Deficiency Records for Carvalho Grove Health and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Carvalho Grove Health and Rehabilitation 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? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-12-27 | 2024-02-01 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-12-27 | 2024-02-01 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-12-27 | 2024-02-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-27 | 2024-02-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-12-27 | 2024-02-01 | 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 | 2023-12-27 | 2024-02-01 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-12-27 | 2024-02-01 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-12-27 | 2024-02-01 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-12-27 | 2024-02-01 | 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 | 2023-12-27 | 2024-02-01 | N |
| Provide or obtain dental services for each resident. | Health | 2023-12-27 | 2024-02-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-27 | 2024-02-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-27 | 2024-02-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-04 | 2024-02-01 | N |
| Have correct number of accessible exits for each story. | Fire Safety | 2021-11-30 | 2022-02-28 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2021-11-30 | 2022-02-28 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2021-11-30 | 2022-02-28 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-11-30 | 2022-01-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-11-30 | 2022-01-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-11-30 | 2022-01-14 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-11-19 | 2022-01-06 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-11-19 | 2022-01-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-11-19 | 2022-01-06 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-11-19 | 2022-01-06 | 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 | 2021-11-19 | 2022-01-06 | N |
| Provide or obtain dental services for each resident. | Health | 2021-11-19 | 2022-01-06 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-09-30 | 2020-11-12 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2020-09-30 | 2020-11-12 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-09-30 | 2020-11-12 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2020-09-30 | 2020-11-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-09-30 | 2020-11-12 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-09-30 | 2020-11-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-09-30 | 2020-11-12 | N |
