McCamey Convalescent Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.The findings included: Interview on 10/14/25 at 9:52 AM the FSS stated the dishwasher went out two months ago. The FSS stated that the facility was getting new quotes. The FSS stated maintenance fixed the dishwasher by replacing the booster heater. The FSS stated then the booster heater went out and had water spraying continuously and the dishwasher went out - it smoked and sparked and sounded like gunshots. The FSS stated that the kitchen was not functioning without it. The FSS said currently the staff washed everything through the 3-compartment sink. The FSS stated they (the kitchen) were waiting for maintenance to get quotes. The FSS stated the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. These failures could place the residents at increased risk of not having their individual needs met, injury, not receiving necessary services, and a decreased quality of life. Findings include: RESIDENT #3 Record review of Resident #3's admission record,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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.Findings included: Observation on 10/15/25 at 11:30 AM revealed the medication cart had the following expired medications: 1. Coreg 6.25mg expired 7/30/2025 (Medication to treat high blood pressure).2. Celexa 40mg expired on 4/26/2024 (Medication to treat depression).This same observation also revealed a medication bottle with no label. Written in black ink on the bottle, it said Celexa 40mg cut in half. Observation on 10/15/2025 at 11:45 AM revealed the refrigerator in the Medication room had the following…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Resident #9. Record review of Resident #9's admission record dated 10/15/2025 revealed she was admitted to the facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The facility failed to ensure residents who receive psychotropic drugs receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. This failure could place residents at risk for adverse reactions…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings included: Review of Resident #6's admission Record, dated [DATE] revealed he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including unstageable pressure ulcer (unable to assess the wound due to hidden tissue) of the sacral area (base of the spine above the buttocks); stage IV pressure ulcer (a wound that has exposed bone, tendon, or muscle often including tunneling or undermining of the surrounding skin) of the right…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.The findings included: Record review of Resident #15's admission record, dated 10/15/2025, revealed she was admitted to the facility on [DATE] with diagnoses of dementia and dependence of supplemental oxygen. She was [AGE] years of age. Record review of Resident #15's order summary report dated 10/14/2025 revealed May use O2 at 2-4 liters per minute via N/C as needed for as needed for low O2 Sat to maintain O2 Sat above 90%. with a start date of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings included: 1. An observation 12/29/24 at 9:20 a.m. revealed an open laptop on the facility's medication cart, outside of room [ROOM NUMBER]. The screen was not locked and displayed Resident #4's information. CMA F was in a resident's room administering medication. During an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: Review of Resident #116's admission Record, dated 12/29/24 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included benign prostatic hyperplasia with lower urinary tract symptoms (blocked urinary tract due to swollen prostate). Review of Resident #116's Significant Change MDS, dated [DATE], revealed: He had a mental status score of 9 of 15 with signs of delirium including inattention and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: NO EBP PRECAUTIONS Review of Resident #116's admission Record, dated 12/29/24 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms (blocked urinary tract due to swollen prostate). Review of Resident #116's Significant Change MDS, dated [DATE], revealed: He had a mental status…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: Resident #12 Review of Resident #12's admission Record, dated 12/30/24, revealed he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included pleural effusion (lungs clogged with mucous). Review of Resident #12's Quarterly MDS Assessment, dated 10/26/24, revealed: He had a mental status score of 8 of 15 (indicating severe cognitive impairment). He had shortness of breath upon…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings included: Observation on 11/07/23 at 09:15 AM, of the kitchen refrigerator revealed: 1, 28-ounce bottle of [NAME] Yellow Mustard with a best by date of 7/21/23 1, 24-ounce bottle of Young Guns Flame Roasted Salsa with a best by date of 1/9/23 1, 32-ounce bottle of Food Club Lemon Juice from concentrate with a best by date of 7/11/23 1, 64-ounce bottle of Food Club Prune Juice unsweetened from concentrate with a best by date of 7/11/23 1, 5-pound container of Mollys California Style Pasta Salad with an expiration date of 10/4/23 21, 8-ounce cartons of Hormel Nectar…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings included: Review of PBJ [Payroll Based Journal] Staffing Data Report, with a run date of 11/01/2023 revealed Failed to have Licensed Nursing Coverage 24 Hours/Day was triggered for the fiscal year Quarter 3 2023 (April 1 - June 30). The infraction dates were 04/01 (SA); 04/07 (FR); 04/09 (SU); 04/16 (SU); 04/23 (SU); 04/29 (SA); 05/06 (SA); 06/03 (SA); 06/17 (SA), 06/25 (SU). Record review of the April 2023 schedule/time sheets indicated an RN only worked 4.5 hours on Sunday 04/09/2023. Time sheets indicate 24-hour licensed nursing coverage for Saturday 04/01/2023, Friday…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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: Record review of Resident #9's face sheet indicated she was [AGE] years old admitted to the facility on [DATE] with diagnoses including dementia, pneumonia, essential hypotension, chronic obstructive pulmonary disease, anemia, vitamin D deficiency. Record review of the MDS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.