Carlyle Place

Inspectors wroteBased on observation, staff interviews, and review of the facility policy titled Food Safety Management System, the facility failed to ensure items stored in the cooler were labeled, dated, and not beyond their expiration date. The facility also failed to ensure that items in the dry storage area were labeled and dated. In addition, the facility failed to ensure that food was held at a safe temperature until served, measured before serving to ensure appropriate serving sizes, and that staff ensured hairnets covered all hair. This deficient practice had the potential to adversely affect 31 of 31 residents receiving an oral diet.

Inspectors wroteBased on observations, staff and resident interviews, and record review, the facility failed to assess one out of 30 sampled residents (R) (R6) to determine if it was clinically appropriate to safely self-administer medications. This failure had the potential to place R6 at risk for adverse consequences.

Inspectors wroteBased on observations, staff interviews, and review of facility policy titled, C-26 Marking Ready to Eat TCS/PHF Foods the facility failed to remove ice build-up on top of food items to prevent contamination in the walk-in freezer; failed to ensure dietary staff label and date opened food items; and failed to ensure no wet nesting with stacks of steam table pans to prevent bacteria growth. The facility census was 32 residents, and all residents were consuming an oral diet.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled, Oxygen Concentrator-Work Instruction-[Facility Name], the facility failed to ensure humidification was provided for one of six residents (R) (R11) receiving oxygen (O2) therapy. The deficient practice had the potential to place the resident at risk for medical complications, unmet needs and a diminished quality of life. Findings Include: Review of the facility's policy titled Oxygen Concentrator-Work Instruction-[Facility Name] dated 10/27/2023 under the section titled Purpose revealed, To establish responsibilities for the care and use of oxygen concentrators. Under the section titled Explanation and Compliance Guidelines revealed, 4. (e) Fill the humidifier container to the correct level with distilled water and attach to concentrator or use a disposable humidifier. [...]

Inspectors wroteBased on interviews, record reviews, and review of the job summaries for the Administrator and Director of Nursing (DON), the facility Administration failed to effectively oversee an abuse prevention program to promote, foster, and maintain an abuse-free environment. The facility census was 32. On 4/16/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. Facility Administrator AA, Director of Nursing (DON), and Hospital Director were informed of the Immediate Jeopardy (IJ) on 4/16/2024 at 11:30 am. The noncompliance related to the Immediate Jeopardy was identified to have existed on 10/27/2023. [...]

Inspectors wroteBased on staff interviews, record review, and a review of the facility's policy titled QAPI Change Process- Work Instruction, the facility failed to identify concerns and effectively implement Quality Assurance Process Improvement (QAPI) plans related to abuse prevention system, including staff to resident abuse allegations and implementing all components of the abuse policies. The facility census was 32. On 4/16/2024 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. Facility Administrator AA, Director of Nursing (DON), and Hospital Director were informed of the Immediate Jeopardy (IJ) on 4/16/2024 at 11:30 am. The noncompliance related to the Immediate Jeopardy was identified to have existed on 10/27/2023. [...]

Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled Freedom of Abuse, Neglect, and Exploitation; Abuse Prevention - Work Instruction, the facility failed to ensure that one resident (R) (R4) was free from involuntary seclusion when one side of his bed was pushed against the wall, and the other side of the bed was barricaded with a mattress lying horizontally on chairs. The mattress and wall blocked R4's view of his room, and he could not get out of his bed from approximately 10:30 pm on [DATE] until [DATE] at 7:30 am when a nurse discovered R4. The facility census was 32. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. [...]

Inspectors wroteBased on staff interviews, record review, and review of the policy titled Freedom of Abuse, Neglect and Exploitation; Abuse Prevention - Work Instruction, the facility failed to protect the resident's right to be free from physical abuse by staff by failing to report an allegation of abuse in a timely manner to the State Agency (SA) for one of three residents (R)(R4) reviewed for abuse. On 4/16/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. Facility Administrator AA, Director of Nursing (DON), and Hospital Director (HD) were informed of the Immediate Jeopardy (IJ) on 4/16/2024 at 11:30 am. The noncompliance related to the Immediate Jeopardy was identified to have existed on 10/27/2023. [...]

Inspectors wroteBased on staff interviews, record review, and a review of the facility's policy titled Freedom of Abuse, Neglect and Exploitation; Abuse Prevention - Work Instruction, the facility failed to investigate, correct, and prevent allegations of abuse by staff for one of three residents (R) (R4) reviewed for involuntary seclusion. Specifically, when staff used a mattress and chairs to barricade R4 in his bed for more than eight hours. On 4/16/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. Facility Administrator AA, Director of Nursing (DON), and Hospital Director, were informed of the Immediate Jeopardy (IJ) on 4/16/2024 at 11:30 am. [...]

Inspectors wroteBased on observations, staff interviews, and review of facility policies titled, Food Safety Product Labeling and Dating and Cleaning and Sanitizing Frequency, the facility failed ensure food items were properly dated and labeled, the facility also failed to ensure that kitchen equipment was clean and sanitary. The deficient practice had the potential to affect 28 residents receiving an oral diet.

Inspectors wroteBased on record review and staff interviews the facility failed to ensure that a comprehensive plan of care was developed for two of three residents (R) (R# 26 and R#86). Specifically, the facility failed to develop a plan of care for R#26 that addressed his Suprapubic Catheter care needs, the facility also failed to develop a plan of care that addressed the behavioral needs of R#86.

Inspectors wroteBased on record review and staff interview the facility failed to ensure that a Discharge Minimum Data Set (MDS) assessment was transmitted within 31 days of completion to CMS (Center for Medicare and Medicaid Services) of Quality Improvement evaluation system (QIES) Assessment Submission and Processing (ASAP) for one of three discharged residents (R) (R#28). Findings Include: Record review for R#28 revealed that an admission Assessment reference date (ARD) of 12/7/2022 was the last MDS transmitted for the resident. The resident was discharged from the facility on 12/22/2022, there was no completed and transmitted discharge assessment noted. Review of the Resident Assessment Instrument (RAI) guidelines revealed that discharge was defined as the date the resident left the facility. [...]

Inspectors wroteBased on observations, staff interviews, record review, and a review of the facility's policy titled, AHNCP Oxygen Concentrator, Nebulizer Therapy and CPAP/BIPAP Cleaning the facility failed to ensure oxygen equipment was properly stored while not in use and failed to have a current physicians order for oxygen administration for 3 of 10 residents (R) (#33, #22, #23) receiving treatment for respiratory care.

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled, Medication Orders: Stop Orders, the facility failed to ensure a stop date was implemented, not to exceed 14 days for antipsychotic medications, for one of six residents (R) (R#7) reviewed for unnecessary medications. Specifically, the facility failed to implement a stop date for two antipsychotic medications ordered as needed (PRN) for R#7, increasing the potential for adverse consequences.