Deficiency Records for Lillian Carter Health and Rehabilitation
Updated as of April 01, 2024
A list of the most recent deficiencies for Lillian Carter Health and Rehabilitation. 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? |
|---|---|---|---|---|
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-03-10 | 2024-04-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-03-10 | 2024-04-24 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-03-10 | 2024-04-24 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2024-03-10 | 2024-04-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-03-10 | 2024-04-24 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2024-03-09 | 2024-04-24 | 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 | 2024-03-09 | 2024-04-24 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-03-09 | 2024-04-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-03-09 | 2024-04-24 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-05-19 | 2022-07-03 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-12-16 | 2022-01-30 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2021-12-16 | 2022-01-30 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-02 | 2019-06-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-05-02 | 2019-06-14 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-04-30 | 2019-06-14 | N |
