Castle Manor Nursing & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Castle Manor Nursing & Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF684Mar 5, 2025

  Based on interview and record review, the facility failed to ensure licensed nurse (LN) 1 performed a complete assessment (a process that evaluates a resident's health by gathering and analyzing information) and notified the physician for one of three residents (Resident 1), when Resident 1 experienced a sudden decrease in oxygen level and blood pressure. As a result, Resident 1 was found with cold, pale skin and without pulse approximately four hours after the decreased blood pressure (Measurement of the force exerted by blood against the walls of the arteries as the heart pumps) and oxygen level was first identified. […]

• No harm, potential for more than minimal, patternF578Mar 27, 2025

  Based on observation, interview, and record review the facility failed to ensure four of twenty-one sampled residents (12,17, 231, 233) had Advanced Directives or documented discussions with Social Services Director (SSD) about Advance Directives. This failure had the potential to prevent residents from making their own decisions in the case of emergency treatment. Cross Reference: F867 Findings: 1. Review of Resident 12's (R12) Admission Record dated 3/26/25 indicated R12 was admitted for diagnoses which included: Acute Respiratory Failure(a life-threatening condition where the lungs are unable to adequately exchange oxygen and carbon dioxide), Asthma(a chronic lung disease), Congestive Heart Failure(a chronic condition where the heart muscle is weakened and cannot pump blood… […]

• No harm, potential for more than minimal, patternF867Mar 27, 2025

  Based on interview and record review the facility's Quality Assessment and Assurance Committee (QAA-facility group that monitors concerning trends in a facility) failed to identify and include in the facility's Quality Assurance Performance Improvement plan (QAPI-plan developed by QAA to help improve conditions in the facility), trends found by surveyors during the recertification survey concerning Advance Directives (a legal document that allows you to make decisions about your future medical care). This failure had the potential for the facility to overlook trends in resident care that might have affected residents' dignity and/or health. […]

• No harm, potential for more than minimal, patternF684Mar 2, 2023

  Based on observation, interview, and record review, the facility failed to consistently provide wound care as ordered by the physician for four of six residents, (Residents 2, 13, 26, 226), reviewed for skin integrity. As a results, residents were at risk for wound deterioration and delayed healing. Findings: 1. Resident 2 was admitted to the facility on [DATE], with diagnoses which included cerebral infarction (stroke) and need for assistance with personal care, per the facility's Admission Record. On 2/27/23 at 9:56 A.M., an observation was conducted outside Resident 2's room. Outside of the room, signage indicated contact precautions were required, and a cart containing PPE (personal protective equipment, medical supplies to maintain infection control) was present. […]

• No harm, potential for more than minimal, isolatedF583Mar 27, 2025

  Based on observation, interview and record review, the facility failed to ensure confidential information was kept private for one of 4 sampled residents (181) when Licensed Nurse (LN) 11 left Resident 181's bubble wrap medications (unit dose packaging organizing medications into individual doses) unattended. As a result, Resident 181's right to privacy and confidentiality was violated. Findings: Resident 181 was admitted to the facility on [DATE] with diagnoses which included fracture (complete or partial brake in a bone) of superior rim of right pubis (upper edge of right pubic bone) per the facility's Admission Record. On 3/26/25 at 10:32 A.M., an observation of LN 11, during medication administration in room [ROOM NUMBER] A was conducted. […]