Carlton Shores Healthcare and Rehabilitation Cente

In the surveyor’s words

From the most serious findings on record at Carlton Shores Healthcare and Rehabilitation Cente, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF908Apr 4, 2024

  Based on observations, interviews, and record review, the facility failed to ensure that all essential equipment in the kitchen was maintained in safe operating condition. The facility's dish machine did not reach 120 degrees F during the rinse cycle, the walk-in freezer had a large accumulation of ice on the floor, on storage racks, and on food boxes, the kitchen ice machine was not working, and the freezer fan was not running. The findings include: On 4/01/2024 at 12:51 pm, Dietary Aide C was asked to test the dish machine. She stated she was not really good at it. She stated Dietary Aide B usually performed this task. She then turned the dish machine on. At this time, none of the temperature gauges moved. She stated most of the time they tested the machine after lunch. […]

• No harm, potential for more than minimal, isolatedF684Apr 28, 2022

  Based on observations, interviews and record reviews, the facility failed to provide treatment and care in accordance with professional standards of practice and the resident's choices, by failing to provide one (Resident #56) of one resident admitted to the facility with the need for hemodialysis (HD) with a meal prior to [CONDITION(S)] and/or a meal/snack to take with him to the [CONDITION(S)] center onm his [CONDITION(S)] days. The findings include: A review of Resident #56's medical record revealed an admission on 11/19/2021 and a documented readmission on 2/23/2022. Resident #56's medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/23/2022, a Mini Nutritional Assessment resulted in a score of 10, indicating At risk for Malnutrition. […]

• No harm, potential for more than minimal, isolatedF759Apr 28, 2022

  Based on observation, interviews with staff, and reviews of the facility's Medication Destruction Policy and the Omnicare Med Pass Checklist, the facility failed to ensure its medication error rate was not 5% or greater (rate 6.67%) for two (Residents in rooms 110B and 304) of seven residents observed during medication administration. The findings include: A medication administration observation was conducted with Registered Nurse (RN) K on 4/26/22 at 4:00 p.m. for the resident in room [ROOM NUMBER] B. RN K reviewed the Medication Administration Record (MAR) and pulled [MEDICATION(S)] 10 milligrams (mg) for blood pressure and [MEDICATION(S)] 10-325 mg for pain from the medication cart. […]

• No harm, potential for more than minimal, isolatedF761Apr 28, 2022

  Based on observations, interviews and document review, the facility failed to ensure the appropriate labeling/storage of medications for four (Residents #48, #55, #77 and #206) of seven residents sampled. Pre-pouring medication placed each resident at risk for a medication administration error by risk of provided the incorrect medications. The findings include: On 4/27/2022 at 5:11 AM, an observation was made of Licensed Practical Nurse (LPN) A's medication cart. Three unlabeled medication cups were observed with an assortment of tablets of different shapes, sizes and colors inside. An interview was conducted with LPN A at the time of observation and she stated the medications were pulled for Residents #48, #55, #77 and #206. […]

• No harm, potential for more than minimal, isolatedF849Apr 28, 2022

  Based on record reviews, interviews, and a review of the hospice agency contract, the facility failed to maintain a hospice plan of care, hospice visits and documentation of care in the resident record for one (Resident #75) of four residents reviewed for hospice services/coordination of care, from a total sample of 43 residents. The findings include: An interview was conducted with Resident #75's daughter on 4/25/22 at 12:41 p.m. She reported her mother was receiving hospice care and the caregiver came to visit on Mondays, Wednesdays, and Fridays, but was not bathing the resident if she was already dressed. A call had been placed to the hospice agency and they were notified of the concern. Resident #75 was lying in bed covered up with blankets and had mats on the floor beside her bed. […]