Signature Healthcare of Carrollton Rehab & Wellnes

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, review of staff training records, and review of the website utilized by the facility for training staff, the facility failed to provide staff training specific to a resident's mental illness diagnoses and behaviors for 1 of 9 sampled residents, Resident (R)1. R1's diagnoses included Borderline Personality Disorder and Schizoaffective Disorder, and the resident exhibited behaviors. However, the facility failed to provide training for staff directly related to R1's mental illness and diagnoses. The findings include: Review of the facility policy titled, Abuse, Neglect and Misappropriation of Property, last revised and reviewed on 09/15/2023, revealed it was the organization's intention to prevent the occurrence of abuse. Review of the policy revealed the facility included training to provide for the protection of the health, welfare, and rights of each resident residing in the facility. Continued review revealed training provided included understanding behavioral symptoms 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 interview, record review, and review of the facility policy, the facility failed to ensure residents were free from verbal abuse for 1 of 9 sampled residents, Resident (R)1. On 08/28/2024, the Housekeeper cussed at and called R1 names after the resident was verbally aggressive towards the Housekeeper. The findings include: Review of the facility policy titled, Abuse, Neglect and Misappropriation of Property, last reviewed and revised 09/15/2023, revealed it was the organization's intention to prevent abuse and protect the health, welfare, and rights of each resident residing in the facility. Per review, instances of abuse, irrespective of any mental or physical condition, caused harm, pain, or mental anguish. Continued review revealed abuse included verbal abuse, which encompassed use of oral language with any threat, frightening, disparaging or derogatory language to residents or within their hearing distance, regardless of age, ability to comprehend, or disability. Review of the facility policy…

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 observation, interview, record review, and facility policy/procedure, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections for one (Resident (R) 51) of 49 sampled residents. Staff entered R51's room, which was designated as a contact precaution room, without first donning proper Personal Protective Equipment (PPE). The findings include: Review of the facility's policy, titled Infection Control, with an effective date of 01/23/2024, revealed the intention of the policy was to help prevent and manage the transmission of diseases and infections. Added review of the policy revealed the objectives were to establish guidelines for implementing Isolation Precautions, including Standard and Transmission-Based Precautions. Review of the facility's signage for contact precautions (procedure to be used) revealed providers and staff must put on gloves and gown before room entry and discard 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 interview, record review, review of facility policy, and review of a police Uniform Citation, the facility failed to ensure that one (Resident (R) 265) of 65 sampled residents was free from misappropriation of resident property. Licensed Practical Nurse (LPN) 10 took R265's narcotic pain medication without authorization. The findings include: Review of the facility policy titled Controlled Medications, dated 11/13/2023, revealed the policy was to ensure controlled medications are handled, stored, disposed of, and there is record keeping is in place. Added review revealed at each shift change or when keys are rendered, a physical inventory on all controlled medications is conducted by two staff members. Continued review of the guidelines included that a licensed nurse or medication technician with possession of the medication keys is to remain on the facility premises. Added review revealed if staff with the keys are leaving the premises, he or she is to surrender the keys and complete a physical inventory of all controlled substances. Review of R265's face sheet revealed…

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 observation, interview, record review, and facility policy review, it was determined the facility failed to provide sufficient nursing staff in order to implement supervision to ensure resident's safety for one (1) of thirty-seven (37) sampled residents (Resident #60). Resident #60 sustained a fall, on 02/04/2020 at 4:15 AM, when the facility-scheduled staff included one (1) nurse and one (1) aide for the North Unit Hall with a census of thirty-one (31) residents, who required care and supervision. The findings include: The facility did not provide a Staff or Staffing Policy upon request. Review of the facility's policy, Safety and Supervision of Resident, reviewed 05/31/18, revealed the facility ensured the safety and well-being of the resident with routine checks on residents. Routine checks involved staff to physical enter the resident's room to determine the residents' needs. The policy identified needs included the change of condition, sleep status, toileting assistance, and possible concerns identified by the resident. The facility addressed resident safety needs on…

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 interview, record review, and review of facility policy, it was determined the facility failed to ensure it honored a decision of care made by a resident's legal representative or Power of Attorney (POA) for one (1) of thirty-seven (37) sampled residents (Resident #46). Review of previous admissions to the facility for Resident #46, revealed the facility had documented the resident's legal representative. Interview revealed the resident's significant other had provided the facility with a copy of Resident #46's POA documentation. Record review and interviews revealed, on 01/24/2020, the POA notified the facility of Resident #46's need to use a respiratory mask which assisted with the resident's respiratory efforts at night. The POA made multiple requests to allow the use of the mask for the resident's respiratory care needs. However, the facility failed to honor the POA's request and told the POA it was in contradiction of the Physician's admission Orders. The findings include: Review of the facility's…

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 interview, record review, and facility policy review, it was determined the facility failed to ensure to develop s resident-centered Comprehensive Care Plan (CCP) which accurately reflected care to meet the medical, physical and mental needs to prevent a fall for one (1) of thirty-seven (37) sampled residents (Resident #60). Resident #60 fell on [DATE] at 4:15 AM, which resulted in a fracture to the resident's right shoulder. The findings include: Review of the facility's policy titled, Comprehensive Care Plan, revised 07/19/18, revealed staff's assessments of the resident reflected the needs of the resident and presented the guide to complete an individualized care plan for residents. Review revealed the resident's care plan included the identified risks and problems which the facility developed the care plan. Review of the policy revealed the resident's interventions addressed the identified problems. Further review revealed the facility was to revise residents' care plans as necessary and to reflect…

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 observation, interview, record review, and review of facility policy, it was determined the facility failed to revise a resident's plan of care with interventions to prevent further falls for one (1) of thirty-seven (37) sampled residents (Resident #60). The findings include: Review of the facility's policy titled, Comprehensive Care Plan, revised 07/19/18, revealed the facility was to revise residents' care plans as necessary and to reflect changes in a resident's condition. Review of the facility's policy titled, Falls, revised 11/06/19, revealed the facility-completed residents' fall risk assessments quarterly and with a change of condition. The facility revised the care plan with necessary and appropriate interventions for the resident. Further review revealed the facility's Interdisciplinary Team (IDT) determined the root cause of a resident's fall and would initiate new interventions for the resident. Review of the facility's policy titled, Aspects of Care, undated, revealed the facility's…

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 observation, interview, record review, and review of the facility's policy, it was determined the facility failed to provide adequate supervision, complete a thorough investigation to determine the root cause, and develop effective interventions to prevent further falls for one (1) of thirty-seven (37) sampled residents (Resident #60). Resident #60, who had a history of falls, sustained another fall on 02/04/2020 at 4:15 AM. When Resident #60 experienced the fall, the only nurse and aide assigned to his/her care were in another resident's room providing wound care. At the time of the fall, thirty-one (31) residents resided on Resident #60's unit, with the one (1) nurse and one (1) aide to provide resident care. Resident #60's fall resulted in transfer of the resident to the hospital emergency room (ER). The ER diagnosed the resident with a right shoulder fracture, with constant unrelieved pain. Additionally, the Director of Nursing's (DON's) fall investigation failed to include interviews with all staff present at the time of the fall to assist in determining the root cause…

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 observation, interview, record review, and review of facility policy, it was determined the facility failed to provide necessary equipment to assist with respiratory function while the resident slept for one (1) of thirty-seven (37) sampled residents (Resident #46). The resident's representative notified the facility at admission, on 01/24/2020, of Resident #46's need for a respiratory support machine called a BiPAP (Bi-Level Positive Airway Pressure) and mask for a known chronic medical condition upon admission. On, 01/26/2020, after staff notified the resident's physician over the concern of the family's removal of oxygen and placement of the mask brought from home, the provider verbalized to order a BiPAP unit with the ability to provide Oxygen. However, the facility never ordered the machine for the resident. The findings include: Review of the Power of Attorney (POA) document for Resident #46, dated 05/09/2017, revealed Resident #46 had given his/her significant other (spouse) the ability to make…

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.