Carrara

Inspectors wroteBased on interview and record review, the facility failed to coordinate assessments with the PASRR program for 1 of 5 residents (Resident #55) reviewed for PASRR assessments. The facility failed to ensure Resident #55 was referred to the appropriate state-designated mental health authority for review when she received a new diagnosis of schizoaffective disorder, bipolar disorder and anxiety disorder. This failure could place residents at risk of not being evaluated and receiving PASRR services needed.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for three of five residents (Residents #1, #2, and #3) reviewed for catheters. The facility failed to ensure Resident #1, #2, and #3's urinary catheters were anchored/secured to protect the resident's urethral openings and maintain proper urine flow. This failure could place residents with urinary catheters at risk of pulling/tension, kinks, and accidental dislodgment which could result in trauma and increase the risk of urinary tract infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 2 (Resident #1 and Resident #2) of 5 residents reviewed for resident rights. The facility failed to ensure LVN A introduced herself and spoke to Resident #1 while administering pain medication. The facility failed to ensure LVN A introduced herself and spoke to Resident #2 while moving his call light. These failures could place residents at risk of not being treated with respect and dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (Resident #1) of 3 residents reviewed for pain management. The facility failed to ensure LVN A assessed the pain level for Resident #1. This failure could place residents at risk of not having their pain managed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident had the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility for 1 (Resident #1) of 5 residents reviewed for reasonable accommodations. The facility failed to ensure CNA A removed Resident #1's lunch tray from the bedside table to accommodate him when requested. The noncompliance was identified as past noncompliance (PNC) that began on 11/03/25 and ended on 11/03/25. The facility had corrected the noncompliance before the state's investigation began. This failure could place residents at risk of not being able to meet their needs.

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 (Resident #1) of 5 residents reviewed for accuracy of medical records in that: The facility failed to document Resident #1's blood pressure before she was transported to dialysis on 08/13/25. This failure could place residents at risk of a change in condition and not receiving proper treatment and care in a timely manner.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #1) of four residents reviewed for respiratory care. The facility failed to ensure Resident #1's nebulizer mask (device used to deliver medication in a mist form through the nose and mouth) was properly stored, in a plastic bag with the resident's name and date on it, when not in use on 08/13/2025. This failure could place residents at risk for respiratory infection and not having their respiratory needs met.

Inspectors wroteBased on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety. 1. The facility failed on 05/01/2025 to ensure dented cans dated 04/28/2025 was placed in a separate storage area to keep from being used for residents' meals. These failures could place residents at risk for food-borne illness and cross contamination.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received adequate supervision to prevent incidents and accidents for one resident (Resident #1) of five residents reviewed for possible accident hazards and incidents. The facility failed to provide adequate supervision for Resident #1 on 07/23/2024 when he slid out of the sling during a mechanical lift transfer from wheelchair to bed. The noncompliance was identified as past noncompliance (PNC). The PNC began on 07/23/24 and ended on 07/28/24. The facility had corrected the noncompliance before the state's survey began. This failure could place residents at risk for possible injuries due to lack of adequate supervision.

Inspectors wroteBased on observation, interview and record review, the facility failed to promote and maintain the residents' right to be treated with respect and dignity for 2 of 8 residents (Resident #2 and Resident #4) reviewed for dignity and respect in that: 1) The facility failed to provide Resident #2 with help using the toilet and was told by staff to wear an adult brief after her preference to use the tiolet with help was voiced. 2) The facility failed to answer call lights in a timely manner for Resident #2 and Resident # 4's. These faillures could place residents at risk of diminished quality of life and loss of dignity and self-worth.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure a resident who was unable to carry out activities of daily living received necessary services to maintain good personally hygiene for 3 out of 8 residents (#2, #5, and #6) reviewed for ADL care. The facility failed to provide timely incontinence care for every two hours or as needed for Resident #2, # 5 and # 6 from 5/17/24 through 5/21/24. The facility failed to provide timely incontinence care on a regular basis for residents #2, #5, and #6. This failure could place residents at risk of skin breakdown, urinary tract infections and loss of dignity.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to ensure the resident environment remains as free of accident hazards as is possible and that residents received adequate supervision to prevent accidents for one (Resident #79) resident of three residents reviewed for elopement. RN A on 07/30/23 failed to report to the Administrator (at that time), the DON (at the time) or communicate to oncoming nursing staff when Resident #79 became agitated and stated he was going to leave the facility. On 08/02/23 Resident #79 became agitated and frustrated and told LVN B he was leaving the facility. LVN B redirected him and did not provide adequate supervision to prevent him from eloping from the facility on 08/02/23. Resident #79 was able to leave the building without staff being aware that he left the building on 08/02/23 sometime after 4:00 p.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 (Resident #80) of 5 residents reviewed for clinical records. 1. The facility failed to ensure staff kept copies of Resident #80's shower sheets from February and March 2024. 2. The facility failed to provide nurses notes on Resident #80's refusals to shower from February and March 2024. These failures could affect residents and place them at risk of inaccurate or incomplete clinical records.