The Carrolton of Plymouth

Inspectors wroteBased on record review and staff interviews, the facility failed to report a resident concern to administration for investigation for 1 of 3 residents reviewed for dignity and respect (Resident #18).

Inspectors wroteBased on observations and interviews with residents, staff, plumbers, Medical Director, and the [NAME] President of Property Management the facility failed to maintain repair or replace corroded sewage pipes, that caused sewage to back up onto the hallway floors for 2 of 4 hallways (200, 500) reviewed for maintaining a safe, clean, comfortable, and homelike environment.

Inspectors wroteBased on observations and interviews with residents and staff, the facility failed to maintain repair or replace corroded sewage pipes, that caused sewage to back up on the hallways and create an accident hazard for 2 of 4 hallways (200 hall and 500 hall) reviewed accident hazards.

Inspectors wroteBased on observation, record review, and staff, [NAME] President of Property Management, and plumber interviews, the governing body failed to ensure the replacement of aged, malfunctioning, and corroded sewer lines. Due to the state of disrepair of the sewer lines, sewage backed up on multiple occasions each month through sewer cleanout access ports to the point where the replacement of the sewer lines was required to stop the sewer lines from overflowing. When the sewer lines would overflow, several facility toilets on the same hall could not be flushed because they would start to overflow. Furthermore, the corrosion of the drainage lines had deteriorated the integrity of the pipe to the point where there were holes in the pipe and wastewater from the sewer lines was draining into the soil under the facility. [...]

Inspectors wroteBased on record review, observation, and interviews with the Medical Director, resident, and staff, the facility failed to protect a severely cognitively impaired resident's (Resident #5) right to be free of verbal and physical abuse when a nurse (Nurse #1) entered Resident #5's room, found him lying on the floor near the bathroom and yelled at him to get up and when Resident #5 reached up to grab on to Nurse #1 she slapped him on his upper left arm and told him to get his pissy hands off of her. The deficient practice occurred for 1 of 2 residents reviewed for abuse (Resident #5).

Inspectors wroteBased on record review and staff interviews, the facility failed to develop a comprehensive care plan for 1 of 3 residents reviewed for tube feeding (Resident #58).

Inspectors wroteBased on observation, record review, and staff interviews the facility failed to ensure there was an order for gastrostomy tube (g-tube) site dressing changes for 1 of 3 residents reviewed for tube feeding (Resident #58).

Inspectors wroteBased on observations, record review, and staff and resident interviews, the facility failed to provide nail care to a dependent resident for 1 of 5 residents reviewed for activities of daily living care (Resident #3).

Inspectors wroteBased on observation, record reviews and staff interviews the facility failed to: example #1.) a.) label the ready to hang prefilled enteral formula (a liquid nutritional product that is delivered into the gastrointestinal tract) that was infusing through a gastrostomy tube (g-tube: a surgically placed tube that provided direct access to the stomach for nutrition, hydration and medication) with the date and time it was started, label the bag used for water flushes or the bag holding the 60 cubic centimeter (cc) syringe. The facility also failed to clean and store a tube feeding syringe with the plunger separate from the barrel which created a potential for bacterial growth. b.) administer the enteral feeding formula at the physician ordered rate. This was for 1 of 3 residents reviewed for enteral feeding management (Resident #28). [...]

Inspectors wroteBased on observation, record review, staff and Medical Director interview the facility failed to follow professional standards of practice and infection prevention measures when a nurse failed to perform hand hygiene and don (put on) sterile gloves after touching and disposing of a soiled split gauze pad and inner cannula and before placing the new sterile inner cannula and clean split gauze. This was for 1 of 1 resident (Resident #28) reviewed for tracheostomy care.

Inspectors wroteBased on record review, and staff, Registered Dietitian and Medical Director interviews the facility failed to maintain dialysis communication forms and monitor the weight status for 1 of 1 resident reviewed for dialysis (Resident #9).

Inspectors wroteBased on observations, staff interviews, and record review the facility failed to attempt alternatives prior to installing side rails for 3 of 3 residents reviewed for side rails (Resident #1, Resident #9 and Resident #58).

Inspectors wroteBased on observations, record review and staff interview the facility's Quality Assessment and Assurance Committee failed to maintain implemented procedures and monitor interventions that the committee had previously put in place following the recertification and complaint surveys of 7/28/21 and 2/16/23. This was for 4 recited deficiencies in the areas of Accuracy of Assessments (F641), Develop/Implement Comprehensive Care Plans (F656), Discharge Summary (F661), and Infection Control (F880). The continued failure during 2 or more federal surveys of record showed a pattern of the facility's inability to sustain an effective Quality Assurance Program.

Inspectors wroteBased on observation and staff interviews the facility failed to maintain infection control for 6 of 6 residents (Resident #54, Resident #56, Resident #61, Resident #26, Resident # 70, and Resident #125) reviewed for Coronavirus disease 2019 (COVID-19) testing. The facility further failed to use a N-95 respirator (N-95) (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) for 1 of 1 resident (Resident #69) reviewed for contact isolation.

Inspectors wroteBased on record review and Physician, resident and staff interviews the facility failed to assess and offer a recommended Pneumococcal vaccine to residents on admission for 4 of 5 residents reviewed for vaccine status (Resident #38, Resident #21, Resident #20, and Resident #55).

Inspectors wroteBased on observation, record review and resident and staff interviews, the facility failed to maintain an effective pest control program for 3 of 5 hallways (Hallways 400, 500, and 600).

Inspectors wroteBased on observation, resident and staff interviews, the facility failed to maintain a pull cord within reach for the resident call system for 1 of 1 resident reviewed (Resident #64) for Resident Call System.

Inspectors wroteBased on observations, record review and staff interviews the facility failed to develop a person-centered comprehensive care. This was for 1 of 3 residents (Resident #225) reviewed for accidents.

Inspectors wroteBased on record review and staff interviews the facility failed to complete a discharge summary and recapitulation of stay for 1 of 1 resident reviewed for hospitalization (Resident #74).

Inspectors wroteBased on record review and resident, staff, dialysis nurse and physician interviews the facility failed to ensure a resident receiving dialysis had a physician's order for dialysis and failed to communicate with the dialysis provider to determine whether the implementation of a fluid restriction was required. This was for 1 of 1 resident (Resident #33) reviewed for dialysis.

Inspectors wroteBased on observation, resident and staff interviews the facility failed to maintain and repair holes in the wall for 1 of 1 resident room (room [ROOM NUMBER]), maintain the walls around the Packaged Terminal Air Conditioner (PTAC) units (a commercial grade air conditioner that is installed directly through a wall) for 2 of 5 resident rooms (rooms [ROOM NUMBERS]), failed to maintain room temperatures within regulatory requirements for 1 of 1 resident room (room [ROOM NUMBER]), and the facility also failed to repair flooring with exposed concrete at the central nursing station. This was for 3 of 3 resident rooms reviewed for a safe, clean, homelike environment.