Carlyle Healthcare & Sr Living

Inspectors wroteBased on interview and record review, the Facility failed to allow a resident visitation with a family member for 1 of 3 residents (R2) reviewed for resident rights in the sample of 7.

Inspectors wroteBased on interview and record review the facility failed to ensure residents remained free from abuse for one (R1) of three residents reviewed for abuse in the sample of 4.

Inspectors wroteBased on interview and record review the failed to ensure allegations of physical abuse were reported immediately to the administrator of the facility and to the State Survey Agency for 1 of 3 residents (R55) reviewed for reporting of allegation of abuse in a sample of 57.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were protected from potential further abuse, after an allegation of abuse. This failure affects 1 of 3 residents (R55) reviewed for abuse allegations in a sample of 57.

Inspectors wroteBased on observation, interview, and record review, the Facility failed to adequately staff the dietary department to ensure meals are served in a timely manner for 4 of 5 residents (R1, R2, R4, R5) reviewed for food and nutrition services in the sample of 5.

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent mental abuse for 1 (R2) of 3 residents reviewed for abuse in the sample of 3. This failure resulted in R2 being tearful and expressing feelings including being upset and fearful of being kicked out of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served in a manner that prevents foodborne illness. This has the potential to affect all 79 residents living in the Facility.

Inspectors wroteBased on interview and record review, the Facility failed to establish an infection prevention and control program that reduces the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use in 4 of 4 residents (R50, R74, R236, R237) reviewed for antibiotic stewardship in the sample of 46.

Inspectors wroteFailures at this level required more than one deficient practice statement. A.) Based on observation, interview and record review, the facility failed to ensure the safety of residents who engage in cigarette smoking activities by failing to develop and implement personalized/individualized care plan interventions. These failures affect three of six residents (R2, R37, R73) reviewed for safety and supervision on the sample list of 46. B.) Based on observation, interview and record review, the facility failed to provide supervision to prevent falls for residents at risk for falls. This failure affects one of six residents (R42) reviewed for safety and supervision on the sample list of 46.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide complete incontinent care for 4 residents (R3, R17, R38, and R59) of 4 residents reviewed for incontinence in a sample of 46.

Inspectors wroteBased on interview, observation, and record review, the facility failed to store medications in a sanitary manner and failed to date an open multidose medication vial. This failure has the potential to affect all 21 residents residing in the dementia unit.

Inspectors wroteBased on observation, interview, and record review the facility failed to remove soiled gloves, perform proper hand hygiene, and dispose of soiled linen properly for 5 of 5 residents (R3, R17, R38, R59, R42) reviewed for infection control in a sample of 46. 1. R17's face sheet, print date 7/11/24, documented R17 has diagnoses of Alzheimer's disease, major depressive disorder, hypertension, macular degeneration, anxiety disorder, and osteoporosis. R17's MDS (Minimum Data Set), dated 4/5/24, documented that R17 is severely cognitively impaired, is always incontinent of urine, and is dependent on staff for all ADLS (Activities of Daily Living). On 7/9/24 at 9:20 AM, V16, CNA (Certified Nurse Assistant) pushed R17 in her reclining wheelchair from the dementia unit dining room to her room. V12 CNA and V16 CNA donned gloves without the benefit of hand hygiene. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served in a manner which prevents potential contamination and food-borne illness. This has the potential to affect all 87 residents living in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure interventions to prevent falls were appropriately implemented for 1 of 8 (R65) residents reviewed for falls in the sample of 43. This failure resulted in R65 falling out of bed sustaining a comminuted intra-articular fracture of distal femur. Findings Include: R65's facility face sheet dated 5/17/22 documents R65 was admitted to the facility on [DATE] with diagnoses that include acquired absence of right and left leg below the knee, heart failure, atrial fibrillation, chronic pain, diabetes, and muscle spasms. R65's Minimum Data Set (MDS) dated [DATE] documents R65 has a Brief Interview for Mental Status (BIMS) score of 15, which indicates R65 is cognitively intact. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide prescribed nutritional supplements and meals as ordered for 3 (R23, R24, R38) of 7 residents reviewed for nutritional services in the sample of 43. This failure resulted in R24 suffering a 7.95% weight loss over the past 3 months. Findings Include: 1. On 05/11/22 at 09:47 AM, R24 was observed in his room, sitting in his wheelchair. An interview with R24 revealed R24 was alert to person only. R24's current physician orders documented active diagnoses including but not limited to shortness of breath, constipation, altered mental status, anorexia, and pain. R24 is documented as admitting to the facility on 9/9/21 from an Assisted Living Facility. Review of R24's weights in his Electronic Health Record documented the following entries: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to check the placement of an enteral tube before initiating a feeding, to monitor monthly and weekly weights, and to provide the correct amount of enteral feeding as per Dietician and Physicians orders for one tube fed resident with significant weight loss (R48) of one resident reviewed for enteral feeding in the sample of 43. This failure resulted in R48 losing a total of 30 pounds between 12/21/21 and 4/6/22.

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare meals as scheduled for puree diets for 6 (R9, R16, R21, R50, R57, R220) of 6 residents reviewed for diet adherence in a sample of 43. The Findings Include: On 5/11/22 at 12:15PM, V7 (Cook) was taking the temperature of the food items on the steam table and the pureed item was mashed potatoes. The menu for the day was documented as chicken with mushroom sauce, broccoli, and buttered noodles. The same menu (with recipe included) had directions indicated for residents receiving pureed diet to have pureed buttered noodles. V7 stated at this time that he doesn't generally puree the buttered noodles by preference, but that he would if a resident requested them. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure that proper food handling, sanitation and serving procedures were followed to prevent cross contamination. This has the potential to affect all residents in the facility. The Findings Include: On 5/11/22, at 9:30 AM, the gelatin salad in the walk-in refrigerator was left uncovered with no date or time of preparation. On 5/11/22, at 12:15 PM, V7 (Cook) took the temperature of the lunch menu items and the buttered noodles were 120 degrees Fahrenheit. V7 did not reheat the noodles prior to beginning of tray line. On 5/11/22 at 10:45AM, V6 (Cook) was observed to use gloved hands to assemble the commercial blender that would puree the food items and use those same gloved hands to pick up the meat, rip it up with her gloved hands and place in the machine. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure expired stock medications were disposed of per current standards of practice for 15 (R2, R3, R4, R8, R12, R15, R24, R26, R30, R32, R44, R49, R56, R60, and R67) of 33 residents reviewed for medication storage in the sample of 43. Findings Include: On 05/11/22 at 03:22 PM, Medication Cart C located on the 2nd floor was reviewed with the following stock medication observations: 1. 1 bottle Ibuprofen 200 mg tablets, exp. 11/2021 2. 1 bottle Vitamin D 50,000 IU (International Units), exp. 7/2021 3. 1 bottle Naproxen Sodium 220 my, exp. 2/2022 4. 1 bottle Guaifenesin 200 my tab; exp. 11/2021 Review of additional stock medication bottles present in the medication cart revealed no additional bottles of the same medication present that were not expired which may have been available for use. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the ombudsman of hospital transfers for 3 (R47, R56, R67) of 3 residents reviewed for hospitalization in the sample of 43. Findings Include: 1. The facility document titled Duration of Bed Hold at Time of Transfer for R47 with a date of 3/30/22 documents R47 was transferred from the facility to the local hospital for evaluation and treatment due to change of status. 2. The facility document titled Duration of Bed Hold at Time of Transfer for R56 with a date of 4/09/22 documents R56 was transferred from the facility to the local hospital for evaluation and treatment due to fall and suspected fx (fracture). 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide aseptic wound care, implement treatment interventions, and obtain physicians orders for a newly identified wound for two (R25 and R48) of five residents reviewed for pressure ulcers in the sample of 43.

Inspectors wroteBased on observation, interview, and record review, the facility failed to replace a nebulizer mask and tubing per physician's order for one of one resident (R43) reviewed for respiratory care in the sample of 43.