Carrara

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to coordinate assessments with the PASRR program for 1 of 5 residents (Resident #55) reviewed for PASRR assessments. The facility failed to ensure Resident #55 was referred to the appropriate state-designated mental health authority for review when she received a new diagnosis of schizoaffective disorder, bipolar disorder and anxiety disorder. This failure could place residents at risk of not being evaluated and receiving PASRR services needed. Findings included: Record review of Resident #55's quarterly MDS Assessment, dated 05/21/2026, reflected the Resident #55 was a [AGE] year old female who was admitted to the facility on [DATE]. Resident #55 had active diagnoses of bipolar disorder (mental health condition characterized by extreme, dramatic shifts in mood, energy, and activity levels, alternating between intense highs (mania or hypomania) and lows) and anxiety (a natural human emotion characterized by feelings of worry, nervousness, or unease,…

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, interviews, and record reviews, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for three of five residents (Residents #1, #2, and #3) reviewed for catheters. The facility failed to ensure Resident #1, #2, and #3's urinary catheters were anchored/secured to protect the resident's urethral openings and maintain proper urine flow.This failure could place residents with urinary catheters at risk of pulling/tension, kinks, and accidental dislodgment which could result in trauma and increase the risk of urinary tract infections.Findings included:Record review of Resident #1's MDS, dated [DATE], reflected she was a [AGE] year-old female who admitted on [DATE]. The resident's diagnoses included stroke affecting her speech and ability to swallow, diabetes, and pressure ulcers. The resident's BIMS score was not calculated due to her medical conditions. Her Functional Ability assessment reflected…

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, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 2 (Resident #1 and Resident #2) of 5 residents reviewed for resident rights. The facility failed to ensure LVN A introduced herself and spoke to Resident #1 while administering pain medication. The facility failed to ensure LVN A introduced herself and spoke to Resident #2 while moving his call light. These failures could place residents at risk of not being treated with respect and dignity.Findings included: Review of Resident #1's admission MDS Assessment, dated 02/20/26, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her BIMS score was 14, which indicated she was cognitively intact. Her diagnoses included arthritis and pelvic fracture. An observation and interview on 02/19/26…

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, and record review, the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (Resident #1) of 3 residents reviewed for pain management. The facility failed to ensure LVN A assessed the pain level for Resident #1. This failure could place residents at risk of not having their pain managed.Findings included: Review of Resident #1's admission MDS Assessment, dated 02/20/26, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her cognitive skills for daily decision making were not impaired. Her BIMS score was 14. Her diagnoses included arthritis and pelvic fracture. Review of Resident #1's Comprehensive Care Plans, dated 02/16/26, reflected:The resident was on pain medication therapy.Facility interventions included: Monitor/document/report adverse reactions to…

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, and record review, the facility failed to ensure each resident had the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility for 1 (Resident #1) of 5 residents reviewed for reasonable accommodations. The facility failed to ensure CNA A removed Resident #1's lunch tray from the bedside table to accommodate him when requested.The noncompliance was identified as past noncompliance (PNC) that began on 11/03/25 and ended on 11/03/25. The facility had corrected the noncompliance before the state's investigation began. This failure could place residents at risk of not being able to meet their needs. Findings included:During a record review of Resident #1's face sheet, dated 11/20/25, revealed an [AGE] year-old man admitted on [DATE] with anxiety disorder (mental health conditions characterized by excessive worry or fear that interferes with daily life). During a record review of Resident #1'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 and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 (Resident #1) of 5 residents reviewed for accuracy of medical records in that: The facility failed to document Resident #1's blood pressure before she was transported to dialysis on 08/13/25. This failure could place residents at risk of a change in condition and not receiving proper treatment and care in a timely manner.Findings included: Record review of Resident #1's face sheet, dated 09/17/25, reflected a [AGE] year-old female with an admission date of 01/24/23. Resident #1 had a diagnosis of Stage 5 Chronic Kidney Disease (the most advanced stage of kidney disease), Acute or Chronic Heart Failure (sudden life-threatening or worsening heart condition), Bacterial Infection (harmful bacteria enter the body and can cause damage), End Stage Renal Disease (kidneys have lost most of the function), Type 2 Diabetes…

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, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #1) of four residents reviewed for respiratory care.The facility failed to ensure Resident #1's nebulizer mask (device used to deliver medication in a mist form through the nose and mouth) was properly stored, in a plastic bag with the resident's name and date on it, when not in use on 08/13/2025.This failure could place residents at risk for respiratory infection and not having their respiratory needs met.Findings included: Record review of Resident #1's Face Sheet, dated 08/13/2025, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #1 had diagnoses which included COPD (disease of the lungs and airway that affects breathing), diabetes (the body does not use…

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, 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. In an interview with [NAME] A on 05/01/2025 at 1:05pm she stated it was the cook's responsibility to store and inspect dry goods in the dry storage upon delivery. She stated if she observed a dented can, she would let the DM know, and placed the dented can in the separate area the kitchen had for dented cans. She stated the DM took a picture of the dented can and sent the photo to the vendor. [NAME] A stated the after the food was…

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, and record review the facility failed to ensure residents received adequate supervision to prevent incidents and accidents for one resident (Resident #1) of five residents reviewed for possible accident hazards and incidents. The facility failed to provide adequate supervision for Resident #1 on 07/23/2024 when he slid out of the sling during a mechanical lift transfer from wheelchair to bed. The noncompliance was identified as past noncompliance (PNC). The PNC began on 07/23/24 and ended on 07/28/24. The facility had corrected the noncompliance before the state's survey began. This failure could place residents at risk for possible injuries due to lack of adequate supervision. Findings included: Review of Resident #1's Face Sheet reflected Resident #1 was a [AGE] year-old male admitted to the facility on [DATE]. Record review of Resident #1's Quarterly MDS dated [DATE] reflected diagnoses including dementia, hypertension (elevated blood pressure), diabetes mellitus (alteration…

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 and record review, the facility failed to promote and maintain the residents' right to be treated with respect and dignity for 2 of 8 residents (Resident #2 and Resident #4) reviewed for dignity and respect in that: 1) The facility failed to provide Resident #2 with help using the toilet and was told by staff to wear an adult brief after her preference to use the tiolet with help was voiced. 2) The facility failed to answer call lights in a timely manner for Resident #2 and Resident # 4's. These faillures could place residents at risk of diminished quality of life and loss of dignity and self-worth. The findings were: 1) Record review of Resident #2's face sheet revealed a [AGE] year-old female, admitted on [DATE]. Diagnoses included: Right Arm Arthritis (swelling and tenderness causes joint pain or stiffness), Overactive Bladder (a problem with bladder function that causes the sudden need to urinate), Unspecified Osteoarthritis (a progressive joint disease that causes…

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, interviews and record reviews, the facility failed to ensure a resident who was unable to carry out activities of daily living received necessary services to maintain good personally hygiene for 3 out of 8 residents (#2, #5, and #6) reviewed for ADL care. The facility failed to provide timely incontinence care for every two hours or as needed for Resident #2, # 5 and # 6 from 5/17/24 through 5/21/24. The facility failed to provide timely incontinence care on a regular basis for residents #2, #5, and #6. This failure could place residents at risk of skin breakdown, urinary tract infections and loss of dignity. Findings included: 1) Record review of Resident #2's face sheet revealed a [AGE] year-old female, admitted on [DATE]. Diagnoses included: Right Arm Arthritis (swelling and tenderness causes joint pain or stiffness), Overactive Bladder (a problem with bladder function that causes the sudden need to urinate), Unspecified Osteoarthritis (a progressive joint disease that causes…

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 and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 (Resident #80) of 5 residents reviewed for clinical records. 1. The facility failed to ensure staff kept copies of Resident #80's shower sheets from February and March 2024. 2. The facility failed to provide nurses notes on Resident #80's refusals to shower from February and March 2024. These failures could affect residents and place them at risk of inaccurate or incomplete clinical records. Findings included: Review of Resident #80's face sheet, dated 03/27/2024, reflected the resident was a [AGE] year-old woman who was admitted to the facility on [DATE] and discharged [DATE]. Her diagnoses included chronic obstructive pulmonary disease, unspecified infectious disease, unspecified fall, hemorrhage of left cerebrum without loss of consciousness, and urinary tract infection. Review of Resident 80's MDS assessment,…

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.