Caring Place, The

In the surveyor’s words

From the most serious findings on record at Caring Place, The, in the surveyor’s own words.

• Immediate jeopardy, patternF689Nov 12, 2021

  Based on observations, review of clinical records, facility documentation, and policy and procedures, and staff and resident interviews, it was determined that the facility failed to safely transfer a resident (Resident R30), putting that resident at risk for harm, and implement sufficient monitoring interventions and supervision to prevent elopement (unauthorized leave from a safe area) and failure to investigate multiple elopements for a resident (Resident R64). This failure placed residents at the facility in an Immediate Jeopardy situation for one of 10 residents reviewed who were identified as at risk for elopement (Resident R64). […]

• Actual harm, isolatedF600Jun 6, 2025

  Based on review of facility policy, facility documentation and clinical record, and staff interviews, it was determined that the facility failed to ensure that one of three residents reviewed (Resident R2) was free from neglect during care which resulted in actual harm of a left femur (upper leg) fracture. This deficiency is cited as past non-compliance. Findings include: A facility policy entitled, Abuse Prohibition dated 5/27/25, revealed that, Neglect is the failure to provide goods and services necessary to avoid physical harm, pain, mental anguish or emotional distress. […]

• Actual harm, isolatedF689Jun 6, 2025

  Based on review of facility documentation and clinical record, and staff interviews, it was determined that the facility failed to appropriately transfer a resident as identified in the plan of care for two of three residents reviewed (Residents R2 and R3), with one transfer which resulted in actual harm of a left femur (upper leg) fracture for one of three residents reviewed (Resident R2). This deficiency is cited as past non-compliance. Findings include: Resident R3's clinical record revealed an admission date of 3/20/25, with diagnoses that included respiratory failure, muscle weakness, abnormal gait and mobility, and need for personal care assistance. […]

• Actual harm, isolatedF600Nov 8, 2024

  Based on review of facility policies, facility documentation and review of clinical records, and staff interviews, it was determined that the facility failed to appropriately transfer a resident to ensure the resident was free from neglect which resulted in actual harm of a fracture of the right humeral head of the right shoulder for one of 13 residents reviewed (Resident R1). Findings include: The Mechanical Lifts and Slings policy, dated 2/05/24, revealed, Mechanical lift transfer status will be maintained indicating the use of a full mechanical lift or sit to stand mechanical lift. Transfer Status will also be documented in the Plan of Care. […]

• No harm, potential for more than minimal, patternF628Jul 2, 2026

  Based on review of facility policies, clinical records, and staff interview it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider upon transfer to the hospital and failed to provide the resident and/or resident representative with a written notice of the facility bed-hold policy (explanation of how long a bed can be held during a leave of absence and the cost per day), for five of six residents reviewed (Residents R2, R5, R43, R55, and R94).Findings include:Review of facility policy entitled Transfer/Discharge - Emergency dated 1/14/26, indicated Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the… […]