Carlin Springs Health & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Carlin Springs Health & Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF686Jul 27, 2022

  Based on resident interview, staff interview, clinical record review and facility document review, the facility staff failed to assess and implement interventions and/or provide care and treatment for the prevention of pressure ulcers for two of 29 residents in the survey sample (Resident #100 and Resident #115). 1). Resident #100 was admitted to the facility on [DATE], with a brace to the left leg in place and a deep tissue injury to the left lower leg. The facility staff failed to remove the brace for 19 days, failed to assess, monitor, implement interventions and/or treat the resident's skin/deep tissue injury. […]

• Actual harm, isolatedF686Sep 15, 2021

  Based on staff interview, facility document review, clinical record review and complaint investigation, the facility staff failed to assess and implement interventions to prevent a pressure ulcer for one of twenty-one residents in the survey sample, Resident #8. Resident #8 developed a sacral pressure ulcer initially identified at an unstageable status with slough covering 30% of the wound. There was no prior assessment of impaired skin on the sacrum. A nurse with knowledge of redness on the sacrum, failed to document, report and obtain physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, patternF656Jul 27, 2026

  Based on staff interview, facility document review, and clinical record review, the facility staff failed to develop and/or implement the comprehensive care plan for three of 52 residents in the survey sample, Residents #9, #13, and #20.The findings include: 1. For Resident #9 (R9), the facility staff failed to monitor the resident for side effects (bleeding) from the anticoagulant (blood thinning) medication Eliquis. R9's comprehensive care plan dated 7/16/25 documented, ANTICOAGULANTS: the resident is at risk for bleeding and bruising related to use of an anticoagulant for diagnosis of Atrial Fibrillation (a heart condition). […]

• No harm, potential for more than minimal, patternF658Jul 27, 2026

  Based on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services to meet professional standards for four of 52 residents in the survey sample, Residents #154, #145, #173, and #13.The findings include: 1. For Resident #154 (R154), the facility staff failed to administer medications in a timely manner on multiple dates in December 2022. A review of R154's MAR (medication administration record) for December 2022 revealed that on the following dates/times. […]

• No harm, potential for more than minimal, patternF691Jul 27, 2022

  Based on clinical record review, staff interview, and resident interview, the facility failed for one of 14 residents in the survey sample (Resident # 105) to ensure the resident had physician's orders for the care of a colostomy. Resident # 105 had a colostomy for at least three years without orders for colostomy care. The findings were: Resident # 105 in the survey sample was admitted with diagnoses that included peripheral vascular disease, sleep apnea, diverticulitis, chronic pain syndrome, diabetes mellitus, idiopathic peripheral autonomic neuropathy, gastroesophageal reflux disease, anemia, hyperlipidemia, morbid obesity, osteoarthritis, atherosclerotic heart disease, hypertension, glaucoma, heart failure, depressive disorder, and colostomy status. […]