Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mccamey Convalescent Center during CMS and state inspections, most recent first.
The facility did not maintain the kitchen dishwasher in safe working order, resulting in staff using a three-compartment sink and residents receiving meals on Styrofoam dishes with flimsy plastic utensils. Staff and administrators reported delays in repair due to administrative processes and an ineffective maintenance request system, with no policy in place for essential equipment.
Surveyors found that the facility did not consistently develop or update care plans to address key aspects such as code status, ADL needs, use of wander guards, and electronic monitoring for several residents. These omissions were confirmed through record review, observation, and staff interviews, revealing that care plans were not always updated to reflect current orders or resident needs, despite facility policy requiring comprehensive interdisciplinary care planning.
Surveyors found expired medications, including Coreg and Celexa, as well as an unlabeled medication bottle in a medication cart, and an expired Covid vaccine in the medication room refrigerator. Staff interviews revealed that required checks for labeling and expiration were not consistently performed, and nursing management audits were not effectively implemented, resulting in expired and unlabeled medications remaining in storage.
Staff failed to follow infection control protocols, including proper hand hygiene and PPE use, during peri-care and wound care for two residents with incontinence and pressure ulcers. Multiple CNAs did not sanitize or wash hands between glove changes, and the ADON did not use PPE or change gloves between wounds. Facility policies required these practices, but observations and interviews confirmed they were not followed, and necessary PPE and signage were not present.
A resident was administered Seroquel, an antipsychotic medication, without documented clinical indication, behavior monitoring, or attempts at gradual dose reduction as required. Medical records lacked justification for continued use, and staff did not follow up on pharmacy recommendations or document clinical contraindications, resulting in a deficiency related to chemical restraint practices.
Two residents with severe pressure ulcers did not consistently receive wound care as ordered, with wounds left uncovered and infection control protocols not followed. Staff failed to change gloves, perform hand hygiene, or use PPE during wound care, and there was no formal process for wound monitoring or effective communication among nursing leadership. Facility policies for daily monitoring, PPE use, and documentation were not consistently implemented.
A resident who required supplemental oxygen did not have their nasal cannula and tubing stored in a protective bag or Wiki-pouch when not in use, as required by facility policy. Instead, the equipment was wrapped around the oxygen tank on the wheelchair, and staff confirmed that proper storage was not consistently provided. Additionally, there was no "oxygen in use" sign posted outside the room, despite the presence of oxygen equipment. These deficiencies were confirmed by observation, staff interviews, and record review.
The facility failed to protect the privacy and confidentiality of residents' medical records. A CMA left a laptop screen unlocked displaying a resident's information while administering medication, and another CMA left screens unlocked showing residents' information when going to the restroom and after taking vital signs. Interviews confirmed awareness of the need to lock screens, and the DON stated that staff had received training on HIPAA compliance.
The facility failed to secure indwelling catheters for four residents, risking discomfort and urinary tract infections. Observations revealed unsecured catheters, and staff acknowledged the oversight. The facility had protocols for securing catheters, but these were not consistently followed.
The facility failed to implement Enhanced Barrier Precautions (EBP) during urinary catheter care for two residents with indwelling catheters. CNAs only used gloves, not gowns, due to a misunderstanding of the EBP policy, which requires PPE for residents with indwelling devices, regardless of infection status. The Infection Preventionist and DON acknowledged the oversight, which could lead to cross-contamination.
The facility failed to properly store respiratory equipment for two residents, leading to potential contamination. A resident with pleural effusion and another on hospice with pneumonia had their breathing treatment masks left unbagged and exposed to air. The DON acknowledged the expectation for proper storage, but noted the absence of the Infection Control Nurse on weekends. Facility policy required equipment to be stored in labeled bags, which was not followed.
Failure to Maintain Kitchen Dishwasher and Essential Equipment
Penalty
Summary
The facility failed to maintain essential mechanical and electrical equipment in safe operating condition, specifically the kitchen dishwasher. According to interviews and observations, the dishwasher had been out of service for several weeks, with staff reporting it initially failed, was temporarily repaired by replacing the booster heater, and then failed again with water spraying, smoking, sparking, and loud noises. Staff resorted to washing all dishes in a three-compartment sink, and residents complained about the use of Styrofoam dishes and flimsy plastic silverware, which made eating difficult. The kitchen staff did not consistently cut meat into bite-sized pieces to accommodate the inadequate utensils. Maintenance attempts to repair the dishwasher were unsuccessful, and the facility was in the process of obtaining quotes for replacement, but there was no clear timeline for repair due to administrative delays. Record review and staff interviews revealed deficiencies in the facility's maintenance request system, as there was no way to verify when requests were submitted or addressed, and staff did not receive acknowledgment or completion notifications. The Administrator was unaware of any resident complaints and stated that the dishwasher's repair depended on decisions from the hospital board, which met monthly. Additionally, the Director of Nursing confirmed there was no policy regarding essential equipment. These actions and inactions resulted in the prolonged use of inadequate dishwashing methods and substandard dining materials for residents.
Failure to Develop and Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and time frames for several residents, as required. Specifically, care plans for five residents did not address critical aspects of their care, including code status, activities of daily living (ADL) needs, use of wander guards, and authorized electronic monitoring. These omissions were identified through observation, interviews, and record reviews, which revealed that care plans were either missing or not updated to reflect current orders and resident needs. For example, one resident with dementia and heart failure had an active full code order, but this was not reflected in the care plan. Another resident with severe cognitive impairment and a need for assistance with personal care lacked care plan documentation for both ADL status and code status. Additional residents with diagnoses such as dementia, heart problems, and adult failure to thrive were found to have care plans that did not address DNR status, ADL ability, use of a wander guard, or consent for electronic monitoring, despite these being present in their medical records or observed during the survey. Interviews with facility staff, including the DON and Administrator, confirmed that these care plan omissions were due to oversight and a lack of timely updates. Staff acknowledged that care plans were typically updated with MDS assessments or when significant changes occurred, but in these cases, updates were missed. The facility's policy requires interdisciplinary care planning based on comprehensive assessments, but this process was not consistently followed for the residents reviewed.
Expired and Unlabeled Medications Found in Medication Storage Areas
Penalty
Summary
Surveyors observed that the facility failed to provide proper pharmaceutical services by not ensuring the medication cart and medication room refrigerator were free of expired and unlabeled medications. Specifically, expired medications including Coreg 6.25mg and Celexa 40mg were found in the medication cart, and an unlabeled bottle marked as Celexa 40mg cut in half was also present. Additionally, an expired Covid Vaccine MRNA Spike Vax was found in the medication room refrigerator. These findings were based on direct observation during the survey. Interviews with staff revealed that it was the responsibility of nurses and medication aides to check medication carts for labeling, dating, and expiration every shift, but this was not consistently done. The CMA interviewed admitted to not checking the entire cart that morning. The Administrator and DON both stated that expired medications should be discarded and that nursing management is responsible for periodic audits, but the process was not effectively implemented, leading to the presence of expired and unlabeled medications.
Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple staff members not following proper hand hygiene and personal protective equipment (PPE) protocols during resident care. Certified Nursing Assistants (CNAs) providing peri-care to a resident with bowel and bladder incontinence did not sanitize or wash their hands after removing soiled gloves and before donning new gloves. This occurred on more than one occasion with different CNAs, despite their acknowledgment during interviews that they were trained to perform hand hygiene between glove changes and understood the risk of cross contamination. Additionally, the Assistant Director of Nursing (ADON) did not use PPE or perform appropriate hand hygiene while providing wound care to a resident with multiple stage IV pressure ulcers. The ADON admitted to not changing gloves between wounds and not remembering if hand hygiene was performed. There was also no Enhanced Barrier Precautions (EBP) signage or PPE available at the resident's door, contrary to facility policy and CDC guidelines. The resident's wound was found uncovered for an extended period, and the ADON confirmed that dressings should be checked daily and reported if found off. Facility policy reviews revealed clear expectations for hand hygiene, PPE use, and EBP for residents with wounds or indwelling devices. However, observations and staff interviews demonstrated that these protocols were not consistently followed. The Director of Nursing (DON) and ADON both acknowledged the lapses in infection control practices, including the lack of PPE availability and signage, and the failure to ensure wounds were properly covered and monitored.
Failure to Ensure Proper Use and Monitoring of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident's right to be free from chemical restraints was upheld, specifically regarding the use of Seroquel, an antipsychotic medication. The resident, who had diagnoses including unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, was prescribed Seroquel 200mg at bedtime. Documentation did not show a clear clinical indication for the continued use of this psychotropic medication, and there was no evidence of behaviors that would warrant its use. The resident's care plan referenced the medication for behavior management and disease process, but lacked a specific care plan for any particular behavior, and there was no documentation of side effect or behavior monitoring as required. Review of the resident's medical records, including the quarterly MDS assessment and physician's orders, revealed that the antipsychotic medication was being administered daily without attempts at gradual dose reduction (GDR) or documentation of clinical contraindication for not attempting GDR. Pharmacy records indicated a request for GDR was made and signed by the nurse practitioner, but there was no acknowledgment or follow-up by the physician, nor was there documentation justifying the continued use of the medication. Interviews with facility staff confirmed that the required monitoring and documentation were not completed, and staff were unsure why the medication had not been reduced or why clinical contraindications were not documented. Observations of the resident showed that he was frequently in bed with his eyes closed, and staff interviews indicated that he did not exhibit significant behaviors, only occasional wandering. The facility's policy required that psychotropic medications be used only with proper clinical indication, that GDRs be attempted unless contraindicated, and that monitoring be performed by the DON, pharmacist, and medical director. These requirements were not met in this case, resulting in the deficiency.
Failure to Provide Proper Pressure Ulcer Care and Infection Control
Penalty
Summary
The facility failed to provide necessary treatment and services consistent with professional standards of practice to promote healing and prevent worsening of pressure injuries for two residents with pressure ulcers. One resident, who was severely cognitively impaired and had multiple stage IV and unstageable pressure ulcers upon admission, did not consistently receive wound care as ordered. Observations revealed that the resident's wounds were left uncovered for extended periods, and wound care supplies, including soiled dressings, were improperly disposed of in the resident's bathroom. The resident reported discomfort in the affected area, and staff interviews confirmed that dressings were not always checked or replaced as required. During wound care observations, the ADON failed to follow infection control protocols, including not changing gloves or performing hand hygiene between wounds, and not donning appropriate PPE. PPE was not available at the resident's door, and there was no PPE hanger present. The ADON acknowledged these lapses, stating that her actions increased the resident's risk for infection. The ADON also admitted that there was no formal process for wound monitoring beyond weekly assessments and that communication between nursing leadership regarding wound care was ineffective. The DON confirmed that staff were expected to follow evidence-based practices, including changing gloves and using PPE during wound care, but acknowledged that these expectations were not consistently met. The DON also stated that there was no formal process in place to ensure ongoing wound monitoring for healing or deterioration, aside from weekly assessments and monthly Quality Assurance meetings. Facility policies required daily monitoring of pressure ulcers, proper use of PPE, and documentation of interventions, but these were not consistently implemented, leading to deficiencies in pressure ulcer care and infection control.
Failure to Ensure Proper Oxygen Management and Safety Precautions
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident who required supplemental oxygen, as observed through multiple deficiencies in oxygen management. Specifically, the resident's nasal cannula and tubing were not stored in a protective bag or Wiki-pouch when not in use, but instead were wrapped around the oxygen tank on the resident's wheelchair. This practice was confirmed by both staff and the resident, with a CNA stating that there were no bags available for storage and acknowledging that improper storage could lead to cross-contamination. The Director of Nursing (DON) and Administrator both stated that the expectation was for the nasal cannula and tubing to be stored in a Wiki-pouch to prevent infection, in accordance with facility policy. Additionally, there was no "oxygen in use" sign posted outside the resident's room, despite the presence of both an oxygen tank and concentrator in the room. Both the DON and Administrator confirmed that such signage was required to alert staff and visitors to the presence of oxygen, which is necessary for safety and infection control. Record reviews indicated that the resident had a history of dementia and was dependent on supplemental oxygen, with care plans and physician orders specifying continuous or as-needed oxygen therapy. These failures were identified through observation, interviews, and record review, and were not in line with professional standards of practice or facility policy.
Failure to Protect Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of personal and medical records for three residents. Specifically, CMA F did not lock the screen of her laptop, which displayed Resident #4's information, while she was in a resident's room administering medication. Similarly, CMA G left her laptop screen unlocked, displaying Resident #5's information, when she went to the restroom. Additionally, CMA G's laptop screen was not locked and showed Resident #6's medication information after taking vital signs. Interviews with the CMAs confirmed that they were aware their laptop screens should have been locked to protect residents' privacy. The Director of Nursing (DON) also confirmed that privacy must be maintained during care and that staff had received training on HIPAA and the importance of keeping medical records private. The facility's policy on access control requires workforce members to log off or lock their electronic devices before leaving them unattended, which was not adhered to in these instances.
Failure to Secure Indwelling Catheters
Penalty
Summary
The facility failed to ensure that residents with indwelling catheters received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. Specifically, the facility did not secure the catheters of four residents, which could lead to discomfort, urethral trauma, and urinary tract infections. Observations and interviews revealed that the catheters of these residents were not secured, and staff acknowledged this oversight. Resident #116, a male with benign prostatic hyperplasia, had an unsecured catheter, as observed during an interview with LVN B. Similarly, Resident #122, who had pressure-induced deep tissue damage, also had an unsecured catheter. Resident #126, a female with neuromuscular dysfunction of the bladder, and Resident #127, a female on hospice services with a fracture of the left femur, were both found with unsecured catheters during the same observation period. Interviews with LVN B and the DON highlighted that the facility had protocols for securing catheters, but these were not followed. The DON stated that catheters should be cleaned and drained regularly, and a device should be used to secure them to prevent movement and urethral traction. However, the staff did not consistently apply these measures, leading to the deficiencies noted in the report.
Failure to Implement Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of proper use of personal protective equipment (PPE) during urinary catheter care for two residents. Both residents had indwelling catheters, which required Enhanced Barrier Precautions (EBP) according to the facility's policy. However, Certified Nursing Assistants (CNAs) A, C, D, and E only used gloves and did not don gowns during catheter care, despite the potential exposure to bodily fluids. Resident #116, a male with benign prostatic hyperplasia and an indwelling catheter, was not placed under EBP precautions. The CNAs involved in his care were unaware of the need for EBP, as they believed it was only necessary for residents with active infections. Similarly, Resident #122, who had pressure-induced deep tissue damage and urinary incontinence, was also not under EBP precautions. The CNAs caring for him shared the same misunderstanding regarding the application of EBP. Interviews with the Infection Preventionist (IP) and the Director of Nursing (DON) revealed a misinterpretation of the facility's EBP policy, which mandates the use of PPE for residents with indwelling devices, regardless of infection status. The IP and DON acknowledged that the staff should have used gowns and gloves during catheter care to prevent cross-contamination. The facility's policy clearly states that EBP should be used for residents with indwelling medical devices, even if they are not known to be infected or colonized with multi-drug resistant organisms (MDROs).
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to provide proper respiratory care for two residents, leading to a deficiency in maintaining professional standards of practice. Resident #12, a male with severe cognitive impairment and pleural effusion, had an order for Ipratropium-Albuterol inhalation solution to be used as needed for shortness of breath. However, during an observation, his small volume nebulizer (SVN) mask was found unbagged and exposed to air on his nightstand, indicating improper storage and potential contamination. Similarly, Resident #127, a female on hospice with pneumonia and severe cognitive impairment, also had an order for Ipratropium-Albuterol inhalation solution. Her breathing treatment mask was observed unbagged and open to air on her bedside table. The Director of Nursing (DON) acknowledged the expectation for masks to be stored in bags to prevent contamination, but noted that the Infection Control Nurse, who typically monitored this, was not present on weekends. The facility's policy required respiratory equipment to be stored in a labeled bag, which was not adhered to in these cases.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Mccamey
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Focused Care At Crane | 21.2 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.