Carondelet Village Care Center

In the surveyor’s words

From the most serious findings on record at Carondelet Village Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Feb 11, 2025

  Based on interview and document review, the facility failed to respect resident wishes for 1 of 3 residents (R1) reviewed for resuscitation status, resulting in receiving cardiac pulmonary resuscitation (CPR) against her wishes established in her Provider Orders for Life Sustaining Treatment (POLST). The IJ began on [DATE] when R1 was found unresponsive in her room and staff performed CPR based on an outdated POLST that was not corrected in R1's electronic medical record (EMR). R1's current POLST on [DATE] indicated DNR/DNI. The IJ was identified on [DATE]. The administrator, the director of nursing, and the regional clinical director were notified on [DATE] at 1:30 p.m. […]

• Immediate jeopardy, isolatedF689Apr 7, 2023

  Based on observation, interview, and document review the facility failed to ensure manufacturer recommendations were followed for a mechanical lift transfers and failed to a comprehensive assessment residents safety when using a mechanical lift. This resulted in immediate jeopardy (IJ) when one sling loop detached resulting in head injury, broken neck, and death. In addition the facility failed to comprehensively assess for sling style and size to ensure safe transfers for 1 of 8 residents (R2) that used a full body mechanical lift. The IJ began on [DATE], at approximately 4:45 p.m. when R1 fell from a mechanical lift when two aides did not follow the care plan and facility policy resulting in R1's death. […]

• Immediate jeopardy, isolatedF689Jul 6, 2022

  Based on interview and document review, the facility failed to use the appropriately sized mechanical lift sling for 1 of 3 residents (R1) reviewed for falls. This resulted in an immediate jeopardy (IJ) when R1 was not properly assess for the use of a mechanical lift and appropriate sling size. R1 fell during a mechanical lift transfer resulting in a subarachnoid hemorrhage, and a closed displace pelvis fracture. The IJ began on 6/25/22, at 4:25 p.m. when facility staff utilized improper sized mechanical lift sling. R1 fell , after being suspended in the air, and hit their head resulting in a subarachnoid hemorrhage, and a closed displace pelvis fracture. The campus administrator and director of nursing (DON) were notified of the IJ on 7/6/22, at 5:30 p.m. […]

• No harm, potential for more than minimal, widespreadF812Oct 17, 2024

  Based on observation, interview and document review, the facility failed to ensure ice packs were stored separately from food storage in all three of the unit kitchenette refrigerators. In addition, the facility failed to ensure the proper use of hair restraints during food service. These practices had the potential to affect all 45 residents residing in the care center who received food from the kitchen or snacks from the unit refrigerators/freezers. Findings include: Ice packs During observation on 10/15/24 at 9:55 a.m., freezer in kitchenette of neighborhood one contained two boxed frozen meals, one tub of ice cream, three ice cream bars and one ice cream cone. […]

• No harm, potential for more than minimal, widespreadF812Dec 15, 2022

  Based on observation, interview, and document review the facility failed to ensure foods were labeled and dated, stored off the floor, and foods past the best by or use by dates were discarded. This had the potential to affect all 42 residents who consumed food from the kitchen. Findings include: During the initial kitchen tour with the culinary director (CD) on 12/12/22, at 11:54 a.m. the CD stated food was prepared in the main kitchen and was sent downstairs in hot carts and served in steam wells. The following was observed during tour of the main kitchen: -Uncovered and unlabeled cheese in the cooler. The CD confirmed this should not be used. -A frozen bag of carrots with a best by date of 9/24. […]