Carlyle Place

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, and review of the facility policy titled Food Safety Management System, the facility failed to ensure items stored in the cooler were labeled, dated, and not beyond their expiration date. The facility also failed to ensure that items in the dry storage area were labeled and dated. In addition, the facility failed to ensure that food was held at a safe temperature until served, measured before serving to ensure appropriate serving sizes, and that staff ensured hairnets covered all hair. This deficient practice had the potential to adversely affect 31 of 31 residents receiving an oral diet. Findings include:Review of the facility policy titled Food Safety Management System, revision date of 5/31/2025, included: C-24 Hot and Cold HoldingHot foods must be held and served at a temperature of 140 degrees F or above. C-26 Date Marking Ready to Eat TCS FoodsRefrigerated, ready to eat, TCS food prepared and held in a food establishment for more than 24 hours must be clearly marked…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff and resident interviews, and record review, the facility failed to assess one out of 30 sampled residents (R) (R6) to determine if it was clinically appropriate to safely self-administer medications. This failure had the potential to place R6 at risk for adverse consequences.Findings include:Review of the Electronic Medical Record (EMR) revealed R6 was admitted to the facility with diagnoses that included, but were not limited to, surgical wound to left hip, s/p (status post) left femoral fracture with repair, melanoma removal to right forehead, and cataract surgery to both eyes.Review of the admission Minimum Data Set (MDS), dated [DATE], for R6 revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of 10 (indicating moderate cognitive impairment). Section M (Skin Conditions) revealed a box checked yes for the use of applications of ointments/medications other than to the feet. Review of physician's orders dated 9/3/2025 for R6 revealed, apply…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interviews, and review of facility policy titled, C-26 Marking Ready to Eat TCS/PHF Foods the facility failed to remove ice build-up on top of food items to prevent contamination in the walk-in freezer; failed to ensure dietary staff label and date opened food items; and failed to ensure no wet nesting with stacks of steam table pans to prevent bacteria growth. The facility census was 32 residents, and all residents were consuming an oral diet. Findings include: 1. Observation on 8/23/2024 at 8:40 am of the walk-in freezer revealed the fan housing to the air condenser was covered with a layer of ice and frost. Icicles were formed on the pipes at the back of the air condenser. Continued observation revealed a case of frozen peaches on the food storage shelf under the right side of the air condenser. The top of the peaches had a layer of ice as well as a mound ice that was three inches in height and three inches in diameter. Further observation revealed a white plastic type pan covered with clear plastic labeled diced mango to the left of the case of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and review of the facility's policy titled, Oxygen Concentrator-Work Instruction-[Facility Name], the facility failed to ensure humidification was provided for one of six residents (R) (R11) receiving oxygen (O2) therapy. The deficient practice had the potential to place the resident at risk for medical complications, unmet needs and a diminished quality of life. Findings Include: Review of the facility's policy titled Oxygen Concentrator-Work Instruction-[Facility Name] dated 10/27/2023 under the section titled Purpose revealed, To establish responsibilities for the care and use of oxygen concentrators. Under the section titled Explanation and Compliance Guidelines revealed, 4. (e) Fill the humidifier container to the correct level with distilled water and attach to concentrator or use a disposable humidifier. 5.(c) Nurse responsibilities: (ii) Change humidifier bottle when empty, every seventy-two hours, or as recommended by the manufacturer. Review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and review of facility policies titled, Food Safety Product Labeling and Dating and Cleaning and Sanitizing Frequency, the facility failed ensure food items were properly dated and labeled, the facility also failed to ensure that kitchen equipment was clean and sanitary. The deficient practice had the potential to affect 28 residents receiving an oral diet. Findings include: Review of facility policy titled, Food Safety Product Labeling and Dating dated 4/1/2022 revealed Refrigerated, ready to eat, TCS/PHF food prepared and held in a food establishment must be clearly marked with a consume by/discard date. Refrigerated, ready to eat, TCS/PHF food prepared and packaged by a food processing plant shall be clearly marked at the time the original container is opened. Review of the facility policy titled, Cleaning and Sanitizing Frequency dated 4/1/2022 revealed Non-food contact surfaces must be cleaned at a frequency necessary to preclude the accumulation of soil residues.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility failed to ensure that a comprehensive plan of care was developed for two of three residents (R) (R# 26 and R#86). Specifically, the facility failed to develop a plan of care for R#26 that addressed his Suprapubic Catheter care needs, the facility also failed to develop a plan of care that addressed the behavioral needs of R#86. Findings include: Record review for R#26 revealed resident was admitted to the facility with the diagnoses of Kidney Failure, Alzheimer's disease, Type 2 Diabetes, hyperlipidemia, abnormalities of gait, Dementia, Psychophysiological insomnia, slow Transit constipation, Benign prostatic hyperplasia with lower urinary tract symptom, retention of urine. Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] Section C (Cognitive Patterns) revealed a Brief Interview for Mental Status (BIMS) score of three (3) indicating resident did have a cognitive impairment. Review of residents' plan of care did not address the care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview the facility failed to ensure that a Discharge Minimum Data Set (MDS) assessment was transmitted within 31 days of completion to CMS (Center for Medicare and Medicaid Services) of Quality Improvement evaluation system (QIES) Assessment Submission and Processing (ASAP) for one of three discharged residents (R) (R#28). Findings Include: Record review for R#28 revealed that an admission Assessment reference date (ARD) of 12/7/2022 was the last MDS transmitted for the resident. The resident was discharged from the facility on 12/22/2022, there was no completed and transmitted discharge assessment noted. Review of the Resident Assessment Instrument (RAI) guidelines revealed that discharge was defined as the date the resident left the facility. The RAI guidelines stated that there were two required discharge assessments, discharge- return anticipated, and discharge return not anticipated. Further review of the (RAI) guidelines further reveals that the discharge assessment must be submitted within a maximum of 31 days from the discharge date .…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and a review of the facility's policy titled, AHNCP Oxygen Concentrator, Nebulizer Therapy and CPAP/BIPAP Cleaning the facility failed to ensure oxygen equipment was properly stored while not in use and failed to have a current physicians order for oxygen administration for 3 of 10 residents (R) (#33, #22, #23) receiving treatment for respiratory care. Findings include: Review of policy titled AHNCP Oxygen Administration revised 10/25/2022, Explanation and Compliance Guidelines: 2. revealed oxygen is administered under the orders of the attending physician, except in the case of an emergency. 4. Use of Concentrator: a. The nurse shall verify the physician's orders for the rate of flow and route of administration of oxygen (mask, nasal cannula, etc.). L. Keep delivery devices covered in plastic bag when not in use. Review of policy titled Nebulizer Therapy revised 4/14/2022, Policy Explanation and Compliance Guidelines: 16. Disassemble and rinse the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interviews, record review, and review of the facility's policy titled, Medication Orders: Stop Orders, the facility failed to ensure a stop date was implemented, not to exceed 14 days for antipsychotic medications, for one of six residents (R) (R#7) reviewed for unnecessary medications. Specifically, the facility failed to implement a stop date for two antipsychotic medications ordered as needed (PRN) for R#7, increasing the potential for adverse consequences. Findings include: A review of the facility's undated policy, Medication Orders-Stop Orders, revealed that all as needed (PRN) antipsychotics will automatically be stopped in 14 days. Record review of the electronic medical record (EMR) for R#7 revealed the resident had a diagnosis including but not limited to secondary parkinsonism, Alzheimer's Disease with late onset, psychophysiological insomnia. Record review of the Physician orders for R#7 on April 29, 2023, at 3:32 p.m. revealed a medical doctor's (MD) order for haloperidol 1 milligram (mg) by mouth every six hours as needed for behavior changes/nausea. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.