Carleton-Willard Village Retirement & Nursing Ctr

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who required two staff members assistance with the mechanical sling lift for all transfers, the Facility failed to ensure he/she was free from neglect, when on 06/03/25 Certified Nurse Aide (CNA) #1, although she was aware of facility policy and that Resident #1 required an assist of two staff persons for transfers with a mechanical sling lift, CNA #1 transferred Resident #1 by herself, and he/she fell from lift on to the floor. CNA #1 also did not immediately report the fall to nursing so Resident #1 could be assessed for potential injury prior to being moved, but instead physically picked Resident #1 up off the floor by herself and put him/her back into bed. Once Resident #1 was back in bed, she still did not report the incident to nursing. [...]

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), whose comprehensive plan of care interventions indicated that he/she required the assistance of two staff members with the mechanical sling lift for all transfers, the Facility failed to ensure that staff consistently implemented and followed interventions related to transfers per his/her plan of care. On 06/03/25, Certified Nurse Aide (CNA) #1 attempted to transfer Resident #1 without the assistance from any other staff member, during the transfer the left upper clip on the mechanical sling lift became disconnected and Resident #1 fell to the floor. [...]

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who required two staff member assistance using the mechanical sling lift for all transfers, the Facility failed to ensure he/she was provided with the necessary level of staff assistance to maintain his/her safety and prevent an incident/accident resulting in significant injuries. On the morning of 06/03/25, Certified Nurse Aide (CNA) #1 attempted to transfer Resident #1 without another staff member present to assist her, and during the transfer the upper left clip of the sling unattached from the lift, and Resident #1 fell around four feet onto the floor. Resident #1 was transferred to the Hospital Emergency Department (ED) and was diagnosed with several fractured ribs, fractured left scapula, several spinal fractures, bilateral subdural bleeds, a head laceration, and other internal injuries.

Inspectors wroteBased on observations, and interviews, the facility failed to ensure medications were labeled and dated once opened, according to manufacturer's guidelines, in three out of three medication carts.

Inspectors wroteBased on observations, interviews and record review, the facility failed to implement a comprehensive person-centered care plan for one Resident (#72) out of a total sample of 20 residents. Specifically, for Resident #72: a.) the facility failed to ensure covered cups for hot beverages were implemented as directed by the plan of care. b.) the facility failed to ensure staff cut up food as directed by the plan of care.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed by nursing as being at high risk for falls, and whose comprehensive plan of care indicated he/she required the use of monitoring devices (bed and chair alarms) to alert staff when he/she attempted to stand or transfer alone, the Facility failed to ensure staff implemented and followed interventions identified in his/her plan of care, when alarms were not consistently used by staff, and he/she experienced two falls less than 24 hours apart, both of which resulted in an injury. After fall on 5/08/24, Resident #1 sustained a head laceration that required six staples to close, and on 5/09/24, Resident #1 fell again, fractured his/her nose and had a large hematoma (bruise) on his/her forehead.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed by nursing as being at high risk for falls, had a fall on 5/08/24 with an injury, was known to be impulsive and whose fall risk interventions included the use of monitoring devices (bed and chair alarms) to alert staff when he/she rose from a sitting or lying position, the Facility failed to ensure he/she was provided with the necessary safety devices and level of staff supervision to maintain his/her safety, when on 05/09/24 Certified Nurse Aide #1 assisted Resident #1 to the toilet, removed his/her alarm and left him/her unattended in the bathroom to go get supplies. [...]

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #2), who had a history of having sustained a subdural hematoma (pool of blood between the brain and it;s outer covering), the Facility failed to ensure staff provided quality of care consistent with professional standards of practice, when on 5/19/24 after finding Resident #2 on the floor after an unwitnessed fall, two Certified Nurse Aides (CNAs) picked him/her up off the floor and put him/her in bed before informing and having nursing assess him/her for the potential for injury, and as a result, his/her neurological signs were not measured or documented per facility policy in the event of an unwitnessed fall, by nursing.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1) who had a diagnosis of dementia and was cognitively impaired, the Facility failed to ensure care and treatment provided by nursing met professional standards of practice when on 08/28/23, Nurse #7 did not properly identify Resident #1 prior to administering him/her medications and administered another resident's medications to him/her. Findings Include: Review of the Facility Policy titled Medication Administration, dated as revised 12/01/19, indicated it was the Facility Policy that licensed nurses administer medications from a mobile medication cart and use a system which demonstrates both safety and efficiency when administering medications to residents. The Policy indicated all residents are identified using the photograph in the Medication Administration Book. [...]

Inspectors wroteBased on records reviewed and interviews for two of three sampled residents (Resident #1 and Resident #3), the Facility failed to ensure residents were free from significant medications errors when 1) on 08/28/23 Resident #1 was administered medications that were ordered for and were to be administered to another resident and 2) on 08/16/23 Physician's Orders for a diuretic medication were not transcribed onto Resident #3's Medication Administration Record and were therefore not administered as ordered. Findings Include: Review of the Facility Policy titled Medication Administration, dated as revised 12/01/19, indicated all residents are identified using the photograph in the Medication Administration Book. 1) Resident #1 was admitted to the Facility in March 2022, diagnoses included dementia, depression, gout, Vitamin D deficiency, peripheral vascular disease, edema, and osteoarthritis. [...]

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #3) the Facility failed to ensure they maintained complete and accurate Medical Records when Medication Administration Record documentation was not consistently completed for Resident #3 related to the administration of a diuretic medication during the month of August 2023. Findings Include: Review of the Facility Medication Pass Observation Tool, dated as revised 2018, indicated documentation of medication administration is completed accurately and charted consistently. Resident #3 was admitted to the Facility in February 2022, diagnoses included dementia, atrial fibrillation, atrioventricular block, depression, syncope, congestive heart failure, and osteoarthritis. [...]