Inspection Reports for
The Carlotta

The facility failed to ensure that two out of three staff members wore the N95 respirator model they were fit tested and approved to wear, posing a potential risk for the spread of COVID-19 among residents and staff. The Infection Preventionist confirmed discrepancies between fit test records and observed mask usage.

The facility failed to ensure that a STAT urinalysis and urine culture specimen was picked up by the laboratory within the required 4-6 hour timeframe, resulting in a delay in laboratory results and potential delay in treatment for one resident. The nurse did not document notifying the lab of the STAT order as required by facility policy.

The complaint investigation found that Resident 1 left the facility AMA on August 9, 2025, without staff knowledge. The resident had mental capacity but left without signing the required AMA form. Staff were unaware of the resident's departure until notified by an unknown visitor. The facility failed to adequately supervise and monitor the resident's whereabouts, and communication about the risk of leaving AMA was insufficient.

The facility failed to provide a safe environment for one resident who left the facility unnoticed by staff, resulting in the resident not receiving information about the risks of leaving AMA and staff being unaware of the resident's departure. Interviews and record reviews confirmed gaps in supervision and communication regarding the resident's AMA discharge.

The facility was found deficient in multiple areas including failure to prevent unnecessary use of psychotropic medications without documented non-pharmacological interventions, inaccurate medication administration, improper storage and disposal of expired medications, unsanitary food storage and preparation practices, improper garbage disposal, and inadequate infection control practices including improper use of PPE and failure to disinfect shared equipment.

The facility failed to ensure that blood sugar readings above 401 mg/dL were reported to the physician in a timely manner as ordered for Resident 1. Licensed Vocational Nurses administered insulin as ordered but did not notify the physician of the high blood sugar levels, which could have led to delays in treatment and potential complications.

The investigation was triggered by a complaint regarding quality of care related to pressure injury prevention and treatment. The complaint was substantiated as failures in skin assessment and treatment initiation were confirmed.

The facility failed to provide treatment and services consistent with professional standards to prevent progression of pressure injuries for two residents. Specifically, weekly skin assessments were not completed, and treatment orders were not properly transcribed or initiated, resulting in worsening of pressure injuries including a Stage 3 pressure injury for Resident 2 and potential progression risk for Resident 1.

The visit was complaint-related, investigating quality-of-care and quality-of-life issues. The complaint was substantiated by findings of inadequate care planning and infection control.

The facility failed to develop complete care plans addressing episodes of diarrhea for two residents and failed to implement appropriate infection prevention and control practices for a resident on isolation precautions, risking potential harm through lack of proper care planning and cross-contamination.

The facility failed to develop and implement complete care plans for residents with pacemakers, skin tears, and indwelling urinary catheters. Additionally, the facility did not properly assess and document a resident's left shoulder wound, improperly stored an expired COVID-19 test in a medication cart, and failed to follow the prescribed procedure for preparing a pureed diet for a resident.

The facility failed to reposition one resident every two hours as required, potentially risking recurrence of a pressure injury. Additionally, the facility did not maintain complete and accurate medical records for another resident, risking improper communication of clinical information.

The complaint investigation was triggered by a quality-of-care issue regarding delayed podiatry consultation and treatment for Resident 1. The complaint was substantiated by findings that the referral was not properly managed, resulting in delayed treatment.

The facility failed to follow-up on the status of an outside podiatry consultation referral for Resident 1, which had the potential to delay treatment for toenail fungus and negatively affect the resident's well-being. Interviews and record reviews revealed that the referral was not properly tracked or sent to the insurance company in a timely manner.

The complaint investigation found substantiated deficiencies related to failure to provide ordered PT and OT treatments to Resident 7, expired IV supplies present in the IV cart, and food safety violations including unlabeled food and dirty kitchen ventilator fans.

The facility failed to provide PT and OT treatments as ordered for Resident 7, did not remove expired IV supplies from the IV cart, and failed to ensure proper food storage and cleanliness in the kitchen, including unlabeled food and dirty ventilator fans. These deficiencies posed potential harm to residents.