the facility rules, regulations,and provided a written copy of the resident's rights; - The policy did not specifically indicate when these rights should be communicated with the residents. During a group interview on 3/19/25 at 9:57 A.M. seven of seven residents said: - They had not received education about their resident rights within the last year; [...]

Inspectors wroteBased on observation and interview, the facility failed to protect the resident's rights when the facility did not provide training to the resident's regarding the State Long Term Care Ombudsman program or how to file a complaint with the State Survey Agency. This had the potential to affect the rights of all residents. The facility census was 67. Review of facility policy, Nursing Home Residents' Rights, undated, showed the resident has the right to be fully informed of contact information for the long-term care ombudsman program and the state survey agency; During a group interview on 3/19/25 at 9:57 A.M. the residents said: - Seven out of seven residents had not received training on the Ombudsman program or on how to contact the state to file a grievance; - Six of seven residents did not know what the Ombudsman position was or what their function entailed; [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain a clean, comfortable, and homelike environment when the facility failed to maintain quiet noise levels during the night shift that affected five resident (Residents #27, #31, #43, #45, #58), failed to limit the use of the overhead paging system, which affected (Resident #43), failed to provide a room free of obstacles and homelike (Resident #5), and failed to maintain cleaning standards for showers and rooms (Residents #10, #24). This affected eight of 17 residents sampled. The facility census was 67. A policy for providing a homelike environment, housekeeping and maintenance of the facility was requested and not provided for review. Record review of resident council meeting notes showed: - 3/13/25 Dirty bed sheets not being changed on shower days; [...]

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a comprehensive resident-centered care plan that met the needs of five residents (Resident #29, #36, #65, #62, and Resident #60). The care plans failed to identify changes in the resident's condition and did not address it in the plan of care for the staff interventions for side rails on Resident #60, did not address Infection prevention and enhanced barrier precautions for Residents #36, #62, and #65, and additionally did not address a resident's indwelling urinary catheter for one resident (Resident #29) This affected five of the 17 sampled residents. The facility census was 67. Review of the facility's Care Planning Policy, revised 6/2020., showed: - The purpose of a care plan is to develop a comprehensive patient centered care plan based on the individual needs of the resident. [...]

Inspectors wroteBased on record review and interview the facility failed to ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, and that each resident and resident representative, if applicable, is involved in developing the care plan and making decisions about his or her care. This affected four residents (Resident #40, #65, #38, & #47) out of the 17 sampled residents. The facility census was 67. Review of the facility's Care Planning Policy, revised 6/2020., showed: - The purpose of a care plan is to develop a comprehensive patient centered care plan based on the individual needs of the resident. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the licensed staff maintained professional standards of quality in care and services according to accepted standards of clinical practice, when licensed staff did not follow through on known infections in the building by ensuring resident's with infections or those who were at risk for infections were identified, isolated appropriately and with proper posted signage outside the room. As well as ensuring that personal protective equipment was accessible and provided for staff to carry out care for the residents in the correct manor according to the infection. Additionally, this failure did not ensure ancillary staff or visitors who entered the resident's rooms were aware of the need for transmission based precautions. [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure the correct installation, use, and maintenance of bed rails included assessing residents for risk of entrapment from bed rails prior to installation, ensure the bed's dimensions were appropriate for the resident's size and weight, and follow the manufacturers' recommendations and specifications for installing and maintaining bed rails. The facility also failed to include an evaluation of attempted alternatives prior to the installation or use of a bed rail on resident beds. This included three of 17 residents sampled (Resident #2, #27, and #60). The facility census was 67. Facility did not provide a policy on bed rails or entrapment. 1. Review of Resident #2's Quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 1/24/25, showed: -Cognition intact; [...]

Inspectors wroteBased on observation and interviews, the facility failed to ensure staff served food to the residents that was palatable, attractive, and served at a safe and appetizing temperature to the residents when hot food was not served at an appetizing temperature to four of seventeen sampled residents (Resident #27, #32, #37, and #69). The facility failed to prepare dietary menus according to their recipes by not using recipe ingredients resulting in bland and tasteless food and the facility failed to serve dessert at appropriate holding temperature. The facility census was 67. Review of facility policy, food temperatures, revised 1/1/25, showed: -Foods prepared and served in the facility will be served at proper temperatures to ensure food safety. -At starting of meal services Hot Foods should be above 135 degrees Fahrenheit (F) and cold foods should be served below 41 degrees F; [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure foods that were stored in resident personal refrigerators and freezers were monitored for safe and appropriate temperatures and discard potential spoiled contents to prevent the potential for food-borne illness. The facility census was 67. Facility did not provide a policy on food storage or resident room refrigerators. Review of facility policy, Food Brought in by Visitors, revised 2/2021, showed: -Food may be brought to a resident by the family members, the resident's responsible party, or friends if the food is compatible with the attending physician's diet order; -Perishable food requiring refrigeration will be discarded after two hours at bedside, and if refrigerated it will then be labeled, dated, and discarded after 48 hours. Review of facility policy, food temperatures, revised 1/1/2025, showed: [...]

Inspectors wrote2. Review of Resident #36's Quarterly MDS (Minimum Data Set) A federally mandated assessment, completed by facility staff, dated 1/9/25., showed: - Cognition severely impaired; - Diagnoses of: Wound Infection, yeast Infection, and stroke with right side paralysis; - Max assist of two for all activities of daily living (ADLS). Observation on 3/17/25 at 1:00P.M. showed the resident' was not on Enhanced Precautions for active infection and no PPE (personal protective equipment) available for staff outside the room. There was no isolation alert sign posted outside or inside the room. Observation on 3/19/25 at 2:00P.M. showed a green sign posted to the outside of the door that read-Stop, Please See The Nurse Before Entering. No type of isolation was posted. PPE holder on the door were empty. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain signed immunization refusals, or administer the influenza vaccine to four residents (Resident's #41, #46, #11 & #9). This affected four of the 17 sampled Residents. The facility census was 67. Review of the facility's Infection prevention and control policy, undated., showed: - The infection preventionist coordinates the development and monitoring of the facility established infection control policies and procedures. - Reports information related to infection control to the administrator and the infection control committee. - Provides infection control related information to the nursing staff and physicians. - Consults on infection risks, and and prevention control strategies. - Provides education and training to staff regarding infection prevention and isolation. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain signed refusals, or administer the Covid vaccine to four residents (Resident's #9, #11, #41, and & #46). This affected four of the 17 sampled Residents. The facility census was 67. Review of the facility's Infection prevention and control policy, undated., showed: - The infection preventionist coordinates the development and monitoring of the facility established infection control policies and procedures. - Reports information related to infection control to the administrator and the infection control committee. - Provides infection control related information to the nursing staff and physicians. - Consults on infection risks, and and prevention control strategies. - Provides education and training to staff regarding infection prevention and isolation. [...]

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure staff provided appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible when the facility staff failed to ensure proper catheter care of one of the 17 sampled residents (Resident #29). The facility census was 67. Review of the facility's Catheter - Care of Policy, dated 06/22, showed: - A resident, with or without a catheter, receives the appropriate care and services to prevent infections to the extent possible. - Collection bags should always be kept below the level of the bladder, including during transport, avoiding contact with the floor. - Take care to ensure the collection bag does not touch the floor at any time. 1. Review of Resident #29's most current MDS dated [DATE] showed: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to recognize, evaluate, and address the hydration needs need of one and failed to offered sufficient fluid intake to maintain proper hydration and health for one of the 17 sampled residents (Resident #29). The facility census was 67. Review of the facility's Nutrition/Hydration Management policy dated 06/20 showed: -The purpose is to ensure that each resident maintains acceptable parameters of nutritional/hydration status such as body weight and protein levels, unless the resident's clinical condition demonstrates this is not possible based on the resident's comprehensive assessment. - A comprehensive care plan is developed by the interdisciplinary care team that addresses nutrition/hydration and an individualized nutrition/hydration management program based on individualized assessed need. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store medications in a locked storage area to ensure medications were inaccessible to unauthorized staff and residents when medications were left at bedside for one resident (Resident #48) and when the medication cart was left unlocked and unattended. The facility census was 67. Review of facility policy, revised 8/2020, showed: -Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. -Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) are permitted to access medications. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to prepare food in a form designed to meet individual needs when one resident was served food not consistent with their dietary orders (Resident #37). This affected one of seventeen sampled residents. The facility census was 67. Review of facility policy, Nutrition/Hydration Management, revised 6/2020, showed: -To ensure each resident maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrations that this is not possible based on the residents comprehensive assessment. To ensure that a resident receives a therapeutic diet when there is a nutritional problem; -Diet orders including texture and consistency specifics. Review of facility policy, therapeutic diets, revised 1/1/25, showed: [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure staff stored food in a sanitary manner and failed to maintain the kitchen in a sanitary manner. This had the potential to affect all residents residing in the facility. The facility census was 64. Review of the facility's policy Cleaning of the Kitchen revised, December 2020, showed: The dietary staff will maintain a sanitary environment in the nutrition services department. The facility did not provide the requested policies for maintence and repair of the dining room and kitchen, cleaning of vents in the kitchen and dining room and dating and storage of food and storing dishes in the kitchen. 1. Observation of the kitchen on 02/27/24, at 10:02 A.M., showed: -Two vents covered with dirt and debris; -The wall by the electrical box with missing paint; [...]

Inspectors wroteBased on observation, and interview , the facility failed to maintain a clean, safe, homelike enviornment when they failed to keep the floors, doors and handrails clean and in good repair. The facility census was 64. The facility did not provide a policy on cleaning and/or general maintanence. Observations on 2/29/24 begining at 12:05 P.M. showed: -The 100 hall had : -loose hand rails by room [ROOM NUMBER] and room [ROOM NUMBER] ; -baseboards had dark crusty debris at floor edges; -white, crusty salt like stains under the registers at the dining room entrance; -dust, crumbs and debris at the corners behind the fire doors; - cracked and dented green floor tile at dining room entrance; -a piece of missing baseboard at the dining room entrance; -heat registers in hallway had broken vents, peeling paint, and chipped and peeling caulk; [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure staff provided a written notice of transfer or discharge to residents or their responsible parties and the reasons for the transfer, unwitting and in a language they understood. The notice should include the effective date of discharge or transfer; the location to which the resident is transferred or discharged ; a statement of the resident's appeal rights, including the name, address (mailing and electronic mail), telephone number of the entity which receives requests and information on how to obtain the appeal form and assistance in completing and submitting it; the name, address (mailing and electronic) and telephone number of the Office of the State Long-Term Care Ombudsman; [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure residents who were unable to carry out their own activities of daily living (ADLs) received the necessary services/cares to maintain good personal hygiene for four residents (Resident #14, #42, #13 and #54 ) out of 16 sampled residents. Residents dependent upon staff for assistance, did not receive repositioning, timely incontinent care or showers. The facility census was 64. The facility did not provide an Activities of Daily Living policy. Review of the facility provided Resident Rights Policy dated 8/2020 showed in part: -The resident has the right to a dignified existence. -The facility must care for each resident in a manner that promotes maintenance or enhancement of his/her quality of life. 1. Review of Resident #14's Quarterly Minimum Data Set (MDS: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide meaningful activities to meet the needs for two of 16 sampled residents (Resident #14, and #42). The facility census was 64 Review of the facility provided policy, Activities Program, dated 2/2020 showed in part: -Encourage residents tto participate in activities to make life more meangful, to stimulate and support physical and mental capabilities to the fullest extent and to enable to resident to maintain the hightest attainable social, physical and emotional functioning. -The facility provides an activity program designed to meet the needs, interests and preferences of residents. -A variety of activities should be offered -Activities are developed for individual, small group and large group participation. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff maintained proper positioning of the tubing and reservoir bag, for one resident (Resident #22) with an indwelling urinary catheter (a tube placed into the bladder to drain urine by gravity) and recent history of a urinary tract infection; and additionally failed to follow infection control practices when providing care of the catheter for two residents (Resident #22 and Resident #4) of the 16 sampled residents. The facility census was 64. Review of the facility provided policy Catheter- Care of, dated 6/2020 showed in part: -Purpose: to prevent catheter associated urinary tract infections. -Cleanse the skin folds, wiping front to back and cleanse the outside of the catheter wiping away from the opening of the body. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff administered medications with an error rate of less than five percent (5%). Staff made five errors out of 25 opportunities for error, which resulted in an error rate of 20%. This affected four of 16 sampled residents, (Resident #28, #34, #62, and #116). The facility census was 64. Review of the facility's undated policy for medication administration, showed, in part: - The purpose is to provide practice standards for safe administration of medications for residents in the facility; - The licensed nurse must know the following information about any medication they are administering: the drug's name (generic and trade); the drug's route of administration; the drug's action; the drug's indication for use and desired outcome; The drug's usual dosage; the drug's side effects and adverse effects; [...]

Inspectors wroteBased on observation, interview, and record review the facility's licensed staff failed to ensure medications were monitored and stored in a safe and effective manner. Licensed staff failed to remove and properly discard discontinued medication from two of two sampled medication rooms. The facility census was 64. Review of the facility provided policy Medication Destruction for non-controlled Medications dated 9/2018 showed in part: -Discontinued medications and medications left in the facility after a resident's discharge that do not qualify for return to the pharmacy for credit are destroyed. -Medication destruction occurs only in the presence of at least two licensed healthcare professionals or according to regulation and applicable law. 1. Observation and interview on 3/01/24 at 10:37 A.M. of the north medication storage room showed: [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to assure that staff served food to the residents that was palatable, attractive, and served at a safe and acceptable temperature. This affected four sampled residents (Resident #18, #30, #50, and #57). The facility census was 64. Review of the facility's Food Temperatures policy, revised, December 2020, showed: -Foods prepared and served at the facility will be served at the proper temperatures to ensure food safety; -Acceptable serving temperatures: o Casseroles - greater than 135 degrees Fahrenheit; o Meat - greater than 135 degrees Fahrenheit; o Potatoes - greater than 135 degrees Fahrenheit; o Pureed foods - greater than 135 degrees Fahrenheit; o Milk - less than 41 degrees Fahrenheit; -Heat plates that hot foods will be served on to maintain temperature. Review of resident council minutes showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents are allowed to make meal choices when facility staff failed to provide three sampled residents (Residents #18, #30, and #53) with alternate food choices or allow choices of menu items. Facility census was 64. The facility did not provide the requested policy on resident choices. Review of the facility provided Resident Rights Policy dated 8/2020 showed in part: -The resident has the right to a dignified existence. -The facility must care for each resident in a manner that promotes maintenance or enhancement of his/her quality of life. 1. Review of Resident #18's care plan dated 8/1/23, showed: -Limited physical mobility due to weakness in bilateral ankles; -Independent with eating; -The resident has a potential nutritional problem; -The resident will be served diet as ordered. [...]

Inspectors wroteBased on observation and interview the facility staff failed to maintain an effective infection control program when dietary staff did not wash their hands before applying clean gloves while preparing food in the kitchen and when staff failed to wash hands before applying clean gloves while preparing resident drinks in the dining room. Also, facility failed to annually review and implement a water management procedure to reduce the risk of bacterial growth and reduce the spread of Legionella (a bacteria that causes Legionnaires' disease, a serious type of pneumonia). This had the potential to affect all the resident in the building. Lastly, the facility failed to ensure that newly hired employees in the last year received a two-step Tuberculin Skin Test (TB), this affected five of the six sampled employees. The facility census was 64. [...]

Inspectors wroteBased on interview and record review, the facility failed to monitor the monthly Medication Regimen Review (MRR) reports for August and November of 2023, completed by the pharmacist, to ensure they reported irregularities to the attending physician, and failed to address these recommendations with the resident's physician until January of 2024. This affected one of 16 sampled residents, (Resident #24). The facility census was 64. The facility did not provide a policy for Medication Regimen Reviews. 1. Review of Resident #24's pharmacist's medication regimen review, dated August 2023, showed: - The resident received Omperazole 40 mg. twice daily since 5/23; - On 8/25/23 the physician noted and agreed to reduce the Omeprazole to every day. The order was not dated or noted by staff. Review of the pharmacist's medication regimen review, dated November 2023, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (Resident #1) of seven sampled residents remained free of mental abuse when staff used racial stereotypes multiple times, taunting the resident. The facility census was 60. Review of the facility policy Abuse Prevention and Prohibition Program dated 8/2020 showed in part: -Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, and misappropriation of property. -Staff must not allow anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment or misappropriation. -The facility is committed to protecting residents from abuse by anyone including staff. Review of the facility policy Resident Rights policy dated 8/2020 showed in part: -All residents have the right to a dignified existence. [...]

Inspectors wroteBased on interviews, observation and record review, the facility failed to maintain resident dignity when the facility staff did not knock on resident doors prior to entry affecting one resident (Resident # 51), facility staff was rude to a resident affecting one resident (Resident # 38), and facility staff failed to keep one resident's body covered to maintain dignity (Resident #168) of 17 sampled resident's. The facility census was 67. Review of the resident dignity policy dated 12/1/21 showed: - All staff members are involved in providing care to residents and are to maintain resident dignity and respect resident rights. - Staff are to respond to requests in a timely manner. - Staff are to speak to resident's respectfully. - Staff are to respect the resident's living space and personal possessions. - Staff are to groom and dress resident's according to the resident's preference. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident #7 was able to safely self-administer medications when 4 pills were left in a medication cup on the resident's bedside table. The facility also failed to ensure Resident #13 was able to safely self-administer medications when 12 pills were left in a medication cup on the resident's bedside table, and Resident #36 was able to safely self-administer medications when 11 pills were left in a medication cup on the bedside table, all unattended by licensed staff. This affected three of 17 sampled residents. The facility census was 67. Review of the medication administration policy dated 12/1/21 showed: - Medications are to be administered by licensed staff as ordered by the physician. - Observe the resident consuming the medications. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to notify the physician of changes in resident's condition when the facility failed to notify the physician of significant weight loss in Resident #5, Resident #53, Resident #61, and the facility failed to notify the physician when Resident #60 legs began to swell and the resident experienced difficulty breathing out of 17 sampled residents Resident #60 was hospitalized and found to have blood clots in his/her legs. The facility census was 67. Review of weight monitoring policy dated 12/1/21 shows: - Significant weight changes may indicate a nutritional problem. - A comprehensive nutritional assessment will be completed upon admission to identify residents at risk for unplanned weight fluctuations. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to update patient-centered care plans when one two resident's had a significant weight loss not updated on the care plan, (Resident #53 and Resident #61), two resident's do not have bed rails care planned, (Resident #36 and Resident #51), and one resident does not have dialysis care planned, (Resident #62). This affected six of the 17 sampled resident's. The facility census was 67. Review of the baseline care plan policy dated 12/1/21 shows: - Will be developed within 48 hours of a resident's admission. - Will include physician orders, dietary orders, therapy and social services. - The baseline care plan is to include special needs such as dialysis. [...]

Inspectors wroteBased on observation, interview, and record review the facility staff failed to provide services that meet professional standards when two residents, (Resident #61 and Resident # 168), had a physician's order for the placement of fall mats on the floor, and the facility staff failed to place the fall mats on the floor, and one resident, (Resident #46) had a physician's order to obtain a urine specimen to check for an infection on 1/7/22 and the facility staff did not obtain the urine specimen until 1/27/22, and one additional resident (Resident #10), that did not receive his/her levothyroxine medication as ordered out of 17 sampled residents. The facility census was 67. Review of the physician's orders policy dated 12/1/21 shows: - The nurse is to note the physicians order, and transcribe the order to the medication administration record or treatment administration record. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide standard and specific care planned Activities of Daily Living (ADLs), including showers/bathing, nail care, hair care, turning/repositioning; including the standard of care to turn/reposition and provide incontinent care every 2 hours for residents who are incontinent of urine/bowel, for eight of 17 sampled residents (Resident #24, #26, #19, #23, #61, #36, #38, and #44), that were unable to perform their own activities of daily living. The facility census was 67. Review of the shower policy dated 11/30/21 shows: - Residents will be provided showers as often as the resident requests and per the facility schedule protocols. - Partial baths may be given between regular shower schedules. - The certified nurse assistant (CNA) will assess the skin during the shower and notify the nurse of any skin changes. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an ongoing program of activities designed to meet the resident's interests for ten of 19 sampled residents (Resident #23, #24, #26, #5, #53, #169, #7, #13, #38 and #44) . The facility census was 67. 1. Review of Resident #23 Minimum Data Set (MDS: a federally mandated assessment completed by facility staff) dated 12/1/21 showed: -Brief Interview of Mental Status (BIMS) of 14. Indicates no cognitive impairment. -Activity preferences that are very important to him/her include: -listening to music -newspapers, books to read -to go outside and get fresh air -participate in favorite activities. -Activity preferences that are somewhat important to him/her include: -participating in activities with groups of people. -Diagnosis include: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that three sampled residents (Resident #5, #53, and #61) maintained acceptable parameters of nutritional status and failed to implement interventions after the residents experienced a significant weight loss. The facility census was 67. Review of the facility's Weight Monitoring Policy, dated 12/1/2021, showed: -A weight monitoring schedule will be developed upon admission for all residents. -Newly admitted residents-monitor weight weekly for 4 weeks -Residents with weight loss-monitor weekly weight -Weight Analysis: The newly recorded resident weight should be compared to the previous recorded weight. A significant change in weight is defined as: -5% change in weight in 1 month (30 days) -7.5% change in weight in 3 months (90 days) -10% change in weight in 6 months (120 days). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide respiratory care, consistent with professional standards of practice for four of 17 residents (Resident #5, #38, #51, and #53) when staff did not date oxygen tubing, failed to cover the tubing when not in use and staff failed to cover nebulizer (a machine that delivers medication into the body by being inhaled as a vapor) tubing when not in use for two sampled residents (Residents #7 and #38). The facility census was 67. Review of the oxygen administration policy, dated 12/1/21, showed: - Change the oxygen tubing weekly and as needed if it becomes contaminated or soiled. - Change humidifier bottle and nebulizer tubing every 72 hours and as needed if they become contaminated. - Keep oxygen tubing and nebulizer tubing covered in a plastic bag when not in use. 1. [...]

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure the safety of resident's that use U-rails, (rails installed at the head of the bed on both side of the bed that is in the shape of an upside-down U) and halo rails, (rails that are installed at the head of the bed on both sides of the bed that are in a circular shape with a stem that extends to the bed frame), (Resident #36 and Resident #51), when the facility staff failed to do an entrapment assessment when the rails were initiated and periodically, failed to obtain informed consent from the resident and/or the responsible party before the installation of U-rails and halo rails, and failed to obtain a physician's order for the use of the rails. This affected two of 17 sampled residents. The facility census was 67. Review of the side rail policy dated 12/1/21 shows: [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide sufficient nursing staff to provide showers, grooming, repositioning and to answer call lights in a timely manner for six of 17 sampled residents (Resident #19, #23, #24, #26, #38, #44). The facility census was 67. Review of the facility policy for Call Lights: Accessibility and Timely Response updated 12/1/21 showed in part: -All staff members who see or hear an activated call light are responsible for responding. -Process for responding: -If assistance is needed with a procedure,summon help by using the call light. Stay with the resident until help arrives. Review of the facility policy Turning and Repositioning date revised 12/1/21 showed in part: -All residents at risk of, or with existing pressure injuries, will be turned and repositioned, unless it is contraindicated. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day seven days a week. The facility maintained a census of greater than 60 residents. The census was 67. Review of facility policy Nursing Services and Sufficient Staff, dated 12/1/21, showed in part: -It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility's census, acuity and diagnosis of the resident population will be considered on the facility assessment. -The facility will supply services by sufficient numbers on a 24 hour basis to provide nursing care for all residents in accordance with resident care plans. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dietary staff maintained clean and sanitary conditions when staff failed to store and dispose of food in a safe and sanitary manner and failed to maintain the scoops for ice machine in a sanitary manner. This had the potential to affect all residents of the facility. The facility census was 67. Review of the facility's Food Safety Requirements Policy, dated 12/1/21, showed: - Food will be stored, prepared and served in accordance with professional standards for food service safety. - Food safety practices shall be followed throughout the facility's entire food handling process. *Storage of food in a manner that helps prevent deterioration or contamination of the food, including growth of microorganisms; *Preparation of food, including thawing, cooking, holding, and reheating; [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain proper infection control protocol when the facility staff failed to perform hand washing when providing resident care for one of 17 sampled resident's, (Resident #51), and one additional resident, (Resident #46); failed to provide perineal care using infection control standards for one resident (Resident #26) ; and failing to follow standards of practice during medication administration when a facility staff member touched a pill with an ungloved hand and placed the pill back in the multi-dose bottle, that affected one additional resident, (Resident #17). The facility census was 67. 1. Review of the facility's hand hygiene policy, dated 11/1/21, showed: - All staff will perform proper hand hygiene to prevent the spread of infection to other resident's. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the safety of one of 17 sampled residents, (Resident #51), by ensuring the resident was free from falls and the facility staff did not do consistent neurological assessments. Facility staff also failed to transfer one additional resident, (Resident #46), in a safe manner. The facility census was 67. Review of the facility fall policy dated 1/20/22 showed: - When a resident falls, the facility will assess the resident. - Complete a post fall assessment and incident report. - Notify the physician and family of the fall. - Update the care plan. Review of the head injury policy dated 11/1/21 showed: - The assessment of the resident with a suspected head injury includes: vital signs, neurological assessment, assessment of the head, ears, eyes, and face, and pain. - Compete a neurological assessment as indicated. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to fully develop and implement their staff vaccination policy for COVID-19 when the policy did not include specific additional measures unvaccinated staff would adhere to in order to mitigate the transmission and spread of COVID 19 and failed to implement a process for tracking and documenting the COVID-19 vaccination status for all staff. Facility census was 70. Review of facility policy; Employee COVID-19 Vaccinations, dated 3/14/22 showed in part: -The facility will ensure that all eligible employees are fully vaccinated against COVID 19 unless religious or medical exemptions are granted per Centers for Medicare and Medicaid Services (CMS) guided time frames. [...]