A list of the most recent deficiencies for Wellbrooke of Carmel. 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? |
|---|---|---|---|---|
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-01-02 | 2024-01-19 | Y |
| 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 | 2023-12-12 | 2023-12-28 | 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 | 2023-12-12 | 2023-12-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-12-12 | 2023-12-28 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-12-12 | 2023-12-28 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-01-02 | 2023-12-26 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-11-20 | 2023-12-15 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-11-20 | 2023-12-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-20 | 2023-12-15 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-11-20 | 2023-12-15 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-11-20 | 2023-12-15 | 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 | 2023-11-20 | 2023-12-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-20 | 2023-12-15 | Y |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-11-22 | 2022-12-08 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-11-22 | 2022-12-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-11-22 | 2022-12-08 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-10-25 | 2022-11-18 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-10-25 | 2022-11-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-25 | 2022-11-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-25 | 2022-11-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-25 | 2022-11-18 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-10-25 | 2022-11-18 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-10-25 | 2022-11-18 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2022-10-25 | 2022-11-18 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-10-25 | 2022-11-18 | 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 | 2022-10-25 | 2022-11-18 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-10-25 | 2022-11-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-25 | 2022-11-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-10-25 | 2022-11-18 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2022-10-25 | 2022-11-18 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-10-25 | 2022-11-18 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-09-20 | 2022-10-07 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-09-20 | 2022-09-20 | Y |
| Meet other general requirements. | Fire Safety | 2019-10-21 | 2019-11-13 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-10-21 | 2019-11-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-10-21 | 2019-11-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-21 | 2019-11-13 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-10-21 | 2019-11-13 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-10-21 | 2019-11-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-10-21 | 2019-11-13 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-08-14 | 2019-09-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-08-14 | 2019-09-10 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2019-08-14 | 2019-09-10 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-08-14 | 2019-09-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-14 | 2019-09-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-14 | 2019-09-10 | N |
