Catered Manor Care Center

In the surveyor’s words

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

• Immediate jeopardy, widespreadF678Aug 6, 2023

  Based on interview and record review, the facility failed to: 1. Ensure Certified Nursing Assistant (CNA 4) immediately initiated Resident 1's cardiopulmonary resuscitation [(CPR) an emergency procedure that can help save a person's life if their breathing or heart stops] when Resident 1 was found unresponsive, with no pulse (no heartbeat), and not breathing on [DATE] at 7:50 a.m. Resident 1 was Covid-19 (a highly contagious infectious disease that can affect various systems of the body) positive and was on isolation (separation of an infected resident to prevent further infection transmission). 2. […]

• Immediate jeopardy, patternF580Aug 30, 2021

  Based on interview and record review, the facility failed to notify a physician of a resident's refusal for respiratory care treatments and episodes of hyperventilation (rapid breathing) for one of three sampled residents (Resident 1). Resident 1, who had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice resulted in a delay of provision of care and an unexpected decline of Resident 1's health. Resident 1 had acute [CONDITION(S)] (deficiency of oxygen levels in the blood) resulting in hypercapnia (high concentration of [MEDICATION(S)] [a gas removed from the body through the lungs by exhalation] of the blood) requiring a transfer to a general acute care hospital (GACH) and died on [DATE]. […]

• Immediate jeopardy, patternF726Aug 30, 2021

  Based on interview, and record review the facility failed to ensure Registered Nurse (RN 1) and Licensed Vocational Nurses (LVNs 1, 2, and 3), were competent and knowledgeable on the use of a Bi-level Positive Airway Pressure ([[CONDITION(S)]] non-invasive ventilation machine that delivers oxygen to assist with breathing) and possessed skills for assessment for one of six sampled residents (Resident 1). Resident 1 complained to facility staff on numerous occasions of the ineffectiveness of the [CONDITION(S)] machine and the error message displayed on the [CONDITION(S)]. […]

• Immediate jeopardy, isolatedF698Dec 26, 2022

  Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) receiving hemodialysis [(HD) a treatment to filter wastes and water from the blood], received dialysis care and services by failing to: 1. Ensure Resident 1 received hemodialysis care, treatment, and services three times a week (every Tuesday, Thursday, and Saturday) from an off-site HD center as ordered by the physician and in accordance with the Hemodialysis Care Plan initiated on 7/22/2022. 2. Notify Resident 1 ' s physician of missed HD treatment and services on 12/13/2022, 12/14/2022 and 12/15/2022. The resident ' s last HD treatment was on 12/10/2022. 3. Ensure Resident 1 was transported to and from an off-site HD center. 4. […]

• Immediate jeopardy, isolatedF689Oct 26, 2021

  Based on observation, interviews and record review, the facility failed to ensure the resident, who had a wandering behavior, did not elope from the facility unnoticed and sustained a fall with abrasions to both knee while outside of the facility for one of four sampled residents (Resident 1). The facility failed to: 1. Ensure the facility's exit doors Wander Guard alarm system was in working condition to alert staff when Resident 1 attempted to elope. 2. Ensure Resident 1's care plan was followed to recognize unsafe conditions. 3. Develop a policy and procedure for maintaining a Wander Guard alarm system in working condition. As a result of this deficient practice Resident 1, eloped from the facility on 9/25/21 unnoticed, fell from a wheelchair, and sustained abrasions to both knees. […]