Carbondale Rehabilitation and Healthcare Center

In the surveyor’s words

From the most serious findings on record at Carbondale Rehabilitation and Healthcare Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Jul 14, 2023

  Based on observation, review of select facility policy and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the food and nutrition services department and two resident pantries. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. […]

• No harm, potential for more than minimal, patternF607Jul 12, 2024

  Based on a review of the facility's abuse prohibition policy and employee personnel files and staff interviews, it was determined that the facility failed to fully develop and implement established abuse prohibition procedures for screening five of five employees for employment (Employee 1, 2, 3,4 and 5) Findings include: According to regulatory requirements under SS483.12(a)(3) and 483.12(b)(1)] the facility must have written procedures for screening for prospective employees, to include reviewing: the employment history (e.g., dates of employment position or title), particularly where there is a pattern of inconsistency; information from former employers, whether favorable or unfavorable; and/or documentation of status and any disciplinary actions from licensing or registration boards… […]

• No harm, potential for more than minimal, patternF758Jul 12, 2024

  Based on a review of clinical records and staff interviews it was determined that the facility failed to ensure the presence of current documented clinical necessity of a resident's continued use of an psychotropic medication prescribed on an as needed basis for one resident out of five sampled (Resident 65). Findings included: A review of the clinical record revealed that Resident 65 had diagnoses of Parkinsons disease (a progressive neurological disease), dementia, and a history of falling. […]

• No harm, potential for more than minimal, patternF865Jul 12, 2024

  Based on review of select facility policy, clinical records, and incident reports and staff interviews, it was determined that the facility failed to demonstrate the implementation of ongoing QAPI programs, to include the use of systems for investigating and analyzing the root cause of adverse events, as evidenced by multiple falls incurred by one resident out of 18 sampled (Resident 65). Findings include: Review of the facility policy entitled Quality assessment and improvement plan last reviewed by the facility January 9, 2024 revealed that the facility is committed to incorporating the principles of Quality Assurance and performance Improvement (QAPI) into all aspects of the center work processes, services lines and departments. […]

• No harm, potential for more than minimal, patternF552Jul 14, 2023

  Based on clinical record review and resident and staff interviews, it was determined that the facility failed to afford a resident the ability to participate in his treatment, be fully informed of treatment decisions and proposed and to chose preferred treatment options for one resident out of 18 sampled (Resident 14). The findings include: Review of the clinical record revealed that Resident 14 was admitted to the facility on [DATE], with diagnoses to include Schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions), dementia (a group of thinking and social symptoms that interfere with daily functioning), and chronic hip pain. […]