McCamey Convalescent Center

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain essential mechanical and electrical equipment in safe operating condition for 1 kitchen of 1 reviewed for essential equipment. The facility failed to ensure the dishwasher worked. This failure could place residents at risk of malfunctioning equipment being used for their service/care.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 5 of 13 residents (Resident #3, Resident #6, Resident #7, Resident #11, and Resident #15) reviewed for accurate care plans. Resident #3, #6, #7, and #15's care plan did not address their current code status. Resident #6 and #11's Care Plan did not address ADL Status Resident #11's Care Plan did not address wander guard use. Resident #11's Care Plan did not address her choice of Authorized Electronic Monitoring. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 out of 1 med rooms reviewed for medication storage and 1 of 1 medication carts reviewed. The facility failed to ensure the medication cart and refrigerator in the medication room did not contain expired medications and unlabeled medications. These failures could place residents at risk of adverse medication reactions.

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 and transmission of communicable disease and infection for 2 of 4 residents (Resident #6 and Resident #9) reviewed for infection control in that:CNA A failed to wash or sanitize her hands after removing her soiled gloves and then putting on a new pair of gloves when she provided peri-care for Resident #9. CNA C and CNA D failed to wash or sanitize their hands after removing their soiled gloves and then putting on a new pair of gloves when they provided peri-care for Resident #9. The facility ADON failed to use PPE while performing wound care on Resident #6 These failures could place residents at risk for cross contamination and the spread of infection.

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents had the right to be free from any physical or chemical restraints imposed for the purpose of discipline or convenience for 1 (Resident #27) of 2 residents reviewed for chemical restraints. The facility failed to ensure Resident #27's Seroquel 200mg at bedtime (atypical antipsychotic medication used to treat several mental health conditions by balancing the levels of dopamine and serotonin in the brain) was only used to treat as indicated for use. The facility failed to ensure that documentation in Resident #27's was done in the clinical record. The facility failed to ensure Resident #27's had documentation on a rationale for the continued provision of the medication. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary treatment and services based on the comprehensive assessment and consistent with professional standards of practice to promote healing and prevent worsening of pressure injuries for 1 (Resident #3) of 2 residents reviewed for pressure ulcers. The facility failed to ensure Resident # 6 received care and services to meet professional standards of practice to heal his pressure ulcer. Resident #6 did not receive wound care to prevent the spread of infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 1 (Resident #3) of 4 residents observed for oxygen management. 1esident #15's oxygen nasal cannula and tube were not covered in a bag when it was not being used. The facility failed to ensure there was oxygen in use sign posted outside Resident #15's room. This failure could affect residents who required respiratory care and place them at risk of not having their needs met.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents had the right to personal privacy and confidentiality of his or her personal and medical records for 3 of 13 residents (#4, #5, #6) reviewed for privacy. 1. CMA F failed to protect Resident #4's record by not locking the screen of her laptop, while CMA F was in a resident's room administering medication. 2. CMA G failed to protect Resident #5's record by not locking the screen of her laptop when going to the restroom. 3. CMA G failed to protect Resident #6's record by not locking the screen of her laptop while in a room checking vital signs. These deficient practices could place residents at-risk of loss of dignity due to lack of privacy.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 4 of 5 (Residents # 116, 122, 126, and 127) reviewed for indwelling catheters. The facility failed to ensure Resident # 116, 122, 126, and 127's indwelling catheter were secured to prevent pulling or tugging. The failure could place residents at risk for discomfort, urethral trauma, and urinary tract infections.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 ( #116 and #122) of 10 residents reviewed for infection control. The facility failed to ensure CNAs A, C, D and E use PPE during urinary catheter care performed for Residents #116 and #122 as the residents were on EBP precautions. This failure could place residents at risk for cross contamination and the spread of infection.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two (Residents #12 and #127) of three residents reviewed for Respiratory Care. The facility failed to ensure Resident #12's and #127's nasal cannula was properly stored when not in use. This failure could place residents at risk for respiratory infection and not having their respiratory needs met.

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure that expired foods were discarded. This failure could affect residents who received meals prepared meals from the kitchen at risk for food borne illness and cross-contamination.

Inspectors wroteBased on interview and record review, the facility failed to use the services of a RN for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility reviewed for Licensed Nursing coverage for 1 of 3 months reviewed for RN coverage. (April 2023), (May 2023), and (June 2023). The facility did not have the required 8 consecutive hours of RN coverage during the month of April 2023 (April 29th). This failure could place residents at risk for not having their nursing care and medical needs met.

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 to help prevent the development and transmission of communicable diseases and infections for one (Resident #9) of 1 resident reviewed for infection control. LVN A failed to sanitize the treatment cart prior to putting down a barrier to prevent cross contamination. LVN A failed to sanitize scissors prior to wound care and after they became contaminated after wound care for Resident #9 prior to placing them back into the treatment cart. This failure could place resident's risk for cross contamination and the spread of infection. Findings Included: [...]