Carleton-Willard Village Retirement & Nursing CTR

In the surveyor’s words

From the most serious findings on record at Carleton-Willard Village Retirement & Nursing CTR, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Jun 10, 2025

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who required two staff members assistance with the mechanical sling lift for all transfers, the Facility failed to ensure he/she was free from neglect, when on 06/03/25 Certified Nurse Aide (CNA) #1, although she was aware of facility policy and that Resident #1 required an assist of two staff persons for transfers with a mechanical sling lift, CNA #1 transferred Resident #1 by herself, and he/she fell from lift on to the floor. CNA #1 also did not immediately report the fall to nursing so Resident #1 could be assessed for potential injury prior to being moved, but instead physically picked Resident #1 up off the floor by herself and put him/her back into bed. […]

• Immediate jeopardy, isolatedF656Jun 10, 2025

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose comprehensive plan of care interventions indicated that he/she required the assistance of two staff members with the mechanical sling lift for all transfers, the Facility failed to ensure that staff consistently implemented and followed interventions related to transfers per his/her plan of care. On 06/03/25, Certified Nurse Aide (CNA) #1 attempted to transfer Resident #1 without the assistance from any other staff member, during the transfer the left upper clip on the mechanical sling lift became disconnected and Resident #1 fell to the floor. […]

• Immediate jeopardy, isolatedF689Jun 10, 2025

  Based on records reviewed and interviews for one of three sampled residents (Resident #1), who required two staff member assistance using the mechanical sling lift for all transfers, the Facility failed to ensure he/she was provided with the necessary level of staff assistance to maintain his/her safety and prevent an incident/accident resulting in significant injuries. On the morning of 06/03/25, Certified Nurse Aide (CNA) #1 attempted to transfer Resident #1 without another staff member present to assist her, and during the transfer the upper left clip of the sling unattached from the lift, and Resident #1 fell around four feet onto the floor. […]

• Actual harm, isolatedF656May 29, 2024

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed by nursing as being at high risk for falls, and whose comprehensive plan of care indicated he/she required the use of monitoring devices (bed and chair alarms) to alert staff when he/she attempted to stand or transfer alone, the Facility failed to ensure staff implemented and followed interventions identified in his/her plan of care, when alarms were not consistently used by staff, and he/she experienced two falls less than 24 hours apart, both of which resulted in an injury. […]

• Actual harm, isolatedF689May 29, 2024

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed by nursing as being at high risk for falls, had a fall on 5/08/24 with an injury, was known to be impulsive and whose fall risk interventions included the use of monitoring devices (bed and chair alarms) to alert staff when he/she rose from a sitting or lying position, the Facility failed to ensure he/she was provided with the necessary safety devices and level of staff supervision to maintain his/her safety, when on 05/09/24 Certified Nurse Aide #1 assisted Resident #1 to the toilet, removed his/her alarm and left him/her unattended in the bathroom to go get supplies. […]