A list of the most recent deficiencies for Caroline Nursing and Rehab. 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-06-02 | 2021-07-09 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-06-02 | 2021-07-09 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-12-06 | 2020-01-15 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-12-06 | 2020-01-15 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-12-06 | 2020-01-15 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-12-06 | 2020-01-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-12-06 | 2020-01-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-12-06 | 2020-01-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-12-06 | 2020-01-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-12-06 | 2020-01-15 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2019-12-06 | 2020-01-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-12-06 | 2020-01-15 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-10-11 | 2019-11-20 | N |
| Respond appropriately to all alleged violations. | Health | 2019-10-11 | 2019-11-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-10-11 | 2019-11-20 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-10-11 | 2019-11-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-11 | 2019-11-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-10-11 | 2019-11-20 | N |
| Provide activities to meet all resident's needs. | Health | 2019-10-11 | 2019-11-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-11 | 2019-11-20 | 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 | 2019-10-11 | 2019-11-20 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-10-11 | 2019-11-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-11 | 2019-11-20 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2018-06-27 | 2018-08-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-05-18 | 2018-07-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-05-18 | 2018-07-13 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-05-18 | 2018-07-13 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2018-05-18 | 2018-07-13 | 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 | 2018-05-18 | 2018-07-13 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-05-18 | 2018-07-13 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-05-18 | 2018-07-13 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-03-02 | 2017-05-01 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-03-02 | 2017-05-01 | N |
| Provide food in a way that meets a resident's needs. | Health | 2017-03-02 | 2017-05-01 | N |
| 1) Review the work of each nurse aide every year; and 2) give regular in-service training based upon these reviews. | Health | 2017-03-02 | 2017-05-01 | 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 | 2017-02-28 | 2017-05-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2017-02-28 | 2017-05-01 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-02-28 | 2017-05-01 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2017-02-28 | 2017-05-01 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2017-02-28 | 2017-05-01 | N |
