Carecore at Mary Scott

In the surveyor’s words

From the most serious findings on record at Carecore at Mary Scott, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 30, 2023

  Based on observations, medical record review, staff and resident interviews, police interview, review of the facility's quality assurance investigation, review of the facility ' s Self-Reported Incident (SRI), and review of facility policies, the facility failed to provide adequate supervision to prevent the elopement of two residents (#35 and #49), without staff knowledge, who were cognitively impaired. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injury, and/or death on [DATE] when Residents #35 and #49 eloped from the facility. Resident #49 was found by staff, a 45-minute waking distance from the facility near a four-lane city street the following day on [DATE]. […]

• Actual harm, isolatedF757Jul 21, 2022

  Based on medical record review, review of hospital documentation, observation, interviews with staff, Certified Nurse Practitioner (CNP) #250 and family, review of facility policy, and review of medication information from Medscape, the facility failed to ensure residents were free from unnecessary medications when the facility failed to adequately monitor Resident #21's blood glucose level before administering insulin. This resulted in Actual Harm when staff administered insulin to Resident #21 without monitoring the residents blood glucose levels and the resident was subsequently found unresponsive by staff and was admitted to a local hospital for [CONDITION(S)]. This affected one (#21) of five residents reviewed for unnecessary medications. […]

• Actual harm, isolatedF686Jun 7, 2022

  Based on record review, staff interview, review of policy, and review of guidelines from the National Pressure Injury Advisory Panel (NPIAP), the facility failed to implement interventions to prevent the development of pressure ulcers and failed to initiate prompt and timely treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . This resulted in actual harm when Resident #33, was admitted to the facility with out pressure sores and being assessed as a moderate risk for the development of pressure ulcers. The facility failed to implement pressure ulcer prevention measures, subsequently, Resident #33 developed an avoidable stage four pressure ulcer (full-thickness skin and tissue loss has occurred, with exposed fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. […]

• Actual harm, isolatedF697Jan 27, 2022

  Based on medical record review, review of hospital records, review of a radiology report, staff interview, and review of email correspondence, the facility failed to provide timely and effective pain management for Resident #75 following a fall. Actual harm occurred when Resident #75 was not provided effective pain relief for roughly 15 hours after experiencing a fall with fracture on 12/30/21 at 10:45 A.M. This affected one (Resident #75) of three residents reviewed for pain management. The facility census was 75. Findings Include: Review of the medical record for Resident #75 revealed an admitted [DATE] and a discharge date of [DATE]. […]

• No harm, potential for more than minimal, widespreadF761Jul 21, 2022

  Based on observation, staff interview and review of facility policy the facility failed to discard expired medications. This affected one (first floor) of two medication rooms observed during the survey and had the potential to affect all residents residing in the facility. The facility failed to ensure medication were labeled, dated and stored appropriately in the medication carts. This affected one (200 hall) of two medication carts reviewed. Facility census was 66. Findings include: Observation and interview on 07/12/22 at 12:22 P.M. of the emergency medications stored in the first floor medication storage room revealed there were greater then 50 different expired medications. The dates varied from 03/15/22 to 07/05/22. […]