Carrara

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Apr 5, 2024

  Based on observations, record reviews and interviews, the facility failed to ensure the resident environment remains as free of accident hazards as is possible and that residents received adequate supervision to prevent accidents for one (Resident #79) resident of three residents reviewed for elopement. RN A on 07/30/23 failed to report to the Administrator (at that time), the DON (at the time) or communicate to oncoming nursing staff when Resident #79 became agitated and stated he was going to leave the facility. On 08/02/23 Resident #79 became agitated and frustrated and told LVN B he was leaving the facility. LVN B redirected him and did not provide adequate supervision to prevent him from eloping from the facility on 08/02/23. […]

• Actual harm, isolatedF684Jul 20, 2023

  Based on observation, interview and record review failed to ensure resident receive treatment and care in accordance with professional standards of practice, based on the comprehensive assessment of a resident, the comprehensive person-centered care plan, and the resident's choices for one (Resident #1) of 5 residents reviewed for quality of care. The facility failed to follow-up with Resident #1's hospital referral for the orthopedic doctor and provide treatment to promote healing of a right should fracture according to professional standards of practice and resident's choice for treatment from 06/08/2023-07/15/2023. […]

• Actual harm, isolatedF689Jul 20, 2023

  47229 Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices and the resident environment remains as free of accident hazards as is possible for one (Resident #1) of 5 residents reviewed for accidents and hazards. The facility failed to ensure residents' environment remained free from accident hazards as is possible by removing water slipping hazard from floor near ice dispensing machine or preventing residents access to the area resulting in Resident #1 slipping and falling in the nutrition room causing the resident to sustain a fracture and pain to her right shoulder. […]

• Actual harm, isolatedF744Dec 28, 2022

  Based on interview and record review, the facility failed to ensure a resident who displayed or was diagnosed with dementia received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental and psychosocial well-being, for 1 of 3 Residents (Resident #3) reviewed for treatment and services, in that: 1. PTA Z held Resident #3 's wrist while the resident was displaying combative behaviors on 12/19/22. 2. On 12/22/22 Resident #3 was discharged into the hospital with multiple bruises on the wrist, left shoulder, right upper arm, knees, lower legs, and hands with handprints noted. […]

• No harm, potential for more than minimal, patternF812May 1, 2025

  Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety. 1. The facility failed on 05/01/2025 to ensure dented cans dated 04/28/2025 was placed in a separate storage area to keep from being used for residents' meals. These failures could place residents at risk for food-borne illness and cross contamination. Findings included: Observation of dry storage on 4/29/2025 at 9:22am revealed the following: two 6lbs 9oz cans of marinara sauce dated 4/28/2025 was dented on the front. […]