Carlin Springs Health & Rehabilitation

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to develop and/or implement the comprehensive care plan for three of 52 residents in the survey sample, Residents #9, #13, and #20.

Inspectors wroteBased on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services to meet professional standards for four of 52 residents in the survey sample, Residents #154, #145, #173, and #13.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide a clean and homelike environment for three of 52 residents in the survey sample, Residents #6, #112, and #38.

Inspectors wroteBased on facility document review and staff interview, it was determined that the facility staff failed to implement their abuse policy for protection of the resident during the investigation of an abuse allegation for one of 52 residents in the survey sample, Resident #162.

Inspectors wroteBased on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to ensure medications were available for administration for one of 52 residents in the survey sample, Resident #156.

Inspectors wroteBased on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to ensure one of 52 residents were free of a significant medication error, Resident #13.

Inspectors wroteBased on resident interview, staff interview, clinical record review and facility document review, the facility staff failed to assess and implement interventions and/or provide care and treatment for the prevention of pressure ulcers for two of 29 residents in the survey sample (Resident #100 and Resident #115). 1). Resident #100 was admitted to the facility on [DATE], with a brace to the left leg in place and a deep tissue injury to the left lower leg. The facility staff failed to remove the brace for 19 days, failed to assess, monitor, implement interventions and/or treat the resident's skin/deep tissue injury. As a result, the the resident developed a 6 x 3.5 centimeter unstageable pressure ulcer, resulting in actual harm. 2.) The facility failed to ensure Resident #115's specialty mattress for pressure relief was plugged in and operating for the prevention of pressure ulcers.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, the facility failed to follow physician orders for one of twenty-nine residents in the survey sample (Resident #82). Resident #82 was not administered a dose of potassium chloride as ordered by the physician.

Inspectors wroteBased on clinical record review, staff interview, and resident interview, the facility failed for one of 14 residents in the survey sample (Resident # 105) to ensure the resident had physician's orders for the care of a colostomy. Resident # 105 had a colostomy for at least three years without orders for colostomy care.

Inspectors wroteBased on staff interview, record review, and in the coarse of a complaint investigation, the facility failed for one of 29 resident's to ensure Resident #119 was free of unnecessary medications. Resident #119 was prescribed and given medications that was ordered in error. The Findings Include: Diagnoses for Resident #119 included: fracture of left pelvis, hypertension, anxiety disorder, hyperlipidemia, arthritis, and gastric reflux. The most current MDS (minimum data set) was an admission assessment with an ARD (assessment reference date) of 3/7/22. Resident #119's cognitive score was a 15 indicating cognitively intact. Resident #119 was admitted for therapy on 3/1/22 and discharged on 3/14/22. [...]

Inspectors wroteBased on observation, staff interview, resident interview, and in the course of a complaint investigation, the facility staff failed to serve food that was palatable and per the resident's choice for one of 29 residents. Resident #13's toast was burned, eggs were scorched, and his lunch tray on 07/27/2022 was cold. This is a complaint deficiency.

Inspectors wroteBased on observation, staff interview, and facility document review the facility staff failed to ensure four of 29 residents were provided food substitutions per request and preferences. This is a complaint deficiency. 1. Resident #13's who chose his own menu, was not served the items requested. 2. Resident # 74 - The facility failed to honor Resident # 74's request to not be served fish. 3. Resident # 47 - The facility failed to honor Resident # 47's dislike of dark meat chicken, i.e., legs and backs. 4. Resident #17 was unable to make advanced food choices and request alternates due to no access to posted menus.

Inspectors wroteBased on observations, clinical record review, resident interview, staff interview, and review of facility documents, the facility failed to serve meals in a timely manner on the East Unit. Breakfast on the East Unit was not served until 9:40 a.m. on 7/26/2022.

Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to ensure the dishwasher in the main kitchen was in proper working order. Wash temperatures and rinse temperatures were not within the manufacturer's recommended range.

Inspectors wroteBased on observation, staff interview and clinical record review, the facility staff failed to promote dignity for one of twenty-nine residents in the survey sample. Resident #115 was left in a soiled gown for over two hours and had no personal clothing to wear.

Inspectors wroteBased on staff interview, clinical record review and facility document review, the facility staff failed to ensure two of three randomly selected residents (Resident #268 and #269), were issued a NOMNC (notice of medicare non coverage) prior to discharge and failed to ensure one of three residents (Resident #270) was issued an ABN (advance beneficiary notice).

Inspectors wroteBased on observations, clinical record review, and resident interview, the facility failed for one of 14 residents in the survey sample (Resident # 114) to ensure the resident had a clean, comfortable, and homelike environment. The toilet in the resident's room did not flush, the bath tub was dirty, and a paper towel dispenser was dirty.

Inspectors wroteBased on resident interview, staff interview and clinical record review, the facility staff failed to ensure one of 29 residents (Resident #100) had physician's orders upon admission, for the immediate care and treatment of a full leg brace and for a deep tissue injury to the resident's left leg.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to ensure a Level I PASRR (preadmission screening and resident review) was completed upon admission for two of 29 residents, Resident #66 and Resident #84.

Inspectors wroteBased on resident interview, staff interview and clinical record review, the facility staff failed to develop a CCP (comprehensive care plan) for one of 29 residents (Resident #100) regarding a leg brace/knee immobilizer and/or deep tissue injury.

Inspectors wroteBased on clinical record review and staff interview, the facility failed for one of 29 residents in the survey sample, Resident # 15, to review and revise the resident's plan of care. Resident # 15's care plan for Foley catheter care was not revised following the discontinuation of the catheter.

Inspectors wroteBased on observation, resident interview, staff interview, and clinical record review, the facility failed to ensure showers were being offered or provided for one of 29 resident's in the survey sample. Resident #322 was not offered a shower. The Findings Include: Diagnoses for Resident #322 included: Prostate Cancer, fractured right hip, chronic kidney disease, hematuria, and diabetes. The most current MDS (minimum data set) was an admission assessment with an ARD (assessment reference date) of 7/22/22. Resident #322's cognitive score was a 15 indicating cognitively intact. On 07/26/22 at 9:05 AM during an interview, Resident #322 was asked if he was receiving baths or showers. Resident #322 responded that he had not had a shower or bath since being admitted (admitted [DATE]) and was unaware that he was allowed to take a shower but would love to get a shower. [...]

Inspectors wroteBased on a medication pass and pour observation, staff interview, clinical record review and facility document review, the facility staff failed to ensure a medication error rate of less than 5 percent. The facility had three errors out of twenty-eight opportunities, which resulted in a medication error rate of 10.7 percent.

Inspectors wroteBased on observation and staff interview the facility staff failed to ensure expired medications were not readily available for distribution on 1 of 4 med carts reviewed and 1 of 4 med rooms reviewed. Observed on the 3W (3 West) medication cart was one opened bottle of Bisacodyl with a manufacture's expiration date of 02/22 (February 2022) and observed in the refrigerator of the first floor medication room were 9 single does syringes of the Influenza vaccine with an expiration date of 06/30/22.

Inspectors wroteBased on staff interview and clinical record review, and in the coarse of a complaint investigation, the facility staff failed to ensure a complete and accurate clinical record for one of 29 residents, Resident #119. This was a closed record review.

Inspectors wroteBased on observation, resident interview, family interview, staff interview, facility document review, clinical record review and in the course of a complaint investigation, facility staff failed to ensure two of four residents identified as smokers were assessed to determine if they were safe to smoke either independently or were at risk. The residents, one of whom was paraplegic, were observed outside without protective aprons and without direct supervision by facility staff. This was identified as Immediate Jeopardy (IJ) in the area of Quality of Care on 02/05/2019 at 5:01 p.m., with resulting SQC (substandard quality of care). The immediacy was abated on 02/05/2019 at 8:23 p.m. After removal of the immediate jeopardy on 02/07/2019 at 9:30 a.m., the Scope and Severity was lowered to Level III, Isolated. [...]

Inspectors wroteBased on staff interview and facility document review, the facility staff failed to ensure policies and procedures were developed and implemented for an effective water management program for the prevention of legionella and other opportunistic pathogens in the facility's water system.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to review and revise the comprehensive care plan (CCP) for the prevention of falls for two of 33 residents in the survey sample, Resident #129 and Resident #34. 1. The facility staff failed to ensure a comprehensive care plan was reviewed, revised and implemented for interventions and supervision for the prevention of falls, for Resident #129. 2. Resident #34's care plan was not reviewed and revised to included increased interventions/safety measures for her continued wandering, falls, and falls with injury.

Inspectors wroteBased on observation, staff interview, and in the coarse of a complaint investigation, the facility failed to ensure appetizing food temperatures. The staff served food on the third floor unit that was less than appetizing in temperature.

Inspectors wroteBased on observations, staff interview, and review of facility policies, the facility failed to store food in a sanitary manner in the main kitchen.

Inspectors wroteBased on the identification of Immediate Jeopardy and Substandard Quality of Care, as well as observations and staff interviews, the facility Administrator failed to exercise due diligence in the day-to-day operation of the facility. The Administrator failed to ensure a paraplegic smoker was assessed for safe smoking, failed to ensure the resident was care planned for smoking, and failed to ensure the resident was supervised during smoking. In addition, door alarms in the building were sounding without a response from the staff. The Administrator failed to ensure there was a specific policy in place that provided staff with direction as to how to respond to door alarms.

Inspectors wroteBased on staff interview and facility document review, the facility staff failed to develop and implement an appropriate plan of action for an identified quality deficiency regarding smoking. The facility QAA (Quality Assessment and Assurance)/QAPI (Quality Assurance and Performance Improvement) committee failed to develop and implement an appropriate plan of action for an identified deficiency with residents' smoking; the facility failed to ensure that an action plan was in place to ensure safe smoking for residents.

Inspectors wroteBased on staff observation and staff interview, the facility staff failed for one of 33 residents in the survey sample (Resident #119), to ensure a dignified dining experience during breakfast on 02/5/19. Staff served residents # 105 and # 16 on paper plates on the weekends without a valid reason.

Inspectors wroteBased on observation and staff interview, the facility staff failed to ensure a safe, clean, homelike environment on two of seven living units. A mechanical lift, chair scale, and floor scale were stored in the residents' dining/activity room on the 100 unit. This room also had damage along the wall where the equipment was stored and a cabinet door in disrepair. The floor covering in room [ROOM NUMBER] was torn and loose across the entrance to the bathroom. The wall near the first bed in this room had widespread vertical scrapes with torn wallpaper. In room [ROOM NUMBER], the drywall behind the bed was in disrepair and the coaxial cable cover was not mounted to the wall.

Inspectors wroteBased on observation, staff interview and clinical record review, the facility staff failed to ensure an accurate MDS (minimum data set) assessment was completed for one of 33 residents in the survey sample, Resident #21. Resident #21's MDS assessment did not accurately reflect the resident's status regarding dental health.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, the facility staff failed to develop a comprehensive care plan for two of 32 residents, Resident #117 and Resident #50. 1. Resident #117 did not have a comprehensive care plan to address smoking. 2. Resident #50 did not have a care plan for the use of oxygen.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed, for one of 33 residents in the survey, to ensure a nurse was knowledgeable of the resident's resuscitation status. A nurse caring for Resident #101 stated the resident's resuscitation status was a DNR (do not resuscitate) when the resident was actually a full code, requiring resuscitation in case of cardiac arrest.

Inspectors wroteBased on observation, clinical record review, and staff interview, the facility staff failed to ensure two of 33 residents (Resident #119 and Resident #45) were provided with care and services to carry out activities of daily living (ADL's). 1. The facility staff failed to provide Resident #119 with feeding assistance during a breakfast meal service. 2. The facility staff failed to provide Resident #45 with nail care.

Inspectors wroteBased on medication pass and pour observation, staff interview, resident interview and clinical record review, the facility staff failed to administer medications per physician order. Resident #117's Symbicort inhaler was not administered per physician orders.

Inspectors wroteBased on observation, staff interview, resident interview and clinical record review, the facility staff failed to provide care and services related to a Foley catheter for one of 16 residents, Resident #116. Resident #116 did not have orders for an indwelling catheter, the catheter was not care planned, the catheter was not anchored, and when the facility staff anchored the catheter it was not done per manufacturer's recommendations.

Inspectors wroteBased on observation, staff interview, clinical record review and facility document review, the facility staff failed to ensure oxygen administration was properly administered for one of 33 residents (Resident #19) and failed to obtain an oxygen order for one of 33 residents (Resident # 50). 1. The facility staff failed to administer oxygen appropriately via trach for Resident #19. 2. Resident #50 did not have a physician's order for the use of oxygen.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure expired medications were not available for use on one of five medication carts inspected. A vial of Lantus insulin, opened for more than 28 days, was available for use on a third floor medication cart.

Inspectors wroteBased on observation, staff interview, clinical record review and facility document review, the facility staff failed to ensure routine and emergency dental services for one of 33 residents in the survey sample, Resident #21. The facility did not provide routine and/or emergency dental services to Resident #21. Resident #21 had poor dental health and had not been seen by a dentist. The resident began having dental pain and was prescribed an antibiotic without being seen by a dentist and/or a physician; no followup care was provided.

Inspectors wroteBased on observation, resident interview, staff interview and facility document review, the facility staff failed to ensure no more than 14 hours elapsed between the evening meal and breakfast, and failed to offer a nourishing bedtime snack on one of seven units, three main.

Inspectors wroteBased on observation and staff interview, the facility staff failed to post daily nurse staffing in a visible area in the facility.

Inspectors wroteBased on clinical record review, resident interview, and staff interview, the facility staff failed for one of 24 residents in the survey sample (Resident # 17) to develop a plan of care that included non-pharmacological interventions to address pain control for the resident.

Inspectors wroteBased on staff interview and facility document review, the facility failed to ensure staff members were knowledgeable of emergency procedures. One of 8 employees interviewed were not familiar with protocols for power outage and/or fire emergencies.