A list of the most recent deficiencies for Carmel Hills Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-08-17 | 2022-09-06 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2022-08-17 | 2022-09-06 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-03-28 | 2022-04-20 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-03-28 | 2022-04-20 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-03-28 | 2022-04-20 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-03-28 | 2022-04-20 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-03-28 | 2022-04-20 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-03-28 | 2022-04-20 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-03-28 | 2022-04-20 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2022-03-28 | 2022-04-20 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-03-28 | 2022-04-20 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-03-28 | 2022-04-20 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2022-03-28 | 2022-04-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-28 | 2022-04-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-28 | 2022-04-20 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-03-28 | 2022-04-20 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-03-28 | 2022-04-20 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-28 | 2022-04-20 | N |
| Keep all essential equipment working safely. | Health | 2022-03-28 | 2022-04-20 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2022-03-29 | 2022-04-11 | N |
| Use approved construction type or materials. | Fire Safety | 2022-03-29 | 2022-04-11 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-03-29 | 2022-04-11 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-03-29 | 2022-04-11 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-03-29 | 2022-04-11 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-03-29 | 2022-04-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-29 | 2022-04-11 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-03-29 | 2022-04-11 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-03-29 | 2022-04-11 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-03-29 | 2022-04-11 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-09-12 | 2019-10-04 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2019-09-12 | 2019-10-04 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-09-12 | 2019-10-04 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-09-12 | 2019-10-04 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-09-12 | 2019-10-04 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-09-12 | 2019-10-04 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2019-09-12 | 2019-10-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-12 | 2019-10-04 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-09-12 | 2019-10-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-09-12 | 2019-10-04 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-09-12 | 2019-10-04 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2019-09-12 | 2019-10-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-12 | 2019-10-04 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-07-12 | 2019-08-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-07-12 | 2019-08-12 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-07-12 | 2019-08-12 | N |
| Provide activities to meet all resident's needs. | Health | 2019-07-12 | 2019-08-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-07-12 | 2019-08-12 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-07-12 | 2019-08-12 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-07-12 | 2019-08-12 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-07-12 | 2019-08-12 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-07-12 | 2019-08-12 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2019-07-12 | 2019-08-12 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-07-12 | 2019-08-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-07-12 | 2019-08-12 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-07-12 | 2019-08-12 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-07-12 | 2019-08-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-12 | 2019-08-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-09-21 | 2018-10-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-09-21 | 2018-10-09 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-09-21 | 2018-10-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-09-21 | 2018-10-09 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-09-21 | 2018-10-09 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-09-21 | 2018-10-09 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-09-21 | 2018-10-09 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-09-21 | 2018-10-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-06-28 | 2018-07-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-06-28 | 2018-07-20 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-06-28 | 2018-07-20 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-06-28 | 2018-07-20 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2018-06-28 | 2018-07-20 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-06-28 | 2018-07-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-06-28 | 2018-07-20 | N |
