The Springs Healthcare Center at the Carlotta

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff were wearing the N95 Respirator (a tight fitting disposable mask that filters out at least 95% of airborne particles including virus') they were approved to wear during Fit Testing (testing that determines the exact make and model of the N95 mask to be worn) for two out of three staff. This failure had the potential for the spread of COVID-19 (A contagious virus spread through respirator droplets) to other residents and staff in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure STAT (immediately) urinalysis (UA) and urine culture and sensitivity (C&S-isolation of microbes and sensitivity to drugs for treatment) specimens were pick up by the laboratory (Lab) within the time frame of 4-6 hours, for one out of three residents (Resident 1). This failure could have resulted in a delay in laboratory values being reported to the residents physician and a delay in necessary treatment for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to provide a safe environment for one of three residents reviewed (Resident 1), when the resident left the facility unnoticed by facility staff. Later, an unknown visitor notified a staff member that Resident 1 left the facility Against Medical Advice (AMA). This failure resulted in Resident 1 not receiving information regarding the risks of leaving AMA which put Resident 1 at risk of possible worsening of her health condition while being outside of the facility setting, and resulted in the staff not knowing Resident 1 had left the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a sanitary environment, store, and prepare food in accordance with professional standards for food service safety when: 1. Multiple large plastic pans stacked in the storage rack were wet; and 2. Four containers of five pounds (lbs - a unit of measurement) low fat cottage cheese were stored in the refrigerator beyond the use-by-date. These failures had the potential to result in cross contamination (bacteria were unintentionally tranferred from one substance or object to another with harmfull effect) and foodborne illnesses (illnesses that result from ingesting contaminated food) for 40 of 40 medically compromised residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly when one re-cycle dumpster lid was widely open, bags of trash were piled and was overflowing one trash container causing the lid not to close, and multiple debris and trash were on the ground. This failure had the potential to attract pests and rodents that can be a source of communicable diseases.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented for four of 40 residents reviewed (Residents 17, 92, 11 and 195), when: 1a. For Resident 17, on Enhanced Barrier Precaution (EBP - an infection control precaution using the Protective Personal Equipment (PPE) such as gown and gloves during high contact resident care activities) the Physical Therapist (PT- healthcare professional who helps individuals improve their movement and functions through various therapies) did not wear the proper PPE when transferring Resident 17 from the wheelchair to the bed; 1b. For Resident 92, on EBP, the Certified Nursing Assistant (CNA) did not wear proper PPE when providing care and changing bed linens; 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two of five sampled residents (Residents 11 and 143) were free from unnecessary psychotropic (drug that affects brain activities associated with the mental processes and behavior) medications when: - For Residents 11 and 143, there was no documented evidence the non-pharmacological interventions (NPI, non-drug alternatives) were attempted, including any trial or evaluation of behavioral, environmental, or person-centered approaches, prior to the initiation of psychotropic medications. Furthermore, there was no documentation indicating non-pharmacological interventions were being implemented and monitored in conjunction with the ongoing, daily administration of psychotropic medications; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the accurate administration of medication in accordance with the physician's order, when a tablet of enteric coated (EC, protective coating designed to dissolve in the small intestine rather than the stomach) aspirin (used to lowers the risk of a heart attack, stroke, or blood clot) was administered to Resident 291 in place of the prescribed order for a chewable aspirin. This failure had the potential for Resident 291 to experience delayed absorption (the time it takes for a medication to be absorbed into the body) and delayed onset (the time it takes for a medication to start working) of aspirin's effect, as enteric coated aspirin is designed to dissolve slowly in the small intestine, whereas chewable aspirin is absorbed more quickly in the stomach.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were properly stored and disposed in accordance with the facility's policies and procedures, when a total of three expired medications were found stored in the Medication Refrigerator, the Medication Room, and Medication Cart 1. These failures had the potential to result in the administration of less effective, expired medications, medication errors and compromised treatment outcomes for residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that high blood sugar level readings above 401 mg/dl (unit of measurement) were reported to the physician in a timely manner as ordered, for one resident reviewed (Resident 1). This failure had potential for delays of treatment for Resident 1 ' s high blood sugar level.

Inspectors wroteBased on interview and record review, the facility failed to provide treatment and services consistent with the professional standards of practice, to prevent progression of pressure injuries (PI-damage to the skin and underlying tissue due to prolonged pressure) for two of three sampled residents (Residents 1 and 2) when: 1. For Resident 2, a consistent weekly skin assessment was not completed to evaluate the changes in the resident's redness to the coccyx identified on admission. In addition, the facility failed to initiate treatment for Resident 2's redness to the coccyx upon admission. These failures resulted in Resident 2's coccyx (tailbone) redness to worsen into a Stage 3 pressure injury (full thickness tissue loss). 2. [...]

Inspectors wroteBased on interview, and record review, the facility failed to develop a care plan to address two of three sampled residents (Residents 1 and 2) episodes of diarrhea. This failure had the potential for facility staff, residents, and family members to be unaware of treatment and services to be provided to Residents 1 and 2's medical condition.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure appropriate infection control practices were implemented for one resident in room [ROOM NUMBER] on isolation precautions. This failure had the potential to result in the spread of infection and cross-contamination that could affect other residents in the facility, visitors, and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a care plan was developed and implemented for two of three residents reviewed (Residents 142 and 143) when: 1. For Resident 142, a pacemaker (a small device used to control irregular heart beats) was identified on admission and there was no care plan that included the pacemaker information - the manufacturer, type of pacemaker, model and serial number, and the date the pacemaker was implanted. This failure had the potential to place Resident 142 at risk for not receiving immediate care and services in the event of pacemaker malfunction; and 2. For Resident 143, multiple bruising of the upper extremities, left hand bruising, and abrasion of the left knee were identified upon admission, and multiple skin tears identified after admission. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the care plan was updated and revised when the resident's indwelling urinary catheter (a devise inserted into the bladder held in place by a water-filled balloon which prevents it from falling) was pulled out for one of four residents reviewed (Resident 143). This failure had the potential to place Resident 143 at risk for further trauma when measurable goals and interventions were not formulated to prevent Resident 143 from pulling his indwelling urinary catheter.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a skin assessment was completed and documented for one resident reviewed (Resident 11). This failure had a potential for a delay of treatment for Resident 11's left shoulder wound.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure medications and biologicals were properly stored and disposed when an expired COVID-19 test (a test used to detect COVID-19 - an infectious disease), was found inside a medication cart, readily available for use. This failure had the potential for the residents to be administered an expired COVID-19 test and could result in an inaccurate test result.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the cook followed the directions for preparing egg salad pureed diet for lunch on April 30, 2024. This failure had the potential to compromise the nutritional status for one resident (Resident 20) reviewed for pureed diet.

Inspectors wroteBased on observation, interview, and record review the facility failed to reposition one of three sampled residents (Resident 2) every 2 hours per facility policy and procedure. This failure had the potential to result in Resident 2 ' s resolved pressure injury to reoccur.

Inspectors wroteBased on interview and record review, the facility did not maintain medical records that were complete and accurate for one of three sampled residents (Resident 1). This failure had the potential to lead to important clinical information not being properly communicated for Resident 1 with the potential for negative clinical outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary services as ordered by the physician, for one resident reviewed for activities of daily living (Resident 7), when it did not evaluate and treat Resident 7 for Physical Therapy (PT) and Occupational Therapy (OT). This failure had the potential to result in Resident 7's difficulty in attaining and maintaining her highest practicable level of physical, mental, functional, and psycho-social well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to remove expired Intravenous (IV)-(injection of a medication into a vein and directly into a bloodstream) supplies from the IV cart. This failure had the potential for the staff to use expired IV supplies on residents requiring IV therapy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food storage, and cleanliness of the kitchen were in accordance with professional standards for food service safety when: 1. One Ziploc plastic bag containing approximately one and a half pound of tater tots was not dated to show when it has to be discarded or used by; and 2. Six ventilator fans in the kitchen were covered with black debris. These failures had the potential to result in cross contamination and food borne illness in a medically vulnerable population of 26 residents who consumed food from the kitchen.