Calera Manor

In the surveyor’s words

From the most serious findings on record at Calera Manor, in the surveyor’s own words.

• Immediate jeopardy, widespreadF610Oct 14, 2022

  A past noncompliance Immediate Jeopardy (IJ) situation was determined to exist effective 03/03/22 related to the facility's failure to thoroughly investigate an allegation of abuse and prevent further potential abuse for all residents while the investigation was in progress for Res #1. On 03/03/22 family member #1 reported observing CNA #1 slap Res #1 across the face. The facility did not provide abuse training upon hire for CNA #1. CNA #1was allowed to return to work before the abuse investigation was completed. Residents were not questioned regarding abuse until four days after the allegation of abuse was made. […]

• No harm, potential for more than minimal, widespreadF727Jun 12, 2025

  Based on record review and interview, the facility failed to ensure an RN was on duty for 8 consecutive hours per day. The DON identified 74 residents who resided in the facility. Findings: A PBJ Staffing Data Report, dated 01/01/25 through 03/31/25 (the second quarter of fiscal year 2025), showed the facility did not have RN coverage on 44 of the 90 days in that quarter. Below are the dates identified as not having RN coverage in January, February, and March 2025. a. January 1st, 2nd, 3rd, 4th, 5th, 6th, 7th, 8th, 9th, 10th, 11th, 12th, 13th, 14th, 15th, 16th, 17th, 18th, 19th, 20th, 21st, 22nd, 23rd, 24th, 25th, 26th, 27th, 28th, 29th, 30th, and 31st. b. February 2nd, 8th, 9th, 15th, 22nd, and 23rd. c. […]

• No harm, potential for more than minimal, widespreadF640Oct 21, 2022

  Based on record review and interview, the facility failed to transmit resident assessments to CMS within 14 days of completion. The Resident Census And Conditions Of Residents report documented 67 residents resided in the facility. Findings: CMS Submission Reports dated 03/16/22 through 10/19/22, documented 403 of of 529 resident assessments were not submitted within 14 days of completion. The facility did not have a policy regarding the submission of resident assessments within 14 days. On 10/20/22 at 9:34 a.m., the MDS coordinator reported they didn't know resident assessments were to be submitted within 14 days of completions. […]

• No harm, potential for more than minimal, widespreadF727Oct 21, 2022

  Based on record review and interview, the facility failed to staff a registered nurse eight hours a day, seven days a week. The Residents Census And Conditions Of Residents documented 67 residents resided in the facility. Findings: Upon review of the facilities payroll report and the staffing schedule, dated September 2022, the facility had a RN for eight hours a day on 09/05/22, 09/25/22 and 09/26/22 for the month of September 2022. On 10/19/22 at 03:15 p.m., the administrator reported the facility did not have a RN on staff seven days a week for eight hours a day for several days in the month of September. The administrator stated only three days in September were covered by a RN. The administrator reported the facility should have scheduled a RN but none was available.

• No harm, potential for more than minimal, patternF605Jun 12, 2025

  Based on record review and interview, the facility failed to ensure residents did not receive antipsychotic medications for the diagnosis of dementia for 2 (#14 and #25) of 6 sampled residents reviewed for unnecessary medications. The DON stated 22 residents were prescribed antipsychotic medications at the facility. 1. A significant change MDS assessment, dated 03/09/25, showed in section C Res #14 had a BIMS score of 3 [this indicated the resident's cognition was severely impaired]. A policy titled Antipsychotic Medication Use, dated April 2007, read in part, Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. […]