A list of the most recent deficiencies for Carmel Manor. 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? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-05-05 | 2023-08-01 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-05 | 2023-08-01 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-05-05 | 2023-08-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-05 | 2023-08-01 | Y |
| 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 | 2023-05-05 | 2023-08-01 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-05-05 | 2023-08-01 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-05-05 | 2023-08-01 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2023-05-04 | 2023-08-01 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-05-04 | 2023-08-01 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-03-17 | 2022-04-22 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-03-17 | 2022-04-22 | 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 | 2022-03-17 | 2022-04-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-17 | 2022-04-22 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-03-17 | 2022-04-22 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-03-17 | 2022-04-22 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-17 | 2022-04-22 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-17 | 2022-04-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-17 | 2022-04-22 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-03-17 | 2022-04-22 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-07-11 | 2019-08-30 | 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 | 2019-07-11 | 2019-08-30 | 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 | 2019-07-11 | 2019-08-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-07-11 | 2019-08-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-11 | 2019-08-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-07-10 | 2019-07-29 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-07-10 | 2019-07-29 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-07-10 | 2019-07-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-07-10 | 2019-07-29 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2019-07-10 | 2019-07-29 | N |
