Carington Park

In the surveyor’s words

From the most serious findings on record at Carington Park, in the surveyor’s own words.

• Actual harm, isolatedF760May 19, 2025

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, medical record review, hospital record review, facility policy review, medication manufacturer guideline review and interview, the facility failed to ensure Resident #94 was free of a significant medication error. Actual Harm occurred beginning on 12/12/24 when Resident #94, who had a diagnosis of schizoaffective disorder, returned from the hospital with orders to continue the medication, Perphenazine, an anti-psychotic; however, Registered Nurse (RN) #604 and Licensed Practical Nurse (LPN) #601 failed to transcribe the order, or notify Resident #94's guardian and/or Psychiatrist #608 of the medication not being continued. […]

• No harm, potential for more than minimal, patternF689Feb 29, 2024

  Based on observation, interview, record review, and policy review the facility failed to administer medications that followed appropriate nursing standards of care and left medications unsecured at Resident #60's bedside. This affected one resident (#60) and had the potential to affect 90 residents (#1, #3, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #17, #18, #19, #20, #22, #25, #26, #27, #28, #29, #30, #32, #33, #34, #35, #36, #37, #38, #41, #42, #43, #45, #47, #48, #49, #51, #53, #54, #55, #57, #59, #60, #61, #62, #63, #64, #66, #69, #70, #71, #76, #78, #79, #82, #83, #84, #85, #86, #89, #91, #93, #97, #109, #110, #113, #114, #115, #116, #117, #118, #120, #122, #123, #125, #127, #129, #130, #132, #137, #139, #140, #142, #145, #147, #301, #351, #401, #402) who were independently mobile… […]

• No harm, potential for more than minimal, isolatedF659Aug 6, 2026

  Based on record review, interview, observation, and review of the Certified Nursing Assistant job and nursing job descriptions, the facility failed to ensure qualified staff administered enteral feedings in accordance with Resident #10's care plan. This affected one (Resident #10) out of two residents reviewed for tube feeding. The facility census was 149. Findings include:Review of the medical record for Resident #10 revealed an admission date of 08/15/22. Diagnoses included chronic obstructive pulmonary disease, type II diabetes, dysphagia, hypertension, bilateral hypertensive retinopathy, peripheral vascular disease, anxiety, major depressive disorder, and paranoid schizophrenia. […]

• No harm, potential for more than minimal, isolatedF580May 19, 2025

  Based on review of the medical record, hospital discharge summary review, interview, observation and facility policy review, the facility failed to ensure Resident #94's guardian and Psychiatrist #608 was notified regarding Resident #94's Perphenazine (anti-psychotic) medication being discontinued. This affected one resident (#94) of three residents reviewed for notification of changes. The facility census was 150. Findings include: Review of the medical record for Resident #94 revealed an admitted [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), diabetes, hypertension, and schizoaffective disorder. […]

• No harm, potential for more than minimal, isolatedF641May 11, 2023

  Based on interview and record review the facility failed to ensure accuracy of assessments when the behavior section did not accurately reflect the status of Residents #88, #159 and #161. This affected three residents (#88, #159 and #161) of four residents reviewed for behaviors. Findings include: 1. Record review revealed Resident #88 was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance, depression, and insomnia. Review of the behavior documentation report for April 2023 revealed Resident #88 demonstrated pacing/wandering on 04/15/23 and 04/21/23 and screaming on 04/17/23 and 04/19/23. […]