Carlton at the Lake, The

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Oct 4, 2023

  Based on interview and record review, the facility failed to ensure a resident was free from Sexual Abuse for 1 (R2) of 4 residents reviewed for abuse. This failure resulted in R2 who is cognitively impaired being found in R11's room naked from the waist down, requiring hospital evaluation and R2's laboratory result from the hospital affirming male DNA (Deoxyribonucleic Acid) was found in the vaginal specimen. This was identified as an Immediate Jeopardy situation which began on 11/19/2022. On 09/28/2023 at 12:56 PM, the administrator was notified of the Immediate Jeopardy. The Immediate Jeopardy Plan was removed on 10/02/2023 at 10:23 AM. However, the deficiency remains at the second level until the facility determines the effectiveness of the implementation of the removal plan. […]

• Actual harm, isolatedF689May 2, 2025

  Based on observation, record review, and interviews, the facility failed to ensure and include medical diagnosis and medication regimen in providing preventive interventions to prevent falls/accidents, failed to utilize fall assessment in providing effective fall interventions in the fall care plan, and failed to identify and address the resident's hypotensive state after the fall to prevent recurrence of similar accidents. These failures affected 1 resident (R2) out of 3 residents reviewed for the right of every resident to be free from injury resulted by accident. […]

• Actual harm, isolatedF692Mar 15, 2024

  Based on interviews and record reviews, the facility failed to a.) evaluate a high-risk resident's (R285) nutritional status within 14 days of admission; b.) implement a person-centered comprehensive care plan with nutritional interventions and goals addressing R285's nutritional risk factors; c.) follow their policy to obtain resident's weights monthly for 4 (R40, R49. R91, R106); d.) identify and address weight loss in a timely manner when significant changes occurred for 5 (R40, R49, R 91, R106, R285). These failures resulting in significant/severe weight loss for 4 (R40, R49, R106, R285) out of 4 residents reviewed for nutrition in a sample of 39. Findings include: 1. […]

• Actual harm, isolatedF689Jan 19, 2024

  Based on interview and review of records, facility failed to follow their policy to ensure appropriate interventions are in place to prevent falls for 1 of 3 (R9) residents reviewed for accidents and hazards. This failure resulted in R9 sustaining a subdural hematoma and being hospitalized . Findings include: On 01/17/2023 at 11:35 AM, R10 stated that she was R9's roommate. R10 stated that the first night (R9) moved into this room (R9) had fallen. That was on 11/13/2023. R10 stated that (R9's) wheelchair was by the window, (R9) said that she was trying to get into her wheelchair and (R9) slipped. R10 stated that (R9) was not sent out to the hospital. R10 stated that (R9) fell a week later trying to get into (R9's) chair. R10 stated that (R9's) falling woke (R10) up from sleep. […]

• Actual harm, isolatedF689Nov 2, 2023

  Based on interview and record review the facility failed to perform a two person assist for repositioning in bed for a dependent resident (R5), who was assessed as a two person assist for bed mobility. This failure resulted in R5 sustaining an acute, mildly displaced proximal left humeral fracture. Findings include: R5 has a diagnosis which includes but not limited to hypoxic ischemic encephalopathy, localized swelling mass, and lump left upper limb, osteomyelitis, colostomy, chronic respiratory failure with hypoxia, tracheostomy, dependence on respirator, flaccid neuropathic bladder, presence of urogenital implants, gastrostomy, dysphagia, type 2 diabetes. […]